COLUMBIA LIBRARIES OFFSITE .HEALTH SCIENCES STANDARD HX00030341 <','i^ant long recognized in medical literature, and because the reputation of M. Fournier as a universally acknowledged authority upon the subjects of Avhich he treats is a sufficient guarantee of its excellence and scientific value. To specialists in this department, and others familiar with the advances made in sypMlography during the last twenty years. Professor Foumier needs no introduction. His long connection with the Lourcine, the St. Louis, and other special hospi- tals of Paris, has placed at his disposition rich stores of clinical experience, which his rare discrimination and practiced powers of analysis have enabled him to utilize to the best advantage. His numerous contributions to the study of Syphilis, notably among which may be men- tioned his studies of syphilis of the brain and the spinal cord, are all stamped with originality and great clinical TRANSLATOR'S PREFACE. v judgment, and rank among the most valuable acquisitions of contemporaneous medical science. Quite recently, a special chair lias been created for Mm in the Faculty of Medicine of Paris — an unusual distinction, and one which shows the high estimation in which his talents and work are regarded. The present work exhibits a profound knowledge of the subject in all its relations, united v/ith a rare skill and tact in treating the delicate social questions necessarily involved in such a line of investigation. The very full synoptical table of contents which pref- aces this work renders an index unnecessary, and I have thought best to dispense with it. New Yoek, October 1, 1880. OOJSTTEIN^TS. PAGE luTKODUCTIOK .......... 1 PART I, BEFOUE MAREIAGE. CHAPTEE I. PRELIMINARY QUESTIONS. Importance of the Subject — How the Question of the Marriage of Syphilitics pre- sents itself to the Physician in Practice — Grave Eesponsibility incurred by the Physician — Deplorable Results of an Error committed under such Cir- cumstances — Precise Eole of the Physician consulted upon the Subject — Two very Different Classes of Consultants — Absolute Necessity for the Physician to judge the Question from an exclusively Medical Point of View, without allowing himself to be influenced by extraneous Considerations — Prelimi- nary Question — Does Syphilis constitute an Express Interdiction, an Absolute Obstacle to Marriage? — Diverse Opinions — Appeal to Observation — Save very Bare Exceptions, Sjrpbilis constitutes only a Temporary Interdiction to Marriage .......... 15 CHAPTEE IT. DANGERS DUE TO SYPHILIS IN MARRIAGE— DIRECT CONTAGION. Dangers introduced by Syphilis into Marriage — Three Orders of Dangers — Divi- sion of the Subject — Dangers relative to the Wife — Frequency of Syphilis among the Young Married — Statistics — First Order of Contamination possible for the Wife — Direct Contagion, or Transmission to the Wife of Contagious Accidents happening to the Husband after Marriage — Clinical Examples . 21 CHAPTEE III. SYPHILIS BY CONCEPTION. Second Order of Contamination possible for the Wife — Syphilis by Conception — How Cases of Syphilis, originating in this Special Manner, present them- selves in Practice — Their Undeniable Authenticity — Their Frequency — Their viii CONTENTS. PAOR Apparent Deviation from tlie General Laws of Syphilitic Infection explained by the Intervention of a Special Element, Pregnancy — Syphilis by Concep- tion, the Analof:fue of the Syphilis v/hich in the Course of Pregnancy is re- flected in an Opposite Direction, from the Motlier to the Child . . ;■'(• CHAPTER IV. PA TERN A L HEREDITY. Dangers relative to the Child — Pecent Doctrines tending to limit, and even to deny altogether the Hereditary Influence of Paternal Syphilis— Exaggerations and Errors of such Doctrines — Discussion — Theoretic Induction— Facts fur- nished by Observation — It is absolutely true that Syphilitic Husbands beget Healthy Children, their Wives remaining uninfected — Examples — Syphilitic Fathers may beget Healthy Children, while actually presenting Syphilitic Symptoms at the Moment of Conception or subsequently thereto — But, on the other hand, the Paternal Influence is exercised upon ihe Cliild in the follow- ing Ways: 1. Sometimes by Direct Transmission of the Syphilis; 2. Much more frequently by Death in Utero., Successive Abortions, Inaptitude for Life revealing itself by Death very shortly after Birth ; 3. By Native Degenera- tion of the Germ, revealing itself afterward under Various Morbid Forms, such as Constitutional Vices, Inherent Infirmities, Arrests of Development, Congenital Malformations, etc. ....... CHAPTER V. MIXED HEREDITY. A Syphilitic Father is dangerous to his future Children on Account of the Syphi- lis which he may communicate to his Wife — Disastrous Consequences to the Offspring of a Contagion transmitted to the Mother — When Father and Mother are both syphilitic the Future of the Child is comprised within the Three Following Alternatives: 1. Death in Uter'o., Abortion, Accouchement before Term ; 2. Hereditary Syphilis ; 3. Syphilitic Heredity wiih Dissimilar Morbid Forms— Native Debility — Inexplicable Sudden Death — Hereditary Morbid Aptitudes — Predisposition to Affections of the Nervous System — Convulsions— Meningitis — Backward, Imbecile, and Idiotic Children — Hydro- cephalus — Lyinphatism, Scrofula — Scrofula not a Degeneration of Syphilis as has been said, but Syphilis certainly constitutes one of the Affluents of Scrofula .......... CHAPTER VI. MA TERN A L HEREDITY. Parallel betv.-con Paternal and Maternal Syphilis as regards their Hereditary In- fluence — The Maternal Influence is veritably pernicious for the Child — Per- sonal Statistics — Other Statistics furnishing Similar Results — Conclusion, the Worst Danger for the Offspring is for the Mother to contract the Infection from the Father .......... OG CONTENTS. ix CHAPTER VII. PEBSOKAL jyANGTCnS OF THE HUSBAND. v:a,v. How a Syphilitic Man may become dangerous to liis Family from the PerKonal Eisks to which he remains exposed from his Disease — Catastrophes, Social Calamities resulting from the Syphilis of the Husband — Various Examples — Moral Aspect of the Question — Has a Syphilitic Man the Eight to associate Others, viz., a "Wife and Children, in the Future Dangers of a Syphilis insuf- ficiently treated ? — Marriage in such Conditions a Culpable Action which Morality sternly reproves — The Dangers to which a Syphilis not treated ex- poses the Patient after a Long Maturity — Duty of the Physician to enlighten his Patients upon these Points — Conclusions . . . . .76 CriAPTEE VIII. CONDITIONS OF ADMISSIBILITY 10 MARRIAGE— ABSENCE OF ACTUAL SPECIFIC ACCIDENTS— ADVANCED AGE OF THE DIATHESIS. In what Conditions does a Patient affected with Syphilis become admissible to Marriage — The Author's Programme — Principal Conditions— Absence of Ac- tual Specific Accidents — Incredible Audacity of Persons who marry while having Actual Symptoms of Syphilis — Various Motives influencing this Revolt- ing Act— Examples of Marriage during the Incubation of Syphilis^Advaneed Age of the Diathesis — General Principle ; the more recent the Husband's Syphilis, the more numerous and the more serious the Dangers which he intro- duces into Marriage — Corollary : — The Advanced Age of the Diathesis consti- tutes a Security for Marriage : 1. From the Point of View of the Eisks of Contagion ; a Recent Syphilis is especially dangerous from the Character of its Accidents, their Multiplicity, their Frequent Eecurrences, their Tendency to Localization toward tlie Mouth and the Genital Organs, their Apparent Be- nignity, etc. ; 2. Attenuating and Corrective Influence of Time upon Heredity ; Gradual Decrease and Final Extinction of the Eeaction of the Parents upon the Children; Probatory Examples ; 3. Comparative Guarantee furnished by the Long Standing of the Disease as to the Husband's Personal Eisks — Age of the Syphilis not the Sole Fact from which to judge of the Admissibility or Noii- admissibility to Marriage— Other Factors to be consulted— Difficulties in determining the Exact Time when a Syphilitic becomes admissible to Marriage —The Minimum Period to be exacted, Three or Four Years usefully devoted to Specific Treatment— Marriage then tolerated ratherthan counseled— A Longer Time afi'ords a Safer Guarantee . . . . . . . 04 CHAPTER IX. PROLONGED PERIOD OF IMMUNITY— NON-MENACING CHARACTER OF THJi DIATHESIS. Stage of Immunity sufficiently prolonged after Last Specific ManifestatioDS — Prog- nostic Significance of this Period — Security much greater when this Period is passed without Therapeutic Intervention — What Duration should be assigned CONTENTS. PAon to tliis Period of Immunity — Mininium strictly required for Marriage — Non- raenaciDg Character of the Diathesis — Original Benignity of a Syphilis a Fa- vorable Condition for Marriage, but does not supply other Required Conditions — Syphilis originally benign may afterward terminate in the Gravest Acci- dents — It may become dangerous for Marriage, not only from the Point of View of Contagion and Heredity, but also from the Personal Eisks of the Husband— Orders of Syphilis especially dangerous for Marriage— Syphilis with Continually Recurring Crops of Secondary Accidents— Syphilis with Grave and Diverse Manifestations- Syphilis electing for its Morbid Determi- nation some Important Organ, as the Eye, Brain, Spinal Cord, etc.— Syphilis of this Order absolutely incompatible with Marriage— The Intrinsic Prognosis of each Particular Case necessary to form a Judgment . . . .111 CHAPTER X. SUFFICIENT SPECIFIC TREATMENT. The Great Condition par excellence — Sufficient Specific Treatment the most Valu- able and Substantial Guarantee of a Syphilitic's Fitness for Marriage : 1. It constitutes the Best Safeguard against the Husband's Risks ; 2. It diminishes and suppresses the Dangers of Contagion ; 3. It diminishes and suppresses the Dangers of Heredity — Influence of Specific Treatment upon Paternal Heredity, upon Maternal Heredity, upon Mixed Heredity — A Provisional Treatment may counteract, temporarily, the Efi'ects of Syphilitic Heredity — What Treatment offers, if not Absolute Security, at least Substantial Guaran- tees — Deplorable Results of Short Treatments — A Chronic Disease requires Chronic Treatment— Plan of Treatment sufficiently protective, both for the Present and the Future . . . . . . . .122 CHAPTER XI. THE USE OF SULPnUJi- WATERS- CONCLUSIONS. Sulphur-Waters as a Criterion of the Cure or the Non-cure of Syphilis— Their so- called Revealing Action — What Degree of Confidence may be accorded to " the Judgment of the Waters " — The Test of the Waters, as applied to a Syphilitic's Fitness for Marriage, a Legend — Conclusions — Review of the Pre- ceding Programme — Reflections and Criticisms — Impossibility of forming a Programme which responds to all Possible Contingencies — The Physician's Opinion must be based upon a Simple Calculation of Probabilities — How Medical Intervention in this Matter may afl"ord Inestimable Services, both to Patients and Society — How the Question of Fitness or Non-fitness for Mar- riage presents itself to the Physician — Rule of Conduct to be strictly ob- eerved — Empirical Confirmation of the Foregoing Facts . , ^ ..132 CONTENTS. xi PART II. AFTEK MAHKIAGIS. CHAPTEE XII. HUSBAND SYPHILITIC AND WIFE HEALTHY. PAOB Syphilis anterior to Marriage— Syphilis posterior to Marriage — Exceptional Cases of Syphilis contracted before Marriage not manifesting itself until after Mar- riage — Dangers resulting from the Introduction of Syphilis into a Young Family — First Order of Situations possible; Husband syphilitic and Wife healthy — Particular Indications then to be fulfilled : to destroy forthwith the Sources of Contagion; to cut short, by a Medication of Especial Intensity, the Contagious Accidents of the Secondary Period ; to avert the Dangers which might result from a Pregnancy, etc. — Two Propositions verified by Experi- ence : 1. In the Great Majority of Cases the Syphilitic Contagions transmitted from Husband to "Wife in Marriage are derived from Secondary Accidents ; 2. These Contagions are almost invariably derived from Secondary Accidents of a Superficial Erosive Form, essentially benign in Appearance, and suscep- tible of remaining unrecognized as to their Real Nature, or of passing entirely unperceived .......... 146 CHAPTER XIII. HUSBAND SYPHILITIC, WIFE HEALTHY BUT ENCEINTE. Dangers which this Situation involves for both Mother and Child — Discussion upon the Propriety of Preventive Intervention — Diverse Opinions — Particular Cases in which this Intervention is expressly indicated .... 152 CHAPTEE XIV. HUSBAND SYPHILITIC AND WIFE RECENTLY CONTAMINATED. Special Difficulties encountered in this Order of Cases — Eole of the Physician in Relation to the Husband — Absolute Interdiction of Paternity — Role of the Physician in Relation to the Wife — Mission of the Physician to treat this Woman with the Obligation to conceal from her the Name and Nature of her Disease — Contests with Feminine Acuteness — The Wives not always the Dupes of the Stratagem — Difficulties of making a Woman ignorant of her Dis- ease accept the Long Treatment necessary — The Husband by no Means an Ardent Auxiliary of the Physician — Lamentable Consequence — Most Married Women contracting Syphilis from their Husbands are never sufficiently treated, and are thus exposed to the most Serious Consequences in the Future — Fre- quency of Tertiary Accidents among these Patients — Why the Nature of such Accidents is liable to remain unrecognized in these Cases — Clinical Exam- ples — The Moral Duty here imposed upon the Physician — Multiple Embai^ rassments of such a Situation — ^Professional Tact and Cleverness demanded . 168-^ xii . COKTENTS. CHAPTER XV. HUSBAKD SYPHILITIC— WIFE SYPniLITIC AND ENCEINTE. PAOB The most Serious Sibuation of all — Probable Fate of the Child procreated under these Conditions — It is not impossible that Treatment may avert a Complete Disaster — Cases where Pregnancy may be brought to Full Term — Exceptional Cases where the Child entirely escapes the Syphilis— Capital Indication to be fulfilled, to treat the Mother — Objections — Pretended Dangers oi' Mercurial Treatment during Pregnancy — Discussion — Popular and even Professional Prejudice attributing to Mercury that which is the Result of Syphilis — Ab- solute Urgency of submitting Syphilitic Women in a State of Gestation to Specific Treatment — Two Existences to be preserved — Confirmatory Eesults of Clinical Experience ........ 179 CHAPTER XVI. DANGERS TO SOCIETY—SOCIAL PROFUYLAXIS. Dangers to Society from the Syphilis of Infants — Contagion of Nurses — Singular Faculty of Expansion, of Irradiation of the Sypliilis of Nurses and Nurslings — Cascades of Contagion — Clinical Examples — Duty of Social Prophylaxis im- posed upon the Physician — Object to be realized : to circumscribe the Pox in its Original Bed, and prevent the Spread of its Ravages outside — Application — The Sole Means practicable ; the Infant, the Prime Origin of these Dangers, must remain in the Family and be nourished by its Mother — Objections — Does Maternal Nursing in such Cases involve Dangers either for the Mother or the Child? — Discussion — Four Orders cf Cases possible — Two Alternatives, perilous theoretically— Law of CoUes — In Point of Fact the Nursing of the Child by its Mother is free from the Dangers v/liich might be supposed — Conclusions — Maternal Nursing is the Sole Rational and Practical Means for the Raising of the Child — The Protection of Society constitutes the Capital, Pi-edominant Indication, which the Physician is bound to satisfy . . 195 NOTES AND ILLUSTRATIVE CASES. I. — Eighty-seven Observations relative to Syphilitic Subjects who, having mar- ried, have never communicated the least Suspicious Symptoms to their "Wives, and more, have begotten a Total of One Hundred and Fifty-six Children absolutely healthy ....... 209 II. — Syphilis — Seven Abortions or Premature Accouchemcnts. (Case.) . . 212 III. — Hereditary Influence of Maternal Syphilis. (Statistics.) . . . 235 IV. — Syphilis contracted before Marriage and not manifesting itself until after Marriage. (Cases.) ........ 239 v.— Premature Marriage of a Syphilitic Subject — Five Cases of Syphilis origi- nating from the Husband's Syphilis — Death of a Strange Nursling. (Case.) . . . . " 213 VI.— Father syphilitic — Child syphilitic — Mother at first apparently uninfected, but presenting. Six Years later, an Accident of Tertiary Syphilis. (Case.) 247 VII. — Of Inaptitude for Life as an Hereditary Consequence of Paternal Syphilis . 251 XI! mTRODUCTIOISr. Gentlemen : I propose to broacli before you, in a series of lectures, a question wMcli, both in a medical and social point of view, is of the most grave and important character, viz., the study of syphilis in its relations with marriage. This question is eminently complex, as you may judge from its mere announcement. It embraces a multitude of diverse problems, problems difficult, delicate, and peril- ous, which affect the dearest interests of families, and involve the heaviest responsibility for the physician. It is my desire and ambition, if not to solve all these problems, at least to state and discuss them before you in a manner to convince you both of the extent of your duty to society in this respect and of the important protective service you have in your power to render it. A very natural division of the subject presents itself here, viz. : 1st. A syphilitic subject wishes to marry, and comes to consult us in relation thereto. What condi- tions ought he to fulfill, medically, in order that we may be justified in permitting him to marry ? Or, conversely, 2 SYPHILIS AND MARRIAGE. in what conditions will it be our duty to defer or even to absolutely interdict tlie marriage ? 2d. The marriage is consummated, and syphilis intro- duced into the conjugal bed. What medical indications are then to be fulfilled in order to lessen or avert the dangers of such a situation ? In other words, what is, what should be, in this case the role of the physician either he/ore or after marriage ? Such is the twofold question which we have now to con- sider. PAET I. BEFORE MARRIAGE. CHAPTER I. PEELIMINAEY QUESTIONS. It will happen to you often, gentlemen, in the course of your practice, to see a patient, known or unknown to you, present himself in your office, who, with countenance preoccupied, almost anxious, will address you as follows : "Doctor, I am contemplating marriage. I have not al- ways been discreet in my bachelor life, and, what is worse, I have not always been fortunate. I contracted syphilis at such a time. I have had such and such accidents. I have been treated in such and such a manner. The matter is now a serious one for me. I have come to ask you if I am thoroughly cured, and if I can, without danger for my wife, without danger for my prospective children, contract the union which I propose. Be good enough to examine me, to interrogate me, and to give me your opinion upon this subject." Now, when such a request is addressed to you, gentlemen, do not misapprehend the gravity of the question. Your response involves interests the most seri- ous, the most sacred, the most dear to the heart of every honorable man, of every respectable family, as well as in- 4 SYPHILIS AND MARRIAGE. terests the most diverse and the most multij)lied. By this opinion which you are about to formulate, you incur a responsibility which I can not otherwise characterize than as considerable ; and I do not think I exaggerate in say- ing that in the province of the physician there are few problems to solve, on the one hand so grave, and on the other hand so complex, so diihcult, so delicate, as this. Judge for yourselves, now, and see what might be the consequences of an error committed by you in such a situation. Suppose that the physician pronounces incon- siderately under such circumstances, and falls into one or other of the only two errors possible to commit in the case. What deplorable results does he not bring uxDon his. patient ! First HypotJiesis. — Take the case of a patient who, although having had syphilis formerly, is, nevertheless, by reason of the treatment he has undergone and the present state of the diathesis, in a condition to contract marriage. The physician consulted in this case mistalces the situation of his patient, and forbids his marriage. Consequence : Here is a man wrongly condemned to celi- bacy, banished from the virtuous life which he i:)roposed to enter, and relegated to an irregular life, with all the miseries, social or otherwise, which it entails. Here is a man whose future and whose heart are both broken by a medical decree that forces him to renounce a union likely to assure his position and his happiness ; here, at all events, is a man deprived of family life, deprived of those two things which, after the turbulence of the first years of foolish youth, become the objects of natural and universal aspiration, viz., home and children. Second Hypothesis. — The error is committed in an opposite direction, and the physician prematurely sane- PRELIMINARY QUESTIONS. 5 tions the marriage of a man whose syphilis is still active and dangerous. Then, indeed, the consequences of such a mistake are truly disastrous and ruinous, for : 1st. This man may infect his wife. And what is more deplorable than to give a virtuous young woman the po:;c as a wedding present ! 3d. This infected couple will engender children that will, inevitably, either die almost as soon as they are con- ceived, or be born with the father's disease. And what more hideous for a young household than the pox in the cradle ! To say nothing of other possible consequences of such a situation, such, for example, as the infection of the nurse, etc.^ Take my word for it, gentlemen, I have witnessed many scenes, many dramas of this kind, and, I declare, I know of no position more heart-rending, more lamentable, more atrocious than that of a man who has introduced the pox into his little household — than the situation of this man (1st) in regard to his disconsolate, weeping wife, whose tears are not even accompanied with recriminations or complaints, for love and affection readily forgive ; (2d) in regard to a new family that will not pardon, that has the right to be severe, and exercises that right ; (3d) in regard to the infant which miserably vegetates, and, in place of being the beautiful child dreamed of by the relatives and mother, is to every one, even to the nearest kin, but an object of disgust and horror ; (4th) finally, in regard to an infected nurse, who threatens, who makes scandal, * In another series of lectures, I have studied the serious consequences of infantile syphilis in relation to nurses. — Nourrices et nourrisojis syphiliiiques. Paris, 18'78. 6 SYPHILIS AND' MARRIAGE. who di^nilges, who throws disgrace u^on the family, etc. Picture to yourselves such a scene, gentlemen, and judge of the regret, of the martyrdom, of the man who has caused such afflictions. Now, it is situations of this kind which you, as physi- cians, are privileged to avert, thanks to your art, your experience, your authority. It is situations of this kind which it is necessary for you to take in at the first glance, when a syphilitic patient comes to consult you upon the admissibility of marriage ; and it is these which you should have present in your mind when, in one way or the other, you formulate your response — let us say, rather, when you pronounce your sentence. Judge, then, from these few words, gentlemen, on the one hand, what an important and exalted post is yours in your capacity as arbiters in such a matter ; and, on the other hand also — I again insist upon this point — what responsibility you incur for the results that may follow. Judge what service you are called upon to render your patient in either alternative : whether you permit him to marry, if expedient ; whether, on the contrary, and better still, you enlighten him upon the possible consequences of his condition (consequences which perhaps he is ignorant of, or which, at least, he but imperfectly comprehends), and thus preserve him from the frightful predicament in which he Avas about to in- volve himself. And, again, note this : At the moment when you render your decision, it is not alone the patient's interests that you hold in hand ; your protective office extends beyond him, and reaches farther. For behind that patient there is a young wife, there are children yet unborn, there is a family, there is society itself, to be shielded at the same tii^e by your prohibition. Behold, then, how extended PRELIMINARY QUESTION'S. Y and elevated the medical adviser's mission becomes when lie finds himself thus the arbiter of so many united in- terests. Before entering into the heart of this question and dis- cussing the different problems which will be the object of this exposition, let us first state a principle by endeavoring to define clearly the situation, as it presents itself in prac- tice, and determining exactly the role which is assigned us. When a patient comes to request our advice, to ask our counsel upon the propriety of marriage, despite syphi- litic antecedents, it is as pTiysicians, as physicians exclu- sively, that we are consulted. Our role is distinctly de- termined by that fact alone. It is as physicians that we are to respond. In other words, it is a question of pathol- ogy, and of that only, that we are called upon to judge, and our duty, our absolute duty, is to decide it upon pathological grounds alone, without allowing ourselves to be influenced by any other considerations, whatever they may be. But, you ask me, wherefore this preface? "Why this rule of conduct laid down at the opening of the exposi- tion? In practice, gentlemen, it is necessary to look upon things as they exist, and to take men for what they are. N'ow, learn this, presuming that you may not know it already : among the numerous patients who will come to consult you upon the propriety of marriage in the special conditions which now engage our attention, there are many, assuredly (let us even say a very large majority), who will present themselves to you with the twofold in- tention of learning precisely how to act in their situation, and of submitting themselves to the decision which you 8 SYPHILIS AND MARRIAGE. will pronounce ; that is to say, of renouncing a projected marriage, if you prohibit them from marrying. This class you do not have to distrust. But there are others of an altogether different Idnd ; and these last, more numerous than you would suppose a priori, will come to you with a tacitly formed resolve to act solely according to their in- clination, whatever you may say to them, and to marry at all hazards, and m spite of all your interdictions, because it pleases them to marry, because they have resolved to marry, before even crossing your threshold. '^' In these * I have seen numbers of syphilitic subjects marry in opposition to all medical prohibitions. One can not even form an idea of the disdainful indiffei'ence which certain people profess with regard to medical prescriptions concerning the subject under consideration. . , . One of our most learned and esteemed confreres, Dr. X., was consulted by a young man, the son of a family of his most intimate friends, for accidents of sec- ondary syphilis consecutive to a recent contagion. Knowing that the young man was then contemplating marriage, he took occasion to accompany his prescription with a long moral upon the dangers of syphilis in relation to marriage, and endeav- ored to obtain from his patient a formal renunciation of all matrimonial projects. ... In response, he received, some weeks later, a letter announcing the marriage, with an invitation to be present at the ceremony, celebration, dinner, etc. It is useless to speak of the reception given to this ironical missive by our con- frere. But the expiation could not be long delayed, and it was severe, as you will see. Three months later, the young couple presented themselves to Dr. X., under the pretext of a " visite de noces." After the usual compliments, the young husband suddenly changed the conversation, and requested some medical advice for his wife, who, in the first place, presented the earlier symptoms of pregnancy, and who, in addition, had had for some weeks a " slight hardness " on the lip. Now, upon ex- amination, this was found to be nothing else than a syphilitic chancre — a chancre manifestly transmitted to the young wife from her husband, who had not ceased for some months to be affected with buccal syphihdes, and was still affected with them at that time. It is almost superfluous to add that the chancre was followed by the accidents of constitutional syphilis. In addition to which, eight months later, the young wife was delivered of a poor, weakly, insignificant infant, which was soon covered with syphilides, and quickly succumbed. Another example of the same kind : A young man contracts syphilis and comes to seek treatment from me. Some months later, still affected with secondary accidents, he announces to me that he PRELIMINARY QUESTIONS. 9 cases, it is not advice, not counsel whicli they expect of you ; it is your consent, your acquiescence in their proj- ects which they hope to wring from you. Such consent, indeed, would set them at ease with their consciences, and, moreover, should things happen to "turn out badly" in the future, it would serve them as an excuse and an exoneration. N^ow, in order to gain their ends, in order to force your convictions, those of this latter category, while pretending to consult you, never fail to shirk the medical aspects of the question almost at once, in order to carry you off finds himself engaged, " almost in spite of himself," to be married, which must necessarily take place quite soon. I energetically insist upon his renouncing such a project ; I depict to him the dangers to which he is about to expose himself and his future family. I endeavor to convince him of the immorality, of the culpability of such an act, etc. Nevertheless, he marries, and I see him no more for a certain time. Some months later he comes to me in a veritable state of affright and distress. He has infected his wife, he tells me, and he comes to ask my attentions to her. I find, in reality, this young wife in an active condition of syphilis. I prescribe a treatment, a hygiene, etc., and, especially, I expressly recommend the husband to avoid at any price the possibility of pregnancy in such a situation. I explain to him, superabundantly, that a pregnancy would be a second disaster, for it could only end, according to every probability, either in an abortion or in the birth of a syphilitic infant. Notwithstanding, two months later, the young wife becomes enceinte. I then treat her so much the more energetically, and I have the happiness to prevent an abortion. Then, when I consider myself sure of obtaining an accouchement at full term, I announce the express absolute obligation for the mother to nurse her child. At least, I say to the husband, arrange it so as to avoid a third misfortune. Do not confide your infant to a nurse, for it is quite probable that the nurse will receive the pox from it. M. Ricord, consulted upon this point, confirms the appre- hensions expressed by myself, and energetically insists upon the absolute neces- sity of the mother nursing the child. Some months pass away, without my again seeing this family. Then, one day, the father reappears, bringing the child covered with syphilides, and the nurse to whom this child had been confided. As I had foreseen, this nurse had become in- fected, and bore upon one of her breasts an indurated chancre of the most typical character. To recapitulate : triple transgression of medical advice and triple disaster, viz., the infection of a young wife, the birth of a syphilitic infant, and the contamination of a nurse. 10 SYPHILIS AND MARRIAGE. to considerations of a totally different character. They have a hundred pretexts at their service to plead their cause and to induce you to share then* feeling. One, for example, "has given his word, he is engaged, formally engaged, and you should not compel him to break his plighted faith." Another will invoke an urgent material necessity. Counting upon the do\viy of his future wife, he has just purchased an office, a practice, a commercial business, or the like. "If you force him to break off the marriage, it will be to bring him to ruin, failure, and dishonor." Still another, more crafty, will work upon your feel- ings. "I love a young lady," he will tell you, "and am beloved of her. Our two families, our aged parents, place thek dearest hopes on this marriage, and a rupture would break all our hearts," etc. All these arguments (copied from life, and reproduced literally, on my honor) — all these arguments, and many others which I pass in silence, have nothing to do, gentle- men, with the situation which we are called upon to ex- amine as physicians. Were such reasons as valid as they are detestable, we have nothing whatever to do vniln them, nor have they any value for us medically. Let them be null and void for us. Let us stand firm under such cir- cumstances and reject everything that does not bear upon the clinical aspect of the case. Let us not quit our own ground, but confine ourselves to a strictly pathological view of a question which for us should not be separated from pure pathology.* I will even go farther, and assert that we should be culpable, veritably culpable, were we to do otherwise ; * Of. Langlebert, La syphilis dans ses rapports avcc le mariage. Paris, 1873, p. 10. PRELIMINARY QUESTIONS. 11 that is to say, were we to allow ourselves to arrive at a decision based upon considerations foreign to our art. And tlie proof of this is the embarrassment which we should have in Justifying our. conduct if a misfortune should occur, if a patient, whom we had permitted to marry from extra-medical considerations, should happen to introduce syphilis into his family. What plea could we then urge against such an accusation thrown in our face as, "What! you judged this man to be medically unfit for marriage, dangerous for marriage, and, because he has alleged questions of convenience, of position, of pecuniary wants, of feelings, you authorized him to run the risk of introducing the pox into his home ! " Let us guard against the possibility of such recrimina- tions, let us guard against a grave fault into which (I can say from experience) we are but too easily led by an ex- cess of kindness ; the more so, as we have a ready means of avoiding it, viz., not to deviate from the role naturally assigned to us by our profession. In a word, consulted under such circumstances, let us keep to medicine, and Judge only as physicians the case submitted to us. Let there be no concessions to argu- ments of a foreign nature ; no condescensions which we may bitterly regret in the future, and which, without bene- fiting any, may prove prejudicial to all, seriously compro- mising both our authority and our dignity. With these preliminaries, we shall enter upon the prin- cipal subject. But, first of all, let us examine a primary question, which, if resolved affirmatively, would exclude all further discussion, by rendering useless that which is now to follow. Does syphilis constitute an express interdiction^ an absolute obstacle^ to marriage f 12 SYPHILIS AND MARRIAQE. Witliout doubt, gentlemen, you have often heard the common adage, '''■ avec la 'oerole il faitt r ester gargony Many people repeat and spread this as an axiom indorsed by all the faculty, who, moreover, in order to discourse more at ease of such things, have never taken the care to study them. It is also affirmed in a much more energetic manner by families (and I excuse them), who have been in- terested in the question and seen syphilis introduced into their household under cover of marriage. These families can not sufficiently reprobate every man who, with the syphilis, would dare ever to aspire to the position of hus- band. In their oj)inion, and in the opinion of all those who have been the victims of similar calamities, the pox is radically " incomj)atible with marriage." By many physicians, syphilis would be regarded as an express contraindication to marriage. I have had the pleasure of conversing upon this subject, which has for many years engaged my attention, with numbers of my confreres, and many of them have said this to me in their own words : " Nobody marries, no one ought ever to mar- ry, when once he has had the misfortune to contract the pox." I could even cite two of our most esteemed con- freres who have joined practice to precept, who have ex- emplified it by remaining unmarried, from the sole con- sideration that they had acquired syphilis in their life as students. One of them, a most distinguished physician, whose heart is on a level with his talent, has never allowed himself to be dissuaded by me (who have the honor to be his friend) from that which he tenns his "incapacity for marriage." "You have spoken to no purpose," he has repeated to me a hundred times. "When one has the pox, one should keep it to himself, A\ithout running the risk of giving it to others, especially to his wife and chil- PRELIMINARY QUESTIONS. 13 dren." To wMcli I have rejoined, on my part, " Wlien one has the pox, one should cure it ; and when* by force of care one has rendered it innocuous for others as well as hin:iself, then, having again entered upon a normal condi- tion, one has the moral right to aspire to marriage." And, in fact, gentlemen, the truth is not with those who would make of syphilis an insurmountable obsta- cle, a permanent, eternal, absolute interdiction to mar- riage. The truth is, that, save very rare exceptions, syphilis constitutes only a temporary interdiction to marriage, and that a syphilitic subject may, after a certain stage of sufficient depuration, return to a state of health which fully restores his fitness for the double role of husband and father. Upon this point, I appeal to common, to daily observa- tion. Do we not encounter almost every moment, both in private and hospital practice, persons who, having had syphilis in their youth, afterward marry, and who, mar- ried, on the one hand, Tiave netier communicated anytliing syphilitic to their loives, and, on the other hand, have had healthy children^ well developed and thriving, as active and as well favored as could be desired. Cases of this kind abound and superabound. I deny that any physician engaged in practice for several years can not bring forward his contingent of personal ex- amples to the support of the proposition, so consoling, which I have Just enunciated. For my part alone, I have in hand (to speak only of recorded facts) eighty- seven observations relative to syphilitic subjects, undoubt- edly syphilitic, who, having married, have never com- municated to their wives the least suspicious phenome- non ; and, what is more, have begotten, these eighty- 14: SYPHILIS AND MAERIAOE. seven, a total of one liundred and fifty-six cMldren abso- lutely healthy.* These observations, which I have chosen among many others, are the most convincing to me, and they will be- come so to you, gentlemen, I trust, when I shall have assured you that they all relate to patients and to families that I have scrupulously examined and followed up, that I have had under observation for many years, and many of whom are still in close relations with me. In addition, allow me to cite you two of these cases as examples : Two of my patients, f onnerly syphilitic, married, one without consulting me, the other after having received my consent. The first has to-day /bztr children, and the sqg- ondi Jive. Now, after a dozen years that I have been the physician of these two families, I can affirm to you with every assurance that (1) the wives of these two patients have never presented the least suspicious phenomenon, or the slightest manifestation which had any analogy with syph- ilis ; (2) that the nine children of these two families are absolutely sound and healthy. Thanks to the solicitude of their mothers, I have been able to look after them at leisure, from their birth until the present time, not only in theu' various sicknesses, but in the slightest indispo- sition, vdth which they have been affected. Never have I detected in them anything which recalled the paternal dis- ease in any degree or in any form whatever. What more do you wish ? Here, then, incontestably, are two families, where the syphilis of the father has x)layed no role what- ever, where things have progressed as they would have progressed in the absence of any syphilitic antecedent. One of these two families (pardon me this incidental digression) presents the perfected type of domestic happi- * V. Notes and Illustrative Cases, Note 1. FRELIMINAEY QUESTIONS. 15 ness, and lias more than once suggested to me a. reflection relative to the subject we are now considering. I have often said to myself, when seated at this happy hearth- stone, and a witness of its intimate joys : " What a mis- take should I have committed if, from an exaggerated fear of the old disease, I had prevented this marriage ! What a mistake should I have committed, if I had nipped in the bud all the present felicity of these two beings so affec- tionately united — if I had prevented these beautiful chil- dren from coming into the world ! " Yes, then, a hundred times yes, one may marry after Jiaving had the pox., and the results of a marriage con- tracted under these conditions may be absolutely safe, medically speaking. This I afiirm and proclaim boldly, after having carefully studied this serious question from both a clinical and a social point of view ; after having conscientiously investigated numbers of cases, personal or contributed by others. This is for me an established fact, a demonstrated verity. But, this said, I would hasten to add immediately : If one may marry after having had the pox, one may not, one ought not, to marry in this special situation without being declared free from liability to subsequent manifestations of the disease ; without satisfying certain conditions which are indispensably necessary. What those conditions are we shall now endeavor to define. CHAPTER II. DANGEES DUE TO SYPHILIS IX MAERIAGE — DIRECT CONTAGIOlSr. IjST order to deteraiine on what conditions, medically and morally, a syphilitic subject may be permitted to contract an alliance, it is necessary, first of all, to ascer- tain how and in what resj)ects that man may become dangerous in marriage. Such is, naturally, the primordial point to establish, for such is the basis of all reasoning in solving the 'prdb- lem which is now imposed upon us. 'Now, in my opinion, and as I understand the question, a man with syphilitic antecedents who contracts marriage may become dangerous in marriage in the three follow- ing relations : 1st, as husband ; 2d, as father ; 3d, as head of the social community constituted by marriage. In other words, he may become dangerous : 1. To his wife. 2. To his children. 3. To the common interests of his family. Let us see what this programme signifies, and examine from every point of view the three terms of the proposi- tion which I have Just formulated. First Point. — A man, toJioioitli sypMlitic antecedents contracts marriage, may become dangerous to Ms wife. DANaERS DUE TO SYPHILIS IN MARRIAGE. 17 TMs is evident ; it admits of no discussion, in fact. It is manifest tliat a healthy young woman delivered over to a syphilitic man may suffer the contre-coup of this syph- ilis. This is what common sense says a priori, and ex- perience confirms it. And, in reality, how often have we not seen, who has not seen, cases of this kind \ A young woman in a perfect state of health marries a man who has acquired syphilis in his bachelor life. Several months later you find her sypMUtic, and syphilitic through the sole agency of her husband. This syphilis in young married women — we may say incidentally, since . occasion presents — is quite frequent, much more frequent than one would suppose. In proof of this, you will find many cases recorded in various re- ports. In proof, also, the following personal statistics : In a total of 672 syphilitic women who have come under my observation in my private practice, I found no fewer than 81 who contracted syphilis /rom their husbands soon after marriage. These figures are sufficiently eloquent by themselves to render all commentary unnecessary. Let this be a warning, then, to families who consider not the health of their future sons-in-law, and who neglect to protect their daughters against careless, indifferent, or un- principled men, to whom it is a matter of little concern to carry the pox into the conjugal bed. This fact, then, is patent : frequently young married women receive syphilis from their husbands. TMs fact we must now explain. How do wives in such circumstances receive syphilis from their husbands ? How does a syphilitic husband be- come dangerous to his wife ? How, in a word, is the syph- ilitic contagion transmitted from the husband to the wife ? 18 SYPHILIS AND MARRIAGE. In two ways, one of wMcli is very simi)le, trite, and commonplace, and tlie other is sj)ecial, mysterious, not materially demonstrable, but wMcli is undeniable, as has been demonstrated by observation. To explain this, cer- tain preliminary statements are necessary. The first mode of contagion, which I have just now characterized as the common, ordinary one, consists simply in this : Transmission to the wife of a contagious lesion occurring in the husband after marriage. A syphilitic husband not yet cured of his syphilis comes to be affected with a supjDurative lesion of a specific nature. He has connection with his wife at this time. IS'aturally, he infects this wife from the lesion which he actually has at the time. There is nothing but what is very simple, nothing but what is absolutely normal in this mode of contagion, which is, as every one knows, the ordinary mode by which syphilis is transmitted, prop- agated, and maintained. As examples of this kind : A young man marries after fifteen months of syphilis. He comes to have on his glans two circinate erosions of the kind which we term in tech- nical language papulo-erosive syphilides of annular form. Regarding these lesions as herpes (another affection to which he is subject at times), he continues to have inter- course with his wife, and thus communicates syphilis to her, Avhich makes its debut by an indurated chancre on the vulva, soon followed by general symptoms. Another young man, belonging to the highest social circles,* marries despite my advice, after two years of * I note by design this particularity, as I shall again note it if occasion serve. And, in fact, numbers of persons imagine and repeat that transmissions of syphilis in marriage are scarcely ever met with except " among the lowest classes," and as a result of ignorance, of carelessness, of misery, etc. Now, this is a delusion, a grave error, against which daily experience protests. The cases of this character DANGERS DUE TO SYPHILIS IN MARRIAGE. 19 syphilis. A great smoker, lie is often affected with slight labial erosions, to which he pays no attention, Notwith- standing my advice, he obstinately refuses to consider them dangerous or to have them treated. Consequence : From one of these erosions, which I had regarded as un- doubtedly syphilitic, he eventually transmits syphilis to his wife, upon whom I afterward discover an indurated chancre of the lower lip. One of my professional friends contracts syphilis. He treats himself. Thinking himself cured, three years later he marries. Some months afterward I receive a despond- ing letter from him. "A lamentable catastrophe," he writes, "has befallen me. Quite recently I have had the misfortune to infect my young wife, nineteen years old ; and I have infected her — it is not to be believed — ^with a miserable little papule on the penis, an erosive papule, it is true, but minute, absolutely minute to the degree that I did not at first perceive it, and afterward took no pre- caution!" And, in like manner, gentlemen, I could accumulate here many other cases of the same character, differing per- haps in detail, but all identical in nature. This first mode of contagion, I repeat, is frequent, then, even in marriage. And how could it be otherwise, considering the extreme contagiousness of the suppurative form of secondary acci- dents — considering the repeated developments, so frequent and so easy, of accidents of this order in syphilitic sub- jects imperfectly treated — considering the multiplicity of are encountered almost equally in all classes, from the humblest to the most ex- alted. I declare, for my part, that I have observed a great number in the higher bourgeoisie, even among the aristocracy — that is to say, in social surroundings where education, intellectual and moral culture, absence of pecuniary cares, per- sonal independence, the free gratification of the desires, etc., etc., ought, it would seem, to exclude such shames. 20 SYPHILIS AND MARRIAGE. the relations, familiarities, and contacts of every kind wMcli, in domestic and family life, expose the wife to in- fection from her husband ? The last consideration which I have just mentioned is of the first importance, and I beg you to remark it. Con- tagion, in fact, is rendered so easy by the close and con- tinual intimacy which results from marriage, that it be- comes almost inevitable. According to exx)erience, it. is rare to see a healthy woman live long in contact with a syphilitic man (or inversely, but the converse does not in- terest us just now) without the healthy partner becoming contaminated by the diseased partner. As that witty ob- server, M. Dechambre, has said : "The pox, like the daily bread, is divided between husband and wife." CHAPTER III. SYPHILIS BY COI^CEPTION. The second mode in wMcli sypMlitic contagion oper- ates in marriage is entirely different from the preced- ing, and absolutely special, as you will see. It consists in wliat is called syphilis hy conception. Little known or at least little believed in by us, denied even by many of the profession, this syphilis by conception ought to receive here some consideration, for it constitutes a part, and a very essential part, of our subject."^ How does it present itself in practice ? How does it manifest itself to observation ? As follows : A pure and healthy young woman is married to a syphilitic man, whose syphilis is not yet eradicated. Summoned to attend her some months later, you find her syphilitic ; you find her, for example, affected with unmistakable secondary symptoms, such as the cutaneous syphilides, buccal mu- cous patches, acneiform crusts of the hairy scalp, cervical adenopathies, pains in the head, wandering neuralgias, lumbago, intermittent febrile attacks, alopecia, etc. There is no doubt possible : this woman is thoroughly syphilitic. This settled, you proceed to investigate the why and * If I did not treat this question in a manner exclusively incidental, I should cite here the opinions and the well-known works of MM. Depaul, Diday, Hutchin- son, de Meric, Melchior Robert, Bazin, etc. 3 22 SYPHILIS AND MARRIAGE. wherefore of tliis sypMlis. How did syphilis attack this young wife ; in what way was it introduced ; what was the initial accident; where was the seat of the chancre, etc.? And, now, a double astonishment begins for you. There is, in the first place, no trace of what is called the primary affection, no vestige of a chancre, no recollection of a localized lesion having preceded the present symptoms by several weeks. " Pass over the chancre," you say to your- self, "for every one knows that in the female the chancre is often but a slight, fugitive lesion, which may easily pass unperceived by the patient, and can not, after a very short time, be detected by the physician. But, at least, I shall find a bubo, for the bubo is not only the ' faithful compan- ion of chancre,' according to M. Ricord, but also a post- Tiumous witness that long survives it — that testifies to its previous existence long after its disappearance and cica- trization." You then search for the bubo, and you do not find it either. There is no trace anywhere of a primitive adenopathy. In a word, there is nothing but secondary accidents, as if the syphilis had manifested itself cTemblee in this patient — as if it had never had a primary stage. At the first blush, this seems very strange, does it not ? But this is not aU. Another surprise immediately awaits you. Syphilis thus verified in the young wife, you take the husband aside, who confesses his syphilitic antecedents to you, if you are not aheady aware of the fact. Then you naturally ask him what/re^/^ accidents he has experi- enced since his marriage which could infect his wife. Upon this, protestations, strong protestations, on the part of your patient ! " ISTo ; I teU you I have had no new symp- toms since my marriage ; nothing, absolutely nothing. I was aware of my condition. I had been warned by my physician of the dangers which my wife would incur if 8YPEILI8 BY CONCEPTION. 23 there should happen to me any accident similar to those I had already had. I have been on my guard, I have ex- amined myself, I have watched myself scrupulously, and I can afS.rm to you in the most positive manner that no- thing suspicious has appeared upon me since the. day of my marriage. That I will answer for." Not content with these assertions, you proceed to make a careful examination of your patient ; the result of the examination is negative. Not the least evidence of the disease is present either upon the skin or upon the mu- cous surfaces — ^not the least trace of a lesion recently van- ished. So that, judging from appearances, one is forced to admit this : that the young wife has become syphilitic from the contact of her syphilitic husband, without the husband having at the time the least external lesion ca- pable of infecting her.^ Without doubt, gentlemen, if cases of this kind were observed only once, perchance in a manner altogether ex- ceptional, one would have the right, strictly, to call them in question, to reject them, and to say : "These cases are null and void, incomplete, defective. These are cases where there has been a mistake, either on the part of the woman, who has not seen or felt the chancre, or on the part of the husband, who deceives himself or who deceives us. Let us pass them, then, without attaching any impor- tance to them." But the truth is, on the .contrary, that cases of this kind are common ; they are frequent ; they * I do not bring into discussion here tlie possibility of a contagion by the sperm. From ancient date it has been established by clinical observation that the sperm of a syphilitic subject is not susceptible of transmitting the contagion. Experimentation has recently pronounced itself in the same sense. Healthy sub- jects have been inoculated with sperm derived from syphilitic subjects, and, as might have been expected, the inoculation has been without result. — (V. Mireur, He- cherches sur la non-inoculabilite sypliilitique au sperme, publiees dans les Annales de dermat. et sypldlic/., t. viii, p. 423 ; Dr. X., oral communication. 24 SYPHILIS AND MARRIAGE. obtrude themselves upon our observation with a significant persistence ; they present themselves always identically the same, always under the same conditions ; finally, they force themselves upon us at times, carrying conviction with them. In reality, this is not a class of cases that can be ig- nored, or in which it can be objected that we have to do with a negligent husband, unconscious of danger, careless of his person — a poor observer, liable to allow a specific accident upon himself to pass unperceived. These are cases of an entirely different character, which have been recorded of husbands very attentive to the state of their health, scru]3ulous, conscientious, apprised of the dangers to which their wives are exposed from their old diathesis, and who never cease to examine themselves with the most minute care. There are cases of this kind, finally, which have been observed by physicians in projjrid persona, in their own families. I know of many of them which, un- fortunately, I am not privileged to cite.'^' Now, when these husbands, who so intelligently appre- ciate their condition, when these professional men repeat to our satisfaction: "No, I assure you, I have not had any symptom since my marriage ; I have not had, either on the penis, or in the mouth, or elsewhere, the smallest erosion, the least scratch, the slightest abrasion capable of infecting my wife" — when from such assertions we are furnished with such guarantees, and when these assertions are reproduced identically parallel, not only in a few cases, but in a multitude of cases of the same kind — when a fact so inexplicable, so extraordinary, as this may appear, be- comes no longer the exception, but the common, habitual, almost general rule — under such circumstances we are * Cf. J. Hutchinson, " Medical Times and Gazette," December, 1876, p. 643. SYPHILIS BY GONGEPTIOK ' 25 forced to yield, to surrender an incredulity, otherwise quite legitimate, and to conclude, finally: "It must be so ; here is a woman who, on the one hand, has the syph- ilis witliout Jiamng presented an initial lesion, and who, on the other hand, has been infected by her husband witli- out the Jiushand presenting any contagious lesion.'''' But, then, what is this mystery ? What, then, is this mystery ? Well, gentlemen, here is the key : That the woman become syphilitic in this man- ner without initial lesion, without chancre, and become syphilitic from the contact of a husband exempt since his marriage from every contagious lesion — that woman is enceinte, and she has received the syphilis by conception. In cases of this kind, gentlemen, there is always a special element which intervenes to complicate the morbid ensemble ; and this new, this supernumerary element (per- mit me the word) is pregnancy. In such a situation, preg- nancy is never absent. If It happens to you (and it will happen many times in your practice) to encounter a wo- man who has acquked syphilis without presenting pri- mary accidents, and, moreover, has acquired syphilis from a syphilitic companion who has for a long time been free from every suspicious symptom, direct your attention al- v/ays to the question of pregnancy ; interrogate, examine the woman from this point of view, and invariably you will succeed in establishing this : either this woman is actually enceinte at the moment of your visit or she has been recently enceinte, and has just been confined, or she has had a miscarriage. Ah, then, if this be the case, if always, and invariably, the facts which we are now studying present themselves thus, with the necessary addition of a special element, pregnancy, this fact becomes a ray of light for us. 26 SYPHILIS AND MARRIAGE. Since these cases which deviate from the normal laws of syphilitic contagion are always complicated by a special element, which intervenes in a constant manner, may not this element prove to be the cause of the said anomaly ? May not pregnancy play a role here in deteiTiiining this apparent modification of the usual modes of contagion? May not this woman, who appears to have contracted the syphilis from her husband, in reality have received it from her child — from the infant which sojourned in the maternal womb — with the syphilis which it received from its father 1 Indeed, yes, gentlemen, and such, there can be no doubt, is the origin of the syphilis in the cases in ques- tion. The wife-mother, infected thus, that is, become syphilitic without initial accident, and become syphilitic from the* contact of a husband long free from every exter- nal manifestation, has received the syphilis, not from her husband, hut from Tier child. We have not here a syphilis transmitted by contagion in the usual, habitual manner : there is here a syphilis conceived in utero, introduced by the infant into the womb of its mother, communicated to the mother by her infant — in a word, it is what is teimed syphilis by con- CEPTIOjN^. It would be foreign to my subject to enter here into the clinical history of syphilis by conception, so differ- ent from ordinary syphilis both in its origin and in its primordial evolution ; but it is im]Dortant that I leave you in no doubt as to its authenticity, and with this view I add the following considerations : 1, In the first place, if we reject this pathogeny of the infection transmitted to the mother by the foetus in the class of cases which we are now considering, viz., the S7PEILIS BY CONCEPTION. 27 syphilis of young wives who never present the primary accident, chancre, and who receive, or seem to receive, the contagion from a non-contagious husband — this syph- ilis, I say, will remain absolutely incomprehensible, abso- lutely inexplicable. And I repeat this again : the cases of this kind are too numerous, too well authenticated for us to refuse to receive them, for us to think of interpreting them by assuming material errors of observation. They actually obtrude themselves in practice, and it is necessary to recognize them as facts without discussing the theory. 2. These same cases, which deviate from the general laws of ordinary syphilis, never thus deviate except with the addition of a special element, which is none other than pregnancy. Always and invariably they occur in women enceinte or recently confined. Is not this signifi- cant? Does it not imply that pregnancy plays here a special role in modifying the usual conditions of syphi- litic contamination ? There are, moreover, certain facts more conclusive still, if possible. These facts may be summarized thus : A healthy woman is united to a syphilitic man. So long as she does not become pregnant, she remains uncontam- inated ; but let her become pregnant, and, immediately, syphilis breaks out upon her. Now, why this immunity before pregnancy, and why this infection taking place with pregnancy, if conception be immaterial, if it have no part ia the specific contamina- tion.* 3. A third argument arises from the morbid condition of the infant. I will explain what happens to the infant * Cases of this order have been signalized already by numbers of physicians. I confine myself to announcing the fact without citing particular examples. 28- SYPHILIS AND MARRIAGE. in tMs class of cases of wliich we are now si)eaking. Most commonly, in truth, it dies before being born. Was it or was it not syx)liilitic ? We know nothing positively upon this point, and we have nothing to say, although the sole fact of its death constitutes a presumption in favor of syphilis. But in other cases it is bom alive, and then it always manifests unequivocal symptoms of syphilis ; it is ahoays sy]?liilitic. Now, if the infant in such circum- stances is tainted with syphilis, what is there impossible or extraordinary in its transmitting the disease to the mother during its intra-uterine life ? If maternal syi^hilis has the power (which every one admits) of reflecting itself upon the infant, why should not the syphilis of the infant reflect itself in like manner upon the mother? What! Here is an infant which, i)rocreated syphilitic by the agency of its father, lives syphilitic during several months in the womb of its mother, and yet you would think it extraordinary, impos- sible, that the infection of the infant should be trans- mitted to the mother! A syphilitic organism included within a healthy organism, and the one not contaminate the other ! In truth, it is not the infection of the mother under such conditions which would in my estimation con- stitute the surprising fact ; for me, the surprising fact would be that the mother remained refi'actory to such chances of contagion. 4. After all, syj)hilis by conception is but the analogue of the syphilis which, in the course of pregnancy, reflects itself in an opposite direction, from the mother to the in- fant. It is necessary, then — common sense indicates it — that it obey the same laws as the latter, and this is precisely what takes place, as you will see. The peculiarity of hereditary syphilis, you know, is to SYPHILIS BY CONGEPTIOK 29 make an invasion WemMee by general symptoms ; that is, to have no primary stage, in a word, to be exempt from those two accidents which constitute the inevitable, neces- sary debut of every syphilis contracted in the usual way of contagion, ^iz., chancre and primitive adenopathy symptomatic of chancre. JSTow, the syphilis of concep- tion has precisely the same peculiarity. It also ad- mits neither chancre nor bubo into the number of its constituent symptoms. It also makes invasion cfemhlee by manifestations of a general order, and this devia- tion from the great laws which govern syphilis in its habitual forms certainly finds its analogue in the special mode which here presides over infection. Such are, in a very succinct form to be sure, but suffi- cient I think for our present subject, the considerations of various kinds which establish the undeniable fact of the possible infection of a woman by way of conception. The fact admitted and accepted, it now remains for us to discuss its interpretation, if this does not exceed the limits withia which we must confine ourselves. How does syph- ilitic impregnation irradiate from the foetus to the mother in the cases we have just considered \ Does the maternal infection result from the contact of a fecundated ovule, and propagate itself, either in the Fallopian tubes or in the uterus, at the time when this ovule is not attached to the mother by any organized graft ? Or, indeed, is it ef- fected subsequently by the exchanges of the placental circulation ? * or does it take place in some other special and unknown manner ? Upon this point we confess our complete ignorance. We know nothing of the process, of * This is what, for example, M. J. Hutchinson declares, who has given to this mode of infection of the mother by the infant the expressive term of fatal blood contamination. — V. Memoir cited, "Medical Times and Gazette," 18*76. 30 SYPHILIS AND MARRIAGE. the meclianism of the infection, and, relative to tMs point, we can only emit hypotheses without value. Infection takes place only in these special conditions, and often, very often, the wives are the victims. The knowledge of this alone is sufficient for our present purpose. Let us, then, accei')t the fact, and leave the interpretation aside. This settled, let us reunite the elements which pre- cede, and summarize the facts relating to our first propo- sition, by saying : A man with syphilitic antecedents who contracts marriage may become dangerous to his wife in two ways : 1. Directly by transmissible contagious lesions, which may ha^Dpen to him after marriage. 2. Lidirectly, ihMOTigkYns, fecundating power ; that is, by the procreation of an infant, the infection of which may he reflected upon the mother. CHAPTEE IV. PATERNAL HEEEDITY. Second Point. — A man witli sypMlitic antecedents who contracts marriage may hecome dangerous to Ms cMldren. 1. Until within a recent period, the theory of the pater- nal heredity of syphilis was accepted without opposition, except from a few. It was not questioned that a syph- ilitic father could, must even, beget syphilitic children. It was an opinion generally admitted, and science seemed definitely settled upon this point. But the aspect of this question has Indeed changed within late years : numerous observations, important in- vestigations, have sprung up on aU sides, tending to sin- gularly restrict the sphere of paternal influence in the hereditary transmission of syphilis.* But this is not aU ; some investigators have gone further in this direction. * CuUerier, De Vheredite de la syphilis. — Memoires de la societe de chirurgie de Paris, 1851, t. ir, p. 230. Notta, Memoire sur VMredite de la syphilis. — Archives generales de medecine, 1860, t. i. Charrier, De VMr&dite syphiliiique. — Archives generales de medecirie, 1862, t. ii. Durac (J. E.), Be Vheredite de la syphilis. — Theses de Montpelier, 1866. Mireur (H.), Essaisur Vheredite de la syphilis. — TTieses de Paris, 1Q&1. Owre (Adam), 8w Vetiologie de la syphilis hereditaire. — Analyse dans les An- nales de dermatologie et de syphiligraphie, t. v, p. 388. Sturgis (F. R.), "Notes upon Certain Points of the Etiology of Hereditary Syphilis." — Analysis in Annales de dermatologie et de syphiligraphie, 1877, t. ix, p. 113. 32 SYPHILIS AND MARRIAGE. They hiave gone to tlie point of denying the paternal influ- ence in the transmission of the disease, and of saying: "The influence of the father is null, absolutely null, in the ti^ansmission of syphilis to the foetus. The child of a syphilitic man is born sound, exempt from syphilis, and perfectly healthy." You can conceive, gentlemen, the importance of this question in connection with the special subject which now engages our attention. For, when a syx)hilitic patient comes to consult us in order to know whether he may or may not marry, our responsibility will be by so much lightened, if we have before us the certainty that this man, although syphilitic, can in no way be prejudicial to his children. That is self-evident. Let us examine this question, then, with all the care, all the solicitude which it merits. The new doctrines which have been introduced relative to the non-transmission of syphilis by paternal heredity, or, more generally, the non-influence of paternal syphilis upon the offspring — these new doctrines, I say, while containing an element of truth, contain manifest ex- aggerations, and more than exaggerations, absolute errors, dangerous from a social point of view, dangerous in every respect, and which, in consequence, should be energeti- cally combated. For my part, indeed, according to my own experience, as well as from numerous observations which have been furnished either from my reading or from communications courteously made to me, I regard it as certain that a syphilitic father can, by vh^tue of a syphilis still recent and active, be eminently preju- dicial to his children. And of this I am in a position to furnish the proofs, as you shall see. In the first place, to consider the matter from a purely theoretical point of view, how can we admit, for a single PATERNAL HEREDITY. 33 instant, that the condition of a syphilitic father can be inoffensive to his offspring ? What ! when we see con- stantly, and in a manner so evident, paternal heredity manifest itself in the child by so many resemblances of every kind ; when we see it attested, not only by physical or moral analogies, bnt also by the most striking patho- logical analogies, we are to believe that this paternal heredity may not be exerted in the case of an essentially chronic, essentially diathetic disease, impregnating the organism so profoundly as to have the twofold property of affecting the whole system, and of developing its mani- festations at all periods and all intervals, up to thirty, forty, and fifty years after its origin ! We are to regard a disease of this character as inactive, hereditarily, from the father to the chUd ! If this were the case, it would be, in truth, an anomaly most strange, a monstrous departure from all that we know concerning the general laws of heredity. The syphilis of the father is not inoffensive to the prod- uct of conception : this is what theory presupposes ; this is what a legitimate induction, based upon the elements of common observation, leads to. But, in considering a question at once so serious and difficult as this, we should not be satisfied with compari- sons, indirect inductions, a priori reasonings. It is facts, and precise facts, which we must have. Let us consult, then, clinical observation, and see what it teaches us. We commence by stating the position as strongly as possible (regretting our inability to make it stronger still) of the partisans of the doctrine that we are about to op- pose, and say with them : Yes, it is true, absolutely true, tJiat we encounter in practice nunibers of men, loho, liais- ing contracted sypliilis before their marriage, ham be- 34 SYPHILIS AND MARRIAGE. gotten children healthy and exempt from syphilis, their wives tliemselxies remaining healthy and uninfected. Examples of tliis kind are observed every day in pri- vate practice. MM, E-icord, Cullerier, Notta, Charrier, Durac, Mireur, and many otliers that I need not mention, liave related cases of this character as authentic and con- vincing as possible. My own personal observation accords fully with that of the authors I have Just cited, and I find in my notes (to speak only of the cases coming under my immediate observation) eighty- seven cases in which syph- ilitic fathers married to healthy women, who remained healthy, have had healthy children, absolutely exempt from every syphilitic manifestation, from every suspicious symptom.* I am reluctant to relate individual cases here, so fre- quent and common are they. Nevertheless, there are so many cases observed in which the non-influence of the father's disease upon the child is sho^vn in a manner so manifest, so striking, that you will pardon me for citing some of them, in order to establish your convictions more thoroughly upon this point. A patient of our distinguished confrere, M. Charrier, had been affected with syphilis for several years, when he became the father, exactly at the same date, of two chil- dren, viz., one born of his wife, to whom he had com- municated syphilis, the other born of a mistress, exempt from every specific antecedent. Now what happened? This: Of these two children, one, the legitimate child, came into the world with syphilis ; the other, the natural child, was born healthy, and remained so.f * V. Illustrative Cases, Note 1. f Charrier, De Vhered'de syphilitique. — Archives generales de medecine, 1862, t, ii, p. 327. PATERNAL HEREDITY. 35 The natural and irresistible conclusion is, that, when the mother is healthy, the syphilitic influence of the father upon the product of conception is null. Another example, furnished by M. MireUr : A man marries after eleven months of syphilis, and becomes the father of a fine child, absolutely healthy (the mother re- maining still uncontaminated). ISTow, this child was so healthy, he was so little tainted with the least syphilitic vice, that at the age of two years he contracted syphilis, and from whom % From his father ! The father had a secondary erosion in his mouth ; he kissed his child upon the mouth, and in this way communicated to him a chancre of the Up.* But there are two classes of facts more confirmatory still, as they embrace an additional, supernumerary ele- ment, viz., the breaking out of syphilitic accidents upon the father, either subsequently to the date of conception or even at the moment of conception. And, nevertheless, children born in such conditions have escaped syphilitic heredity, although the paternal affection was still mani- festly persistent, or even exhibited actual symptoms, at the time of procreation. I will explain : I. It is a matter of frequent occurrence for syphilitic men to beget healthy children, and afterward present such and such accidents of syphilis, unequivocal evidences of the persistence of the diathesis at the time when con- ception takes place. Example : One of my patients, syphilitic for ten years, married while exempt from every apparent diathetic phenomenon, and became the father of six children. These six children, of whom the eldest is at present eleven years of age, I have had under my observation since * Tlike dtee, p. 26. 36 SYPHILIS AND MARRIAGE. their bii'tli ; I have attended them in all their indis- positions, even the slightest, and I am justified in declar- ing them absolutely healthy. Their mother, moreover, has never jDresented the least suspicious symi3tom. Now, after the Mrth of tlie third cliild, this man was affected with a tubercular syphilide upon the thorax; and, in addition, consecuthely to the Mrth of the fifth child, I again treated him for a gummous tumor of the palate of a very threatening aspect. Here, then, is a man who has begotten six healthy children, despite a syphilis, active, persistent, and still re- vealing itself by intense symptoms after the date of con- ception of these several children. Again, one of my old patients married, without con- sulting me, despite a syphilis very insufficiently treated. He has two . children, that I have not lost sight of since their birth, and who have always remained free from the slightest specific manifestation. (The elder is at present fourteen years of age, the younger twelve.) ISTow, this man recently died from cerebral syphilis, not only diag- nosticated such from the clinical symptoms, but verified by microscoj)ic examination. Are not these two cases, and many others which I could add, absolutely convincing ? * But, still, this is not all. I have known syphilitic pa- tients to procreate healthy children, free from the least suspicious symptom, when they were in the full second- ary period, when they were affected, even at the moment of conception, with various syphilitic accidents — when, in * In statistics which will be produced farther on (V. Notes and Illustrative Cases), the reader will find not less than thirty-five cases of this kind, all relating to syphilitic subjects who have engendered healthy children, and who, after the birth of these children, have been again attacked with various specific accidents. PATERNAL HEREDITY. 37 a word, they had not passed that formidable period where the diathesis has, so to speak, its acute crisis, and seems really to be the most pernicious, so far as the dangers of hereditary transmission are concerned."^" I have among my notes cases of this kind, but none of them, certainly, so convincing as a case of the same character which has been obligingly communicated to me by our very distinguished colleague, M. Maurice Ray- naud, and which, occurring under conditions altogether special, offering a chronology of quasi-mathematical pre- cision, merits in every respect a place here : A married man contracts syphilis in an extra-conjugal adventure. During several months he invents ingenious pretexts to avoid connection with his wife ; but, finally, one day he forgets himself. The next day he rushes frightened to M, Raynaud, who discovers mucous patches in his mouth. Mne months later, to a day, and without any other sub- sequent intercourse, the young wife was confined, and confined of a healthy child, which, though now ten years old, has never exhibited the slightest evidence of syphi- litic infection. Thus, here is a syphilitic man who, tlie mry day when Tie procreates a cliild, presents accidents of the secondary stage, and whose child, nevertheless, is born exempt from syphilis ! What more convincing ! You see, then, gentlemen, I dissemble nothing. Very far from it. On the contrary, I insist with all my strength upon the importance of these facts, so curious; of the non-hereditary transmission of syphilis through paternal influence ; for these facts constitute, in my view, one of the most interesting acquisitions of contemporary science ; * Many cases of this kind are found embodied in the interesting work of M.. Notta, to which we have previously made allusion. — Arch. gen. de med., 1860, t. J. 38- SYPHILIS AND MARRIAGE. and I need say nothing of the importance they acquire in connection -with the subject which we are now consider- ing. The conclusion from the foregoing is, that syphilitic heredity proceeding from the father (and from the father alone, the mother remaining healthy) is much less active, much more restricted, than had heretofore been suj)posed. Under given conditions, on tlie one hand, a sypMlitic Jiushand, and on the other a healthy wife, the chances altogether are that the child issuing from this couple loill he horn exempt from syphilis. This, contrary to the old beliefs, contemporary researches have clearly and positive- ly established ; and this result, certainly, in what con- cerns us, can not fail to be most consoling. II. But, this fact recognized, this concession.made to the partisans of the doctrine which I oppose, I at once resume my position on the strength of observation, on the strength of clinical facts, and I say to my opponents : ISTo, it is not true, very unfortunately, in the case of syphilis, that the paternal influence is so immaterial as has been pretended ; still less is it true that it is null, that it exercises no influence whatever upon the foetus. To enunciate such propositions, you must look only upon one side of the question, you must regard only one element of the problem ; for there is a vast difference between the conclusions at vv^hich you have arrived and those which are derived from an integral observation of the clinical facts. Judge of this, however, by what follows : In the first place, if paternal heredity, as we have termed it, exercises its influence in a rare, exceptional manner, still it exercises it sometimes. AVe have seen that children are bom syphilitic through the agency of their fa- ther, their mother remaining exempt from all contamina- tion. Numbers of cases of this kind have been related by PATERNAL HEREDITY. 39 different authors, notably Iby MM. Ricord, Trousseau, Di- day, Depaul, Cazenave, Bazin, Hardy, Barensprung, Hut- chinson, Bassereau, Beyran, Martinez y Sancliez, Liegeois, De Meric, Martin, Parrot, Lancereaux, Kassowitz, Char- pentier, Pozzi, Keyfel, Carl Ruge, and others.* I my- self have likewise observed some cases, although rela- tively few, I confess, t I recently met one of my confreres who, while doing me the honor to consult me for an old syphilis, said to me that " he had had five syphilitic chil- dren, although his vdfe (examined by him with the most vigilant care), submitted to the most assiduous observa- tion, had never presented the least diathetic symptom." That, among the facts cited in support of this argu- * See an interesting work of Dr. Leon Richard {J&tude sur VMredite dans la syphi- lis ; de Vinfluence dupere. — TJieses de Paris, 18'JO), which reproduces en resume a certain number of cases under consideration here. See also : Piquand, Influence de la syphilis des generateurs sur la grossesse. — TJieses de Paris, 1868. Bricard (Ph.), De la transmission de la syphilis du pere d V enfant avec immunite de la mere. — Theses de Paris, 18 '71. Kassowitz, Die Vererhung der Syphilis. Vienna, 1876. Carl Ruge, Ueber die Fodus Sanguinolentus. — Zeif fur Gehurtsh. und Gynakologie, B. I. — Analysis in Pevue des sciences medicales, t. xii, p. 203, Professor Parrot has recently narrated to me a case of this kind observed by him under special conditions which leave no possibility of error : " A young man, married, with a syphilis in full activity. He had two children, who both presented undoubted symptoms of hereditary syphilis. Now, their mother, closely watched over, minutely examined from time to time since her marriage, has never presented, and still does not present, any suspicious symptom. Without doubt, she remains entirely exempt." Mr. Hutchinson is still much more pronounced in favor of paternal heredity : " I am firmly of 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" ("Medical Times and Gazette," December, 18*76; v. likewise, "A Clin- ical Memoir on Certain Diseases of the Eye and Ear, consequent on Inherited Syphilis," p. 209, London, 1863 ; " On the Transmission of Syphilis from Parent to Offspring," " British and Foreign Med.-Chir. Review," 1877, vol. Ix, p. 455). f I find in my notes only eight cases of this kind. Even some of these are wanting, I admit, in the guarantees of authenticity which would be required in a matter so delicate and so disputed. 40 SYPHILIS AND MARRIAGE. ment, and reproduced in various monographs and reports, there are a certain number to be excluded, to be chal- lenged on account of insufficient guarantees, I do not deny ; rather, I will affirm it, if need be. But will it be possible to challenge all, at once and in a lump ? Is it to be believed that all the authors, who have seen, jDublished, and commented upon such facts, have together fallen into the same en-or, in aU failing to recognize syphilis in the mothers of the children that they had under observation ? ISTo, indeed. That is not admissible. However zealous a partisan one may be of the new doctrine, one is not au- thorized, it seems to me, to throw overboard the whole bundle of former observations which contravene this doc- trine, except after a long, very long and ultra-sufficient ex- perience. ISTow, an experience of this kind is still wanting to us ; so that, actually, in the present state of our knowl- edge, it is absolutely necessary for us to take cognizance of the facts brought forward in favor of paternal heredity, and to admit this : That, Tioioever rare, Tioioemr excep- tional the hereditary transmission of syphilis from the father to the foetus may appear to lye, it may, nevertJieless, exert itself in this way in a certain nuonher of cases. Consequently, in that which concerns us, this is the first danger which it is necessary to calculate, in order to render a verdict upon the fitness for marriage of a patient tainted with syphilis. III. But even this, as you will see, and as I am anxious to convince you, is only the lesser side of the question. For, in a manner much more frequent and much less con- testable, the syphilis of the father creates for the child other dangers of a graver character. What, then, are these dangers ? To summarize, they consist in this : 1. Inaptitude for life, revealing itself by the early PATERNAL HEREDITY. 41 death of the foetus, either in utero or very shortly after birth. 2. Constitutional vices, morbid aptitudes, defects, in- herent infirmities, congenital malformations, arrests of development, etc., which I, like many physicians, look upon as constituting the modified, transformed expres- sions of specific heredity. We have here, certainly, relative to the question which we are examining, a whole series of considerations well worthy of our careful attention. We are here in the very heart of our subject. Let us insist, then, upon the sev- eral points which I have Just raised. I have said, in the first place, that one of the conse- quences of paternal syphilis for the child may be inapti- tude for life, inaptitude revealing itself by death in utero. In other words, a child horn of a syphilitic father and of a healthy motlier is liable, hy the fact of the paternal syphilis, to die before coming into the world. That is a principal point upon which my conviction is now well established. Formerly, I was struck with the frequency of abortions in families where the husband was infected with syphUis, while the wife remained perfectly healthy. Afterward, I determined to confirm this general impres- sion by instituting a precise inquiry into the matter. With this view, I applied myself to note the results of the union of a syphilitic man with a healthy woman in a very exact manner in all the cases which came under my observation. IN'ow, after several years of investigation in this direction, an abstract of my observations furnishes me with no fewer than fifty abortions occurring under the above-mentioned conditions, and produced without other possible cause to be alleged than the paternal diathesis. And be pleased to note (it is essential to specify this) that 42 SYPHILIS AND MARRIAGE. the dements of these statistics have been collected in private practice, in a hourgeoise practice ; that is to say, in a social medium where the anti-hygienic conditions of misery, of forced work, of fatigue, of insufficient ali- mentation, of excess, of debauch, etc., have not played any role as predisposing causes of the abortion. ]S"ote that they have been collected (thus the analysis of my observations demonstrates) among young women in very good health for the most part, recently married, pre- senting no uterine lesion, etc. So that, in all these cases (excepting two or three at most), no other cause, either constitutional or accidental, could be alleged as sufficient reason for the abortion. The abortion remains inexpli- cable upon the assumption of the influences, predisposing or determinant, to which it is usually attributable, while, on the contrary, a common etiological element reunites all these cases and serves as a common explanation for them, viz., tJie sypMlis of tlie Tiusband. Is not this well adapted to enforce conviction % Add, moreover, that this fatal influence of paternal heredity does not manifest itself always by a single abor- tion. Often it is prolonged ; it is continued in the course of several pregnancies more or less close together. So that two, three, four miscarriages sometimes succeed, one after another, without other exj)lanation than the syphilis of the husband. The cases of this kind are not rare, I repeat. I can cite more than twenty examples in my practice alone. "^ Such facts, certainly, are significant of themselves, but they assume a value much more exact still, when a counter-proof comes to be added as follows : Apprised by * J. Hutchinson, " On the Transmission of Syphilis from Parent to Offspring." —"Brit, and For. Med.-Chirurg. Review," IS?*?, vol. Lx. PATEBNAL HEREDITY. 43 his physician of the probable cause of these successive abortions, the husband submits himself to a prolonged specific treatment. There occurs afterward a new preg- nancy, which results in an infant at full term. Other pregnancies succeed, and these are not less fortunate, Now, then, the evidence is conclusive ; how can we deny, under such circumstances, the corrective influence of the treatment upon the syphilitic diathesis, and how can we fail to recognize the influence of this diathesis upon former pregnancies ? Successive abortions he/ore treatment ; for- tunate pregnancies after treatment; what could be more demonstrative I Now, cases of this kind exist in medical literature. They exist especially in a very much larger number in the memory of practitioners, as I have con- vinced myself by many conversations with my confreres. I myself have observed several, such as the following, for example, which vividly impressed me at the beginning of my career, and which I can not resist the desire to relate to you briefly : Fifteen years ago I encountered, by chance, an old college comrade whom I had long lost from view. We talked together, and he related his troubles to me. " You see me disappointed," he said ; " my wife has just had her fourth miscarriage in an early period of preg- nancy ; and, what is worse, all these miscarriages have taken place without the least cause — without a fall, with- out imprudence on her part. My wife is large, strong, well developed, perfectly healthy ; and, nevertheless, I foresee, to my great grief, that she will never bear me children." The recollection of a certain circumstance then crossed my mind, and I replied: "But, perhaps, your wife is not so responsible as yourself for these suc- cessive miscarriages. I knew you many years ago, in the Quartier Latin, with a fine pox, which you did not 44 SYPHILIS AND MARRIAGE. appear to me to attend to in a very exemplary manner. In your place, I would commence a course of treatment ; I would again take mercury and iodide." Altliough this interview took place in tlie street, my advice was followed, and specific treatment was pur- sued actively. Fifteen months later my friend's wife was delivered, at full term, of a living cliild, wMcli is now twelve years old. And since that she has had three other pregnancies equally favora]:)le.'^" The undeniable inference from all this is, that numbers of abortions happening without cause in healthy women admit of no other ex- planation than that of the husband's syphilis. The sypMUtic influence of tlie father Mils the foetus in utero. Here is a fact which, supported by observations as authentic as they are numerous, merits a place in sci- ence ; and I am astonished that it has not been more re- marked before. In the second place, this same iiiaptitude for life of the infant procreated by a syphilitic father reveals itself by death immediately upon., or soon after, delimry. In the statistics from which I have borrowed the fore- going facts, I find no fewer than thirty-six other cases of pregnancy (always the issue of a syphiUtic father and a healthy woman) which have resulted at term in infants torn dead or dying, or sickly, stunted, emaciated, senile children, doomed to an early death. Sometimes, again (a detail curious and essential to know in practice), infants procreated under these circumstances come into the world in a passable or average condition ; then, after a few days, after a few weeks at most, they are suddenly extin- guished ; they die without disease, without apparent cause, from one day to another. Of what do they * M, Depaul has related several facts of this kind in his able clinical lectures. PATERNAL EEEEDITY. 45 die ? I am unable to say ; for, in those cases in wl^ich I have had an opportunity to make an autopsy, I have dis- covered nothing which could explain this kind of death. They always succumb very rapidly, almost instantaneous- ly, and this without an attack, without very pronounced morbid symptoms, to the very great surprise of their parents and of the physician. And, without doubt, they succumb only on account of a congenital vice, of a native debility, of an ^'- inlierent inaptitude for life,'''' rather than from a superadded, contingent, incidental morbid cause. This is not all yet. The more I advance in practice, the more I perceive myself pervaded by the conviction that the infl.uen9e of a syphilitic father upon his child still reveals itself after birth in various ways : by a gen- eral organic debility ; by a constitution enfeebled, impov- erished, " delicate," as the common people say, below the normal average ; by a slight power of resistance to mor- bific causes, which impresses upon incidental maladies a character of pernicious malignity ; by a tendency to nervous accidents, notably to convulsions ; by a tendency to lymphatic and scrofulous affections, etc. But let me, for the present, reserve this class of con- siderations until we come to discuss the question of mixed heredity — I mean paternal heredity and maternal heredity combined. To recapitulate, then, the hereditary influence of pater- nal syphilis is far from being so innocuous, so slight, so "null," as it has pleased certain authors to assert. They have said that the procreation of an infant by a syphilitic father signified nothing, since the child had nothing to fear from paternal inheritance."^ This is a * Criticising this doctrine, M. Voillemier has wittily said : " If one accepts the 40 SYPHILIS AKD MARRIAGE. great and dangerous error, whicli good sense reproves a priori, and which clinical observation refutes. In reality, paternal influence, while not exercising it- self (as we have previously shown) except in a limited number of cases, is none the less liable to exercise itself sometimes in a manner very positive, very manifest, and then it reveals itself according to three modes : Either (this is the exceptional case) by the transmission of syphilis to the foetus ; or (this is much more common) by the death of the child ; or, finally, by inherent degen- eration of the germ, which reveals itself subsequently under very diversified morbid forms. ideas of M. Cullerier, the father would be only the accidental occasion of a child. One would be, in reality, the child of his mother only." — Gazette des Hopitaux, 1854, p. 303. CHAPTER V. MIXED HEREDITY. Let us not lose sight of tliis other cardinal point : A syphilitic father is dangerous to his children not only in his character of progenitor ; he is, or may become, danger- ous to them in his character as the husband of their mother, if I may so express it. In other words, he may endanger them through tJie syphilis which he runs the risJc of comTnunicating to Ms wife. And then, the father and the mother both becoming syphilitic, what must be the fate of the children issuing from this infected couple ? Ah ! here, gentlemen, is presented a page of pathology distressing to write ; here commences for these families a situation truly heart-rending, which it is necessary to have observed in all its details and in its diverse forms in order to comprehend its miseries. This situation, which I am anxious to depict faithfully to you in the interest of the grave subject now before us, is here copied from nature in its sad reality : Two young persons were married a short time ago. The wife has become enceinte, and yearns after her title of mother. The two families, full of the sweet hope which preludes the coming of the new-born, impatiently await the result of this pregnancy. Now, what will be the re- sult ? What will happen to the infant procreated under 48 SYPHILIS AND MARRIAGE. the conditions which we are now supposing — that is to say, issuing fi-om a father and mother both syphilitic? As physicians, we can predict what will haj^pen to it, for, save rare exceptions, its future is comprised within the three folloAving alternatives : 1, either this infant will die before hirth ; 2, or it will come into the world with syph- ilis., and ^^ith all the possible and serious consequences of infantile syphilis, which, in most cases, is almost equiv- alent to a sentence of death ; 3, or, finally, it will come into the world mthout sj^philis, but with a health com- promised, with an innate dehility, and a constitution impoverished, which -udll expose it to an early death, with menacing morbid aptitudes, and with a tendency to cer- tain organic vices. And this is not all, for there may succeed a second, a third, a fourth pregnancy. It may be that this identical fate awaits the second, the third, the fourth infant ; and so on until the diathesis has been exhausted by the effect of time or by the intervention of an energetic treatment. What a situation ! What affliction for a young couple ! "\Yhat grief for their two families ! And, in another point of view, what a social calamity ! That, gentlemen, is what the pox does, or can do, when the paternal influence and the maternal influence are asso- ciated ; when both conspire together against the product of conception. And these sad results I do not give you as only con- tingent, as simply possible ; I give them to you, if not as constant (for, in fact, nothing is constant in heredity), at least as very frequent, very common, absolutely habitual. But (for the matter is worth the trouble) let us insist upon and legitimize the summarized facts which precede : 1st. I said to you a moment ago that the infant bom MIXED HEREDITY. 49 of a syphilitic father and mother is almost necessarily doomed to one or another of the three alternatives which I have jnst specified, and which it now remains for ns to study in detail. The first is deatli in utero ; whence abortion, or delivery before term. Upon this first point there is no possible contradiction. Here medical science is fixed, and securely fixed, by the unanimity of its practitioners. Open your books ; run over the observations contained in the classic treatises, in the special works, and you will find not only hundreds but thousands of cases, which, in the point of view from which we are speaking, all testify to the same effect, and seem copied one from another. Everywhere and always, it is identically the same observa- tion, stereotyped, so to speak, reproducing itself in the same terms, and summarizing itself thus : "A man in a syphilitic condition marries. In one way or another he infects his wife. She becomes enceinte., and aborts in a few months, or is delivered before term of a dead infant." The intra-uterine death of the foetus, the offspring of syphilitic parents, is certainly the most habitual expres- \sion of the hereditary influence of the diathesis. In truth, this fact is so common, so trite, so accurately verified by numerous observations, that I restrict myself here to enun- ciating it only. It would be but an abuse of your time for me to stop here in order to cite particular cases. The pernicious influence of mixed syphilitic heredity, that is, proceeding from both husband and wife, does not always end here in such a situation. Yery often, still, this is continued, is prolonged in a series of successive abortions. We have seen many and many cases of unfortunate 50 SYPHILIS AND MARRIAGE. syphilitic wives, who have become enceinte from contact with syphilitic men, terminate thus twice, three times, four times, five times, six times, and even seven times in succession, either from abortion or from exi)ulsion before term of infants dead or moribund. This very day I can show you in our wards a case of this kind. The patient lying in bed No. 35, St. Thomas's Ward, received syphilis from her husband several years ago. Since then, this woman has become enceinte six times, and she has aborted six times in the third, fourth, or fifth month of her preg- nancies. Likewise, one of my patients, young and well developed, contracted syphilis from her husband soon after marriage. She became enceinte four times in three years, and aborted/owr times. Cases of this kind have been cited by a number of ob- servers. But I know nothing of this descriiDtion compar- able to the history of a patient that I treated for a long time at the Lourcine — a history which you wiU permit me to reproduce here briefly. This woman, large, vigorous, perfectly healthy, mar- ried at nineteen years of age. She commenced by having three "superb" children, two of whom are still living, and are, according to her statement, in excellent health. The third appears to have succumbed to some incidental disease of an acute form. After her third confinement, this woman received syphilis from her husband, which he had contracted a short time previously in an amorous es- capade. Since then, she has been enceinte seven times. Now, what has been the termination of these numerous pregnancies subsequent to the contagion? The result is curious and dismal, in truth : First pregnancy (after the syphilis) : Abortion in the fifth month. MIXED HEREDITY. 51 Second pregnancy : Premature accoucliement at seven months and a half. Infant sickly, emaciated, dying the fifteenth day. Third pregnancy : Accouchement almost at term. In- fant born dead. Fourth pregnancy : Accouchement premature. Infant still-born. Fifth pregnancy : Accouchement premature. Infant stiU-born. Sixth pregnancy : Abortion at three and a half months. Seventh pregnancy : Abortion at six weeks. Resume : Ten pregnancies, of v^hich the three previous to the syphilis resulted in three children at full term and perfectly healthy, and the seven subsequent to the syphilis resulted in four premature deliveries and three abortions ! What fact more instructive % and what could you de- mand more probatory in support of the thesis which we are developing ? * 2d. Second alternative: The infant issuing from a syphilitic couple may be born alive, but it is horn with sypMlis, and bears all the consequences, so grave and so formidable, of hereditary syphilis. Here, again, long developments are not needed to es- tablish two facts which are patent, which spring, with an evidence unfortunately too manifest, from common, al- most daily experience, viz. : 1. That the offspring of syphilitic parents are most ha- * See Illustrative Cases, Note 11, the relation in extenso of this curious case. I owe the communication of another analogous case to Dr. Le Pileur, physician to Saint Lazare. This case is briefly as follows: Wife, syphilitic, becomes en- ceinte eleven times. Of these eleven pregnancies, five are terminated by abortion or by the expulsion of still-born infants at various epochs of gestation. Six others resulted in living children, of whom five died from convulsions, viz. : four the first or second day, and the-fifth at six weeks. One child alone has survived. Eleven pregnancies, ending in a sole case of survival ! 52 SYPHILIS AFD MAREIAOE. bitually born syphilitic, especially in the course of tlie ear- lier pregnancies wliich succeed the infection of the parents, that is to say, when time and treatment, those two great correctives of the pox, have not yet exercised upon the diathesis of the generating couple their attenuating and depurative influence. This first fact is neither contestable nor contested. It is useless, then, to insist further upon it. 2. That children who are born with hereditary sjrphilis are exposed, by virtue of this syi)hilis, to multiple and most serious dangers. By dint of care, we succeed, indeed, in curing a certain number of them. But, whatever we may do, despite all treatment, a very large number suc- cumb. I do not hesitate to confess that my personal sta- tistics of the syphilitic new-born, even when treated, are truly deplorable as a mortuary table. Nothing is so mur- derous as hereditary infantile syphilis. This is a second fact which again it will suffice simply to enunciate, so com- monly is it observed. 3d. Third and last alternative : It is possible that a child born of syphilitic parents may escape death in utero, or even the syphilis. But it is not yet free from danger for all that, since the syphilitic influence may still exert itself ui3on it in other forms, which it now remains for me briefly to point out. I must tell you that we have here to deal with one of the most difficult and most delicate points iu pathology. Indeed, just as hereditary influences are direct and unmis- takable when transmitted from one generation to another by the reproduction of the same malady, so they become doubtful and questionable in opposite conditions, that is to say, when they reveal themselves in the offs]oring by symptoms different from those manifested in the parents. And, nevertheless, this lieredity with dissimilar morhid MIXED HEREDITY, 53 forms, if I may thus express it, is no less authentic than is the other heredity, with identical morbid forms, only it oftener escapes attention, as it does scientific demonstra- tion. Such is the case here. The entire profession grants the syphilitic heredity which reveals itself from one gen- eration to the following generation by symptoms of a syphilitic order, while they have long discussed, and will long continue to discuss, the question whether the syph- ilitic influence of parents can exert itself upon their descendants by manifestations or morbid tendencies not directly entering into the list of symptoms of this diathesis. As for me, my position is taken upon this question, which has loug engaged my attention, and which I have studied, I believe I can say, with minute attention. After having doubted, I doubt no longer, and my present con- viction is that the syphilitic influence of parents does not reveal itself in their children by symptoms of a syphilitic order only, but also by morbid conditions, by morbid dis- positions, nowise syphilitic in themselves, which have nothing to do with the classic symptomatology of the pox, which are even as different from it as possible, but which, nevertheless, do constitute modified expressions of the dia- thetic state of the ancestors, do constitute, if I may so ex- press it, a sort of indirect descent of the pox. And, moreover, what is there singular, what abnormal, what inexplicable in this hereditary modality? Does syphilis have for symptoms in the subject which it affects only manifestations of a specific order? Is everything that it produces, everything that it determines in the way of morbid troubles, always and invariably of a specific order ? Parallel with its peculiar lesions, has it not also a train of general symptoms ? At the same time that it 64 SYPHILIS AND MARRIAGE. attests itself in dermatoses, erosions, ulcerations, infiltra- tions of organs, visceral neoplasms, etc., does it not on the other hand also reveal itself, generally, by phenomena of anaemia, malnutrition, emaciation, impoverishment, and organic deterioration, sometimes also by nervous troubles — in a word, by reactions of a general character upon the various organs ? Does not syphilis, as M. Eicord so justly declares, awaken scrofula in the scrofulous ? Does it not also awaken dartre in the dartrous, as our lamented col- league, M. Bazin,* taught here? Does it not also react upon traumatic lesions, as M. Yerneuil and his pupils are now in a fair way to demonstrate ? f Syphilis, then, is not simply a disease with syphilitic symptoms. It is a disease of the whole system. It is a disease which creates a gen- eral disturbance in the whole organism, which affects, or may affect, that which is commonly called "the health," which awakens, or may awaken, very diverse morbid ten- dencies — in a word, it is a disease with diversified and polymorphous reactions. N'ow, if this is the case, if syphilis is capable of intro- ducing disturbances so profound, and at the same time so complex, into the organism which it affects, what is there astonishing in heredity reflecting these varied morbid dis- positions in the product of conception, in the child, the offspring of syphilitic parents 1 However, let us leave these theoretical discussions and consider only what observation and the clinic teach us. The clinic teaches us that children born of syphilitic parents are exposed to certain morbid conditions, to cer- * See Lemons iMoriques ei cliniqucs sur la syphilis et les sypJdlides, second edition, Paris, 1866. f See Henri Petit, De la syphilis dans ses rapports avec le traumatisme. — Tlihes de Paris, 1875. Tiie reader will find in this estimable work a very complete his- tory of the subject. MIXED HEREDITY. 55 tain morbid aptitudes wMch are produced in them witli a significant frequency. Let us proceed to precise facts. These children are very frequently remarkable, almost recognizable, I may say, by their native debility. They come into the world small, singularly weak and puny, poorly developed, wrinkled and shriveled, stunted, with the " old man look," as it is usually termed. One would call them old people in miniature, with a skin too large for them over certain points. Sometimes, again (a particu- lar sign to which I call your attention), they present on the anterior surfaces of the legs a condition of sub-oedem- atous puffiness of the integument, which no longer glides over the subjacent parts, 1but which seems to be united to the cellular tissue and the aponeurotic tissues of this region. Nothing else, however, of a special character attests a well-pronounced syphilitic state in these chil- dren, these little old people, as they are called ; nothing else indicates the existence of any other malady. And, nevertheless, at the first glance, one Judges correctly that they will not live. Even the nurses do not make a mis- take in this respect. I have known many to refuse such nurslings, because, they said, "they would not succeed in raising them." Scarcely, in fact, have these children the strength to nurse ; "they do not draw," their mothers or their nurses repeat to you ; they sleep upon the breast. Then they become more and more feeble, and soon your first previsions are confirmed. These children do not die, properly speaking ; they fade out rather than die ; they cease to live, for the sole reason that they are not viable, that they are unequal to life on account of the functional insufiaciency of their organs. 2.. At other times (and here I am going to reproduce a 56 SYPHILIS AND MARRIAGE. pathological fact wMch I have alluded to in a preceding chapter) — at other times, I say, these children present more favorable appearances. They come into the world feebly constituted, without doubt, but, on the whole, with an average or passable development, which permits us to consider them viable. We have reason to hope that with care and a good nurse they will "pull through," as is the case with so many other new-born, who, feeble, puny, and delicate at first, soon develop and become strong in the course of the fii'st weeks. And, in reality, these children continue to live without accidents and without apparent disease. Then, after some days, after some weeks, sud- denly they commence to pine away, and rapidly fade out without an attack, without apparent reason, without any morbid incident superadded. Sometimes, even, as I have already remarked to you, they die in a moment, in a man- ner the most unexpected, the most unlooked for, without their parents and physicians knowing how and wherefore this sudden death is produced. I have now among my notes more than half a score of cases of this kind, and, as an example, you will permit me to cite the following, which I observed with the cooperation of one of our most distinguished and well-known accoucheurs : A young man contracts syphilis and is not treated for it, or is treated in an ephemeral fashion, altogether insuf- ficient. Some time afterward he marries. His wife be- comes pregnant almost immediately. During the course of her pregnancy she begins to be affected with the various phenomena of secondary syphilis. She is confined almost at term of an infant of average size, passably developed, and free from every ai^jDarent sign of syphilis. ISTursed by its mother, attended by my colleague and myself, this child grows regularly for several weeks without presenting MIXED HEREDITY. 57 the least morbid symptom, syphilitic or otherwise. AU appears to go well, at least relatively, when one morning we learn that the child suddenly succumbed during the night. The evening previous it had been examined by my colleague, who had found it in a quite satisfactory condi- tion. One hour before its death, its mother had held it in her arms and changed its diapers " without remarking any- thing unusual." In brief, death occurred in a manner ab- solutely sudden and unexpected. !N"ote well, gentlemen, these cases of inexplicable sud- den deaths not preceded by any apparent morbid phenom- enon. You will certainly encounter them in practice, for they are by no means rare. Many accoucheurs among my colleagues or friends have told me that they, like myself, have observed them, and almost always in " children syph- ilitic or the issue of syphilitic parents." Here, then, is a fact which I commend to your attention. 3. In other cases, children born of syphilitic fathers and mothers escape both death and syphilis. But they present themselves with a wretched appearance, with a poor and debilitated constitution, with a condition of anaemia, persistent and rebellious to aU treatment, with a vital resistance inferior to the normal average. One has a presentiment, at a glance, that they will readily yield to a slight disease, that they are subjects predis- posed to what is called the malignity, the occult in- sidiousness, of diseases. And, in reality, they are often carried off by maladies which could have been easily controlled in subjects with a better established health and a more vigorous temperament. 4. Another point of which I am convinced is, that children, sprung from syphilitic ancestors, present a de- cided predisposition to affections of the nerwus system. 5,8 SYPHILIS AND MARRIAGE. A very large number, for example, die from convulsions. In examining my individual observations, I find no fewer than fifty cases wliere children born in these conditions, whether syphilitic or not, suddenly died in the course of one or more convulsive attacks. And, on the other hand, numbers of cases of the same character are found signal- ized in special treatises or in periodical publications. Again, these same children are powerfully predisposed to meningitis. This is a remark which I made long ago, and I have not been the only one to make it.* I should not be surj)rised if the pretended successes of iodide of potassium in tubercular meningitis (some cases of this kind have been published, as you are aware) were explicable by the specific character of the lesions for which this remedy was administered. In its acute forms, this meningitis of the children of syphilitic parents is almost invariably fatal. In its mild, progressive forms, it may spare the life, only to end, most generally, in a state of intellectual incapacity, bordering on imbecility or idiocy. You may be sure that many children, backward, imbecile, or idiotic, are nothing else than the products of syphilitic heredity. I have under observation at this moment an example * At the moment I was reading the proofs of this volume, chance furnished me a new and deplorable example of this hereditary influence of syphilis in the pro- duction of meningitis. One of our most distinguished confreres from the country came to pay me a friendly visit. The conversation turned upon one of our mutual friends, a physician like ourselves. " You remember well," my confrlre said, " poor Dr. X , that we have both treated for a grave, persistent syphilis ? Well, he has just lost his third child, which succumbed, from meningitis, like the first two. He has no doubt — nor have I, for that matter — that these successive meningites, which have carried off all his children, are the remote results of his old diathesis. . . . However," added my confrere, " I, for my part, firmly believe in the hereditary influence of syphilis as a cause of meningitis among infants. I have seen too many cases in my practice not to be convinced upon this subject." MIXED HEREDITY. 69 of the kind, wMch is too complete and too demonstrative for me to resist the desire to relate it to you. A child is born of a syphilitic father and mother, who have already engendered two syphilitic children, both soon dying. From the first, it does not develop physically ; its growth is retarded ; so that, at twelve years of age, you would take it for a child of six years at most. Toward his thirteenth year he becomes unintelligent, obtuse, as if foolish ; he forgets the little that he knew ; he loses his memory ; he can scarcely find words to speak. He falls into a sort of torpor. Then occurs an acute crisis of encephalo- meningitis, vomitings, obstinate constipation, strabismus, delirium, partial convulsions, tremors, epileptiform at tacks, alternating with long periods of resolution and of coma, paralyses, contractures, etc. Specific medication (iodide of potassium and mercurial frictions), although administered very tardily, dissipates all these morbid symptoms with a significant rapidity. But his intelligence is not reestablished. Far from this, it remains abolished, extinguished, annihilated in every sense of the word ; so completely, that the child is to-day no more, to speak definitely, than a veritable idiot* It is, to my mind, no less evident that the hereditary syphilitic influence (even limited to the father alone) con- stitutes a predisposition to hydrocepJialus. This is at- tested by a number of facts which I have had occasion to record in my practice. I could cite, among others, the * I have from my colleague and friend, Dr. Tarnier, a case of congenital idiocy in a child born from a syphilitic father. " From the earliest period of its life," says this learned accoucheur, " the strange aspect and the general condition of the child had directed my attention toward the search of a syphilitic etiology, although nothing special justified this suspicion. I interrogated the father with this view, and was informed by him that he had contracted syphilis but a short time before his marriage, and had been treated for it in a very insufficient manner only." And also other similar cases, which I could produce. 60 SYPHILIS AND MARRIAGE. case of one of my patients, who, having had the impru- dence to contract a marriage despite a syphilis not treated, has had three hydrocephalic children in succession. I should add that, in my investigation of this subject, I have encountered here and there, scattered thi'ough medical literature, numerous observations of the same character. 5. Finally, there rises the question of lympliatism and scrofula, which, by certain authors, are regarded as only disguised forms of hereditary syphilis. Assuredly, it would be a great exaggeration to regard scrofula as a degeneration of syphilis. Assuredly, it would be a serious error, from a pathological point of view, to make it subordinate to syphilis, to consider it in the light of a bastard, transformed, metamorphosed syphilitic affec- tion. Scrofula, unquestionably, has no need of syphilis in order to exist. It exists by itself alone, or, at least, it is the effect of causes which have nothing to do with the syphilitic virus. Ordinarily, we encounter scrofulous children descended from parents who have never presented the least syphilitic symptom. But, on the other hand, it is no less certain that syph- ilis constitutes, if you will permit me the expression, one of the affluents of scrofula. It brings its contingent to scrofula, by virtue of its being a debilitating, ansemiating disease, a disease impoverishing the organism, deteriorat- ing the constitution, ruining the vital forces. It beckons scrofula in its train, it predisposes to it in the same man- ner as do all depressing causes, in the same manner as misery, insufficient alimentation, captivity, etc. And this action which it exercises upon the health of the parents is reflected and revealed afterward in the child, by mani- festations peculiar to lymphatism in general, and to the highest degree of lymphatism, that is, scrofula. MIXED UEREDITY. Q\ Sucli are, to speak only of facts well established, the states or morbid aptitudes wMcli may be derived from syphilis as hereditary consequences. Still, I am far from saying to you all that I think. For I strongly suspect that syphilis serves as the origin of other functional or organic disorders, such, for example, as congenital mal- formations, arrests, retardations or deviations of de- velopment, spinal curvatures, deafness, keratitis, strabis- mus, etc. But I pass on from these several points, which might become a matter of dispute, and of which I should not have the right to speak to you with a sufficient degree of certainty. CHAPTEE yi. MATERNAL HEKEDITY. Feom what precedes, tliere follows this general con- clusion: Hereditary influence becomes veritably disas- trous when both father and mother are diseased. That stated, may we now go farther ? Is it possible for us to distinguish in this mixed influence that which is due to the father and that which is due to the mother, that is to say, to estimate the quotum, if I may so express it, of the hereditary reaction of each of these two parents upon the foetus ? This is a problem more than difficult, and one which it would be impossible to solve in the present state of our knowledge, for the numerical data which would enable us to institute a parallel between the results of paternal heredity and maternal heredity exercised sepa- rately are wanting. All that we can say in a general way, avoiding a more minute analysis, is : The syphilitic influ- ence derived from the father reacts upon the child in only a limited number of cases, while the syphilitic influence derived from the mother is exercised upon the child in a manner much more frequent, much more active, and alto- gether much more dangerous. A child born of a syphilitic father and a healthy mother has numerous chances of escaping both death and syphilis, and the indirect conse- quences of syphilis. On the contrary, when a child is bom of a syphilitic MATERNAL HEREDITY. 63 motlier, tlie father being free from syphilis, it has but a slight chance of escaping the hereditary influence, in what- ever form it may be exercised. One may even predict that it will inevitably die, if the maternal syphilis is of recent date, or if it has not been repressed by specific treatment. It may be said, very positively, and without any exag- geration, that the syphilitic influence of the mother is NQY\\2h\j pernicious for the foetus.* The following statistics, collected from different sources, and which I intentionally give separately, go to establish this with a numerical evidence unfortunately too complete, f I. The first relates to syphilitic women observed in the city, in private practice. It comprises eighty-five cases of pregnancy, which, considered only in their result the most direct and the least subject to error, viz., the death or the survival of the infant, have furnished me with the follow- ing figures : Cases of survival 27 Cases of death (abortions, premature accouchements, infants still-born, infants dead within a short time after delivery) 58 Total 85 Thus, in eighty-five births, fifty-eight deaths, that is to say, in round numbers, more tlian two cases of death to enery tTiree MrtJis. A lamentable proportion, to be sure, but much smaller, nevertheless, than the following. * In order to appreciate the isolated influence of maternal syphilis upon the foetus in an absolutely rigorous manner, it will be necessary to consider the cases where the mother alone is syphiUtic, while conversely the father is healthy. Now, the cases of this kind (especially those which are free from every chance of error) are very rare in practice, and I have not yet succeeded in collecting more than a small number. We are, then, forced to confine ourselves to a parallel between the cases in which the mother is healthy and those in which she is infected. With the first we are already familiar, from what precedes, and we are now about to see what pertains to the second. t v. Illustrative Cases, Note III. 64 ■ SYPHILIS AND MARRIAGE. II. Our second statistics have been recorded of patients observed in the hospital, for the most part at the Lourcine, some at the Saint Lonis. Let us explain in advance, in extenuation of the unfor- tunate results we are about to X3resent, that, in the patients of this second series, the syi)hilitic influence was mani- festly complicated by other factors, which it would be un- just to ignore, and which are eminently prejudicial to the success of pregnancy, such, for example, as poverty, pri- vations, irregular and insufficient alimentation, excessive labor, fatiguing vigils, debauch, and often professional debauch (the word is strictly exact), excess of every kind, alcoholism, lack of common hygiene and special treat- ment, etc. Under such conditions, it is evident that the mortality of the children is destined to be increased. This is, in effect, what occurs, but in proportions assuredly much larger than one would suppose. The abstract of my hosjoital notes gives the following results in 167 cases of pregnancy coincident with syphilis : Cases of survival of infant 23 Cases of death of infant (abortions, accouchements premature, still-born, infants dead a short time after accouchement) . . 145 Total 167 145 deaths among 167 bu^ths, that is to say, in round numbers, only one infant surmving in seven to eight MrtJis ! What a monstrous proportion ! What frightful mortality ! In truth, this would not be credited, and I myself would not believe it if I had not under my eyes the irrefutable data which have furnished me the elements of this calculation.* * It will not be useless, I think, to add certaia commentaries upon these last statistics, the truly frightful results of which demand an explanation. In the first place, the larger proportion of the cases upon which the observations are based MATERNAL HEREDITY. 65 I have not been tlie only one, moreover, to estalblisli the foregoing unfortunate results. In this same theatre of observation, the Lourcine, Dr. Coffin arrives at figures much more dismal still. Thus, in 28 pregnancies of syphilitic women which were terminated at the hospital, he has verified this : Infants dead (abortions, accouchements before term, death from 1st to 45th day) 37 cases. Infants surviving 1 case alone. Only one child surviving in 28 pregnancies ! What a proportion ! * One of my former pupils, Dr. Le Pileur, at present physician of Saint Lazare, at my request has kindly ex- amined the administrative registers of Lourcine for a period of ten years, and prepared statistics of mortality among children, the issue of syphilitic mothers. This long work has given the following results : 1. In 414 pregnancies, 154 were terminated either by abortion or by the expulsion of still-born infants at dif- ferent periods of gestation. have been collected at the Lourcine, that is to say, in a public hospital especially for females, composed in great part of prostitutes, making a business of debauch, and addicted to all excesses, etc. In the second place, I ought to remark that almost all the patients who figure in these statistics were women affected with secondary syphilis more or less recent. Consequently, they were in that stage of the diathesis which is the most pernicious for the foetus. Let it be added that the great ma- jority of them had never followed any treatment, at least, any systematic treat- ment, before their entrance into the hospital. And more, we know by experience how the patients at the Lourcine behave themselves — contriving all manner of ruses in order to escape a mercurial treatment, quitting the hospital when scarcely cured of the more visible accidents, only to reenter, and again leave ; in addition, observ- ing no regimen, no medication, no hygiene, etc. So that, without fear of departing from the truth, one might regard the preceding statistics as constituted by cases of syphilis not treated, abandoned to its own evolution, and exercising upon the prod- uct of conception the fullness of its destructive influence. * £tude clinical pour servir d Vhistoire de Vinfiuence de la syphilis, du traitement mercuriel, ei dcs ulcerations du col sur la grossesse. — TJieses de Paris, 1851. 66 SYPHILIS AND MARRIAGE. 2. Of 260 infants born at term and living, 141 died within a very short time (only 22 survived more than one month). Let us add up. This makes a total of 295 deaths in 414 pregnancies, that is to say, in round numbers, almost three deaths in every four births. And note again that, among these children considered here as "surviving," there are assuredly a certain num- ber who must have succumbed later directly from their disease.* Likewise, again, M. Durac, observing at Toulouse, has seen, in 46 pregnancies of syphilitic women, 36 terminate fatally to the infant, f After such statistics, all commentary would be super- fluous. It is only too evident from these figures that the infection of the mother exerts, or may exert, upon the in- fant an influence the most active, the most noxious, the most murderous. So, then, as regards our present sub- ject, the worst danger which an infant to be born from the union of a syphilitic man with a healthy woman can incur is for this woman to contract the infection from her husband, since, in this new situation, the health and life of the infant will be found most seriously com^Dro- mised. And thus, gentlemen, you see how and in what differ- ent ways a man with a syphilis not eradicated, contracting marriage, may become dangerous to his children. * That for two reasons : 1st, because hereditary syphilis most often only makes its invasion some weeks after birth, that is to say, at a period when the mother and the infant may have already quitted the hospital ; 2d, because numbers of patients of the Lourcine insist upon demanding their discharge when they see that their child is about to die, "not wishing," say they, "that it should die at Lourcine" — not wishing, in reality, that the disease of the said child should testify to their presence in that hospital. f De fldredite de la syphilis. — Theses dc Ifonipelier, 1866. CHAPTER VII. PERSONAL DANGERS OF THE HUSBAlSrD. Third Point. — A man., who enters into marriage., with a syphilis not extinct, may become dangerous through himself to the interests of his family. ^ In other words, lie may become dangerous to his fam- ily by reason even of the personal dangers to which he remains exposed from his disease, from his persistent diathesis. With this third point, generally neglected, forgotten, sacrificed — I can not explain the reason why — we are about to touch upon the most delicate and the most diffi- cult side of the problem which we are now considering. Here there are no longer questions of pure iDathology alone that we have to examine and discuss. Morality is about to join itself and enter in line. Reassure yourselves, however. I know to whom I speak, and I will not waste my time nor yours in preaching to the convinced. I shall only need in this new path to invoke certain principles, certain obligations, certain duties which exist inherent in the breast of every honest man, which are unquestioned as they are unquestionable ; and, at the proper time, I will apply them to our subject in strict measure, where they will be indispensable to it. Speaking to physicians, I have not to remind you, by 68 . SYPEILIS AND MARRIAGE. way of premise, tliat syphilis is a serious, a very serious disease, liable to end, when left to itself or insufficiently treated, either in important affections or in serious infir- mities ; or even (frequently, much more frequently than is stated or seems to be believed) in a termination more lam- entable still — in death. This is a matter of common no- toriety, almost hackneyed. But what I wish to particu- larize, because it directly concerns our present subject, is that, save exceptions rare and of a special order, syphilis but seldom ends in serious or fatal accidents until after a remote maturity, that is to say, after a long series of years, for example, after ten, fifteen, twenty years, and more. It is, as you know, in the tertiary period, a period almost indefinite in duration, that the grave manifestations, the veritable catastrophes of the pox, occur. That is to say, syphilis, ordinarily contracted in the foolish years of youth, during single life, has its grave complications only in mature life, when the former gay youth is transformed into a serious man, is metamorphosed into a husband and father. Such are the pathological aspects of the case, are they not ? Now, if this be so, remark then, I beg you, what be- comes the situation of a man who, with a syphilis con- tracted in his youth and not sufficiently treated, presents himself for marriage under such conditions ? The situation, medically, is that of a man who has every chance to be exposed, in a more or less distant fu- ture, to the assaults, more or less formidable, of the diath- esis. The situation is that "^'im malade pour Vavenir,^^ if I may thus express it, that of a man with health com- promised, of a man damaged physically, indebted to the pox, and destined, sooner or later, to discharge that debt. In such conditions, is it admissible that this man should PERSONAL DANaERS OF THE HUSBAND. 69 aspire to marriage? Is it honest, is it moral that this "future sick man" should think of becoming a husband and a father? And, if he consults us, as physicians, to know whether he is fit for marriage, can we, ought we to allow him to engage in this undertaking upon our own responsibility ? No ; it is not admissible ; it is not honor- able ; it is not moral for a syphilitic subject to contract a marriage in the conditions we have Just specified. And, when he comes to ask our advice, our duty is to enlighten him upon this subject, to refuse him the authori^;ation, the free patent — ^permit the word — which he comes to claim from us, a^nd to explain to him this refusal for the reasons which we are about to indicate. What, then, is marriage in its completeness, gentlemen ? Marriage is not only an affair of sentiment, of passion, of convenience, and of interests. To consider it from a stand-point more practical, and at the same time more ele- vated, marriage is an association freely entered into, where each contracting party is pledged to bring in good faith a share of health and physical vigor, with the view of co- operating, on the one hand, for the material prosperity of the family, and, on the other hand, for the raising of chil- dren — ^the supreme and sacred end of every union. Now, what in this case, I ask of you, will be the share contributed to the partnership by a husband, syphilitic, and not cured of his syphilis. His share will be that of a health compromised, hypothecated, burdened with a debt (I again use the word designedly) hereafter due the pox, that pitiless creditor. On account of the pox, it may happen that this man may experience one day or another such and such serious affections which will ruin his health ; such and such an infirmity which will render him incapable of work, inca- 6 70 ■ SYPHILIS AND MARRIAOE. pable of earning his daily bread. And then what will be- come of the family of which this man is the recognized support ? What will become of his wife ? What will become of his children? On account of the i)ox, also, this man may die. What may happen, he being dead, to this wife and to these children? Is it admissible, then, that a man should think of creating for him- self a family when he is liable to fail this family? Is it admissible, is it right, is it moral that a man should dream of having a wife and children when he offers the possible prospect of widowhood to this wife, of oi-phanage to these children, of poverty to this family ? No, a hun- dred times no ! Also, and I do not hesitate to say it, the man who, syphilitic and not cured of his syphilis, fears not, nevertheless, to append his signature to the marriage contract, commits at this moment a base act, an act im- moral and corrui)t, an act which good people ■wdll be unan- imous in condemning. A comparison will confirm my idea by embodying it in a common illustration : Two individuals associate their in- terests, let us suppose, in some bu^siness, whatever it may be. One contributes his partnership share in good money or in good values ; the other, T\dthout the knowledge of the first, furnishes his share in values, doubtful, hypothe- cated, adulterated, stamped with an inevitable deprecia- tion of market value in the future. What think you of the action committed by the latter ? Well, the last is our syphilitic, who brings into the partnership of marriage a depreciated health, a health of j)oor quality, if I may thus express it, with the prospect, certain or probable, of pathological catastrophes, compromising, or capable of compromising at a given time, the material interests of the association. PERSONAL DANGERS OF TEE HUSBAND. 71 In the two cases, the form of the arrangement is very different, assuredly, but the principle remains the same, and there is the same immorality in both. And do not accuse me here, gentlemen, of exaggeration. Do not think that, for the requirements of my cause, I designedly em- phasize the situation and darken the picture. It is not so. I speak after what I have seen, exclusively, and without fantastic additions. Unfortunately, it is only too true that, even from the sole point of view from which we are speaking, even from the sole point of view of the personal dangers of the husband, the pox is a frequent source of social miseries the most lamentable, of domestic dramas the most heart-rending. If you doubt it, I have the wherewithal to convince you. I open my notes and I copy from life : A young man marries some years after a syphilis very negligently treated. Six months after his marriage he is seized with cerebral accidents of a specific nature. He dies, leaving a wife and a young child in ab- solute destitution. An artist formerly very well known, and quite cele- brated on the stage, marries, despite a syphilis which had never been otherwise treated (the expression is his) than "by contempt." He has the good fortune not to infect his wife, and to have a healthy child. But, some years later, he begins to be affected with a tuberculo -ulcerative syphilide, which, still treated with the same stupid indif- ference, takes on a phagedenic character, plows up the whole face, then destroys entirely the nose and the upper lip, then penetrates into the nasal fossae, and devours the whole internal bony structure of this cavity, the entire palate, the soft j)alate, the pharynx, etc. This unfortu- nate man thus becomes a hideous and infected monster, an object of horror and disgust to all who approach him. 72 SYPHILIS AN'D MARRIAGE. He drags along thus many years in a condition more and more frightful, before ending in a death that to him came too slowly. What a situation ! What a spectacle for a young wife, for a child, for a family ! — without speaking of moral punishment, and of pecuniary ruin. Another artist, this one a painter, full of talent and of promise, marries, with a syphilis very insufficiently treat- ed. All goes well during several years. The pictures sell, the little household prospers, and is enriched with a child. Then the husband has an inflammation of the eyes, the nature of which is at first misapj)rehended, and which, attacked too tardily by specific medication, tenninates in complete blindness. Consequence : family ruined, falling into absolute indigence, and forced to inscribe themselves at the bureau of charity in order not to perish of hunger. A young man comes to consult me for various accidents resulting from a neglected syphilis. I treat him, and all disappears. Some months later, in spite of all my advice and remonstrances, he marries. Twelve days after his marriage, on his wedding journey, he is seized with a vio- lent epileptic attack, the first symptom of a cerebral syph- ilis, which is soon emphasized by troubles of intelligence, and left hemiplegia. IN'otwithstanding all my care, he succumbs some months later, leaving his young wife en- ceinte. A student of medicine acquires syphilis, and judges it proper to treat himself exclusively with the iodide of po- tassium, not being willing to take mercury. A short time after his doctorate he marries. Some years later he is af- fected with a slight paraplegia, which is referred to syphi- lis by common consent of all the physicians whom he con- sults. ^Notwithstanding, he still treats himself in a very irregular fashion, " by fits and starts," using his own ex- PERSONAL DANGERS OF TEE HUSBAND. 73 pression. Finally, lie becomes absolutely paralyzed in the legs, and I find him, when he presents himself to me, in a state of absolute incurability. Judge of the situation of our unfortunate confrere when you learn that, without resources, he remains infirm, with the charge of a decrejjit mother, a wife, and two young children ! A young business man contracts syphilis, and is treat- ed quite regularly for some months. Relieved from all apparent manifestations of the disease, he believes him- self out of danger and discontinues all treatment. Three years later, without consulting a physician, he marries. Scarcely married, he communicates syphilis to his wife by a relapse of secondary accidents which occur on the penis. Then he is attacked with symptoms of cerebral syphilis, which I succeed in subduing at first, but which make a new invasion and rapidly carry off the patient. Epilogue. — The young wife, becoming enceinte at the beginning of her marriage, brings forth a syphilitic infant which an active medication succeeds in saving. Yery soon she presents multiple symptoms of malignant syphilis — confluent eruptions, cephalalgia, violent neuralgias, ec- thymatous eruptions with phagedenic tendency, repro- ducing themselves when scarcely cured, and ending in covering the body with monstrous sores. Under the in- fluence of such symptoms, her health is altered: ema- ciation, decline of strength, loss of appetite, digestive troubles, diarrhoea, finally pulmonary tuberculosis, and death from the cachexia — an orphan and without re- sources, the child has to be relieved by public charity. A last example — for I could not finish them if I chose to recount all the miseries of this kind which I have wit- nessed.'* * At the moment that I write these lines, a new and very sad example of the 74 SYPHILIS AND MARRIAGE. A manufacturer marries, notwithstanding a syphilis very negligently treated. Thanks to his knowledge of business and the rich dowry of his wife, he founds a great manufactory, which prospers marvelously. Some years later he is affected with gummy periostoses and exostoses of the cranium. There come on gradually cerebral mani- festations of various forms : intellectual troubles, vertigo, epileptiform attacks, hemiplegia. He then compromises his fortune and his commercial honor in grandiose and adventurous operations which he is no longer capable of directing, or, to speak more correctly, he would not have undertaken in a sound state of his reasoning faculties, and he is ruined. Finally, he falls into dementia and dies, leaving his wife and four young children in a destitute condition. What is to be said, gentlemen, of such things, such social calamities ? And what is to be said of those who have caused them, who, after all, are the responsible authors ? In their extenuation, let us admit that they have been more ignorant, more imprudent, than culpable ; let us admit (for this is true in the great majority of cases) that they were not conscious of the injury they might occa- sion others, of the misery, of the disasters which they ran the risk of spreading around them. But their "victims are, on this account, none the less sad examples of the terrible same order has just presented itself to me. Summoned within a few days to a consultation in a lunatic asylum, I found there a young man affected with a grave cerebral syphilis, and a prey to the most violent delirium. His condition was such as to leave little ground for hope. Now, the history of this patient is traced in that of all the subjects that we have just been considering. At nineteen years he contracted the pox, and was treated for it only just long enough to dissipate the apparent manifestations. Later, he married (about sixteen months since), notwith- . standing his syphilitic antecedents. He became a father about a month ago. Being without means, he was dependent upon his labor. What a situation for his wife, what a future for his child ! PERSONAL DANGERS OF THE HUSBAND. T5 consequences which may result from their indifference, their recklessness, their thoughtlessness. Well, at any rate, let not these lamentable examples be lost ; let them serve as lessons to show us our professional duty, or, rather, the social duty which devolves upon us under such circumstances. And this duty, which you have antici- pated, is this : If it is not the province of men of the world and of patients to know what the effects of the pox not treated may be, after a long interval, it is our province to know this and to instruct those who are ignorant. It is our mission to enlighten upon this point patients who come to us, and, more especially still, those who come to consult us upon the propriety of marriage, notwithstanding a syphilis insufficiently treated, and which remains mena- cing for the future. It is our mission to divert from mar- riage every patient who presents himself to us under such conditions, to dissuade him from it to his own great ad- vantage and to the great advantage of others, to show him the abyss about to open under his feet, to reveal to him the dangers to which he would expose his future family by a premature union, and to say to him, finally, this, with the authority of our science and our character : " IN'o, sir, no ; it is not allowable, in your present condition, for you to dream of marriage, considering only the personal risks to which you remain exposed from your old disease. Until now you have thought it best to live with the pox, to preserve the pox. That was your right, and no one had anything to say, for you were single and, consequently, alone liable for your imprudence. But now, since you aspire to marriage, the situation becomes very different. To marry is to have charge of lives ; and, since you do me the honor to consult me, you make it my duty to remind 76- SYPHILIS AND MARRIAGE. you that yon have not the moral right to associate others in your personal risks — that is to say, to make a wife and childi'en share the possible consequences of your disease." Here terminates, gentlemen, the first part of this expo- sition. I have told you how a syphilitic man may be, or may become, dangerous in marriage. I have endeavored to show you that he may be dangerous in a triple manner : to his wife, in transmitting to her the disease with which he is affected ; to his children, by way of heredity ; to his family, from the personal risks to which he remains ex- posed. This will serve us as a point of departure and a basis for the discussion which we are now about to open. From what precedes, the natural conclusion is : 1. That marriage should be forbidden to every man who still presents a syphilis sufficiently active to be dan- gerous. 2. That, conversely, it may be permitted to every man in the opposite conditions. But such general facts are not sufficient for the solu- tion of the essentially practical problem which we are discussing. It is necessary that we now grasp the ques- tion more closely, that we descend to details, and search out the clinical elements from which we may be able to judge whether a syphilitic subject has or has not ceased to be dangerous in marriage, and whether we should ac- cord him the authorization which he comes to claim from us, or flatly place our veto upon his projects of a union. CHAPTER VIII. COJSTDITIOlSrS OF ADMISSIBILITY TO MAEEIAGE — ABSENCE OF EXISTING SPECIFIC ACCIDENTS — ^ADVANCED AGE OF THE DIATHESIS. GrENTLEMEN" : The natural order of our subject now leads me to tlie discussion of the following question : In what conditions does a patient affected with syphilis cease to be dangerous in marriage ? or, what amounts to the same thing, in what conditions does he become ad/mis- sible to marriage^ if I may thus express it ? ISTow, as we have been hitherto unrestrained in our progress toward determining the perils which affect a syphilitic man in marriage, and in stating theoretically the general principles of the admissibility or of the non-admis- sibility to marriage from a medical point of view, so now, in passing from theory to practice, we are about to en- counter embarrassment and difficulties in appreciating the variable conditions, multiple and complex, of particular cases. And this embarrassment, these difficulties, we shall experience so much more iDointedly, as we are now tread- ing upon ground not yet cultivated. The experience of our seniors, of our predecessors, of those whom, with just respect, we regard as the masters of our art, is almost entirely wanting here. And, in fact, gentlemen, you may 78 ■ SYPHILIS AND MARRIAGE. run througli the classical works, you may examine the special treatises, but you will nowhere find this gi-ave question of the marriage of syphilitics confronted, dis- cussed, debated. Without doubt, you will find here and there certain general hints, certain indications— always ' more or less vague — incidentally thrown out upon this subject. But nowhere, I assure you from my o^ti experi- ence, Avill you encounter a veritable programme formulated in extenso, or even outlined, upon this matter. All re- mains to be done, or very nearly so, and this constitutes by no means the least embarrassment of him who has the honor to now address you.* Let us venture, nevertheless, to attack this difficult and perilous problem, taking for guides, on the one hand, the principles which we have established in our preceding lec- tures, and, on the other hand, the results furnished by the clinic. In my opinion, according to what I myself have seen, and the results of my reading, the principal condi- tions which a syphilitic subject ought to satisfy in order to have the moral right to aspire to marriage (that which I will term, by abbreviation, conditions oftlie admissibility to marriage of a syphilitic subject) may be summaiized in the following programme : 1. Absence of EXisTmo specific accidents. 2. Advanced age of the diathesis. * It would be a serious injustice, nevertheless, not to mention here -with praise the names of two contemporaneous physicians who have specially treated some of the questions bearing upon our present study, viz., M. Edmond Langlebert, author of an interesting work, very admirably written, upon La sypldlis dans aes relations avec le mariage (Paris, 18Y-3). The reader will there find several chapters exhaust- ively studied, and stamped with great clinical judgment. Unfortunately, it is to be regretted that the author should have allowed himself to be diverted from his prin- cipal subject by devoting a considerable portion of his book to foreign questions. And also M. Diday, who, in several of his publications, notably in his TJierapeutique des affections veneriennes (Paris, IS'ze), has treated the same subject with that sparkling verve, that vivacity, that humor, which every one recognizes as his. CONDITIONS OF ADMISSIBILITY TO MARRIAGE. 79 3. a ceetain period of absolute immunity con- secutive to the last specific manifestations. 4. non-theeatening chaeactee of the disease. 5. Sufficient specific treatment. Sucli is, at least according to tlie results of my experi- ence, the enseuible of conditions medically to be required of every sypMlitic patient in order that the doors of mar- riage may be opened to him. If the said patient satisfies all these combined conditions, I consider him fit to become a husband and father without danger. In the contrary case, I do not consider myself author- ized to grant my consent — the moral authorization which he comes to ask of me. I dissuade him from marriage ; I forbid his marriage with all my power. But let us enter into details. Let us explain, comment upon, and Justify this programme, which I am very far from presenting to you as definitive, as not susceptible of modifications, and of further amendments, but which seems to me at least to contain the principal conditions to which it is necessary to restrict every syphilitic subject aspiring to marriage. First condition : Absence of existing specific acci- dents. This first point certainly will not arouse dispute. It is elementary, in fact, for all the world — for the i^eople as well as for physicians — that the first obligation for a syph- ilitic candidate for marriage to fulfill is. that he present no syphilitic accidents at the very time of his marriage. For the existence of the least syphilitic accident is a flam- ing evidence of the disease, of the disease not only poten- tial but actual. And it matters little, moreover, whether this accident be of a transmissible nature or not, for — 1. If it be of a transmissible nature, the contraindication of marriage is as express and absolute as possible ; 2. If it 80 SYPHILIS AND MARRIAGE. be not of a contagious nature, it none the less reveals a permanent diathesis, with all its dangers and consequences. But we need not insist upon this, for the evidence is too direct. And one might be astonished that a proposition like this, the absence of accidents at the epoch of marriage, should even need to be enunciated. A priori, in fact, one would scarcely believe that men could be found so desti- tute of moral sense, so ignoble, so shameless as to dare become husbands with the existing accidents of the pox. And, nevertheless, do not deceive yourselves, gentle- men, this incredible audacity is sometimes encountered. You will find certain cases already signalized in medical literature. For my part, I have witnessed such cases a dozen times. I have seen (and I hold up the fact to public indignation) people marry while presenting the i^ery day of their nuptials such or such syphilitic symptoms, as cutaneous syphilides (palmar psoriasis, papulo- squamous syphiMe, ecthyma of the legs), mucous patches of the mouth or throat, genital mucous patches, specific sarco- cele, accidents premonitory of cerebral syphilis.* I have in my notes the histories of two individuals, who, in spite * The last case to which I make allusion is truly so extraordinary in all respects as to merit special mention. A young man, syphilitic for several years, allowed himself to be engaged in marriage despite various cerebral phenomena, the nature of whicb, moreover, he but imperfectly comprehended (heaviness of the head, pass- ing vertigo, little aptitude for work, change of character, and, especially, defects of memory). The day of the wedding arrived, but the bridegroom did not appear at the ceremony. He was sought after, and was found occupied with nothing but Bitting at the comer of his hearth, reading a paper, having totally forgotten that he was to be married that day. Nevertheless, the affair was proceeded with, and (it can scarcely be believed) the marriage took place. The cerebral trouble, be it well understood, became aggravated after this. Some months later, a separation of the married couple had to be pronounced, because of the abuse, cruelties, and violences of the husband toward his wife. Then the patient had an attack of mania, presented various accidents more and more intense of specific encepha- lopathy, and finally fell into dementia. An English physician of my acquaintance has informed me that he had observed a case almost identical with the preceding. CONDITIONS OF ADMISSIBILITY TO MARRIAGE. 81 of my most energetic protestations, were married when they each had on the penis an indurated chancre in the stage of full development. That is not to be believed, is it ? But it is true, I assure you, I give you my word, and it proves once more that "the truth is not probable." What motives, what morbid incitements thus impel certain persons to marry under such conditions, in spite of actual syphilitic symptoms ? This is a question, a sub- ject of study, which concerns the philosopher, the moral- ist, rather than the physician. It is not, however, a matter of indifference to us, for we often need, in the exercise of our vocation, to understand the moral as well as the phys- ical pathology of our patients. Allow me, then, to say a few words in regard to it. ]^ow, according to my observation, the motives that in- fluence certain persons to a course of action so unjustifi- able are not ordinarily those which one would be inclined a priori to suppose, viz., ignorance or interest. Without doubt, there are persons who marry in an active stage of the pox from an absolute ignorance of the dangers to which they expose their wives, their future children, and themselves. They do not know what they have, they make no account of it ; they have not, from thoughtless- ness or stupidity, even dreamed of consulting a physician. These are the simple, the indifferent, the imbecile. Without doubt, there are others who understand per- fectly both what they have and what they may transmit ; who take an exact account of the situation, and, while appreciating all its dangers, nevertheless brave these dangers, because they have a superlative interest in brav- ing them, viz., a dowry to secure, a situation to make, a "position" to gain. They are the audacious and the infamous. 82 SYPHILIS AND MARRIAGE. But most often this is not the case. In general (at least according to the result of my personal observation) the in- dividuals who are led on to this revolting act of marriage, while the pox is in full activity, are frivolous and of feeble character, who foolishly, thoughtlessly, become engaged to be married when they are as unfit for it as possible ; then, when the fatal moment arrives, they find themselves driven into a corner from which they dare not escape. Although very much ashamed of the act which they are about to commit, w^hile regretting it, deploring it even in their inmost conscience, they have not the courage to re- cede, to withdraw, for fear of a scandal, of the publicity of a rupture without avowable motives, for fear of what peojole may say, of public malice coming to suspect their disease^ In brief, to save apjoearances they commit no- thing less than the worst cowardice. Are these last less culpable than the former ? At any rate, they only arrive at the same result in other ways.f * Example : Some years ago a young man from the country came to ask my advice for certain existing accidents of secondary syphilis (buccal syphilides, alo- pecia, crusts of the hairy scalp, etc.). The consultation completed, he added, with a confused air, that he was engaged in matrimonial projects, and finished by avow- ing that he was even contemplating a quite early marriage. I hastened immediately to declare to him that it was absolutely impossible for him to carry out such projects in the condition in which he was, and I gave him the reasons : I insisted energetically, seeing him little inclined to allow himself to be convinced, and I unfolded to him the entire series of dangers to which he was about to expose himself and his future family. Now, to all my arguments this young man opposed an obstinate response, always the same, viz., that " he is constrained to marry for fear that his disease might be suspected." " I should like to follow your counsels, doctor, but this is not possible under the circumstances. What motive can I assign for a rupture that shall satisfy the two families ? What would they say of me in my little vil- lage in the country ? They will suspect or succeed in finding out the true motive of my withdrawal, and then I shall be ruined, disgraced," etc. And some months later I heard, indirectly, the news of his marriage. f If I did not fear to exceed the limits of my programme, I would annex to this chapter some considerations relative to those subjects who marry during the actual period of the incuhaiion of syphilis. Cases of this kind are, of course, very rare, CONDITIONS OF ADMISSIBILITY TO MARRIAGE. 83 Second condition: Advanced age of the diathe- sis. With this second point we touch, upon one of the most important and essential conditions of our programme. In a general manner, indeed, it may be stated as an ax- iom : The more recent the sypliilis of the husband, the more numerous, the more serious will he the dangers vjhich he introduces into marriage. "Whence this corol- lary : The older our patient' s syphilis, the more shall we be authorized (save for special indications of another kind) to toler^^te his marriage. Let us Justify the preceding proposition. In the first place, let us examine the question from the point of view of the dangers of infection for the wife. Without possible contradiction, it may be asserted that a young syphilis is especially dangerous, in so far as con- but nevertheless worthy of attention. They may be thus summarized : A healthy man, some days before his marriage (a fortnight, for example), has connection with a woman infected with syphilis, and receives the contagion from her. As the first symptoms of the disease are always separated from the date when contagion was effected by a period of three weeks, on an average, sometimes a month, and even more, this man marries with the appearance of perfect immunity. It is not until from eight to ten or fifteen days afterward that the initial phenomena of in- fection begin to reveal themselves, und6r the foi'm of one or more local erosions. So that the syphilis contracted before marriage does not reveal itself until after mar- riage, thanks to the prolonged incubation which always preludes its outbreak. Now, what happens in these conditions ? It is that the husband, not initiated into the secrets of syphilitic incubation, and believing himself exempt from all possi- bility of contagion, scarcely pays any attention to the lesion which has just com- menced to appear upon him. He is far from supposing that this lesion may be of a contagious nature ; he mistakes it for an " abrasion, a scratch, an insignificant trifle." Consequently, he does not abstain from intercourse with his young wife, and in this way he transmits the syphilis to her. I have already observed four cases of this kind ; and in these four cases the contagion was invariably trans- mitted to the young vi'ife. As an example, I will hereafter relate the history of one of these cases (vide " Notes and Illustrative Cases," Note IV). The possibility of a contamination of this kind in marriage is scarcely known, and it would seem to have but little engaged the attention of clinicians. For the interests of all, it is desirable that it should become of more general notoriety. 84- SYPHILIS AND MARRIAGE. tagiousness is concerned. In fact — 1. It is a common no^ tion that the disseminated, scattered manifestations of the diathesis, which, under the name of mucous patches, or, better, of erosive, papulo-erosive, papulo-ulcerative syphi- lides, etc., so frequently affect the various mucous surfaces and the skin— it is a common notion, I say, that these le- sions especially belong, chronologically, to the earlier stage of the disease, to what is termed the secondary period. It is in the first months, in the first two or three years of the infection, that they are observed almost exclusively. Now, the contagiousness of such accidents needs no deijionstra- tion to-day. We can even say that accidents of this or- der constitute the principal source which feeds and prop- agates the pox among us. 2. Every one knows, in the second place, that, in the first two or three years of the diathesis, the morbid manifestations of which we have Just spoken are more particularly apt to multiply, to recur, and that with a persistence sometimes desperate. Let us cite, for example, the buccal mucous patches which, among smokers more particularly, are produced and re- produced vdth many repetitions in the course of the first months or the first years of the disease. 3. In addition, at this same period of the diathesis, there are two centers of predilection which influence the morbid determinations, viz., the mouth and the genital organs. Now, it is precisely these two localities which are the most dangerous from the point of view which now occu- pies us, for it is from these centers that the contagion vdll naturally have the most numerous chances to transmit itself in marriage. Let us add still another consideration: secondary syphilis is particularly dangerous, as regards contagion, from the henignity^ even, of its accidents. Very often the CONDITIONS OF ADMISSIBILITY TO MARRIAGE. 85 lesions wMch it determines upon the mucous membranes, in the mouth or on the penis, notably, consist only in very superficial erosions, slight in extent, almost simply des- quamative. Now, such lesions may easily pass unper- ceived, even by careful persons, attentive to their health. They are also apt to be confounded with common, or^ dinary, insignificant erosions. On the penis, for example, they are frequently taken for simple excoriations, for her- petic or other inflammatory abrasions. In the mouth, they pass not less commonly for aphthae, fissures, etc., ," local irritations from the cigar or cigarette," etc. Altogether, for one reason or another, one does not mistrust tJiem, so inoffensive are they in appearance. And this, indeed, constitutes the danger, for such slight, benign accidents do not seem to necessitate continence, and they thus be- come the origin of frequent contagion in marriage. This is a point which I restrict myself to simply indicating for the moment ; hereafter I shall have occasion to return to it in detail. Such, gentlemen, are various reasons on account of which a young syphilis is so formidable from the point of view of contagion. Quite the contrary, at a more re- mote period, and a fortiori, in an advanced stage of the diathesis, these same dangers of contagion no longer ex- ist, or, at least, only present themselves in a manner much more restricted, relatively, and much less common. And this is on account of reasons exactly the opposite, viz. : be- cause an old syphilis reveals itself only by manifestations infinitely less multiple, more discrete, less subject to re- currence, etc. ; because it no longer affects with the same predilection those two centers so favorable to contagion, the mouth and the penis ; because the lesions which it determines in this period consist no longer in minute, 7 86 SYPHILIS AND MARRIAGE. superficial erosions, susceptible either of passing unper- ceived, or of being confounded with inoffensive accidents of a common order, but in large, profound, important, persistent ulcerations whicli could neither escape the at- tention of the patient, nor permit the possibility of conta- gion through indifference, inadvertence, etc. And do not, gentlemen, regard what precedes as pure theory, but, on the contrary, as conclusions deduced from experience. In addition, consult the results of the clinic, and search at what period of the diathesis contagion is principally produced. Observe, especially, who are the husbands that communicate syphilis to their wives. I have made this investigation for my part, I have just examined my notes on this subject, and without qualifi- cation I have arrived at this : If not always, at least in an enoimous majority of cases, the husbands that communicate syphilis to their wives are those who have entered into marriage with a sypMlis still young — that is to say, with a syphihs dat- ing back several months, one year, two years, more rarely three or four years. When a man marries with a recent syphilis still active, the infection of the wife is an almost constant occurrence. On the contrary, much more rare are the cases where the infection of the wife is produced when the husband's syphilis is more or less old — that is to say, dates back six, eight, ten years or more. Upon these two points, I re- peat it, my observations are precise — as positive and con- vincing as possible. And I recapitulate by saying : BypM- litic contagion in marriage is much the more to he feared for the wife the more recent the date of the syphilis of the liustand. II. Likewise, from the point of view of hereditary in- CONDITIONS OF ADMISSIBILITY TO MARHIAGB. 87 fluence, an advanced age of the paternal syphilis is a con- dition equally favorable. It is a fact remarked of ancient date, recorded in a positive manner by various authors, that the syphilitic in- fluence of the father upon his children undergoes a pro- gressive decrease in proportion as the diathesis becomes old. Thus, for my part, in those cases where I have ob- served the syphilis pass directly from the father to the child without contamination of the mother, I have re- marked that the paternal affection was always of recent date — that is to say, it has never exceeded, at the maxi- mum, three or four years. Beyond this term, I have never clearly made out the transmission of syphilis by paternal heredity. Another proof still is furnished to us by those cases of successive abortions which I have already referred to as the possible consequences of the syphilis of the husband. More than once this has been observed ; a healthy woman, exempt from syphilis, begins by having several miscar- riages ; then (the first improvement being realized under the sole influence of time, the husband still continuing to neglect treatment) this same woman does not abort any more, she only is confined he/ore term, and always of a dead infant ; then, second stage of improvement (since we are compelled to characterize this by the term improve- ment), she is delivered at term of an infant dead or des- tined to a speedy death ; still later, at length she brings forth one or more living infants. What could more thoroughly demonstrate the normal decrease of the hereditary syphilitic infiuence under the sole action of time f A propos of this, allow me to cite a curious case related by one of our English confreres, well known among us, Mr. Hutchinson : 88 SYPHILIS AND MARRIAGE. A physician contracts syphilis and treats himself for about six months. Believing himself cured, and free from all api^rehension, he marries three or four years later. His wife remains Tiealtliy and becomes enceinte eleven times. Now, gentlemen, look at the results furnished by these different pregnancies, and mark the progressive at- tenuation which the diathesis undergoes under the sole influence of time : First pregnancy : child still-horn. Second pregnancy : child still-horn. Third pregnancy : child bom alwe^ but sypMUtic and dying, with the characteristic symptoms of hereditary syphilis. Fourth pregnancy : child born alive, but sypMlitic and dying, likewise from syphilis. On the contrary, the last seven pregnancies furnish children who, although syphilitic, resist the disease and all remain living.* And, moreover, could one call in doubt the attenuating and corrective influence of time upon paternal heredity when this same influence shows itself in so positive and evident a manner upon ma- ternal heredity, or, collectively, upon mixed heredity derived from the two parents? Is not this a fact ab- solutely demonstrated, is not this a veritable pathologi- cal law, the gradual diminution, then the final extinc- tion of the syphilitic reaction of the parents upon the children? Examples quite convincing in this respect have been given by different authors — by Bertin,t by * Memoir cited, "Brit, and For. Med.-Chirurg. Review," 1877, vol. Ix. •)• Here is the summary of the curious case of Bertin, to which allusion is made : Father and mother sj-philitic. First pregnancy : abortion at six months ; in- fant still-born. Second pregnancy : abortion at seven months ; infant living eight hours. Third pregnancy : accouchement at seven and a half months, of a dead infant. Fourth pregnancy : accouchement at term ; child syphilitic, surviving CONDITIONS OF ADMISSIBILITY TO MARRIAGE. 89 M. Diday,* by M. Bazin, f by M. Roger, % by M. Kas- sowitz, § and many others. But none is more cogent and better calculated to carry conviction tlian a very curious case of M. Mireur, summarized thus : A young mason contracts an indurated chancre, and marries at the very dehut of the secondary stage. He does not fail, for he can not, to infect his young wife im- mediately. After this there occur eight pregnancies, the results of which are unfolded according to the characteristic ten- dency of the disease, the liusband and wife remaining exempt from all treatment. ISTow, these eight pregnancies terminate in the follow- ing manner : First pregnancy : abortion at fifth month. Second pregnancy, abortion at seventh month. Third pregnancy : accouchement before term ; cliild dead. eighteen days. Fifth pregnancy : accouchement at term ; child syphilitic, sur- viving six weeks. Sixth pregnancy : accouchement at term ; child syphiHtic, but surviving. — Traite de la nialadie venerienne chez les nouveau-nes, Paris, 1870, p. 142. * Traite de la syphilis des nouveau-nes et des enfants d la mamelle, Paris, 1854, p. 183. f Legons theoretiques et cliniques sur la syphilis et les sypJiilides, Paris, 1866, p. 164. I Summary of an observation related by M. Roger : Father and mother syphi- litic. First pregnancy : accouchement at eight and a half months ; infant dead. Second pregnancy : accouchement at term ; infant dead. Third pregnancy : Ac- couchement at term ; child living but syphilitic, covered with lumps when one month old, and dying at four months. Fourth pregnancy : accouchement at term; child living, strong and well nourished. From the second to the third month this child was affected with a syphilide limited to the buttocks, afterward with a very intense coryza ; died at eight months. Fifth pregnancy : accouchement at term ; " child syphilitic, hke the others, but in a less degree of severity (roseola simplex). Treated by mercurial medication, it was completely cured. It is now seventeen months old and perfectly well." — ^tude clinique sur la syphilis infantile (Union Medicale, 1865, t. i, p. 147). § Die Vei-ei-hung der Syphilis, Vienne, 18*76. 90 STPHILIS AND MARRIAGE. Fourtli and fifth pregnancies : Children living, but both sypTiilitic — the first dying at thirty days, the second at one month and a half. Sixth, seventh, and eighth pregnancies : children living and healthy.* Such a fact is sufficiently eloquent of itself to ren- der all comment unnecessary. Now, if it be thus for mixed heredity, one can scarcely comprehend that it could be otherwise for paternal heredity alone. Then, time exhausts the paternal syphilitic influence and renders it less and less dangerous for the offspring ; here is a point which appears to be well demonstrated. From this there follows the practical conclusion that with syphilis all the chances are in loaiting the longest possible time before aspiring to the role of father of a family. This, at least, seems to me to result in a manner as direct as possible from the facts observed by me up to this time. III. From the point of view of the personal risk which a syphilitic subject carries with him into marriage, an ad- vanced age of the diathesis is again a condition certainly favorable, and constitutes an additional guarantee — a guarantee not positive and absolute, be it well understood, but at least relative. And, in reality, the advanced age of the diathesis per- mits us, in a certain measure, to better appreciate the "quality" of this diathesis, its degree of intensity, its general prognosis. Not, assuredly, that in the case of syphilis the past is always, as it has been termed, "the * Thesis cited, p. 91. A curious point is that consecutively to the last three pregnancies, which resulted in living and healthy children, the father and mother Btill presented various syphihtic accidents of a grave form, such as " gummoua and ulcerated tubercles, abundantly diffused over the limbs." CONDITIOFS OF ADMISSIBILITY TO MARRIAGE. 91 mirror of the future"; far from it. Not tliat a syphilis primarily benign may not result in serious or mortal accidents at a remote period. But it is always the case that, at a period more or less advanced, certain accidents, certain menacing, malignant forms of the disease, are no longer to be feared. Moreover — and this is the essential point — the stage comprised between the debut of the disease and the present time may have been employed advantageously in a long and salutary treatment, which confers the best and most substantial of guarantees in all such cases. Hence, in every respect, you see, the long standing of the disease constitutes an essential, an indispensable con- dition of admissibility to marriage. In my opinion, a syphilitic subject has neither the privilege nor the right to aspire to marriage unless his disease dates back a certain time, unless it has already behind it a certain duration. This I positively affirm, and lay down as a principle, it being my absolute conviction, now based upon a very large number of observations. Now, you will very properly press me further, and, de- manding of me more precise indications, will say: "Be it so ; a certain duration of the disease is indispensable for admissibility to marriage. But speak more definitely ; state in precise figures what is, what in your opinion ought to be, this duration?" Ah! here comes the deli- cate point. As long as we have to deal with general terms solutions are easy. But when it becomes necessary to fix an arithmetical measure, when we come to figures, the difficulties begin. Nevertheless, the same facts which, have served me in stating the general rules which precede will permit me, within a certain limit, to satisfy you, and I shall reply as follows : 92 . SYPHILIS AND MARRIAGE. In the first place, the age of a syphilis is not the sole fact from which one may determine the admissibility or non-admissibihty to marriage. This decision embraces other factors, involves other important and paramount conditions, of which we shall siDeak shortly, such as the nature of the anterior specific accidents, the "quality" of the diathesis (you will see what I mean by this word), the intervention of a sufficient treatment, the influence exer- cised by such treatment, etc. So that the age alone of the disease can never be taken as a basis to solve the problem before us, namely, to decide whether a syphilitic subject has or has not become fit for marriage. With these reservations, I shall enter uj)on the question to which you await a resjoonse, and at once give you my profession of faith, which may thus be summarized : To regard for the moment only the fact of the age, I do not think that a syphilitic subject should be permitted to think of marriage until after a minimum period of three or four years devoted to a most careful treatment. Three or four years is, in my opinion, the minimum (note well the word, I beg of you), the necessary indis- pensable minimum, in order that the diathesis may be suf- ficiently weakened under the double influence of time and treatment ; in order that the patient, restored to ordinary conditions, may properly aspire to become husband, fa- ther, head of a family. Yes, three or four years ; for it is not too much. My requirements are not excessive. A longer time would he better, I am quite certain. For, with syphilis, it is al- Avays advantageous to wait, to defer, when there are such interests at stake as those of a young wife and an entire family. So that I affirm anew the proposition which I have just formulated, and which is the result of experi- CONDITIONS OF ADMISSIBILITY TO MARRIAGE. 93 ence : Short of the minimum above cited, there is every- thing to fear, and the dangers of syphilis in the hus- band are revealed by catastrophes which, if not inevitable and constant, are at least frequent and habitual. Beyond that term, the dangers from the syphilis of the husband decrease and disappear, if not in a manner absolutely certain (for mathematical certainty is and ever will be unattainable in such matters), at least very frequently, so frequently, at any rate, as to warrant us in allowing mar- riage. Still it is necessary, be it understood (and here is a point upon which I do not hesitate to insist again), that, during the period in question, the curative influence of a systematic, methodic, active, and prolonged treatment shall be added to the corrective influence of time. Before three or four years are past, I could never dare, for my part, whatever may have been the activity of the treatment, to grant a clear license of marriage to a syphi- litic subject. For I have seen the saddest, the most un- fortunate consequences succeed premature unions of this kind. After three or four years usefully devoted to a depurative medication, I believe that I am authorized by experience to tolerate marriage, unless there be some par- ticular contraindication noticed in some other portion of my programme. And this because I have seen numbers of syphilitic subjects marry in these conditions without becoming noxious to their wives or their children. By design, I have Just said that in the conditions cited I considered myself right in tolerating marriage. And, in fact, I tolerate it in such a case rather than counsel it. I tolerate it because I consider the term of three or four years as strictly sufficient to protect the interests which I have at heart. But I will frankly say that a longer delay would be much more satisfactory to me, as affording more 9 J: SYPHILIS AND MARRIAGE. effective guarantees. In tlie case of a patient whose syph- ilis (besides having been well treated) dates back six, eight, or ten years, I feel much more at ease in giving him a clean bill of health ; and this, I repeat again, because, from numerous points of view, the security increases with the age of the diathesis. So, iDractically, my rule of conduct is the following: When consulted upon the propriety of marriage by a patient whose syphilis (although regularly treated) dates back only three or four years, I always begin by coun- seling him to wait, to defer his project of union, and I insist anew upon treatment, with the view of increasing and perfecting his chances of security. But, if, never- theless, the patient urges serious and paramount reasons for an immediate marriage, and if, in addition, he satis- fies all the other requirements of my programme, I do not think that I have the right to thwart his projects. I tolerate his marriage under these circumstances. I grant him the medical authorization which he comes to claim of me — not, however, without adding certain advice, cer- tain indispensable recommendations, of which I shall speak hereafter at the close of this exposition. CHAPTER IX. PEOLOI^^GED PERIOD OF IMMUNITY — NON-MENACING CHAfi- ACTEE OF THE DIATHESIS. Third condition : Stage of immunity sufficiently pro- longed after the last specific manifestations, A third condition wMch I regard as indisi^ensable in this matter is, that a period more or less prolonged be- tween the last manifestations presented by the disease and the date fixed for marriage should elapse without specific accidents. That is to say, before a patient has the right to think of marriage, it is necessary that he remain ex- empt from any diathetic manifestation during a time suf- ficiently prolonged, and that this lapse of time, which I designate as the period of immunity, pass without any specific symptom, without any outbreak of the syphilis. Now, this period of immunity constitutes a necessary, indispensable guarantee for admissibility to marriage for several reasons : In the first place, it has a significance. It proves that the diathesis has passed its acute stage, I mean that especially formidable period where the syphi- litic outbursts succeed each other at short intervals, some- times without remission, and which are no less dangerous from their number than from the contagious quality of their manifestations. In the second place, this time, more or less lengthened, passed without accidents, permits us to 96 SYPHILIS AND MARRIAGE. judge of tlie degree of amelioration of the diathesis. It is an evidence of the non-activity, of the actual sedation of the diathesis. Without doubt, it is possible that the absence of accidents during a certain j)eriod may be only a truce granted by the disease, which, after a certain time, will reassert all its rights. But it is possible, also, in cases where treatment has been vigorously employed, that it may be the commencement of a definitive peace. Why should it begin, if it be not actually a definitive peace ? At all events, it is undeniable that a prolonged immu- nity constitutes a good sign — a sign which corresponds to an arrest of the disease, which attests its decrease, its decline, at least provisionally. And if this favorable con- dition be strengthened by the additional guarantee of a sufficient medication, there is reason to hope that the di- athesis has definitively imposed silence upon all further manifestations. Security is then acquired for marriage. So true is all this, that a prudent physician will never permit a syphilitic subject, who has recently had syphilitic manifestations, to marry. For my part, I never allow one of my patients to marry soon after any specific accident whatever, no matter how trifling it may have been. And this for two reasons : first, because the occurrence of any syphilitic accident proves not only that the diathesis con- tinues to exist, but that it exists in full activity ; and, in the second place, because, in such cases, it is impossible to predict what may follow. Are not other morbid determi- nations about to arise in the near future, or is a calm about to ensue ? Time alone can decide this question. To wait is, then, the rigorous rule in such a situation. On the con- trary, if a patient comes to me saying, " It now is two years, four years, six years, ten years since I have exx^erienced anything," this long silence of the disease puts me quite PROLONGED PERIOD OF IMMUNITY. 97 at ease. I perceive that I have to do with, a diathesis in process of sedation, with a diathesis which has passed its active stage, which will not reproduce those secondary phases so dangerous as regards contagion, heredity, etc. Consequently, my apprehensions, so far as relates to mar- riage, are by so much diminished. I will add that this period of immunity will satisfy me much better still, if it has coincided with a prolonged suspension of specific treatment, for then it assumes a much more significant import ; it testifies that the disease, even when left to its own course, and independently of all repressive influence of treatment, has shown no tendency to reproduce its manifestations. And this is not with- out an important interest for us. We know, in fact, that there are certain cases of syphilis, which, at the same time tractable and rebellious to the action of our remedies, seem to be cured when they are treated, only to burst forth anew soon after the suppression of treatment.'-^ "We must distrust this class of cases, and not forget that an immu- nity prolonged, without any tlierapeutic intervention, * There are, without doubt, certain cases of syphilis in which one can not, so to speak, relax the treatment beyond a certain time without the occurrence of a new outbreak. So long as they are subjected to specific treatment they remain inactive. But let this treatment be suspended, and almost immediately — or, at least, after a certain time — they develop new symptoms. It will be necessary to always continue treating them, in order to keep them quiet. Now, from our present point of view, what guarantee does an immunity due to & permanent therapeutic influence afford in such cases ? Should we allow a patient affected with a syphilis of this kind to marry, basing our decision upon the twofold guarantee of a long immunity and a protracted treatment ? But it may happen that, so soon as the treatment is sus- pended, new accidents may be produced, with all their consequent dangers. Then, indeed, the marriage should not be tolerated, except in the special condition that a long period shall have passed without accidents, and that, too, loithout any thera- peutic intervention. The forms of syphilis to which I have just alluded are not absolutely rare. It is necessary to distrust them when met with in practice, as long as they preserve their active characteristics and their tendency to continued recurrences. 98 SYPHILIS AND MARRIAGE. alone constitutes a veritably substantial guarantee with relation to marriage. This point stated as a principle — viz., the necessity of a certain period of complete immunity before marriage — I anticipate that here again, as before, you are about to demand the figures of me, to insist upon a precise length of time, and say, "What, then, in your opinion, ought to be the exact duration of this period of immunity, of this sort of probational stage which you requu-e of your patient?" Now, here again, as before, I can only partly satisfy you. I must confine myself to answering only what I am justified in answering, viz., that — 1. It would be impossible to lay down a fixed, precise term. One must, from the very nature of such questions, depend upon approximative averages mthin sufficiently wide limits. 2. The longer this period of immunity, the more reas- suring will it be in every respect, especially as affecting the question of marriage. 3. Finally, in order to fix a minimum, I conclude, from my personal observation, that it would be imprudent to reduce this period of complete immunity to less than from eigliteen months to tioo years. Eighteen months to two years passed without any accident, without any awaken- ing of the diathesis, seems to me a strictly necessary minimum which should be rigorously required of every syiDhilitic subject before allowing him to marry. Moreover, let us note well that the duration of this stage of morbid immunity naturally rests subject to varia- ble conditions. It should be longer or shorter with differ- ent patients, and the physician's duty will be to proportion it to the exigencies of each particular case. It is evident, PBOLONOED PERIOD OF IMMUNITY. 99 for example, that we shall be justified in extending it longer if the most recent accidents presented by the patient have been of a serious nature ; or, again, if the diathesis, in general, has assumed a threatening character. And, conversely, also, we can depart from such a severity in cases where the conditions are directly opposite. But I perceive that we are about to encroach upon the fourth point of my programme with considerations of this kind. Let us reserve them for the next section. Fourth condition : Non-meistacing character of the DIATHESIS. Evidently there is syphilis and syphilis, as has been so often said and repeated, especially in our day. There is, unquestionably, a 'benign sypliilis and a gram sypJiilis. There are light, benign cases of syphilis, which, how- ever little they may be subjected to treatment, limit their manifestations to a small number of external, superficial, and unimportant accidents ; while there are, also, grave cases of syphilis, which, although systematically and energetically treated, none the less determine serious and important manifestations — doubly important both on ac- count of the number and of the character of their acci- dents. JN'ow, the quality (permit me the word), the quality, I say, of the syphilis with which a patient has been affected is far from being without interest in deciding the special question which now engages our attention. Quite the contrary ; it has a superior significance in this matter — a significance very essential to appreciate, and to which there is reason to attach great importance in the solution of our problem. And, in fact, given the case of a patient who comes to 100 SYPHILIS ANI> MARIilAOE. ask our advice upon the propriety of marriage, if tlie syph- ilis with which he has been affected has been only average or light, if it has been limited to a small number of crops, if the accidents composing these crops have been super- ficial and benign, if the diathesis has shown itself tractable to treatment, and readily and rapidly amends under the influence of therapeutic agents, we have here, unquestion- ably, so many excellent conditions which ought to influ- ence our judgment favorably. This ensemble of benignity is well adapted, assuredly, to insi^ire confidence, and in- duce, the physician to depart, almost in spite of himself, from the severity usually necessary in so serious a situa- tion. The past seems here a guarantee of the future, and compels, if I may thus express it, his acquiescence in the marriage. Indeed, this is only Justice, for, according to experi- ence, the progTiostications of good augury deduced from antecedents so favorable are almost always confirmed by subsequent developments, especially when the patient counts among his assets a long and careful treatment. Nevertheless, one should not go too far in this direc- tion. Certainly, an original benignity of a syphilis con- stitutes a favorable condition for marriage, but it con- stitutes no more than this ; it does not, of itself alone, sui^ply the place of the other requirements of the complex programme which we are studying. To trust to this alone, in permitting marriage, would be a grave impru- dence, which would lead to the most unhappy conse- quences ; and I regret to say that, in practice, this imprudence is too frequently committed, the proofs of which I have in my possession. I shall not hesitate to insist upon this point, and I repeat that, however benign may have been a syphilis in its earlier stages, one is not NON-MEFAOma GEARAGTER OF TEE DIATEE8I8. 101 anthorized by tliis fact alone, by this sole condition, with- out more ample investigation, without requirements of another kind, to permit marriage. In spite of this benig- nity, which I have just recognized, and the importance of which, from our present point of view, I again affirm, it is, in my opinion, no less necessary that the patient fully satisfy other general conditions to which every syphilitic candidate for marriage is subject. This is indispensable, and here is the reason : On the one hand, experience teaches us that cases of syphilis, originally benign, may reveal themselves, more or less tardily, by severe manifestations, if they have not been subjected to an' active and prolonged treatment. And it has been often seen that a syphilis of this kind negligently treated, on account of its apparent benignity, becomes later on singularly dangerous in marriage from the double point of view of contagion and Tieredity. On the other hand, and this is no less important, these same cases of syphilis, inoffensive in appearance at first, nevertheless present a dark outlook for the future, and this dark outlook (permit me the expression) relates to the personal risJcs of the liusband. I will explain my meaning. It is now thoroughly proved — (and you will do me the justice, I trust, to admit that I have contributed in part to this important demonstration) — it is to-day well proved, I say, that the initial benignity of a syphilis by no means constitutes an absolute guarantee for the future. Such a syphilis, although beginning well, is no less liable on that account to end badly. ^ It is thus very frequently that * This is a point upon whicli I do not cease to insist in all my courses of lec- tures. I have studied and developed it at length in my Legons sur la syphilis chez lafemme^ and in this work will be found a long series of observations relative ta 8 102 . SYPHILIS AND MARRIAGE. one observes patients who, while presenting at the debut of the diathesis only slight, almost insignificant secondary- accidents, are affected after a long interval — ten, fifteen, or twenty years later, with the most severe tertiary manifes- tations. Cerebral syphilis, for example, as I have shown in a recent publication,'^ seems to affect from preference subjects with specific antecedents of an unusual benignity. It is likewise the case, as I hope to show you soon, with syphilis of the spinal cord. And, besides, gentlemen, I am now preaching to those who ought to be converts, for I am speaking to the pupils of the Saint Louis, of the hospital which is the chosen refuge of old syphilitics. Now, do we not encounter here, almost daily, patients affected ^dth tertiary lesions of every character, and with tertiary lesions unfavorable in prognosis local or general, yet whose syphilis commenced the most light, the most benign, the most favorable in appearance ? So true is this, that among numbers of them we have great difficulty even in determining the original date of their disease — a date almost forgotten, not only by reason of its chronological distance, but by reason of the trifling importance of the accidents which signalized it. Those curious cases of syphilis which, after having been characterized by a singular initial benignity, have finally ended in the gravest accidents, have been discussed at length. For my part, I see nothiDg extraordinary in them ; and I consider them simply cases of syphilis which, patients who, presenting at the debut of the diathesis only the shghtest and most benign accidents, have afterward experienced the severest forms of the tertiary stage, p. 1012. * La syphilis dn cerveau, clinical lectures recorded by E. Brissaud, Paris, 1879. M. Broadbeut professes a similar opinion. " From the cases which I have seen," he writes, " I have formed this opinion, viz., that the subjects most exposed to accidents of the nervous system are those in whom the secondary symptoms have been transitory or light." NON-MENAGINQ GEARACTER 01 TEE DIATEESIB. 103 having been insufficiently treated, on account of their ap- parent benignity, have afterward resulted in those acci- dents vv^hich every syphilis not treated may determine. At all events, from the foregoing facts we may deduce this definite and important conclusion, viz. : that the ini- tial benignity of a syphilis does not constitute a pledge of security for marriage, if it he not joined with addition- al guarantees— notably that of a sufficient treatment. After these remarks upon benign syphilis, we come now to the study of syphilis of a directly opposite character. There is, I have said, a bad syphilis for marriage. This bad syphilis (I retain the word and explain it) com- prises all those cases which, from various causes, are more liable than others to become dangerous in marriage. What are they? They are numerous and of various orders. I can not enumerate them all, for one can not foresee them all, and the particular cases are multiple and infinitely variable. But I will cite here the principal ones, those which it is essentially important to recognize, in order to distrust them, in order to guard against them in the solution of the problem which we are now studying : 1. In the first place, bad for marriage are certain cases of syphilis which, without being severe, present an un- usual tendency to continual reproduction — to a ready, repeated, and almost incessant multiplication of various accidents of the secondary stage, notably erosions of the mucous surfaces. It is thus that certain subjects remain exposed during many consecutive years, sometimes even in spite of the best regular treatment, to erosive lesions, localized espe- cially in the mouth, affecting more rarely the genital mu- cous surface. These lesions are always superficial, limited, benign ; they are cured with the utmost facility under the 104 , SYPHILIS AND MARRIAGE. influence of cauterization, aided by certain local attention, but tliey are cured only to be reproduced, to be incessantly renewed. Intrinsically, tliey are of no importance ; but, for all that, they are none the less dangerous as regards contagion. Such is the case, for example, of a patient that I have been treating for a long time. This young man has been affected for five years with a syphilis which one would be justified in classing as benign, since, after the initial chancre, it has never shown itself except by a roseola, a palmar syphilide of light intensity, and buccal mucous patches. He has been under treatment almost from the debut of the disease, and quite regularly. Several times he has been subjected by me to an active mercurialization (fifteen to twenty centigrammes of the proto-iodide daily). Now, despite this treatment, despite all my efforts, this patient (who is a smoker, a circumstance essential to note) has not for five years past ceased to be affected with lingual syphilides, with repetitions almost unremitting, I cure him of one crop ; a month or two later a new crop invades the tongue, Tlien, new treat- ment, new cure ; then, rapid return ; and so on in succes- sion. In brief, I always cure him, and "always have to begin again," according to his o"\vn expression. After long resistance, upon my earnest entreaty, he entirely re- nounced the use of tobacco. The crops then became less frequent, but did not entirely cease. And, recently, I have again seen him, with the syphilides covering almost the whole dorsal surface of the tongue. Now, what would have happened if I, trusting to the comparative benignity of this syphilis and the activity of its regular treatment, had allowed this patient to marry in the interval between two crops of these accidents % I have NON-MENAOINa CHARACTER OF THE DIATHESIS. 105 not to predict, theoretically, wliat would have happened, for I have had a practical demonstration. This young man last year took for a mistress a young vt^oman until then perfectly healthy and free from every venereal acci- dent. Some weeks later he brought her to me affected with an indurated labial chancre, a chancre evidently derived by contagion from the lingual syphilides of my patient. 2. Equally bad for marriage are the numerous varieties of syphilis which, in various respects, one may character- ize as grave : grave it may be on account of the multiplici- ty and intensity of their accidents (precocious, malignant syphilis, for example) ; it may be on account of the nature of their manifestations (ulcerations, deep, extensive, pha- gedenic, menacing, etc.); it may be on account of their precocious tendency to the visceral form, or, more gener- ally, to morbid determinations which ordinarily occur only in an advanced age of the diathesis ; it may be on account of the reaction which they exert upon the consti- tution, the nutrition, the health (syphilis of an asthenic, depressive, innutritive form, etc.) ; it may be on account of their character of obstinacy to treatment ; it may be, finally, on account of such or such other peculiarities, in- finitely variable, but all presenting this common quality, all unequivocally testifying to an unusual intensity, to a real malignity, even, of the diathesis. 3. Bad again, more particularly from the same point of view, are those cases of syphilis which elect for their morbid determinations some important organ, such as the eye, the brain, the spinal cord, etc. The cases of syphilis with ocular localizations, for ex- ample, are very often remarkable for their obstinacy, for their tenacity, for their relapses after cure, and altogether 106 SYPHILIS AND MARRIAGE. by the serious functional troubles whicli they leave in their train. ISTumbers of times have I seen them result in com- plete blindness, despite the most energetic treatment and the efforts of the most skiLTful ophthalmologists. What is to be said of cerebral syphilis ? Every locali- zation of the diathesis toward the brain presages the most serious results both for the present and for the future. To be sure, a cerebral syphilis, even though very grave, can be cured ; I have cited examj)les of this. But, in the first place, how can it be cured ? At the price of a most active treatment — of a treatment which must be pro- longed, which must be resumed after the cure many and many times ; and more, at the price of a s^Decial hygiene, upon which I have elsewhere insisted at length, and which requires an observance almost indefinite in duration.* Then, the cure obtained, there still remains the chapter of recurrences, and recurrences in this form of the disease are the most common, and at the same time the most serious. Many a patient, who resists the first assault of the diathesis upon the brain, succumbs to a second or to a third. These recurrences are so habitual that they almost constitute the rule f — hence, in all other respects, as well as in relation to the question of marriage, the particularly serious prognosis of every cerebral manifestation depen- dent upon syphilis. So, when consulted upon the propriety of marriage by a subject who gives a history of such or such symptoms of cerebral syphilis in his specific antecedents, the physician ought more than ever to be armed with prudence and firm- ness. In my opinion, from my own observation, every spe- cific manifestation toward the brain constitutes an almost express interdiction to marriage by reason of the future * V. Syphilis du cerveau, p. 590. f Vide same work, p. 628. NON-MENACma CHARACTER OF THE DIATHESIS. 107 consequences to which it leaves the patient exposed. For my part, I would most energetically dissnade from all de- signs of marriage any man who, even though cured of his syphilis, had disclosed to me undoubted accidents of specific encex3halopathy in his past history, such as an epileptiform attack, an apoplectiform stroke, hemiplegia, mental affections, etc. Such accidents are, in my opinion, ^^oluielj incompatible with marriage. I will not even discuss the supposition of a possible marriage under these conditions. But if, nevertheless, the diathesis, although positively affecting the brain, has limited itself to the most super- ficial expressions, to the lightest, most benign functional troubles, then only should I consider myself justified in departing from an absolute interdiction. But, even then, I should not grant my consent until after a mature analy- sis of the clinical features, and the fulfillment of certain express conditions, such as the following : if the patient is absolutely cured of every cerebral trouble ; if he has been a long time cured— that is to say, several years at the minimum ; if, since then, no new accident, however slight, has occurred ; if the most energetic treatment has been followed since the cure ; if a long period of immunity after the suspension of the treatment appears to prove a com- plete cure, etc. And still — I confess it — even in spite of these guarantees, it would be not without a secret appre- hension — it would be only reluctantly, and with a veri- table regret — that I should allow, upon my ovyTQ. respon- sibility, a patient who had been affected with such acci- dents to engage himself in marriage. In this matter, gentlemen, you will perhaps say that I am very strict. But I will reply to you, once for all, that we must be strict now or never when it concerns (1) an 108 SYPHILIS AND MARRIAOE. optional act sucli as marriage, to which, no one is com- pelled except by his own free will and his individual con- venience ; (2) of multiple and important interests involving the future of an entii^e family. At all events, I do not thus speak to you without being authorized to do so by lamentable and painful examples. Such are the two fol- lowing, among many others, which I desire to make known to you : A young man, syphilitic for nine years, having pre- sented only slight specific accidents, and never having been treated, except in a very insufficient manner, sud- denly experiences symptoms of a cerebral character. One day, in hunting, he perceives that he can no longer carry his gun in his left hand. His left arm, without being completely paralyzed, has become suddenly inert, be- numbed, "half dead." An energetic treatment (mercu- rial fi'ictions and iodide) is resorted to immediately, and promptly corrects these accidents. The year following, there is a return of the same symptoms. After many rejDe- titions of the same kind, he experiences an embarrassment in the use of his tongue, with sputtering and stammering, and a difficulty in finding and articulating words. A new treatment of the same kind, and all disappears. The pa- tient then writes to me to consult me uioon the subject of a marriage which is proposed to him. I strongly advise him to let such projects di'op. I^otwithstanding, he goes his own way and marries. Now, ten days after his mar- riage he is suddenly seized with cerebral accidents of the utmost gravity : apoplectiform stroke, hemiplegia, com- plete amnesia, intellectual troubles, etc. In spite of treatment, all these phenomena persist, and become aggravated. Progressive intellectual depression, general enfeeblement, death from dementia six months later. NON-MENAOma GHABAOTEB OF THE DIATHESIS. 109 Second case, almost identical with the preceding. A young man, syphilitic since 1863, is taken in 1870 with a violent attack of cephalalgia, with incomplete paralysis of the third pair (external strabismus, mydriasis, diplopia). I treat him, and I have the happiness to cure him rapidly. At this time he leaves Paris, and I entirely lose sight of him. In the country he marries, in opposition to the ad- vice of one of my former pupils, consulted upon this sub- ject. Some years later (in 1875) I am again summoned to see him, and I find him in the most lamentable situation : left hemiplegia, amnesia, psychic troubles, hebetude, etc. A vigorous treatment is then instituted, and pursued for a long time. The patient' s life is saved, but he remains with his left arm weakened and his intellect enfeebled. ]N"o longer capable of managing his affairs, he has liquidated his business, not without great material losses ; so that to- day, with a wife and two children in his charge, he vege- tates in a situation the most deplorable, almost allied to misery. What I have Just said of syphilitic aifections of the eye and the brain as so many contraindications to marriage, I could repeat literally respecting the specific lesions of the medulla, which also are specially remarkable for their ob- stinacy, their recrudescences, their recurrences, and which also frequently terminate in the most serious infirmities. To convince you of this, I would recall the case of the un- fortunate patient now lying in bed N"o. 27 of Saint-Louis ward. Affected at three different times with paraplegic symptoms, which depend, from all the evidence, upon an old syphilis, he recovered three times, thanks to an ener- getic treatment, prescribed in turn by M. Yidal, by M. A. Guerin, and by myself. A fourth time within the past year the same accidents are again renewed, but with an no SYPHILIS AND MARRIAGE. added intensity. So that, despite a most active medica- tion, notwithstanding all that I can do for him, the pa- tient finds himself to-day in a situation almost absolutely desperate, even under the menace of a fatal termination that can not be long delayed. After these different examples which I have just cited, it would be useless, I think, to continue this enumeration. The foregoing facts ought to suffice amply for the demon- stration of the proposition which I wish to establish, viz., that a certain kind of syphilis, and even a certain class of syphilitic symptoms, are of a nature to make the physician very circumspect and very strict in the verdict which he is called upon to render as to a syphilitic' s fitness for marriage. One of the essential elements of such a verdict lies, as we have Just demonstrated, in the appreciation of the in- trinsic prognosis of each particular case — in the exact determination — at least as exact, as precise as possible — of the quality of the syphilis which affects the patient, who comes to seek our advice and submit his destinies to our direction. It is, then, the business of the man of art, in such cir- cumstances, to inform himself as thoroughly as possible upon his patient's antecedents and upon the nature of the accidents which he has presented. It is his business to prepare from a careful and minute inventory what I will call t\LQ pathological balance- slieet of his patient, to judge of the quality of the diathesis under observation ; then, this analysis made, to decide finally whether, from a med- ical point of view, there is reason to consider said diathesis dangerous for marriage or not. In this matter there are no general rules to lay down ; for here all depends upon the individual case and the par- NON-MENACING CHARACTER OF THE DIATHESIS. HI ticular circumstances whicli surround it, and all remains subject to the knowledge, to the tact, to the experience of the physician. Here is the true clinical aspect of the problem, and I need not speak of the considerable importance which attaches to it CHAPTER X. SUFFICIENT SPECIFIC TEEATMENT. Fifth Condition : Sufficieistt Specific Treatment. — A treatment sufficiently prolonged, a treatment sufficiently protective, sncli is the fifth and last condition of our pro- gramme. And this, certainly, is the great condition par excellence. For, after all, in the problem which we are studying all converges, all reverts to this question : a syphilitic patient aspiring to marriage, is he or is he not sufficiently well cured of his diathesis to be no longer dan- gerous in marriage ? From this point of view the ques- tion of the admissibility to marriage of a syphilitic subject is almost equivalent to the cure or the non-cure of his dis- ease. We shall not, in consequence, have to spend much time in demonstrating that which no longer requires to be demonstrated — that which is to-day accepted by every one, viz., that the treatment termed specific does in a general manner diminish and avert the dangers of syphilis. "\Vhence results this quite natural corollary concerning our subject : specific treatment diminishes or averts the dangers of syphilis in relation to marriage. It confers upon a patient formerly affected with syphilis the most valuable and the most substantial guarantee of his fitness for marriage. This proposition will find its proofs in the several con- siderations following : SUFFICIENT SPEOIFIG TREATMENT. 113 I. In the first place, according to all evidence, specific treatment constitutes the best safeguard, the surest guar- antee against the personal risks which affect the husband in the relation of marriage. To be convinced of this, it suffices to compare, in an advanced stage of their evolution, cases of syphilis treated and cases of syphilis not treated/' Exception made of certain cases which baffle all our therapeutic efforts, one may say that a syphilis treated (I mean treated with method, energy, and perseverance) will not have a tertiary period. Beyond a variable number of initial crops, it produces nothing more ; it becomes and remains quiet, and the patient, henceforth exempt from accidents, seems to have been restored to the ordinary conditions of health. Quite on the contrary, syphilis treated insufficiently, or not at all, terminates certainly, constantly, in grave ter- tiary lesions at a period more or less advanced. The tertiary period is the time of maturity, when the indifferent, negligent syphilitic pays his accumulated debt to the disease, and " the pox," as M. Ricord has said, "is a pitiless creditor, and grants grace to no one." What examples of this kind have you not here under your eyes ! What of tertiary lesions here in our wards ! And almost all consecutive to cases of syphilis carelessly treated in their early stage, or even (which is not rare) absolutely undisturbed by any treatment. But we leave the consideration of this point, which, I repeat, is now admitted by every one, save very rare and almost unaccountable exceptions. * See upon this subject, in my Legons sur la syphilis chez lafemme, a long chap- ter devoted to a parallel drawn between the cases of syphilis treated and those not treated. I think I have there demonstrated — as so many others have done — the inestimable benefits of a systematic treatment, no less than the disastrous conse- quences of a system of expectation when applied to the pox (p. 1052, and following). 114 SYPHILIS AND MARRIAGE. II. It is no less evident that specific treatment dimin- ishes and suppresses the chances of contagion in marriage. In effect, a large majority, if not all, patients submitted to specific treatment very quickly acquire an immunity. Look at what takes place in every-day practice. A pa- tient comes to us in the full secondary stage, and we sub- ject him to the usual treatment. What is the result, at least nineteen times out of twenty ? In the first place, the patient remains subject during the course of the first few months, sometimes even during the first year, to secondary crops, more or less numerous, more or less intense, accord- ing to the quality of the diathesis, but, generally, they are lessened and rendered milder by the treatment. Then, afterward, from about the second year, the crops com- mence decreasing ; they are limited to a few isolated and benign manifestations — for examiDle, to certain buccal ero- sions. Then, again, later on, the calm becomes more pro- nounced ; it becomes complete with the third, or, later, with the fourth year. After that time it is all over with the secondary period ; and with it are finished those con- tagious accidents which it comprises, and which constitute the principal danger relative to marriage. Such is the rule. That there are exceptions to this rule I know only too well, and I have given examples of them previously (vide page 104). But these exceptions are always rare ; and, moreover, they belong to that class of cases which I have pointed out to you as constituting the contraindications to marriage. III. In the same way, finally, specific treatment dimin- ishes and suppresses the Jiereditary risks of syphilis. In the first place, this is superabundantly demonstrated in the case of paternal hereditary syphilis. Recall, as SUFFICIENT 8PFGIFIG TREATMENl. 115 examples, those very convincing cases of wMcli I liave previously spoken to you, a^nd whicli may thus be recajjit- ulated : A healthy woman aborts many times in succession without cause and without explanation. We become un- easy ; we search for the wherefore of these successive abortions, and we find no other possible explanation than the syphilis of the husband. Empirically, the husband is then submitted to a severe specific treatment. Wew preg- nancies occur, and these terminate altogether favorably — that is to say, they produce at full term healthy children. What more convincing ? Now, this favorable effect of treatment is no less evident upon both maternal heredity and the mixed heredity of the parents. And here you will pardon me a short digres- sion, which, though separating us a moment from our ■present line of inquiry, will shortly find its application. Specific treatment, I say, corrects v/ith equal effective- ness the influence of maternal heredity. In proof of this, innumerable cases are seen where syphilitic women begin by having several abortions, or by bringing forth syphilitic children ; then, after having been submitted to a specific medication, they bring forth at term living and healthy children. The cases of this kind are so common and so numerous, that I think in truth it would be useless to stop here for particular citations.'^' Sometimes, again, the influence of treatment upon ma- ternal heredity reveals itself in a much more striking manner, on account of the peculiarities of certain partic- ular cases. Such is, for example, the following case : A * Example : A woman contracts syphilis, and then has eight miscarriages, with- out being able to carry an infant to term. She submits herself to a prolonged mercurial treatment, again becomes enceinte, and is delivered at term of a well- developed child, which is now five years old, and has never exhibited the slightest trace of syphilis (Notta, memoir cited). IIG . SYPHILIS AND MARRIAGE. young woman receives sypliilis from her first husband, and is treated in a very ephemeral fashion. Left a vs^idow, she is married again to a healthy man, and by this hus- band conceives several children, that either die in utero^ or are born syphilitic. She is then treated, and after treatment she brings forth only healthy children. In the third place, the influence of treatment upon mixed Jieredity is still more often confirmed in practice. Not unfrequently the following order of events is en- countered : Two syphilitic parents begin by engendering a succession of children, all of which either die before birth or are born syphilitic. The parents are then treated. Consecutively to this treatment they i^rocreate other chil- dren, which are born at term, living and healthy. One may often trace in a series of consecutive pregnan- cies the progressive influence of treatment — when each pregnancy is marked by a step toward a cure. I have col- lected many facts of this kind, among others the following : A young man marries, notwithstanding a still recent and very negligently treated syxDhilis. His wife, almost immediately infected, aborts some months later. The two parents then commence to be treated in earnest. There succeed four pregnancies quite close to one another, which terminate as follows : 1. Accouchement before term ; child still-born. 2. Accouchement at term ; child syphilitic, dying some days later. 3. Accouchement at term ; child syphilitic, but sur- viving. 4. Accouchement at term ; child healthy. But this is not aU ; and here should be noted a fact of twofold significance, which has not been as yet, it seems to me, sufficiently remarked : SUFFICIENT SPECIFIC TREATMENT. 117 1. It is not necessary, in order tliat syphilitic parents procreate healthy children, that the diathesis be annihi- lated in these parents. In other terms, and to speak more clearly, it may happen that the offspring of syphilitic parents may be born healthy, altJiougJi tJieir parents are still under the impress of tlie diathesis^ which is proved by the appearance of specific accidents npon them sub- sequent to the birth of their children. This is incontest- able, so far as relates to the father, as we have previously shown.* It may be likewise demonstrated as regards the mother. As an example, see one of our present patients, in bed ]^o. 31, in St. Thomas's ward. This woman entered the hospital affected with a sclero-gummatous glossitis, the origin of which dated back three or four months. Now, her last child, aged fourteen months, has never presented the least suspicious accident ; it is a very fine child, ab- solutely healthy, as you have been able to, and may again, convince yourself by sight. Likewise, a young woman among my patients, who became syphilitic from contact with a syphilitic husband, has had two children absolutely healthy, although after each one of her confinements she has been affected with a very intense eruption of squamous syphilides.f * Yide page 36, and Illustrative Cases, Note I. ■{■ Here is a summary of this curious case : X., twenty-two years old, vigorous constitution. At twenty years married a man affected with a recent syphilis. First pregnancy in 1868. Secondary accidents toward the fifth month (erythemato- papular syphilide, buccal and vulvar syphilides, alopecia, cervical adenopathies). Energetic treatment with mercury ; accouchement at term ; child healthy ; con- tinues so ever since. Two months before accouchement, psoriasiform annular syphilide, occupying the lateral surface of the left foot. Ecthyma of the left leg ; mercurial and iodide of potassium treatment. Second pregnancy in 1872; accouchement at term; child healthy; continues well to this day. Three months before accouchement papulo-squamous, psoriasi- 9 118 SYPHILIS AND MARRIAGE. 2. In order that a child be born healthy of syphilitic parents, it may suffice that these parents are being sub- jected to mercurial influence at the time of its procreation. However singular, however paradoxical, and, above all, however inexjDlicable, such a fact may at first glance ap- pear, it would seem to be evident from a certain number of well-authenticated cases. Such is, for instance, a case mentioned by Turhmann (de Schoenfeld), and w^hich is briefly as follows : A syphilitic woman first of all has seven pregnancies, during which she is not treated. Seven times she gives birth to syphilitic children, which soon die. Becoming pregnant an eighth and a ninth time, she is treated during the course of these two pregnancies, and each time she is delivered of a sound, healthy infant. A tenth pregnancy ensues ; this time the patient is not treated. She is delivered of a sypJiilUio child, which dies at six months. Finally, an eleventh pregnancy, in the course of which treatment is resorted to, results in a TieaMliy infant.* Had this case been fabricated out and out, imagined theoretically to meet a necessity, it could not, in truth, have been more convincing. For my part, I have already among my notes certain observations of the same kind relative to syphilitic par- ents who have alternately engendered healthy children, at a time when they were subjected preliminarily to a specific treatment, and syphilitic children during a period when they were not being treated, f form, circinate sypbilide, constituting a ring of large diameter upon the dorsal aspect of left foot. Resumption of treatment ; cure of the accidents. * Vide Gazette Medicale, June 24, 1843. f The same fact has been likewise remarked by M. Kassowitz {Die Vererbung dcr Si/philis, Vienna, 1876). Among a number of observations testifying in the same way, I will cite the following, which is accompanied with all possible guarantees SUFFICIENT 8PEGIFIG TREATMENT. ' 119 It would seem, then, from this, that even the temporary influence of treatment may sufiice to avert for the time being the effects of syphilitic heredity. Such, at least, would be the conclusion to be drawn from the preceding cases. But I am not willing to give you this last conclu- sion as an absolutely demonstrated fact. More prudently, I restrict myself to presenting it to you as a subject for further study — very interesting assuredly, already ren- dered probable by certain observations apparently well authenticated, but still lacking in a sufficient number of guarantees to assure it the right to be cited as a scientific fact. All the considerations which precede concur in many ways in establishing the modifying, corrective, depurative influence which treatment exerts upon the diathesis. And the natural conclusion which results from all this, as far as we are specially concerned, is that — The essential^ capital condition to he fulfilled by ewry sypTiilitic subject aspiring to marriage consists of authenticity : A young workman marries in the third year of a syphiUs quite vigorously treated. His wife becomes enceinte after some months, and toward the end of the first half of pregnancy begins to present symptoms of secondary syphi- lis (roseola, neuralgias, mucous syphiUdes, alopecia, etc.). She is submitted to a very active treatment, and accouches at term. The infant is born syphilitic, and dies of consumption when one month old. The young wife continues to be treated and becomes enceinte five months later. She is delivered of a fine child, which, very carefully observed, remains exempt from every suspicious phenomenon, and is to-day in perfect health. Reassured as to the condition of this woman by the fact of her giving birth to a healthy child, her physician does not treat her any more. She becomes enceinte a year later and aborts. New pregnancy some months later ; another abortion. Two years later a fifth pregnancy ensues ; birth at term, of twin children, both syphilitic. Even supposing that the influence of treatment gives occasion for dispute in this case, the fact no less remains established, by this and similar observations, that a syphilitic woman may alternately engender syphilitic children and healthy childre7i. This is an actual fact, which forces itself on the conviction, however strange and para- doxical it may appear. It remains for us to find its explanation ; but it is only upon the explanation, and not upon the fact itself, that there can be differences of opinion. 120 . SYPHILIS AND MARRIAGE. in a tliorougTi specific treatment., in a treatment sufficient to confer a complete immunity from tlie multiple and diverse dangers whicTi syphilis carries with it in mar- riage. In order tliat a sypMlitic j)atieiit may have the moral right to become husband, father, and support of a family, it is necessary, it is indispensable, that he shall, by virtue of a treatment suflBiciently protective, have ceased to be dangerous to his wife, his children, and himself. But what is this treatment, ^'■sufficient, sufficiently protective,'''' to which we are constantly referring as our best safeguard ? This, gentlemen, I have gone over with you at length in a former series of lectures, tracing for you in detail the rules for the treatment of syphilis, such, at least, as I comprehend them ; such as they have been taught to me both by my masters and by my personal experience.* At present, then, I have only to refer you to these lectures, a portion of which has already been given for publica- tion, and which you may consult at leisure. I will limit myself to-day to only reminding you in quite a brief manner that a treatment worthy to be characterized as " sufficient " is this : 1. A treatment which is based upon the administration of the two great remedies which, with just reason, are commonly called the "specifics for the pox," viz., mercury and iodide of potassium. 2. A treatment which is based upon the administration of these two remedies in doses veritably active and cu- rative, very different from the insufficient, timid, indiffer- * Du traiiemcnt de la syphilis (lectures delivered at tlie Saint-Louis Hospital). In press. SUFFICIENT SPEGIFIO TREATMENT. 121 ent, almost inert, doses in which, according to traditional routine, they are most often prescribed. 3. A treatment which is prescribed and regulated ac- cording to a certain method, which has for its aim and result to conserve for these remedies, notwithstanding their prolonged administration, their primitive intensity of action (called the system of intermittent or successive treatments).'^ 4. A treatment which, in these conditions, is rigorously pursued during semral consecutive years — at the mini- mum, three ovfour years. I especially insist upon the importance of this last point, and I say, a chronic disease^ in effect, requires chronic treatment. Such is the absolute general law. Long, very long, should be the medication, if we are not content alone with a present effect ; if we desire to obtain a complete, thorough, permanent cure. According to experience, it is false, absolutely false, that one has "finished with the pox" after a treatment of some months, of one year, of two years even (the extreme limit which is scarcely surpassed ordinarily). Treatment of this kind furnishes nothing more than a provisional immunity, a temporary silence of the disease, leaving the diathesis in full force, with all its future dangers, with the * Vide LeQons sur la syphilis etudiee plus particulierement cliez la femme. Paris, 1873, p. 1087, et suiv. A fact, of which experience has absolutely convinced me, is that mercury and iodide of potassium, when administered for a long time, and without intermission, singularly lose their efficacy. The continued use of these two remedies, as well as of many others besides, creates a tolerance which enfee- bles, lessens, and ends by annulling their therapeutical effects. On this account I was forced to devise for my patients a method of treatment which should conserve the full intensity of therapeutic action of both the mercury and the iodide during the entire duration of treatment. This method I have exposed at length in my teachings under the name of ihe method of successive or hitermitteni tr-eatments. I think I am authorized jp saying that it has been of real service in practice, and I commend it to the attention of my confreres. 122 SYPHILIS AND MARRIAGE. certain immineiice of tertiary accidents at a subsequent period. Treatment of tliis kind, I may say, is to-day con- demned by its numerous deplorable results. It is, indeed, liigli time to renounce, once for all, these curtailed medi- cations, to approacli tlie pox from tlie same therapeutic point of view as we do other constitutional diseases, such as scrofula, gout, malaria, etc., which are, by common consent, curable only by a long-protracted treatment, only by a series of successive cures, only by the repeated, al- most chronic, intervention of the remedies appropriate to combat them. For my part, I consider myself authorized to assert, from my own experience, that in no case should the dura- tion of an anti-syphilitic treatment fall below three or four years, with whatever form of the disease we may have to do, however benignly the diathesis may have been origi- nally announced. Three or four years methodically de- voted to an energetic medication — such, in my opinion, is the necessary minimum, I will not say to cure the disease, but to avert its dangerous manifestations both for the present and for the future. Again, it is prudent that, after this term, the patient submit himself from time to time — every two or three years, for example — to a new iodide treatment, so as to keep the diathesis incessantly in check, if I may thus ex- press it, and to hold the ground gained. Combined with time, the specific treatment of the diathesis constitutes certainly the hest guarantee in favor of the syphilitic subject who aspires to marriage. Time, on the one hand, treatment, on the other, are unquestionably the two grand correctives of the pox, the two essential conditions to require of every syphilitic sub- ject before opening to him the gates of marriage. CHAPTEE XI. THE USE OF SULPHUE-WATEES. — COlSTCLUSIOl^rS. I cAisr not quit this subject of treatment mthout add- ^ ing some remarks relative to a custom very fashionable, and considered by the public as an infallible criterion of the cure of syphilis. A popular belief, as you know, ascribes to the sulphur mineral waters the singular property of revealing, of "bringing out," the pox in syphilitic subjects not yet cured of their disease. With this object in view, numbers of patients journey each year to such or such sulphur spring, either at their own suggestion or by the advice of their physicians. There they religiously take the waters during the tradi- tional twenty-one days, awaiting, not without anxiety, the result of this treatment. According to their theory, "if they have anything in the blood the waters will bring it out ; while, if they are cured, if they have nothing, nothing will come forth." In the first alternative, the appearance upon the skin of new syphilitic symptoms will be an indi- cation that they must undergo fresh treatment ; while, in the second, the absence of external manifestations will constitute a pledge of cure. N"ow, this ^^ judgment of tlie waters " has been applied (and it could not fail to be) to the serious question of mar- 124 S7PEILIS Ayn MARRIAGE. riage. You will find this opinion entertained by numbers of your patients, that, before thinking of taking a wife, it is the duty of every syphilitic subject to make a pilgi^im- age to some sulphur spring, in order to ascertain what pertains to his specific state in general, and his matrimo- nial fitness in particular. Now — have I need to say it ? — this pretended revealing action of the suli)hur- waters is far from being what it is gratuitously sup^Dosed to be. It is very far from the truth that it ^^ unveils the un^nown,^^ following the classic ex- pression, and that it furnishes a sort of criterion of the cure of syphilis. Without doubt, sulphur- waters may determine specific eruptions in syphilitic subjects in some cases ; and it could not well be otherwise, considering the excitant, irritant action which they exert upon the skin, especially when used daily in the form of baths, douches, vapor-baths, etc., as is the case in the great majority of our bathing stations. All hydropathic physicians have observed and reported cases of this kind, and I could myself relate several examples. But this action of the waters, we must remark, is not constant ; and here is the proof : In the first place, num- bers of syphilitic patients are sent each year to sulphur stations from divers motives. Even when they are sup- posed to be by no means cured they are sent there, for example, in order to be built up, in order "to recruit both from their disease and from the effects of treatment." But we observe that they almost all return from these thermal stations without having experienced the least new manifestation upon the skin, mthout having perceived the least cutaneous awakening of the diathesis. On the other hand, we have now the experience of these so-called reveal- TEE USE OF SULPEUR-WATEES. 125 ing cures, and we know what they are worth. I have in my notes hundreds of observations relating to patients who have taken one, two, three, and up to six courses of sulphur- waters without having had any eruption produced upon them, and who afterward, at quite distant intervals, have suffered from several severe assaults of the disease. Within a few days, for example, I have been called to treat a man stiU young, presenting undoubted symptoms of cerebral syphilis. ITow, this patient, like so many others, had gone to Luchon before his marriage, and on account, even, of his projected marriage. He had been there three seasons, and nothing had been mani- fested upon him. After such assurance, it was thought that he might be allowed to marry without apprehen- sion. The result has shown the justness of the prog- nosis ! A similar result has occurred likewise in many and many other cases which I could cite, and of which every physician could enlarge the list. The revealing action of the sulphur- waters constitutes, then, in no respect a criterion which can be relied upon. The test of the waters is a legend to be abandoned like so many others. It is false, absolutely false, that the sulphur- waters "disengage" the pox from the organism in the manner of a reagent, w^hich disengages a body from a chemical combination. And, clinically, we can expect no solid guarantee from a thermal treatment in order to de- termine the question of the cure of our patients who are contemplating marriage. For one time that this revealing action takes place, it will fail twenty times, fifty times, perhaps. "What security can a process so subject to failure furnish ? What would be thought in chemistry, for example, of a reagent which, 126 SYPHILIS AND MARRIAGE. nineteen times out of twenty, did not disclose tlie special body wMch it was intended to reveal ? And let no one accuse me of making a war of prejudice against sulphur- waters. The accusation would fall to the ground, as I am "a believer" in sulphur- waters — I pre- scribe them frequently, quite frequently, in the course of syphilis, and every year I send numerous patients to our stations in the Alps and the Pyrenees. But I believe in these waters, and I prescribe them, for other indications than that of their pretended revealing property. I believe in their utility as tonic, renovating agents, especially in cases of syphilis of the asthenic form, or of syphilis com- plicated with lymphatism, scrofula, etc. I believe also that they may render incontestable service in facilitating the tolerance of strong mercurial medication in those cases where there is occasion to require of mercury its full in- tensity of action. I do not deny that they may sometimes come in as an aid to diagnosis, in determining cutaneous manifestations ujoon our patients which could not be pro- duced without them. That only which I deny, which I energetically repel as a dangerous error, is their pretended faculty of arbitration in questions so grave as these — the cure or the non-cure of the pox — the fitness or the un- fitness of a syphilitic subject for marriage. I have just passed in review before you, gentlemen, the several conditions which, in my opinion, a syphilitic subject should satisfy in order to justify him in aspiring to marriage. From the foregoing, you have already deduced these natural conclusions : 1. To every patient not fulfilling the conditions — all the conditions of this programme — I believe that the physician ought expressly and energetically to interdict marriage. CONCLUSIONS. 127 3. To every patient satisfying fully and completely all these conditions, I believe tliat the physician may safely permit marriage.* This, in effect, is only the necessary deduction from the premises which we have established. It is the application of them, pure and simple. However, after having traced and defined for you this programme of admissibility to marriage, such as I under- stand it, I should like to add a few reflections, a few com- ments which appear to me indispensable. In the first place, take this programme only for what it is and what it is worth. It is not a programme received, discussed, and accepted by contemporary science. It is purely and simjoly the condensed result of my personal observation, aided by certain contributions which I have been able to gather here and there from diverse sources. It is, in the second place, a programme subject to re- visions, susceptible of amendments, additions, and correc- tions, and which I shall be the first to modify as soon as further observations shall point out the changes to be in- * I regard it as superfluous to speak here of the various recommendations with which the physician should accompany his acquiescence in the marriage of a syph- ilitic subject, and which are quite naturally suggested by the preceding considera- tions. Of these recommendations, the principal and most indispensable one is that which relates to the minute and careful watch which the future husband should exercise over his own person, so as to allow nothing to pass unperceived which could give rise to an offensive return of the diathesis. It is very essential that we should warn our patients of the possible dangers of every lesion which mani- fests itself upon them, however minute and however insignificant it may appear to be. It is very essential that they receive from us the explicit injunction to refrain from all relations, from every contact, in case they should be affected with any lesion whatever, either of the genital organs or of the mouth, the throat, etc. How often have I heard such or such a patient, who had had the misfortune to infect his wife, bitterly censure his physician because he had not sufSciently enlightened him upon the dangers of contagion ! It is always the same complaint which hus- bands repeat to us in these unfortimate situations : " I was not forewarned. If I had known what I have since learned to my cost, I should never have communi- cated the disease to my wife," etc. Let us be warned in our turn, and not risk the possibility of such a reproach. 128 S7PEILI8 AND MARRIAGE. troduced, and certain points of the question, still obscure and inexplicable for me, shall have been elucidated.* Besides, gentlemen, do not delude yourselves with the possibility of ever constituting that which I would call (permit me the phrase) a perfect code of marriage, for the use of sypliiUtic subjects — that is to say, of building up a programme which shall respond to all possible contingen- cies, which, in a manner absolutely certain, shall deter- mine in all cases the fitness or the unfitness for marriage of a patient tainted with syphilis. A categorical solution of a problem of this kind, a solution stamped with mathe- * To speak only of one of these points, which I can not explain, and which is to me a source of perpetual astonishment, viz., that certain cases of syphilis show themselves so dangerous, so pernicious, and certain others so benign, so inoffensive, as regards their consequences in marriage. I have in hand certain observations relative to patients who have married in spite of a severe and insufficiently treated syphilis, and have, nevertheless, remained inoffensive both for their wives and for their children. Such is the history of one of my patients who married in spite of me, when scarcely cured of a guttural phagedena of the most menacing character. Such is the case of another patient who, without consulting me, contracted marriage when scarcely cured of multiple accidents of a malignant syphilis (profound ecthy- ma, rupia, cephalalgia, hemiplegia, etc.). Now, these two imprudent syphilitics, contrary to all rational previsions, have had healthy children, and their wives have remained uncontaminated. Conversely, we sometimes see patients who, although having been affected with only an average or benign type of syphilis, and treated for a more or less protracted time, after conscientiously waiting several years be- fore contracting marriage, have, nevertheless, procreated syphilitic children, and, in one way or another, infected their wives. As an example, I will cite the case of one of my present patients. In 1864 he contracted syphilis, which manifested itself by slight accidents (mucous patches of the throat, crusts of the hairy scalp, temporary falling out of the hair, etc.). lie was treated during two or three years. Having been exempt from every suspicious symptom for about five years, in 1871 he thought that he might marry — not, however, without having taken the advice of one of our eminent confrercn upon this subject. And then he procreated a syphi- litic infant, which communicated the syphilis to its mother in ufcro ! What con- trast, what disparity between these two orders of cases ! Both, assuredly, have their raisons d'etre^ their material, organic explanation. But we are forced to con- fess that in the present state of our knowledge this explanation absolutely baffles us. There is, assuredly, an unknown quantity which eludes us, at least for the present, and doubtless numerous observations will yet be necessary to disengage it from the multiple elements of so complex a problem. GONGLUSIONS: 129 matical precision, is not, and never will be, possible. To even liope for it would be evidence of a non-professional understanding. Always, whatever we may do, our verdict will be based upon a simi)le calculation of probabilities — tliat is to say, upon an appreciation, essentially difficult and delicate, of vague and ill-defined elements, such as, on the one hand, the previsional diagnosis of a diathesis, and, on the other hand, the degree of corrective, preventive influence ex- erted upon this diathesis by treatment. Consequently, we should not conceal it from ourselves, nor, for that mat- ter, from our patients, that our decision can only have a degree of certainty proportionate to the elements which serve as its basis. That is to say, whatever the attention, whatever the painstaking care we may bring to the ex- amination of a particular case, it is not impossible that the results may baffle our expectations ; it is not impos- sible that we may fall into an error. For, I repeat the expression by design, we rely upon, and we can only rely upon, "a calculation of probabilities" in forming our opinion. And yet, gentlemen, do not get a wrong impression from this last sentence. Because a mathematical cer- tainty fails us in this matter, it does not follow — far from it — that the physician may not be competent to render to patients and to society frequent and inestimable services in this grave matter of the marriage of syphilitic subjects. Consider, for a moment, how these things present them- selves, and appreciate exactly the situation as it occurs in practice. A patient consults his physician in order to know if he may or may not marry, notwithstanding an anterior syphi- lis. The physician interrogates and examines this patient, 130 . SYPHILIS AND MARRIAGE. searches out tlie conditions favorable or unfavorable for marriage — in a word, prepares a balance-sheet of the case, and endeavors to form an oj)inion. One of tAvo things then happens, viz. : either the physician will have gathered from this examination facts sufficient to satisfy him as to the condition of his patient, and enable him to pronounce an opinion in one way or the other (and, in this case, there are but few risks that his Judgment will be discredited by the results) ; or, indeed, he will fail to find the necessary elements upon which to found his opinion, to satisfy his Judgment. In this second alternative, he will refrain from announcing a verdict. For, be it understood, the physi- cian is not bound even to have an opinion ; he is not in the position of a Judge who, from his hie;h tribunal, is under obligation to decide, to pronounce Judgment be- tween two adverse parties. On the contrary, he has the opportunity of excusing himself, of appealing to the fu- ture, and of saying to his patient: "Under the present conditions it is impossible to know how to act in your position. You might perhaps still be dangerous in mar- riage. For the present, then, we will not come to a de- cision ; it is necessary for you to wait.'''' Such is the situation, and not otherwise : please remark it, for one is too apt to forget it. And, I again repeat, the physician is not obliged to fall either into an error, or to risk a hazardous Judgment, when he has not the elements necessary for the solution of the problem before him. It is by remaining faithful to this rule of conduct, by abiding within these limits, within this boundary, that the physi- cian -will respect science, and will most effectively serve the interests of his patient. I have often seen patients marry against the advice and express prohibition of their physician. And, upon CONCLUSIONS. 131 consulting either my recollections or my written notes, I find this : that if some few of these imprudent individuals have not had cause to repent of their rashness, yet a very large number of them (I may even say an enormous ma- jority) have experienced the most lamentable catastrophes, either by introducing the pox into their homes, or in pro- creating children syphilitic or puny, and almost always doomed to an early death ; * or, finally, in paying their personal debt to syphilis to the great detriment of their family. On the other hand, also, I have seen patients marry after a medical examination, and with the consent of their physician. And here, again, the same proportion was met with in the results, but in a directly opposite sense. Save certain very rare, really exceptional cases, where the anticipations of the physician were negatived by the developments, the almost absolute rule was that these patients were not dangerous subsequently, either to their wives, to their children, or to themselves. * I have just observed a case which well merits, by way of example, to be re- corded here : A young man contracts the syphilis. At its outset he only expe- riences slight accidents — roseola, erosive syphilides of the mouth, crusts of the hairy scalp, cervical adenopathies, etc. He is treated with mercury during several months. Everything disappears, and he considers himself cured. About six months later he marries, in sjnte of the explicit prohibition of his physician. His young wife becomes enceinte almost immediately. Toward the fourth month of her pregnancy she begins to present unmistakable signs of secondary syphilis (erythemato-papular syphilide, vulvar and buccal syphilides, iritis, cephalalgia, lumbago, neuralgias, sleeplessness, nervous accidents, etc.). She aborts at the sixth month. The following year two other pregnancies ensue — abortion at fifth month ; accouchement almost at term of a syphilitic infant, which succumbs in twenty-four hours. Fifteen months afterward, fourth pregnancy : accouchement at eight months of a still-born infant. Treatment always irregularly followed by the liusband and by the wife. Ten years later, the husband is attacked with cerebral accidents, which, by common consent of several other physicians and myself, are referred to a specific encephalopathy. Tardily administered, the anti-diathetic treatment only succeeds in temporarily suppressing the accidents, and the patient is rapidly carried off. 132 SYPHILIS AND MARRIAGE. The marriages contracted under these conditions have almost invariably terminated in happy results. This I 'am in a position to vouch for, figures in hand. Is it enough to say, then, that the judgment of an intelligent and prudent physician affords in this matter, even from this "calculation of probabilities," substantial guaran- tees ? Is it enough to say, finally — and I do not revert with- out satisfaction to this last point — that the physician con- sulted upon the question of the marriage of a syphilitic patient renders a most important and valuable service by protecting, in this solemn moment, on the one hand, the interests of his patient, and, on the other hand, behind this patient, the interests of society ? PAET II. AFTER MARRIAGE. CHAPTEE XII. HUSBAND SYPHILITIC AND WIFE HEALTHY. We are about, gentlemen, to continue and complete our study of the relations of syphilis witli marriage. Hitherto we have considered the question only defore marriage. It now remains for us to study it after mar- riage. The evil which we desired to prevent is accomplished. A syphilitic man, not cured of his syphilis, has been married. He is a husband. What dangers may result from this situation ? And what role have we to play, medically, in order to avert or lessen these dangers? Such is the question which it is now necessary for us to approach. A practical question, if there ever was one ; a ques- tion teeming, as you m^II see but too well in the course of this exposition, with embarrassments and difficulties of many kinds, with situations equivocal, delicate, complex, etc. ; a question seldom to be met mth in the hospital, but of frequent occurrence in private practice, where it forces itself upon the physician's attention. Consequent- 10 134 SYPEILIS AND MARRIAGE. ly, I have thouglit it would be useful to discuss it before you in detail, in order to spare you an apprenticesliip, always more or less painful to undergo, in personal ex- perience. The evil is consummated, I said. A syphilitic man, although not cured, is married, and is now a husband, with a syphilis in full vigor, in full activity of manifesta- tion. A dejplorable situation, by no means uncommon, from various causes. It may be that the patient (as is most commonly the case), believing himself cured, incon- siderately contracts a premature marriage ; it may be that, consciously and voluntarily, he braves the dangers of such a position ; or, it may be that, ignorant of his real disease, he mistakes the nature of the lesions Avith which he was affected before his marriage. And, if you will, we shall place side by side with facts of this kind two other classes of cases which, though very different from the first, as regards the chronological order of the accidents, are no less liable to terminate in a situation exactly identical, viz. : 1. The cases (very numerous these are) in which a married man contracts syphilis after his marriage in an extra-conjugal adventure, or rather misadventure. 2. The cases (infinitely more rare, really exceptional) where syphilis breaks out upon a man quite recently mar- ried, from the fact of a contagion to which he was exposed some days before marriage. I will explain by an example borrowed from my notes : A young man, of high social position, has connection, eleven days before his marriage, with one of his former mistresses, who is affected at the time (as is afterward demonstrated) with mucous patches of the vulva. He marries absolutely healthy in appearance. Eight days HUSBAND 87PEILITI0 AND WIFE EEALTEY. 135 after his nuptials lie notices a slight redness upon the glans, which soon degenerates into a typical indurated chancre, the beginning of a constitutional syphilis, which he soon transmits to his young wife.* Whatever be the chronological origin of syphilis, whether the contagion be anterior or posterior to mar- riage, the situation, I repeat, is absolutely the same in these diverse cases. We always find the same scene re- curring with the same personages, viz., on the one hand, a healthy woman; on the other, a syphilitic husband. These conditions existing, what will take place? What will take place, first of all, is that this husband, on the first invasion of a suspicious phenomenon, will rush into the office of a physician, and, burning with excitement and anxiety, will address him in the following language (which I reproduce from reality, you may believe me): "Doctor, save me ! I believe I have symptoms of syphi- lis. Now, / amn married. Just consider a moment my situation, if I were to give the pox to my wife — ^if I were to have syphilitic children ! Preserve me from this, I beg of you, and explain to me everything I should do in order to guard against such dangers." Consulted under such circumstances (and you will often be, I assure you), what will you reply ? In my opinion, your professional role is all traced out ; and, if you will be advised by me, your reply will be the following : "I see three orders of dangers in the situation for which you do me the honor to seek my advice, viz. : "1. Your own personal dangers, those which may re- sult to yourself from your disease. * Cases of this kind are extremely important to know in practice. I have called the attention of my readers to them (vide " Illustrative Cases," Note IV). 136 . SYPHILIS AND MARRIAGE. " 2. A danger of contagion for your wife. " 3. A danger of heredity for your future children. "Now, it is not only necessary that we should guard against these three orders of dangers ; it is necessary, too, for us to attend to them all in an equal measure ; for you would be culpable, and I should be culpable with you, if we aimed only at your individual security, without taking precautions for your wife and your children. In conse- quence, it is a triple consultation that I have to give you. "And, first, let us consider the most urgent indication. Let us speak of yourself. That will be my first step. "As to you, sir, you must be treated in the most ener- getic manner, and everything be done in order to cure you at the earliest possible moment. For it is from you, in brief, that all the consequences proceed which may fall upon others. "To this end, here is my advice," etc. But, before going further in this scene, what are you about to advise this patient to do — this syphilitic present- ing himself to you under these special conditions ? Certainly, as regards the nature and the character of the remedies, you will prescribe for him what you would prescribe for any one else, for there are not, that I am aware of, any special remedies for the particular use of syphilitic husbands. But as regards intensity, as regards vigor of medica- tion, it is an altogether different affair, in my estimation. Bear in mind that you are in the presence of a husband, of a husband living in contact with a young wife, liable to infect this wife in the thousand intimacies of domestic life, without even speaking of sexual relations, from which, it is to be feared that, notwithstanding all your warnings, your patient will not abstain. I will add to this last state- EUSBAFD SYPHILITIC AND WIFE HEALTHY. 137 ment — and it is well to know it in practice — that in such cases your patient will show himself much less tractable to your prescription of continence, as he has an interest in concealing his condition, and is not willing, as he will tell you, "that his wife should divine his disease," etc. Be less sure of him in this particular than you would be of any other patient in a diiferent situation.* Now, from these special conditions are practically de- rived special indications, of which you will comprehend in advance both the object and the useful results. These indications, even speaking of the principal ones only, are briefly as follows : I. In the first place, to suppress forthwith the sources of contagion, and to suppress them by a cauterization at once sufficient and energetically corrective. If, for instance, the case be one (by far the most com- mon) of secondary accidents of the mouth, of the throat, or of the penis, etc., destroy them immediately by a vigor- ous cauterization. As for the nitrate of silver, a feeble caustic, there might be risk of its proving insufficient; choose, in preference, the acid nitrate of mercury, a more active caustic, and much more certain as regards effects. Should this cauterization not succeed in correcting im- mediately, in situ, the contagious nature of these acci- dents, it vdn at least certainly provoke their cicatrization in a short time ; and this is what we desire. * I have known syphilitic hiisbands to not dare abstain from intercourse with their wives during a period when the contagion was transmissible, from the fear that a suspension of habitual relations might give a hint as to their disease. In order to avoid suspicion, they risk transmitting the pox to their wives ! The fact is scarcely credible, but it is none the less authentic, nevertheless. It is authentic to the extent that two of my patients, in conditions of this kind, have, in endeavor- ing to prcveiit suspicion, ended by infecting their wives. Facts of this kind ought to be signalized, for one would not imagine them a priori, one would not suppose them possible, without having had peremptory proofs from personal observation. 138 SYPHILIS AND MARRIAGE. It is superfluous to add that tlie cauterization should be immediately followed up by the employment of such topical applications as are best adapted to promote the speedy cure of those centers of contagion. II. To cut sliort, hy a medication of especial intensity, the contagious accidents of the secondary stage. Under ordinary circumstances, when called upon to treat syphilis, the medication which we usually prescribe to patients is at once mild, guarded, cautious, careful, our endeavor being to adapt it to individual tolerance. We go slowly, gently, patiently, for we have time before us ; and proceed with moderation, even allowing the diathesis to get the upper hand from time to time in temporary outbursts. But, under the special circumstances now under consideration, the case is different. It is urgent here to avert the imminent dangers of contagion. With this view, the indication is to malce haste and to striJce hard, if I may thus speak, in order to silence all menacing mani- festations — menacing, be it well understood, not for the patient, but for his wife, whom it is necessary to protect. So, then, in place of the usual medication, in place of the traditional "five centigrammes" of proto-iodide, I be- lieve that there is every advantage in instituting from the outset an energetic repressive treatment. I believe that we' should act in this emergency as we act when in pres- ence of grave specific accidents which it is important to suppress promptly. In a word, I am here in favor of a swift and violent treatment, yet avoiding extremes, and without running the risk, in going too fast, of being forced to go backward — I mean forced to suspend the medication. With this intention, prescribe, then, from the very first, strong mercurial doses. Ten to fifteen centigrammes of the proto-iodide, two or three, and even HUSBAND SYPHILITIC AND WIFE HEALTHY. 139 four, centigrammes of the sublimate, daily, would not constitute an excessive average, at least in general, ex- ception made for individual tolerance, which, is always to be taken into account. Often, even, it will not be inju- dicious to associate the iodide with the mercury, in order to render the medication still more active. Pursue this treatment about two months, then discontinue it for some weeks, in order to avoid the effects of habituation, be- ginning again afterward in the same way, for the same time, and so on successively."^ Proceeding in this manner, you will often, if not al- ways, succeed in suppressing all or a part of the second- ary manifestations ; you will succeed notably — and this is the object you have in view — in diminishing the num- ber and intensity, even perhaps in averting completely, the crops of eruption upon the mucous surfaces, which, under the name of mucous patches, are so formidable as regards contagion, and constitute the common, habitual source of contamination in marriage. Without doubt, this desperate treatment will not al- ways be to your patient's taste. Without doubt, it will cause a certain degree of disturbance, it may be, of his gums, it may be of his digestive functions. But, with a careful supervision, with moderation and caution in your vigor, you will almost always succeed in accustoming him to accept and tolerate this plan of treatment, f * I do not speak here of mercurial frictions, and for cause. Frictions certainly constitute an excellent mode of treatment, and would, in point of fact, be very use- ful. But in this contingency they are almost always inapplicable, for it is neces- sary to have regard to the exigencies of each particular case. How could a young husband accept our prescription to pomade and bundle himself up every night, and then present himself in such attire in the conjugal bed ? Such a plan of medication would little favor the concealment of a condition which the patient has a special interest in concealing. f I do not say, be it understood, that a treatment of this kind should be applied 140 - SYPHILIS AND MARRIAGE. As an example of this kind, I will cite the case of a patient that I treated in this way, five years ago, for a syphilis breaking out the tenth day after his mar- riage. This young man (whose history is exactly identi- cal, as regards peculiarity of debut, with one of our pre- ceding cases) — this young man, I say, a fortnight before his nuptials, in compliance with the traditional ceremony called Venterrement de la me de gargon., passed the night with a former mistress whom he thought safe. He thus acquired the pox, w^hich, after an incubation of twenty- five days, manifested itself by a chancre on the gians. The situation was then most critical. I employed the method which I have just mentioned, and I have the satisfaction of saying that it was crowned mth complete success. The secondary period remained almost entirely quiet ; all risk of contagion was averted; all was saved, "even to^ appearances," following the expression of my patient. And yet it was not without difficulty that I prevailed upon him to undergo this severe treatment. Many times he kicked against my prescriptions, against what he called my "horse-treatment," but which I myself would, in more ex- act terms, characterize as "a treatment for the use of syphilitic husbands who do not wish to infect their wives." The first point in the situation which occupies us set- tled, let us now proceed to a consideration of the second, which relates to the dangers of contagion incurred by the wife. These dangers you will recognize from what pre- cedes. They are of two orders : 1. Dangers of direct contamination from the transmis- sion of a contagious accident from the husband. in all cases ; but I say — which is quite different — that, in cases where it can be applied^ it ought to be made use of. It constitutes, in effect, the surest means of preventing the contagious manifestations of the secondary period. HUSBAND SYPHILITIO AND WIFE EEALTEY. 141 2. Dangers of indirect contamination, resulting from a pregnancy (syphilis by conception), IS'ow, it is a question of the preservation of the young wife from these two perils. With this object in view, what must be done % As regards the dangers of direct contagion, our role, our duty, is all traced out : it is to warn the husband upon this particular point in a manner the most explicit, the most complete ; it is to frighten him a little as to the risks incurred by his wife. A little scare would not be harmful, in order to render him more cautious and more prudent. Inform the husband, then, exactly of the dangers of such contagion — dangers which he can not be aware of, at least sufficiently. Do not restrict yourself to simply say- ing to him (as is generally done), that he may be con- tagious, and that he ought to abstain from all intercourse with his wife, in case he should be affected with any syphilitic symptoms. That is too vague. Press the mat- ter home to him ; do not fear to enter into details, for it is worth the pains, and convince him thoroughly of this — that, in his state of disease, every sore, every erosion, every lesion, excoriative or humid, contains, or may con- tain, a germ of contagion ; that however slight, however insignificant, however innocent any lesion whatever may appear to him, that lesion is no less dangerous on this account ; that it matters not, besides, what may be the situation of a lesion, as far as its contagiousness is con- cerned; that there may be contagious lesions in the mouth as well as upon the genital organs, etc^' Then . * A widespread opinion among the laity is that syphilitic contagion can only be transmitted by the genital organs. For them, the idea of syphilis implies that of a genital contamination. This is an error which it is important to correct on 142 SYPHILIS AND MARRIAGE, you will add, in conclusion, " That loMch you haw im- poses upon you the express, absolute obligation to abstain from all intercourse, from all contact with your wife, for there may result from it the worst of contagions to her." And, gentlemen, you are not only authorized to say this, but it is your duty to say it, and in these terms ; for such statements are in perfect harmony with the facts of science relative to the usual mode of contagion in mar- riage. Do you know what clinical observation actually teaches upon this subject ? My notes are absolutely explicit in this regard, and permit me to affirm these two proposi- tions : 1. In the enormous majority of cases, tlie syphilitiG contagions transmitted in marriage from hushand to wife are derived from secondary forms of accidents. 2. These contagions are almost invariably derived from secondary accidents of a superficial, erosive, or ex- ulcer ative, at most, papulo-erosive form — that is to say, from accidents essentially benign in appearance — almost insignificant, by reason of their seeming benignity, with- out importance, upon the whole, and quite susceptible of being misunderstood as regards their nature, or of even passing unx)erceived. And it is evident that this twofold proposition results from the essential nature of these con- ditions. For, on the one hand, syphilis is infinitely more dan- gerous in its secondary stage than at any other period, by reason of the extreme multiplicity and the possible dis- semination of its accidents ; and, on the other hand, the contagions which take place in marriage can only be the « every occasion, and more especially still in the class of situations which we are now considerinET. ■ HUSBAND SYPEILITIG AND WIFE HEALTHY. 143 result of lesions so unimportant that the husband, con- scious of his condition, disregards them, or fails to recog- nize their existence. A husband, in fact, does not infect his wife as prostitutes are infected, who, from interest or indifference, indulge in coition, whatever may be the con- dition of their health ; a husband never transmits syphilis to his wife, except through ignorance or inadvertence. Then, he transmits it to her only through the medium of lesions so minute, so benign, that he has not suspected their true nature, or may not even have been conscious of their existence. I have often said, and I shall not cease to repeat it, the slightest accidents of the secondary period are the most dangerous as regards contagion. And they are the most dangerous by reason even of their apparent be- nignity. They seem to be so trifling, they have an ap- pearance so innocent, that one disregards them, that one does not suspect their nature ; and, consequently, one is so much the more liable to communicate them. Let us add, moreover, that they may easily pass en- tirely unperceived. The small secondary erosions of the lips, of the tongue, of the penis, are the most usual sources of contagion in marriage. Recall, as examples of this, two cases which I cited to you at the beginning of this exposition. In one, the contagion was transmitted by secondary erosions on the glans, which had been taken for herpes ; in the other, it was the result of minute erosions of the lips — erosions scarcely desquamative, and altogether comparable to those epithelial exfoliations occasioned by the abuse of tobacco. Well, to these two cases I could add at least fifty others, all testifying to the same effect. Almost invariably, then, it is by these minute lesions, by these simply erosive sec- 14:4: SYPHILIS AND MARRIAGE. ondary syphilides, that syphilis passes from the husband to the wife. This is so true, that patients as attentive as possible to the state of their health, as conscientious observers of themselves as could be imagined, suffer contagions of this kind to happen. Physicians, even, thoroughly competent observers, have not escaped this danger in their own families. The following case is an example, which I con- sider worthy, in every respect, of being cited to you : A most distinguished physician, one of those men who do honor to our profession as much by their personal char- acter as by their talent, contracted syphilis in the exercise of his art. Being married, he immediately forewarned his wife, and watched himself mth the most scrupulous care. Each day, night and morning, he examined himself with the greatest attention. And, nevertheless, in spite of all his vigilance, he finally infected his wife. Let us hear him recount his misfortune, in a letter which he did me the honor to address me upon this subject : " One morning last year, upon awakening, I was astounded to observe, in the furrow of the glans, a small spot scarcely apparent, of the size of a lentil, dry in almost its whole extent, the center slightly excoriated, in a point of surface comparable to the head of a pin. I was astounded, be- cause the night immediately preceding this discovery I had had connection with my wife. And, nevertheless, I had examined myself, as was my custom, the evening before. . . . Now, it was undoubtedly this miserable pim- ple, this insignificant lesion, which infected my poor wife. For, after the classic delay — that is to say, three weeks later — she commenced to feel a hardness upon the vulva, which soon developed into a chancre. Let not my example be lost. Let it be of advantage to you, my dear HUSBAND SYPHILITIC AND WIFE HEALTHY. 145 Mend, who are occupied with such special studies, in order to tell those who will hear you how contagion may be produced in marriage, in order to convince them that this contagion may be effected by a lesion the most slight, the most inoffensive — so inoffensive, so slight, as to escape the suspicious eye of an honest husband and of an attentive and watchful physician." There is nothing to add, after this sad and very in- structive example. This is not all, gentlemen. A third point claims our attention. You have not lost sight of the situation, the study of which we are pursuing. A married man has come to ask your counsel for the accidents of sy]3hilis. In the first place, you have prescribed a treatment for him. In the second place, you have put him on his guard against the dangers incurred by his wife fi'om direct contagion. Your task is not finished ; there remains the danger of a pregnancy ; and this pregnancy, occurring under such conditions, would be the occasion of a double misfortune, viz. : of a misfortune which concerns the mother, in exposing her to the danger of receiving the syphilis from her child ; of a misfortune which concerns the child, which would be subjected to all the risks of sj^philitic heredity, J^ow, upon you devolves the duty of preventing this double disaster. It is to be assumed that your patient has no idea, or that he has a very incomplete understanding, of the per- nicious results which may succeed a pregnancy occurring in these conditions. It is your duty, then, to enlighten him upon this point, and to enlighten him in extenso, clearly, comprehensively, so that, with a full knowledge of the situation, he shall know how to regulate his con- duct. 146 SYPHILIS AND MARRIAGE. Consequently, in order to fulfill this last indication, you will, if you trust to me, continue your advice with special reference to three points, as follows : "And, especially, sir, under the present circumstances, there must be no child. Guard well against pregnancy ; avoid at any price your wife becoming enceinte! — for, on the one hand, the infant which she would conceive by you might either inherit your disease, or, more likely still, die before being born ; and, on the other hand, your wife might be infected by her infant — that is to say, might receive from this infant the pox which it would have in- herited from you. Then, you understand me well, you must arrange not to have a child." And you are at liberty, gentlemen, to insist, if need be, and to add a complement of instructions, as you may judge necessary, according to the attitude of your pa- tient ; you are at liberty, as M. Diday has very properly said, "to make yourself teacher even as to the most minute details — teacher always decent, but sufficiently clear." Such, gentlemen, is the first of the situations which syphilis creates in marriage. However complex and delicate this situation may be in more than one point, it is, nevertheless, the simplest of all as regards the medical indications which it compre- hends. Let us pursue our study, then, expecting difficulties much more serious. CHAPTER XIII. HUSBAND SYPHILITIC ; WIFE HEALTHY, BUT EIS'CEINTE. A SECO]S"D order of cases is presented, as follows : A man, recently married, has been reattacked with specific accidents, resulting from a syphilis incompletely treated during his bachelor life. His wife remains nncontami- nated, but she is enceinte. And, justly alarmed, this man comes to request your advice, submitting to you this double question : "1. What ought I to do for myself ? "2. Is there anything to be done for my wife and the infant which she carries in her womb ? " This second situation is much more complex than the one we have previously studied, since it embraces all the difficulties of the first, with the grave complication of a pregnancy superadded. What is the physician's duty in such a case ? I. As far as the husband is concerned, there is no embarrassment. Our role is exactly what is was in the first order of cases previously considered, and we have nothing to do but to prescribe a treatment appropriate to the character of the existing accidents, and to put our patient on guard, by properly given advice, against the possibility of a contagion which, in this case, would have 148 STPEILIS AFD MARRIAGE. results doubly unfortunate, since a wife and a child are at the same time interested.* II. But it is in that which concerns the wife and child that you will encounter the real practical difficulties. It is evident that both are threatened. In the first place, this young mother may be contaminated by this offspring of a syi3liilitic father, whose syphilis is still sufficiently active to manifest itself by present accidents. Then arise all the dangers of syphilis by conceiDtion. On the other hand, this infant is liable, from its hereditary dangers, either to be born syphilitic, or (which is most commonly the case) to die before being born. ISTow, this question presents itself : May we not hope to ward off these eminently grave results by anticipating them — that is to say, by administering specific treatment to the mother prophylactically ? Is not the attenuating and corrective influence of this treatment demonstrated in cases which, if not identical, are at least analogous? Have we not seen, for example, the opportune adminis- tration of anti-syphilitic medication cut short a series of successive abortions, resulting from paternal syphilitic influence, and conduct a pregnancy to full tenn ? The intervention of preventive treatment has here, then, at least a rational indication. But, on the other hand, are we Justified in this pre- * In reference to this last point, I have thought it useless to remind you that a contagion transmitted in the course of a pregnancy involves a twofold order of dangers, viz. : 1. Dangers relative to the mother ; these are only too evident. 2. Dangers relative to the infant. It may happen that the invasion of syphilis in the course of pregnancy may determine either an abortion or & premature accouchement. It may happen, also, that the infection of the mother may he transmitted to the foetus, with all the serious consequences of a congenital diathesis. Facts of this kind are so common that it will suffice, I think, to simply announce them, without bringing new proofs to their support. Many examples, moreover, will be incidentally fur- nished in the statistics which may be found at the end of this volume (vide " Illus- trative Cases," Note III). HUSBAND SYPHILITIC; WIFE HEALTHY— ENCEINTE. 149 ventive intervention ? What do we actually know of the state of the infant ? whence do we derive our fears for the mother ? Without doubt, this infant runs risks of pater- nal hereditary infection : that is incontestable. But we have previously shown that syphilitic heredity has no- thing inevitable in it, especially when derived from the father. It may be that the infant has received nothing from its father ; and, in this case, the mother has nothing to fear from the infant. It may be, then, that our inter- vention would be without object. In this uncertainty, what is to be done ? Is it neces- sary to resolve upon a treatment directed, perhaps, against illusory dangers ? Or, indeed, should we trust to expecta- tion, and "run the chances," as it is commonly termed? This is a grave question as regards results ; and a ques- tion, unfortunately, still undecided in the present state of science. To no purpose will you interrogate your books upon this subject ; vainly will you search for a precise, cate- gorical solution. In the greater number of our classical, special treatises, the problem is not even stated. And if you consult professional opinion, as I have done, you will find it singularly hesitating upon this subject. For my part, I have tried this experiment : I instituted a sort of inquiry upon this matter, and consulted a great number of physicians, and I arrived at this result : that certain of our confreres express themselves resolutely in favor of preventive treatment ; that, to others, this practice is re- pugnant ; while the greater number have no settled ideas, and remain undecided, wavering between two contrary opinions. I wished to have, in order to communicate it to you, the opinion of an illustrious master — of the man who is. 11 150 • SYPHILIS AND MARRIAGE. the most often found grappling witli difficulties of tMs kind, and whose vast experience is so valuable to consult. I went, therefore, a few days since, to confer with M. Ricord upon this special subject, and I found him, also, hesitating and uncertain. "It would be impossible for me," he replied, "to give a categorical solution of the grave question of which you speak, and one which has deeply interested me for a long time. However, from my own experience, I have been led to believe that the part of inaction, of expectation, is altogether the most judi- cious in this matter. . . . Whatever may be my desire to save a compromised future, it is repugnant to me to act at hazard, to try a campaign of adventure. I am loath to condemn to a mercurial treatment a young woman who has at present nothing syphilitic ; v/ho may, indeed, both she and her infant, have escaped the pox, and whom, be- sides, a treatment would not, perhaps, save from the pox if she had already received it. . . . Still, I do not con- demn, I have not the right to condemn, those who think otherwise, who base their practice upon an intention cer- tainly rational in thus taking a salutary precaution. . . . It is for further experience to decide. But, at present, I confess that my preferences are for the expectant doc- trine; and, should a case of this kind present itself to me to-day, I should remain inactive, rather than act at random." Such is, likewise, the rule of conduct which I should follow, for my part — still, without having, I confess, rea- sons clinically sufficient to justify it. Definitely, then, you see, gentlemen, the question re- mains undecided. It is not because it is still new, but it is so delicate, so difficult to appreciate in a categorical manner, that there is no occasion to be astonished at the HUSBAND SYPHILITIC; WIFE HEALTHY— ENCEINTE. 151 absence of a precise solution. See liow the clinical ob- servations, which conld alone serve to decide the question, are really susceptible here of opposite interpretations. Paternal heredity is not inevitable, as I have many times said to you. So that the children of syphilitic fathers are sometimes born living and healthy ; sometimes they die in utero, or are born syphilitic. Likewise, they some- times leave their mothers uncontaminated, and sometimes they react upon them, communicating syphilis to them. !N"ow, suppose that in a case of the kind we are con- sidering we try the intervention of treatment. The wife is confined at term of a healthy child, which remains healthy. Should we be authorized in attributing this happy result to the treatment ? But we are immediately told that ' ' v/ithout treatment the thing occurs just the same," and, in support of this statement, a certain num- ber of well-authenticated facts may be invoked. In order to judge this question conclusively, it would be necessary to make use of a considerable number of observations of this kind, drawing a parallel upon a very large scale be- tween the results of therapeutic intervention and those of expectation. Then, before the imposing figures of such statistics every one would be forced to bow. Unfortu- nately, statistics of such convincing importance are stiU wanting to us, and I am forced to repeat, in conclusion, that the problem remains simply stated, without any pos- sibility of a solution being assigned it at present. I shall make, nevertheless, one reservation. There are, in my opinion, particular cases where the doctrine of expectation ought to be abandoned, and give place to an active intervention. What are the cases to which I refer ? I will specify by an example : a healthy, well- developed woman, married to a syphilitic man, has had 152, STPEILTS AND MARRIAGE. several miscarriages in succession, and that without cause, without reason. You examine her most carefully, and you find no other plausible explanation than the syphilis of the husband. Now, this woman again becomes enceinte. Anxious as to the result, she comes to consult you, or (what is more common) one of her family — her husband, for example — comes to consult you on her account. In these circum- stances, shall you remain inactive ? No, certainly not ; for, on the one hand, you know, from the experience of the past, how expectancy would again result, at least, according to every probability ; and, on the other hand, you have at your disposition a treatment which, directed against the probable cause of these successive miscar- riages, may weaken and correct this cause. Why not make use of this resource ? Why not have recourse to this treatment ? Here, at least, is a chance to be gained ; and this chance you have not the right, it seems to me, to ■withhold from your patient.* For my part, in such conditions, I do not hesitate to prescribe specific medication as the sole means capable of parrying the danger which threatens the child, and of conducting the pregnancy to term, I do not hesitate to prescribe . mercury. I consider myself justified by the needs of the case in disguising it from the young wife under a respectable pseudonym, in concert with the hus- band. x\nd, if I am not mistaken, I believe I can claim that this practice has often furnished me with real, incon- testable successes. * Professor Depaul has developed the same opinion in his Clinical Lectures. According to him, " After a series of miscarriages, for which we can not find a cause, the physician is justified in prescribing, empirically, a specific medication — a medication, moreover, inofEensive when it is properly administered." CHAPTER XIV. HUSBAND SYPHILITIC AND WIFE EECENTLY CONTAMI- NATED. Thied situation, which is, tinfortunately, the most common. A sypJiilitic sicbject married Jias infected Ms wife. Summoned in such conditions, what have you to do ? What medical indications present themselves to be ful- filled? " The matter is most simple," you will perhaps say to me; "we have here two patients; well, we will treat these two patients." Without doubt ; but that does not terminate, ought not to terminate, your role, which, in reality, is much more complex than you would at first suppose. You are, let us assume, in actual practice, and you are about to experience the difficulties of practice, which one can not fully appreciate unless he has served a personal apprenticeship. Let us be explicit. I. In regard to the husband there is no embarrass- ment. As far as he is concerned, there is nothing to do but this : 1. To prescribe for him a treatment. 2. To intimate to him, in the most direct and forcible manner, the interdiction of paternity. 154 • SYPHILIS AND MARRIAGE. You Ivnow well, gentlemen, liow a pregnancy results when botli parents are contaminated ; especially when the maternal syphilis is recent, and has not yet been sub- jected to the depurative effect of treatment. A pregnancy in such a condition is a disaster. Then, it will be your duty to enlighten your patient upon this point, and, in order to leave him in no doubt, you should address him in the following language: "In the present circumstances, with the disease with which your wife and yourself are at the same time affected, a pregnancy would be the worst misfortune which could befall you. For, one of two things would happen : either your child would die before being born ; or it would come into the world wifh the pox, and you may imagine the effect of this for yourself, for your wife, for your two families, for others, etc. ; without taking into account that the poor creature could not long survive, despite all care. Then, in your own interest, as in the interest of all, avoid, at any price, the possibility of a pregnancy until further orders." Such is the urgent advice to give — ^more easy to give than to be followed, it appears, as we shall have proof in a moment. II. Here, then, is the situation regulated, so far as re- lates to the husband. But there remains the wife. And it is in relation to her that there is about to begin for us a most delicate situation — by so much the more delicate, as it will be necessary to combine mth our usual preroga- tives the role of the tactician and the diplomate. And, in reality, in the large majority of cases, these things hai^pen in such a way that the wife is entirely ig- norant of the disease with which she is attacked, and it is your moral duty to deceive her in this matter, by dis- simulating the real name and nature of her affection. Why ? Because nine times out of ten, at least, the situa- HUSBAND SFPEILITIG; WIFE RECENTLY INFECTED. 155 tion involves you with it, as follows : The young husband who has infected his wife rushes distracted to his physi- cian, and thus begins the interview : "Doctor, a great mis- fortune has befallen me. I had the pox. I made the mistake of marrying before being completely cured. I have given the pox to my wife. I come to ask you to treat her. But, above all, I beg this of you, I ask it of you in the name of all you hold most dear : do not dis- close the truth to yoar future patient ; keep her for ever ignorant of the name and nature of her disease. For, if she knew this, I should be ruined ; it would be the death- blow to her affection and esteem for me. And, if she should tell her family, imagine the result ! Then i^romise me your best care for her, and, at the same time, perfect discretion — an absolute silence as to the nature of her condition." Could you, gentlemen, excuse yourselves under such circumstances, and refuse the double service which is thus requested of you '? Certainly not. So that, at the first step, you are here involved in a singular predicament — that of a physician treating a pa- tient, with the obligation to conceal from her the disease for which he treats her. A singular situation, I have said, but a situation to be accepted, since it has nothing incom- patible with our professional dignity ; for, after all, we are not responsible for this situation ; we only submit to it, and we submit to it from a motive essentially moral and beneficent, viz., with a view of concealing a culpable action, and, following the consecrated expression, of pre- serving the peace of a family. On the other hand, gentlemen, do not misapprehend the difficulties, altogether special, of the mission which you will have accepted under these circumstances. To 156 S7PEILIS AND MARRIAGE. treat a woman with syphilis (and to treat her a long time, as is necessitated by the nature of this disease), without tliis iDoman ever dlmning or sus'pecting the truths is a task which a diplomate might undertake, but for which a physician is poorly prepared. And, indeed, it will be necessary for you to do certain things to which you have not been accustomed, viz. , to manoeuvre in a line of per- petual dissimulation — to satisfy ex ahruxoto a hundred questions with which your patient will besiege you : "IsTow, doctor, what is it I have ? What are you treating me for \ How did I take this disease % How does it hap- pen that I have the same symptoms as my husband % " etc. — to confer upon the different morbid manifestations which arise different i)seudonyms, which must be irre- proachable, acceptable, probable — to mask under imagi- nary names the specific remedies which you will have to prescribe ; and, in all this, never to hesitate or evade for an instant, never to betray yourself. ISTow, this role — as you v»411 appreciate only too fully in practice — comprises more than one difficulty ; it de- mands an assurance, an aplomb, an address, which can only be acquired by practice. In brief, it is less easy, believe me, than one would imagine a priori to manoeuvre upon such a field ; and more than one able tactician has succumbed in this contest with feminine acuteness. Con- sider yourselves warned, then, gentlemen, and, when you engage, or, rather, when one engages you, in an under- taking of this sort, do not lose sight of the fact that you Avill meet your match. And yet, be assured, the women that we pretend to impose upon in this way are very far from being always the dujoes of the stratagem. In reality, we deceive them much less often and less completely than we ourselves HUSBAND SYPHILITIC; WIFE RECENTLY INFECTED. 157 think, and, especially, than their husbands think. Many- times, for my part alone, I have perceived that certain of my patients, whom I thought I had misled as to the nature of their disease, knew perfectly well what was the matter with them. Only, before myself, as before their husbands, they accepted — because they chose to accept it — the role of deluded wives. Some of them, more- over, after a certain time, place the physician at ease by making him understand that they are aware of the situation. "Now, do not give yourself so much trou- ble," one of my patients said to me one day, "to per- suade me that' I have a disease other than that for which you are treating me. I have for a long time understood the nature and the wherefore of my disease. Only, so far as my husband is concerned, I shall always remain igno- rant, for uny dignity obliges me to ignore tJiat wliich I could not pardon.'''' Another — a woman of intelligence — you will pardon me the anecdote — seemed absolutely con- fiding in my imaginative diagnostics, until one day she disabused my mind by the following little speech : "I am very much obliged to you, dear doctor, for all the trouble which you have for so long a time taken to dissemble the disease with which I am affected ; and you might have succeeded, perhaps, had it not been for my husband and M. Littre ; but my husband guarded too preciously your prescriptions not to inspire me with a desire to read them ; and I have read them, as you may believe ; and you had forgotten to make a recommendation to M, Littre not to indicate in his dictionary the synonym of your fallacious word hydrargyrum." These things happen thus quite frequently, and it is well to be acquainted with them for the demands of practice. There is another point of capital importance. If it be 158 SYPHILIS AND MARRIAGE. difficult, as we have just seen, to treat a woman for syphi- lis without arousing her susi)icions, it is much more diffi- cult still to treat her as it would be desirable that she were, as you would AAdsh that she were treated — that is to say, in an energetic, prolonged, and sufficient manner. I will explain myself, and I shall not hesitate to insist upon this point, for a considerable interest, which merits all our solicitude, is attached to it. You know that one cures the pox, or rather that one definitely imposes silence upon the manifestations of the pox, only at the price of a longj- very long, treatment, re- quiiing, at the minimum, several years. You know, in addition, that this treatment, in order to be efficacious, requires a particular direction — that it ought to be by turns interrupted, recommenced, stop^Ded altogether, re- sumed in various forms. All this demands much time and patience, a medical supervision, if not constant, at least iDrolonged. In a word, the pox is a chronic disease, which one gets rid of only by a chronic treatment. ISTow, Judge whether, in this special case, such a treat- ment would be easily applicable. In the first place, how will you force the acceptance of a treatment of this kind upon a woman who is ignorant of the nature of the disease with which she is affected, to whom you have not the right to explain what the disease is, what its multii)le consequences and its dangers for the future may be, etc. ? And more, how make a woman accept this treatment who is constantly deceived as to her condition, to whom her husband, by way of consolation, or in extenuation of a fault still unavowed, does not cease to repeat to her every day that "what she has is nothing," that "it will soon pass away," etc. ? HUSBAND 8YPEILITIG; WIFE RECENTLY INFECTED. 159 ITote, moreover, tliat tlie said husband, at a certain stage of the malady, as soon as its evident manifestations have disappeared, as soon as the syphilis no longer ex- poses itself by external symptoms, becomes for you an auxiliary less than ardent. As at first he was most zeal- ous in his efforts to obtain from you an active medica- tion, and to have you supervise its application ; so, later on, you will find him lukewarm, when, the ostensible acci- dents having been effaced, he no longer insists upon a preventive treatment. You were "a savior," you were welcome in his house a few months ago. But now "that all is finished," "that there is nothing more the matter," your presence with his wife, your visits, your prescriptions, your treatment, "which, without doubt, have done well, but which should have the merit of being less prolonged," all this becomes for him a source of vexation, of irritation, of disquietude, by renewing disagreeable souvenirs, by prolonging a difllcult situation, naturally calculated to excite suspicion. In brief, to speak clearly, this hus- band longs for nothing more than to be disembarrassed of you (the word is strictly exact), and your disappearance from the scene will be a veritable deliverance for him. Hence this lamentable consequence, viz., that every inar- ried woman, contracting the sypMlis in tlie conditions wliicJi we are now considering, will never he otherwise than insufficiently, very incompletely treated, and will, on that account, remain exposed to the most serious dan- gers in the future. Such, gentlemen, is the invariable history of women who have been infected by their husbands. In the be- ginning of their disease, these women have always been treated some little (exception made of some, who, thanks to the selfishness of their husbands, have received no 160 SYPHILIS AND MARRIAGE. treatment whatever). They have been "whitewashed," permit me the common but consecrated expression. Then the i)hysician is hastened into relinquishing a treatment which might have awakened susj)icions, and become com- promising for the husband. As soon as possible the phy- sician is dismissed, and things rest there. What happens then? The syphilis, be it well understood, does not re- linquish its hold upon these unfortunate women, despite their quality of married women, of honest women ; and ten, fifteen, twenty years later it is manifested upon them by accidents of diverse forms, more or less severe, very serious sometimes, even mortal. Add to this another consideration still more aggra- vating : that, occurring in married women, who appear guaranteed from syphilis by an entire past of irreproach- able morality and of thorough respectability, these specific accidents of the tertiary period run the risk very often of remaining unrecognized, and consequently they are not submitted to the sole treatment which is appropriate to them, and they have every chance, on this account, of terminating in the most disastrous results. A diagnostic error as to the nature of these accidents is, in such a case, more than easy to commit. In the first place the phy- sician, by reason even of the character of the person — I mean by* reason even of the presumed antecedents of his patient — does not dream of syphilis ; he is far from sus- j)ecting syphilis in the virtuous, respectable, venerated surroundings where he finds himself called. Can he sus- pect it, moreover, when he receives from his patient no acknowledgment, no indication — for the excellent reason that this woman can not reveal a disease of which she has always been ignorant ? On the other hand, he is hardly more enlightened — at least, ordinarily — by the husband, EUSBARD SYPHILITIC; WIFE RECENTLY INFECTED. 161 by no means eager to revive a compromising past, little dis- posed to confidences whicli lie Judges absolutely useless, etc. So that, as an almost general rule, a correct diagnosis is not formed, at least when (which is the exceptional case) it does not declare itself by the objective character of the lesions. And I leave you to judge of the conse- quences of a mistake in conditions of this kind — that is to say, in presence of lesions so serious as those of ter- tiary syphilis.* I insist, and I repeat, that among women nothing is so frequent in practice as tJie tertiary acci- dents of syphilis contracted in marriage. Observations of this kind abound and superabound. I count them by hundreds in my notes of hospital and private practice. And, for the most part, for the enormous majority, they relate, I repeat it, to women who have been treated in a very insufficient way at the debut of the disease, who have been treated only for the time actually necessary to dissipate the first accidents, in order to save appear- ances, and exonerate the husband from responsibility most quickly. Very far from my purpose, assuredly, is it to pretend that it is a cold and cowardly calculation of selfishness * One may perhaps say, " But the antecedents of the patient will be known to her own physician, who, in consequence, will not mistake the nature of any acci- dents which may afterward happen." "Yes," I would reply, "if the physician called to examine these last accidents is indeed the one who originally treated the patient. But, in the contrary case — how then ? Now, there are numerous chances that the contrary case will be frequently met with in practice. It most often happens — this is the result of experience — that the physician who is called upon to treat the syphilis of a woman contaminated by her husband is not the regular physician of this patient. Almost always he is, after a certain time, supplanted by a confrere, and this through the agency of the husband, who is distrustful and little anxious to keep near his wife the confidant of a compromising past. Then, for this or some other reason, it frequently happens that the antecedents of the patient remain unrecognized, when upon these alone depends the establishment ©f a correct diagnosis as to the nature of consecutive accidents. 162 SYPHILIS AKD MARRIAGE. which induces numbers of husbands to sacrifice in this way the future of their wives to the immediate interests of their o^^Tl dignity ; or, from personal concern, to cover up the fault of which they have been culpable. That would be an unwarrantable, exaggerated, ridiculous accu- sation. But I can not refrain from remarking that which exists, and from reading in certain facts the condemna- tion which they carry ^vith them. I can not refrain, for example, from condemning energetically the conduct of those husbands who, in order to avert suspicion, do not scruple to abridge the treatment prescribed for their wives, and who compromise the health of others in order to pre- serve what they call "their respectability." Neither can I forbear accusing of carelessness, of imprudence, of indif- ference, etc., such others as, when once the first symptoms have disappeared from their wives, do not further concern themselves with what may follow ; they let things go as they will ; they repose in a security all the more comj)lete, as theh own health is not in jeopardy, and thus pre- pare, with an absolute indifference, dreadful catastrophes for the future. Certainly, examples to cite in justification of the preceding are not wanting to me. The following, among many others, will strengthen your convictions : A young lady, of high birth, marries a syphilitic man, and is very soon infected by him. Thereupon, great com- motion. M. Ricord is immediately summoned, and treats the patient. Everything disappears. They qiiickly turn their backs on M. Ricord ; they have no further use for him ; they would almost svv^ear never to have known him. JSTevertheless, the syphilis retains its potency, and reveals itself by the ill-omened results of three pregnancies, which, one after another, produce still-born infants. Several years pass in peace. Then .the young wife is attacked HUSBAND 8TPHILITIG; WIFE RECENTLY INFECTED. 163 with, singular accidents of the nose. She is troubled, with- out cessation, with a "cold in the head," and the dis- charge of an abundance of sanious or purulent mucus from the nostrils. !N"umerous plans of treatment are brought into requisition, but all without benefit. Two seasons of sulphur-waters produce no better results. A physician at this Juncture suspects syphilis, and interro- gates the patient in this direction, who, in the ignorance of her specific antecedents, quite naturally defends her- self by indignant denials. The husband, who is present at this consultation, remains impassible and mute, persuaded that " his wife has been cured of what she formerly had, and that the present accidents have nothing to do with the little misfortune of earlier days." Still the nasal lesions continue and become aggravated, until they result, on the one hand, in a frightful ozsena, and, on the other hand, in a perforation of the palate. Then, only, does the husband's conviction become shaken. Then, only, does he consent to recall M. Ricord, who immediately recognizes the specific nature of the disease. I am sum- moned in turn, and have only the easy role of confirming both the diagnosis and the treatment of my illustrious master. But at this time the lesions ha.ve become such that the whole nasal bony structure is necrosed. Three entire years this unhappy woman is condemned to abso- lute seclusion, on account of the insupportable odor which she spreads around her, and which every imaginable medication succeeds only in imperfectly correcting. She is cured only after the expulsion of numerous sequestra and the comi3lete loss of the palate. Likewise, I have among my notes numbers of other observations relative to women who, after having acquired syphilis from their husbands at the beginning of marriage, 164 SYPHILIS AND MARRIAGE. have only been subjected to short treatments, and have afterward experienced the most severe tertiary accidents — this one, for example, a x^hagedenic syphilide which invaded the face, and disfigured it most horribly ; that one the loss of the nose ; another a rectal stricture, which had to be operated upon, with failure to relieve the pa- tient ; another a cirrhosis which, misunderstood as to its nature, carried her off rapidly ; still another, lesions of the cranial bones and cerebral gummata, which XDroduced, successively, ei^ileptif orm attacks, hemiplegia, gradual fad- ing of the intelligence, dementia, and death ; etc., etc. Accidents of this kind are certainly qmiQ common, and I do not give them to you as constituting manifesta- tions peculiar to the order of cases which occupy us at this moment. But certainly, also, it is at the same time both remarkable and distressing that such accidents are common in marriage. Again, they are frequently en- countered in the highest classes of society, where the multiple conditions of social position, of knowledge, of civilization, of moral training, ought, it would seem, to exclude such shames. Finally, and still more, they im- pose a responsibility upon those who, the first authors of the evil, were under obligations to do everything to avert its terrible consequences, and v^^ho, notwithstanding, have for one reason or another evaded this direct duty. In such circumstances, gentlemen, a humanitarian role is also imposed upon you ; and this role you have already comprehended in advance, you have already anticipated in the course of the preceding discussion. This role is to take care of the woman who is confided to you, and in re- lation to whom you have until now only been the accom- plice of the liushand, charged with deceiving her as to the nature and possible consequences of her disease ; it is to HUSBAND SYPHILITIC; WIFE RECENTLY INFECTED. 165 protect the health of this woman in the present and in the future from the neglect of this selfish or indifferent hus- band ; it is, in a word, to employ every means, through your double influence of physician and man, that this wo- man may have the benefit, like every other patient, of an energetic, prolonged, active, sufficiently preservative treat- ment. It goes without saying that in numerous cases this role will be rendered easy by the good disposition of the hus- band, a man of heart, regretting bitterly the misfortune of which he is the cause, and ready to do everything in his power to repair his fault. It will suffice, then, to explain to him the future dangers to which his wife will remain exposed in the absence of a sufficient treatment, in order to obtain from him a carte hlancJie relative to the di- rection and the duration of your therapeutic interven- tion. But, on the other hand, you must expect to encounter other cases where your position will become much more de- licate, much more embarrassing ; when, for example, you will have to contend with the selfishness, the indifference, the prejudices, the fears, the ignorance, of the interested principal. In such a case, it will be your duty by your tact, by your experience of the human heart, to struggle with difficulties of diverse kinds in the best interests of your patient. It will be your duty to sustain this contest with a persevering ability ; and, finally, if you perceive yourself overruled, to energetically remind the husband of the duties which are imposed upon him as upon your- self in such a situation. I do not advise you, assuredly, to make an exposure, to pose yourself as a redresser of wrongs, to undertake the ridiculous role of a Don Quixote of married women. But what I say to you is, if you are 12 166 SYPHILIS AND MARRIAGE. forced to do it, attack the position from the front, by ad- dressing to the husband language both firm and severe, such as the following, for example : " Without doubt, sir, it may be extremely disagreeable to j^ou that the treat- ment of your wife needs to be still continued for a long time, but it is not in my power that it should be other- wise. I have consented, in order to save you from a false step, to be your accomplice against your wife, and I have given you my word. But I will not go further, and I throw ujDon you the whole responsibility of what may follow, in case, by your act, the treatment should not be pursued as it ought to be. Honor and humanity demand that you do for your wife what you would think necessary to do for yourself. Allow me, then, to finish the work begun, and complete a cure which ought to be the object of our common efforts." You may be sure, gentlemen, that in si)eaking in this way, in accepting and sustaining the role which I have just traced for you, you will fulfill a moral duty of which you have not the right to divest yourselves. Be equally sure that you will accomplish a salutary service in thus snatching from the tertiary grasps of the diathesis the unfortunate women w^ho were not designed for the pox, but whom the selfishness or the carelessness of their hus- bands would leave easily exposed to drain to the dregs the chalice of the disease. Still this is not all, and you have not yet exhausted the embarrassments of this special situation. On the other hand, indeed, you will have to contend with a difficulty of a different order, viz., with the repug- nances, with the resistances, which you will encounter from the person interested, on the part even of the patient that you have to treat ; and your position in relation to HUSBAND 8TPEILITIG; WIFE RECENTLY INFECTED. 167 her will demand a certain cleverness, even a certain pro- fessional tact, on your part. I explain : You have cured this woman, I suppose, of her first accidents. All has disappeared ; all is going for the bet- ter. And now you speak of a new treatment. But why this treatment ? Wherefore, and for what indication ? you are asked. Admit that your remedies are again accepted this time. But what welcome will you receive when you return to the charge a third, a fourth, a fifth time, etc. ? And, nevertheless, necessity imposes this ; you must obtain this from your patient ; it is the price of her cure. This difficulty — and many others of the same kind — you will only overcome by dint of patience, of pro- fessional tact, of practiced cleverness. You will only overcome them by being able to exercise over your pa- tient an authority which vsdll assure her confidence and render her docile to your prescriptions. Then, in view of the future, do not neglect to establish the situation well at your first visit, and that in a sense the most favorable to the purpose you have in view. As- suredly, you are under obligation to conceal from your patient not only the name of her disease but the special dangers to which she is exposed, and the terrible conse- quences which may result after an indefinite period. On the other hand, however, do not commit the mistake of declaring to her, as her husband would wish, that "she has nothing," that "her affection is a passing, trifling in- disposition, which will not be followed by consequences," etc. On the contrary, as soon as you may judge it prudent and opportune, express clearly the opinion that her present symptoms indicate a veritable disease — a disease which you may, however, disguise under whatever respectable pseudonym seems to you best under the cir- 168 STPEILIS AND MARRIAGE. cumstances. Let her understand that this malady will probably be of long duration ; that it may have disagree- able returns, relapses, recurrences. Assure her that the affection to which she is subject ought to be the object of an attentive surveillance ; that it is quite curable, with- out any doubt, but that, in order to be cured, it will de- mand prolonged care, etc. In brief, prepare the way and anticipate the objections, the rebellions, that you have to fear in the future, by indicating in advance the long thera- peutical intervention which will be necessary. I do not maintain by any means that you should frighten your patient. That would be absurd, out of place. But, believe me, you will defeat the end which you have in view by reassuring her too much, by not al- lowing her a certain degree of vague apprehension which will serve you as a valuable auxiliary. All patients (and women more than others) are so constituted that they will not be treated when they think they have nothing to dread, when they do not experience "a little fear" (per- mit me the word). Do not overlook this general disposi- tion of the human heart, and utilize it for the interest of your cause — that is to say, for the protection of the pa- tient, whose health is confided to you, under conditions so especially difficult and delicate. CHAPTER XY. HUSBAND SYPHILITIC ; WIFE SYPHILITIC AND ENCEINTE. FouETH order of cases : Husband sypMUtic ; wife sypMlitic and enceinte. We now come to the fourth and last situation possible. A man is married despite a syphilis not yet extinct ; he has infected his young wife ; and, in addition, this wife is enceinte. It would be superfluous to say that this situation is more serious than any we have previously studied, the most prolific in dangers, in catastrophes of various kinds, as also in practical difliculties for the physician. What may, in reality, result from such a state of things ? In the first place, the infant procreated in such con- ditions — that is to say, the issue of a father and mother both syphilitic — is subject to the gravest prognosis. It is destined, it may be, to die after some months of intra- uterine life ; it may be, to come to term still-born or mori- bund ; it may be, to be born with the pox. Of these three alternatives, let us concede the best — the infant is born with the syphilis. N"ow, this child may be confided to a healthy nurse, and you may be sure that it will transmit the infection to her — that is almost inevi- table. This nurse, in her turn, may infect her own child ; 170 • SYPHILIS AND MARRIAGE. may infect her husband, as has been seen so many times. Bnt I spare yon the enumeration of the possible ricodhets Qti these last contaminations. Such is, in brief, the perspective offered to us by this fourth order of cases ; it is, then, most certainly a subject of study which demands all our attention. In the first place, I will reassure you by saying : The situation is very critical, very serious, assuredly ; but it is not desperate, either for the present, or a fortiori for the future. As for the future, the outlook is not doubtful. For, treat this syphilitic couple actively, methodically, pro- tractedly, and you will bring it about that they will have, later on, living and healthy children, exempt from every specific phenomenon. And, even as to the present, as regards the existing pregnancy, it is not impossible — ^it is not impossible, I say no more than this — that treatment may avert a complete disaster. In other words, it is not impossible that the mother, submitted to an active treat- ment during gestation, may give birth to a living and viable child, and one which may even remain free from every specific accident. Thus : 1. Many times I have obtained from specific medica- tion this prime and inestimable success — the prevention of abortion, and the bringing of the pregnancy to full term. The child born under these conditions does not, it is true, escape syphilis ; but it is born viable, resisting, capable of tolerating specific medication, capable, in a word, of living with the syphilis, and of being cured of this syphilis by subsequent treatment. Examples of this kind are so numerous that I regard any particular citation as super- fluous. 2. In such circumstances, I have even seen children born healthy, exempt from every syphilitic symptom. HUSBAND SYPHILITIG; WIFE 8YPEILITIG— ENCEINTE. 171 Example : A young man is married while in the active secondary period, notwithstanding the advice of his phy- sician. Five months later, his wife becomes enceinte. In the second month of pregnancy she is brought to me, and I discover upon her specific accidents as manifest, as indubitable as possible. I then treat her energetically, and I pursue the medication with vigor during the entire period of her gestation. I have the happiness, first of all, of bringing the pregnancy to full term. Besides, the child is born healthy, well-nourished, and of almost the average development. It continues to live, and remains exempt from all specific manifestations. I observed it most carefully for about fifteen months, after which I lost sight of it ; and I can guarantee that during all this period it did not present the least suspicious phenom- enon. M. Langlebert has related a case almost identical. "Madame X married, in November, 1869, one of my patients, whom I had been treating for some months for constitutional syphilis. She immediately became en- ceinte., and must have contracted her husband's disease about the same time. She had scarcely completed the third month of her pregnancy when a confluent roseola covered her body. Blackish crusts disseminated over the hairy scalp, a very pronounced alopecia, a cervical ade- nopathy, tonsillar mucous patches of ulcerating form — everything seemed to indicate the debut of a very severe syphilis that she must inevitably transmit to her infant — if, indeed, this infant should see the light, wMch then appeared by no means probable. I immediately prescribed for Madame X pills of the sublimate ; afterward I submitted her to the use of the iodide of potassium, con- tinuing the mercury at the same time. The pregnancy 172 • SYPHILIS AND MARRIAGE. followed its regular course, and toward the end of August, 1870, Madame X gave birth to a. very smaU but healthy- girl, which she nursed herself, according to my advice. Now, this child has not ceased for a single moment to continue in good health. She has had nothing upon her body — neither spots, nor lumps, nor the least symptom of suspicious appearance. To-day she is a little over two years of age ; she is large, well developed, and is marvel- ously well. She has, then, escaped the syphilis, and this result she owes to the treatment, which could alone preserve her from the infection which her mother's con- dition during gestation must otherwise have rendered inevitable.* Successes of this kind, obtained under conditions so unfavorable, are well adapted, certainly, to encourage the physician, and indicate to him the line of conduct to be followed in like circumstances. That settled, we now come to the indications to be ful- filled in the class of cases which it remains for us to study. Relatively to the husband, there is nothing more simple — nothing more to do than to prescribe for him the usual treatment for the diathesis. But it is the wife, especially, that claims our solicitude at present. This wife must be treated, and treated with so much more of care, of method, of attention, of vigilance, as she represents two patients, if I may thus express it, two beings to be preserved. And, indeed, it is a question of the mother, first of all ; but it is no less a question of the infant which she carries in her womb, of the infant more endangered than she, and which we can only reach, only protect, through her. To treat the motJier, then, is the capital indication to be fulfiUed. * La syphilis dans ses rapports avec le niariage, p. 237. HUSBAND 8YPEILITI0; WIFE SYPHILITIC— ENGEIITTE. 1Y3 Well, gentlemen, this indication, so simple, so rational, and, moreover, so completely authorized by experience, you must not regard as accepted by all. It has its op- ponents. It has excited objections ; it has given rise to controversies which have recently again agitated one of our learned societies. It has been said : "What ! This pregnant woman you are going to treat, and to treat how ? You will prescribe for her mercury ? But this mercury, do you not fear that it may be prejudicial to her in several respects ? Will it not, in the first place, increase and complicate the gastric troubles of pregnancy ? Will it not add its own special angemiating action — to the anaemia, the hydrosemia of pregnancy ? And especially, a capital danger, does it not involve the risk of producing abortion ? For, every day, we see abortion produced in syphilitic women treated by mercury," etc. To all that, gentlemen, our reply will be as direct, as categorical as possible. Yes, without doubt, we will say, mercury maladministered is open to such objections. Yes, without doubt, with mercury given in certain forms or in certain doses we may produce the accidents alluded to — that is to say, aggravate gastric troubles, increase ansemia, and even favor or determine abortion.^ But that is not the question, and we have here nothing to do with the toxic or industrial use of mercury. What is alone relevant to our present inquiry is the safe and prudent administration of mercury as a remedy ; it is a mercurial treatment appropriate to the forces and to the special con- ditions of the patient. I^ow, a treatment of this kind, * Vide Ad. Lize, Influence de Vintoxication mercurielle lente sur le produit de la conception {Union Medicale, 1862, t. i, p. 106). H. Hallopeau, Du mercure, action pJiysiologique et tJierapeutique {Theses d'agregation, Paris, IS'ZS). 17i • SYPHILIS AND MARRIAGE. metliodically instituted and supervised, will not only re- main innocent of the dangers which have been ascribed to it, but it will, moreover, constitute the best and the surest means at our disposition of bringing the pregnancy to term, and of j)reserving the fcetus in such a case. ISTow, let us enter into details, and discuss, point by point, the various objections which precede. The matter is worth the trouble, since the existence of the infant is here in jeopardy, and depends upon medical intervention or non-intervention : I. In the first place, as regards the gastric troubles, ex- perience demonstrates that we can easily avoid them. We should guard against administering to our patients the sublimate, the biniodide, the syrup of Gibert, or all other analogous preparations, which are badly tolerated by wo- men in general, and especially by women in a state of pregnancy. We should be careful to prescribe other mer- curial combinations which are not apt to disturb the digestive functions to the same degree. We should pre- scribe, for example, the proto-iodide, a milder remedy, which, in a medium dose, from five to eight, or even ten, centigrammes daily, is ordinarily well tolerated by the stomach. Here we are accustomed to administer the pro- to-iodide every day to our syphilitic women in a state of pregnancy, and, nine times out of ten, we see them remain undisturbed in their gastro-intestinal functions. Should it determine, exceptionally, some malaise^ some gastric or intestinal disorder, we almost always succeed in causing it to be tolerated by some expedient or another ; it may be by giving it before or during the meals ; it may be by associating with it a small dose of opium ; it may be by prescribing some digestive adjuvant, such as wine of quinquina, wine of gentian, coffee, etc. If, however, the HUSBAND 8YPEILITI0; WIFE STPEILITIO— ENCEINTE. 175 stomacli still shows itself rebellious to tliis remedy, if gastric or intestinal troubles continue to be occasioned by- it, there always remains a resource by which the patient may enjoy the benefit of a mercurial influence without in- jury to the digestive functions. This resource you have anticipated in advance : it is the resort to mercurial fric- tions^ a mode of treatment whose energetic action needs no longer to be demonstrated in a general manner, and which has been highly extolled in a special manner by some physicians as peculiarly adapted to syphilitic wo- men during the state of gestation. II. The second objection is altogether theoretical. JS'ever, for my part, have I seen the ansemia of pregnancy increased under the influence of a mercurial treatment in- telligently conducted. And as to the special ansemia of syphilis, it is now well demonstrated that it has its true remedy in mercury. It has been said, with all reason, that from the point of view of the phenomena of specific ansemia, " le mercure est lefer de la mrole.'''' III. Finally, it is absolutely false that mercury pro- motes abortion in syphilis, as certain physicians contend. From the fact that it is not rare to see syphilitic women abort during, or at the termination of, a mercurial course of treatment, it has been inferred that the abortion is due to the mercury in such case. This induction is, in truth, very illegitimate ; it is even, I would say, devoid of all foundation, for it disregards a factor more than essential in this matter, viz., the disease itself, syphilis. It attrib- utes to tlie treatment that which is the result of the dis- ease. It is needless to remind you again that syphilis causes a most powerful predisposition to abortion ; there are few morbid states that may be comparable to it from this point of view, and that furnish so considerable a 176 - SYPHILIS AND MARRIAGE. contingent to the sum total of abortions.* So that, when a syphilitic woman, submitted to a mercurial treatment, comes to have a miscarriage, one is justified in attributing this miscarriage, not to the influence of mercury, but to the exclusive influence of the specific diathesis. Do you wish the proof of this ? This proof may be found in these two results of clinical experience, viz. : 1. That numbers of syphilitic women abort without ever having taken an atom of mercury. The frequency of this first fact is notorious. 2. That numbers of syphilitic women, who, without treatment, have had a series of miscarriages, succeed in carrying a pregnancy to full term only after having un- dergone a mercurial treatment. This is a point upon which I have insisted at length in a preceding chapter, and which it will be suflicient, I think, to simply enunci- ate again without more ample development. So the opinion which considers mercury a cause of abortion in syphilis should not prevail against what I would call clinical evidence — that is to say, against the imposing mass of clinical facts, which, collected from all sides, related by observers exercising their art in the most different quarters, all accord, nevertheless, not only in exculpating mercury from this special accusation, but also in presenting it as the best safeguard that we possess against the abortive tendencies of syphilis. This opinion I energetically condemn ; for my part, I do not hesitate to characterize it as mischievous, in fact, for it has as a logical consequence the privation of syphi- * I may be permitted, in this connection, to refer the reader to a chapter of my Lcfons sur la syphilis etudiee plus particulieremeni chez la femme, p. 955. Vide also " Illustrative Cases," Note I. HUSBAND SYPHILITIC; WIFE SYPHILITIO— ENCEINTE. 177 litic women in the state of gestation from the benefit of a potent remedy, which is equivalent to the surest means of condemning them to the probable chances of abortion. For the rest, there is to-day, with very rare exceptions, an agreement upon this question ; and, without insisting further, I will summarize, what may be called the present state of science relative to this subject, by formulating the two following propositions : 1. Mercury does not always prevent abortion in syph- ilitic women, but nothing demonstrates that it has ever contributed to its production, at least when administered in therapeutic, non-excessive, non-toxic doses. 2. It often succeeds in a very evident manner in pre- venting abortion, in prolonging pregnancy, in conducting it to its normal term.* In practice, then, when we meet * What authorities could I not quote here ! Let me cite at hazard :"....! should be disposed to place syphilis among the most frequent causes of abortion. . . . We may, nevertheless, be quite sure of destroying this cause of abortion as soon as we are able to recognize it. Mercury properly administered almost always succeeds. . . . We commonly fear to have recourse to mercury during pregnancy, because we imagine that it may cause abortion. But a large experience has con- vinced me that this opinion is devoid of all foundation, and that, with prudence, we may administer mercury in doses sufficient to cure all the symptoms of syphilis during the entire period of pregnancy, without any injury to the mother and the child. . . . When a pregnant woman is evidently attacked with syphilis, or when I have strong reasons to believe Ker infected, I never hesitate to make use of this great remedy. This course has always appeared to me advantageous." — Benjamin Bell, " Treatment of Virulent Gonorrhoea and of Venereal Diseases " (trans, of Brosquillen, t. ii, p. 608). " Gestation, so far from contraindicating the employment of energetic treat- ment, demands still more attention and intelligent promptitude. I have seen many more abortions in syphilitic women not treated than in those who, taken in time, have been subjected to a methodic medication." — Ricord, Traife pratique des maladies vineriennes, 1838. That which M. Ricord intends by a "methodic medication " is none other than the usual treatment of syphiHs with mercury. " The mercurial treatment is regarded at Lourcine as the preservative against abortion " (Coffin, work cited). " Administered properly, mercury is the most powerful preservative for the 178 SYPHILIS AND MARRIAGE. with, a sypliilitic woman in a state of pregnancy, our first care should be to submit her to specific treatment. And if this woman — as, indeed, is the case in the class of situations Avhich we are now studying — is affected with a syphilis still recent, demanding the employment of mercury, we should not hesitate to prescribe mercury. We should prescribe it, without doubt, in moderate doses, appropriate to the patient's strength and gas- tric tolerance ; but we should prescribe it in an active, .sustained, prolonged, veritably efficacious manner, suf- ficient, in a word, to accomplish the object we have in view. And this treatment, gentlemen — I do not fear to repeat infant; and, as M. Vannoni has established (i7 raccogJ. mcd., August, 1872), if it does not prove itself a preventive of abortion, it is because it is not given early enough or for a sufficiently long time. There is an urgent necessity of taking pregnancy into consideration in the therapeutics of syphilis, since we have seen a mercurial treatment administered to pregnant women preserve the infants born in the earlier confinements, and allow the disease to destroy those of later preg- nancies when treatment was omitted." — Rollet, Traite des maladies vmericnnes, Paris, 1865. " The dangers of giving mercurial preparations to enceinte women have been much exaggerated ; it is now recognized, on the contrary, that they render immense service when syphilis has been the suspected cause of former abortions, for the dis- ease may rest latent in the mother, or attack the foetus only. It is doubtless in Buch cases of obscure cause that Young, Beatty, and Russel, in England, have ob- tained successes of which they refer all the honor to mercury." — Devilliers, article Avortement in the Nouvcau diclionnaire de medccine et de clditirgie prcdiqucs, t. iv, p. 323. " Without any doubt, the administration of mercury, of the iodide and of other medicaments which contain a toxic principle, when carried to the point of produc- ing a sort of chronic intoxication, is a powerful cause of abortion, and the cases of abortion attributed to mercury are not all from errors of interpretation. . . . But it is no less true — and observation confirms it every day to every mind divested of preconceived ideas — that a treatment during pregnancy by mercury or by any other active agent in order to combat syphilitic symptoms, to destroy the diathesis, or build up the constitution, so far from being a danger, is, on the contrary, an advantage both for the mother and for the infant, if this treatment be directed with prudence, and given in moderate doses." — Jacquemier, article AvorlemciU, in the Diclionnaire encyclopedique des sciences medicalcs, t. vii, p. 539. HUSBAND SYPHILITIC; WIFE SYPHILITIC— ENGEINTE. 179 it again in conclusion — we should institute with so much more of care, we should supervise with so much more of method, of solicitude, of vigilance, because it is not a question of only one patient to be cured, but because with this patient and through her there is another exist- ence to be preserved, that of the infant which at this period intimately shares its mother's destinies. CHAPTER XVI. DANGERS TO SOCIETY — SOCIAL PEOPHTLAXIS. We have jnst passed in review tlie four different situa- tions whicli may be presented, when syphilis has been in- troduced into a household by a syphilitic husband. And apropos of each of these situations, I have endeavored to trace out for you the line of conduct to be followed by the physician, and determine the numerous indications which it is incumbent upon us to fulfill under such cir- cumstances. Our subject, nevertheless, is not altogether exhausted. An essential and most practical point remains for me to mention to you ; and with it we will terminate our present lecture. This point relates to a veritable social duty (you will see that there is no exaggeration in this word), which is imposed upon the physician in the particular circum- stances which we have just been considering — a duty at once manifest and undeniable, and the accomplishment of which is fruitful in useful results, but, nevertheless, a duty often omitted, neglected, violated even, in ordinary practice, to the great detriment of those whom it is our professional mission to protect. The greater number of our classic treatises remain ab- solutely silent upon the question which is about to follow. DANGERS TO SOCIETY— SOCIAL PE0PHYLAXI8. 181 You will permit me, then, to treat it somewhat in detail, in order to show you its importance and practical diffi- culties. When syphilis has contaminated a husband and wife there is a great risk, as we have previously shown, of their child being born tainted with syphilis. Now, this infant, supposing it to be syphilitic, evidently carries with it the dangers of contagion. That is to say, it is possible that the syphilis with which it is affected may radiate from it to the persons who surround it, who are called upon to take care of it, and who, in various ways, come in contact with it. Well, then — and this is the point to which I wish to direct your attention — what will happen should this in- fant be confided to a nurse ? The answer is easy : almost infallibly this child will infect the nurse. It is thus, then, that syphilis proceeds from the family of the infant and attacks persons outside. First misfortune, first deplora- ble consequence of the situation which now occupies us. But this is not all. You know, since you have often- times heard me repeat it,* what a singular faculty of expansion, of irradiation, the syphilis of nurslings and nurses presents, which propagates or may propagate it- self by a series of unexpected ricochets in such a way as to constitute a source of multiple contaminations. How many times, for example, has it not happened that a syphilitic nursling has infected many persons of its en- tour age,-\ or, indeed, that a nurse infected by a syphilitic * Nourrices el nourrissons sypliiliiigues, Paris, 18*78. f Example of the kind : A nurse infected with syphilis conaes into a young family, whose infant is confided to her. She infects this child. The nature of the morbid symptoms remains unrecognized at first, as would almost necessarily be the case, so that no precautions are taken against the possible dangers of such a contam- ination. What happens ? The infant, on its part, infects — 1. Its mother ; 2. Its grand- ' 13 182 - SYPHILIS AND MAERIAGE. infant has transmitted the disease to her own child, to her own husband, to a strange nursling? And how many- times, also, has not each one of these new contagions be- come, in its turn, the origin of other contagions ? The cases in which these cascades of contagion are produced, if I may thus speak, primarily originating from the syphilis of a new - born child, abound and super- abound. AVithout exaggeration, they literally swarm in medical literature. I have already cited a great number of them when giving you the history of the syphilis of nurses and nurslings. Allow me to briefly recall to you, as types of this Mnd, the three following cases : 1. A young man afl'ected with syphilis marries prema- turely. He immediately infects his wife. A child born of this marriage is confided to a nurse, and infects this nurse. She, in her turn, transmits the syi^hilis to her mother; 3 and 4. Two uursery-maids of the family, girls of absolutely irreproach- able character. Aud the young wife transmits the contagion to her husband some months later. I have often said that nofhhiff is so dangerous to the persons surrounding it as a syphililic infant. The thousand attentions which the new-born requires in its raising — the kisses, the caresses, which are lavished upon it — serve as the origin of easy and frequent contaminations. I have, in my notes, to speak only of cases observed by myself, a dozen cases of contagions of this order. It is thus, for example, that a grandmother, sixty-five years of age, was infected by her little grandson that she fed with a spoon, having taken the pains to carry each spoonful to her mouth before giving it to the child ; the virus was certainly trans- mitted in this case from the lips of the infant to those of the grandmother. Like- wise, I now have under my care a young woman who was infected by her child, which had been infected by a nurse. My learned colleague, M. Hillairet, has recounted to me the following case : A young man affected with syphilis marries prematurely, and soon infects his wife. A child born of this couple presents the accidents of hereditary syphilis several weeks later, and infects its nurse. Con- fided then to its maternal grandparents, it transmits the contagion to both of them by the intermediary of a nursing-bottle. The grandfather and the grand- mother had the habit of putting the nursing-bottle to their lips, and that with- out taking the precaution to wipe it after it came from the mouth of the child. Now, the child being affected with labial syphilides, both were infected in the mouth, and presented an indurated labial chancre, soon followed by general ac- cidents. DANGERS TO SOCIETY— SOCIAL PROPHYLAXIS. 183 own child, in tlie first place ; then, to another nursling ; then, two months later, to her husband.* 2. A syphilitic child, born in an apparently healthy condition, is confided to a nurse, whom it soon infects. This nurse, who is nursing another child at the same time, infects this child, which soon dies. She then takes a third nursling, which, in its turn, contracts the syphilis and dies. Another nurse, a friend of the former, having, through kindness, given the breast to this last child, re- ceives the syphilis from it. She then infects her nursling. Please remark, gentlemen, this makes five contagions from this syphilis, and two deaths. 3. Another example, related by one of our most dis- tinguished colleagues — M. le Dr. Dron (of Lyons) : A syphilitic child infects its nurse. This nurse, in order to empty her breast, suckles three nurslings — all three of which take syphilis. Each of these children infects its mother ; each of these three mothers infects her husband, f Count again : ten syphilitic contaminations derived par ricocliet from the syphilis of a nursling ! And do they stop here % % It is useless to add, moreover, from another point of view, what you well appreciate, what goes without saying, viz., that a syphilis derived from such an origin has every chance of remaining unrecognized, at least during a cer- tain time ; and, in consequence of being abandoned to * Vide " Illustrative Cases," Note V. f Achille Dron, Mode particulicr de transmission de la sypliilis au nourrisson par la nourrice dans Vallaitemcnt, Lyon, IRVO. \ Sometimes even (but this is only exceptional, it is true) similar cascades of contagion have made a still more considerable nimiber of victims. Thus, one has seen a syphilitic nurse, going into a small village, transmit syphilis to sixteen, eighteen, twenty-three persons, and become the origin of a small local epidemic {vide Amilcare Ricordi, Sifilide da allattamenio e forme iniziali della sijilide, Milan, 1863). 184 SYPHILIS AND MARRIAGE. itself, left without treatment. Also, tliat it can not fail, and does not fail, in numbers of cases, to result in veri- table catastrophes — it may be, for example, in the death of the nurslings contaminated by their nurses ; it may be in serious accidents developed upon the nurse, or upon other iDersons who have been the victims of such conta- gions.* Now, to return to our subject, gentlemen, it is pre- cisely dangers of this kind which the physician ought to foresee, when he finds himself in a position to prevent them. He recognizes these dangers ; he knows that they will occur if he does not interfere ; it is his business, then, to interfere in order to avert them. And here be- gins for him an actual duty, which, without exaggeration, I have already characterized as a social duty, since it has for aim and for result the protection of the interests of society. This duty, I do not hesitate to say, is im- posed upon the pliysiciany who would be culpable in neglecting it, in divesting himself of it ; by so much more as, in fulfilling it, he mil at the same time satisfy the in- terests of Ms patient. This principle stated, let us come to its application : To circumscribe the pox in its original bed so as to * Here are examples of the kind, selected from many others : 1. An infant, born of a syphilitic father, is confided to a healthy nurse. It soon presents various syphilitic accidents and infects its nurse. She, in her turn, infects her husband. The husband is affected with an iritis and loses one eye. The wife is attacked some years later with a syphilitic paralysis, to which she suc- cumbs (Dr. Delore de Lyon). 2. One of my syphilitic patients marries, in spite of me, and transmits the syphilis to his wife soon after his marriage. A child is born, which (without my knowledge, it is needless to say) is confided to a nurse. This child soon presents numerous symptoms of syphilis, and infects the nurse. This woman, in her turn, infects — 1. Her child, which dies in some months ; 2. Her husband ; affected with a severe iritis, he loses an eye. A year later, she is delivered of an infant which presents grave accidents of syphilis, and dies at the age of two months. DANGERS TO SOCIETY— SOCIAL PROPHYLAXIS. 185 prevent the spread of its ravages outside, sucli is the ob- ject to be realized. Now, how attain this ? For this there is bnt one practical means : it is to so arrange that the syphilitic infant, the first origin of the dangers which we are seeking to avert, remains in the family, and is suckled by its motlier. It is evident that, if it does not leave the paternal hearth, if it receives its mother's breast, there will be no opportunity of its transmitting to a nurse and to other persons the dreadful contagion of which it bears the germ. It is, then, to this object that the physician should direct his efforts. He must, by his influence, by his ad- vice, by his moral authority, arrange a situation which will protect the interests of all, and not allow a different arrangement, prejudicial to all, to be organized indepen- dently of him. It is necessary, to speak clearly — 1. That the new-born child, the offspring of syphilitic parents, be- retained under the roof where it was born, so that he may watch over this child, treat it, if necessary, and suppress as quickly as possible the contagious acci- dents which may arise. 2. And especially is it necessary that he oppose with an his might this child being confided to a nurse ; he must make the family accept, as an absolute, unavoidable necessity, the nourishment of this infant from the mater- nal bosom. Let us now come to the practical point. In brief, what is to be done in order to attain this result % This : At a favorable moment, when the pregnancy of the mother is so far advanced as to permit the hope of an accouchement at term, to address yourself to the husband, and explicitly expose the situation to him, with all the 186 SYPHILIS AND MARRIAGE. dangers it involves — to say to Mm tliat his prospective infant runs the serious risks of hereditary syphilis; to make him comprehend that under these circumstances the child should not be intrusted to a nurse, who would almost inevitably receive the contagion ; to unfold to him, without reservation, all the consequences of such a con- tagion — the just and outspoken recriminations of the nurse, a scandalous exposure, a possible lawsuit, humili- ating publicity, etc. ; to conclude, finally, with the abso- lute obligation imposed upon the mother to nurse her child, the sole moral expedient, proper, and at the same time efficacious, which can retrieve the situation. "Then," you will add, "arrange it, sir, that your wife shall nurse this infant. The interests of all — yours and your infant's — depend upon this. Accept it as an abso- lute obligation, as an indispensable necessity, considering the circumstances under which you are placed. There- fore, if your wife contemplates nursing it, do not dissuade her from it. And, if she is not disposed to do so, antici- pate her objections, and endeavor by all the means which you can bring to bear to modify her resolution. For, from every consideration, I again repeat it to you, it is she and she alone who ought to act as nurse for your infant." By thus stating the situation, it will be rare, indeed, that the physician does not accomplish the purpose he has in view. Consequently, his object will be realized ; the infant, syphilitic, or suspected of syphilis, will remain in the family, and will be nursed by its mother, and thus obviate danger to others.'^ * If I had not considered at length this subject in another work, I would in- sist here upon numerous practical details which I pass in silence. It appears to me indispensable, nevertheless, to add to the foregoing some considerations DANGERS TO SOCIETY— SOCIAL PROPHYLAXIS. 187 Kow, tMs result, gentlemen, do not doubt it, will be a considerable, ca-pital service rendered to public prophy- laxis. To be convinced of this, recall wliat I liave else- where demonstrated in tracing the history of the syphilis of nurses and nu.rslings. Recall the frequency of these contagions transmitted by nursing ; recall the disastrous, lamentable consequences which result from them, the relative to a point of especial importance. I will borrow them from my Le^oois sui- tes nourrices ei les nourrissons syphUitiques (Paris, 1878). " .... Do not hope, gentlemen, that your advice to confide the nursing to the mother will always be accepted without opposition. Without speaking of rea- sons which do not exist, of reasons based upon pretended conveniences, upon society, or other considerations, it will often be objected that the mother ' is too feeble to nourish it,' that she could not endure the fatigues of nursing without danger to herself, etc. Insist (for it is quite rare that a mother can not, at least for some months, nurse her child) — insist, and say this, ' It may be that the mother can not nourish it as long as an infant ought generally to be nursed, but she should do what is possible, and that is all we ask of her. Let her give it the breast dur- ing the first months ; that will enable us to form an opinion, and we will advise after that time. At all events, there is an urgent necessity that the mother nurse it during some months.' And wherefore this, gentlemen ? Wherefor require at least these few months of maternal nourishment ? It is that when infantile syphi- lis must reveal itself, it does reveal itself, if not always, at least almost always, with- in the first two or three months. In 158 cases, M. Diday has seen it break out 146 times within this period. Such figures have such a significance that we may dis- pense with all commentary. " Then these few months of maternal nursing may serve us as a criterion of the health of the infant, and as a gidde for our subsequent action. "And, in effect — 1. If within this period of time syphilis reveals itself in the infant, all is said. The infant must undergo the common lot of all syphilitic in- fants. In any case, it may not be confided to a nurse, and it is essential to know this from the point of view of general prophylaxis. " In this first alternative, either the maternal nursing should be prolonged, if that be possible, or else we shall be compelled to have recourse to the special pro- cedures that I have previously indicated to you as being able to serve for the rais- ing of syphilitic children (recourse to a syphilitic nurse, alimentation from a goat- nurse, etc.). 2. But, if, on the contrary, after three months, or, better still, after four or five months, of observation, nothing suspicious occurs upon the infant, there are strong presumptions (I say presumptions, and nothing more) that it may have escaped the hereditary influence, that it may not be syphilitic. And here we are more at liberty in our movements ; for, in case the mother is unable to continue giving it the breast, nourishment by a nurse may be permitted — not, however, with- out still subjecting the nursling to a surveillance close and minute, sufficient to prevent all risk of contagion." 188 SYPHILIS AWD MARRIAGE. physical catastrophes which they may entail, the moral miseries which they may expose to publicity, the scanda- lous actions at law which they sometimes give rise to, the humiliation and the shame which they cause in fami- lies, etc. In all respects, then, it is important that the physician — whenever he can do so, and he often can — should curb such contagions, by circumscribing the pox in its original home, by preventing it from carrying its dangerous pollu- tions elsewhere. This is for him a professional obligation in relation to society, an obligation in which he should not fail. But I foresee an objection : "Be it so," you are, per- haps, about to say to me ; "we comprehend perfectly the importance to society, to everybody, of thus circumscrib- ing the pox in its home, and we grant you that the means proposed by you favors this end in a measure. Neverthe- less, if this means has for its undeniable result the pre- vention of the spread of the contagion outside of its home in a family, is it not defective, dangerous even, from other points of view? 'Thus,' you say to us, 'let the child be nursed by its mother.' But what will haj^pen from this procedure if the mother is syj)hilitic and the child healthy ; or, conversely, if the mother is healthy and the child syph- ilitic ? Will not the contagion be then transmitted from the mother to the child, or from the child to the mother ? Will not this syphilitic mother infect this healthy child ? Or, indeed, will not this healthy mother be infected by this syphilitic child ? " The objection, I recognize, has, indeed, its value — at least apparently. Let us discuss it, then, with all the care which it merits, in order not to leave any reservation, any uncer- tainty in your minds in relation to that which precedes. BANGERS TO SOCIETY— SOCIAL PROPHYLAXIS. 189 Four orders of cases are possible in the situation we are now considering. Thus : 1. Either the mother and the child have both escaped the dangers of the paternal syphilis — that is to say, remain healthy. 2. Or the mother and the child have both received the infection emanating from the father — that is, have become syphilitic. 3. Or, the mother remains healthy, while the child has undergone the contamination. 4. Or else, finally and conversely, the mother is syphi- litic, while the child remains healthy. There we have — have we not? — the four alternatives, and the four only alternatives, which can or could be pre- sented. Besides these, there is none other to be supposed, to even be imagined theoretically'. ISTow, let us consider each of these in detail, and see, apropos of each, what may be the dangers of maternal nursing, either for the mother or for the child — a discus- sion which may, perhaps, seem to you somewhat long and monotonous, but which is indispensable to the clear understanding of our subject. , First hypothesis : The mother and the child have both escaped the infection. In this case, quite evidently, there is nothing to fear for either the one or the other ; for, according to the proverb, '■'■qui n^a Hen ne donne rieny The nursing of the child by the mother involves no danger, then, in any respect. Let us pass it by. Second hypothesis : The mother and child are both syphilitic. Here, again, there is no possible danger of contagion. The mother and the child, both having syphilis, have no- 190 . SYPHILIS AXD MARRIAGE. tiling to fear from each other ; for syphilis does not duplicate itself ; it is not twice acquired. Let us even say that in this case the maternal nursing alone can be medi- cally accex^table ; for, at no price, for no reason, should we ever j)ennit a syphilitic infant to be confided to a healthy nurse. Third hypothesis: Mother healthy and child syphi- litic. It is here only that the objection we are considering seems to assume a real value. For here the possibility of a contagion arises from the simple statement even of the terms of the proposition. But we say, in the first place, that this third situation rarely presents itself in practice. We have shown that it is almost exceptional to encounter a healthy mother vdth a sy]3hilitic child. Almost always, syphilis in the infant implies syphilis in the mother. Still, however rare they may be, cases of this kind have been cited, and I have observed, at least I think I have observed, a certain number. They may, then, be taken into consideration in the present discussion. Now, the question presented in such a case is the fol- lowing : Will the mother who nurses her child in these conditions be in danger of receiving syphilis from it? Theoretically, one would be induced to answer in the af- firmative. Wherefore, in fact, should not this mother, who is healthy, receive the infection from her child who is syphilitic ? Practically, on the contrary, one comes to an opposite conclusion. Practically, one never sees a child, syphilitic from birth (from birth, be it well understood), infect * its * On the contrary, an infant born healthy, and afterward contracting syphi- lis from another person (it may be a nurse, for example), is ultra-contagious DANGERS TO SOCIETY— SOCIAL PROPHYLAXIS. 191 motlier while nursing it. Never does one encounter a case, however plausible in theory it may be, of a mother nursing her own syphilitic child and contracting syjjhilis from it. Let one explain this as one chooses, it matters little to us at this moment. It is always a fact, a substantial fact, which obtrudes itself in the name of clinical ob- servation, and which involves, in our present study, a considerable interest. Pointed out long ago by an Eng- lish author — Abraham CoUes ^" — and known to us un- for its mother. It is thus, as has been many times observed, that the contagion of the mother is oecasioned by the infant, under the following conditions : An infant is born healthy, of healthy parents ; it is temporarily confided to a syphilitic nurse and receives the syphilis from her ; returning to the maternal breast it then in- oculates the mother with syphilis. Cases of this kind are found signalized every- where. I have related a number in my Legons sur les nourrices et les nourrissons syphilitiques, and I think it sufficient here to simply announce the fact without supporting it by particular citations. * It is a curious fact that I have never witnessed nor ever heard of an instance in which a child deriving the infection of syphilis from its parents has caused an ulceration in the breast of its mother." — Abraham Colles, " Practical Observations on the Venereal Disease and on the Use of Mercury," London, 1837. I am aware that many cases have been cited in opposition to this law, or, if the word appears a little ambitious, to the proposition of Colles. What the cases in question are worth I can not say ; for my part, I have never encountered similar ones, at least up to the present time. It; is assuredly a very surprising thing to see a healthy woman nursing her infant, covered with syphilis, remaining healthy in contact with this infant, not contracting the syphilis from it. This is indeed so extraordinary that one always questions if one is not deceived, if this woman is indeed really exempt, if she does not escape the contagion for the simple reason that she has already been con- taminated, either before or during pregnancy. In a word, one is always tempted to believe that this woman is syphilitic, but, for some reason or another, syphilis has not been detected in her at an opportune moment — that is to say, at a mo- ment when unequivocal manifestations would surely have been attested. Such is, at least, the interpretation which physicians, who deny the paternal heredity of syphilis, give to the proposition of Colles. For them, there can be no syphilitic infant without a syphilitic mother ; for them, the infection of the infant implies the infection of the mother. " Then," say they, " there is nothing astonishing that a syphilitic infant does not infect its mother. It can not infect her, because she is already syphilitic. One syphilitic has nothing to fear from another syphi- Utic." The question, in effect, would be decided in this sense if one always verified 192 . SYPHILIS AND MARRIAGE. der tlie name of the laio of Colles, tMs singular immu- nity of the mother against infection from her infant has since then impressed numbers of physicians. It is, we may say, generally accepted in our day as an undeni- able fact, even confirmed by an almost unanimous assent. syphilis in the mothers of syphilitic infants. But that is precisely what one does not always establish. Must one believe that it -exists, even when one has no proof of it ? It is this conclusion which certain of our confreres arrive at. Mr. Hutch- inson has even built a complete theory upon this basis, to which it will not be without interest to call the attention of the reader. According to our eminent colleague, the law of Colles can find no other possible explanation than in the infection of the mother. And yet he is the iirst to recog- nize that most commonly one can not verify the signs of infection in the mother. If, then, says he, this woman be syphilitic, she must be so in a peculiar manner, according to a certain mode which admits of her being syphilitic without apparent manifestations. Well, continues he, that is what takes place, very probably. It is to be believed that the maternal syphilis, derived in utero from a syphilitic foetus, is a syphilis of a special order — a syphilis miligatcd, tempered, modified, susceptible of not betray- ing itself by any external symptom, or indeed of remaining a long time latent — even indefinitely latent. Consequently, this syphilis may escape us, may elude all our investigations, when, nevertheless, it exists, and infects the maternal organism so profoundly as to render it refractory to subsequent contamination. As an argument for the support of this more than bold hypothesis, Mr. Hutch- inson recalls to mind that virulent diseases manifest an evolution and a gravity quite different, according to their mode of penetration into the economy. See, says he, the variolous virus. Inti'oduced into the organism by way of inoculation, it only determines an affection comparatively light, which results in death only once in five hundred times. Absorbed by inhalation, on the contrary, it produces a very grave disease, which becomes fatal once in four times. Apply this to syphilis, and you will easily comprehend that a syphilis derived from contamination of the fcetal blood may differ absolutely from the syphilis derived from a tegumentary inoculation, both in the symptoms of its evolution and in gravity. Developing the exposition of his theory, Mr. Hutchinson admits the possibility of three orders of cases in syphilis by conception, viz. : " 1. A first group, in which the diathesis manifests itself by the habitual symp- toms of the secondary period. This is only exceptional ; and it is even to be believed, according to the author, that the cases of this kind are derived from a syphilis by ordinary contagion, rather than from a syphilis by conception. " 2. A second group, in which the infection is characterized by specific symp- toms, but of a light order, of a form essentially benign ; an unhealthy condition during pregnancy, loss of hair, and, later on, ' months or years later,' ulcerations of the tongue, palmar lesions, gummata of the cellular tissue. " 3. A third group (this comprehending, at least, one half of the cases), in which the disease docs not betray itself by awj symptom, by any disturbance of the health. DANGERS TO SOCIETY— SOCIAL PROPHYLAXIS. 193 "It is certain," M. Ricord has written, " that, in the case where the mother has escaped syphilis while carrying a syphilitic infant in her womb, she never afterward con- tracts the syphilis by nursing her diseased infant. " Like- wise, M. Diday : "ISTever does an infant, syphilitic from birth, communicate the disease to the mother who nurses it." As to myself, I have never, to this day, observed a single well-authenticated fact in contravention of the law of CoUes, and I hold this law as absolutely consistent with the results of the clinic. Then, to return to our subject, here again, even in this situation, so perilous in aj^pearance, of a healthy mother This absence of all symptoms during the first years does not exclude the possi- bility of tertiary accidents in a future, more or less distant. But, nu)st often, no- thing is produced, and the syphilitic woman infected in this way generally remains free from all specific manifestations during her life." — (" On Colles's Law and on the Communication of Syphilis from the Fcetus to its Mother," " Medical Times and Gazette," December, 1876, p. 643.) I will not stop here to discuss this theory, for, to speak truly, it defies at present all criticism. If would be necessary, in fact, either for its verification or its refutation, to bring a whole series of clinical facts minutely observed in a special direction, and we are not prepared with a criterion of this kind. This is a new field of investigation which is opened to us, but in which the first landmarks are hardly yet placed. I shall consider it my duty, however, to mention an interesting observation which has just been communicated to me by Dr. Charrier, and which confirms, in one point, the doctrine of Mr. Hutchinson. The reader will find this observation reproduced among the " Notes and Illustrative Cases " appended to this work (Note VI). Definitely, in the present state of science, two important facts result from clinical observation, viz. : 1. That a healthy woman becoming enceinte from contact with a syphilitic man may give birth to a syphilitic infant, while she remains healthy (in appearance, at least). 2. That this woman, nursing a syphilitic infant, is not liable to receive the con- tagion from it. It only remains to interpret this singular immunity, and, notably, to determine if it be explicable, as certain authorities pretend, by a sort of special and latent in- fection of the mother — an infection derived from the fcetus by a not less special mode of contamination. This the future alone can teach us, and we are compelled at present to reserve judgment. 194 SYPHILIS AND MARRIAGE. exposed to tlie contact of a sypliilitic infant, maternal nursing does not involve any danger. There remains, finally, a fourth and last alternative : mother syphilitic and child healthy. This is the preceding situation reversed. Well, as in the preceding case, contagion is not exerted here. A child born healthy, although the offspring of syphilitic parents, has never taken the syphilis in nursing from its mother. As to myself, I declare that I have never seen anything of this character. I declare that I am not aware of a single example of a mother having given birth to a healthy in- fant, then afterward infecting it in the capacity of nurse.* Recapitulating, then, gentlemen, whichever it may be of the four alternatives that we are considering, always and invariably we find that the nursing of the infant by its mother is free from the theoretical dangers which might be supiDOsed. From this an easy conclusion is to be deduced : it is that on no account should one oppose in either case the mother nursing her infant. Now, as from the other point of view there is a valid reason, superior to every other, against the infant being confided to a nurse, the question is resolved essentially the same in two different ways. And we come to this as a final conclusion : That under such conditions the maternal nursing is the only rational and %>ractical means for tJie raising of the infant. * It is to be well understood — and I only insist, to avoid a shade even of am- biguity — that I speak here of a mother having contracted syphilis either before or during pregnancy. For a mother contracting syphilis after her accouchement is ultra-contagious for her infant. That is a fact of common observation. It will be sufficient to recall, in this connection, those cases so numerous in which one has seen the unfortunate nurse, after having contracted syphilis from a syphilitic nurs- ling, afterward communicate it to her own infant. DANGERS TO SOCIETY— SOCIAL PROPHYLAXIS. 195 Given tlie case of an infant syphilitic or only suspected of syphilis, it is the mother of this infant who alone may and ought to serve as its nurse. This is not doubtful ; for a number of reasons which I can not here unfold, it does not admit of discussion. Such is the law. And, besides, I will add, in conclusion, that even if, in such circumstances, the maternal nurs- ing should be attended with some danger, either for the mother or for the child, this consideration would in no wise modify the duty which is imposed upon the physician toward society. This duty, in any state of the case, would none the less continue to exist. In this hypothesis, that is to say, if the maternal nurs- ing should offer some danger, it would be your duty as physicians to contend with this new difficulty, to devise some expedient by which the possibility of contagion from the mother to the infant, or from the infant to the mother, might be averted. But we should not on that account be relieved from the strict and imperative obligation which a respect for the health of others imjposes upon us. At no price, on no account, should we consent that an infant syphilitic, or even only suspected of syphilis, be confided to a healthy nurse. The protection of society constitutes, then, in this re- spect — I repeat it again, and I can not too often repeat it — the capital, predominant indication, superior to every other consideration — and this, because this indication re- sponds to interests of a general order, because it tends to a result which ought to be the aim of our common and constant efforts, viz., to prevent tlie diffusion of the pox by confining it to its sources of origin, by preventing it from being spread abroad and disseminating its germs of contagion. NOTES AND ILLUSTRATIVE CASES. NOTE I. ". . . . Foe my part alone, I have in hand (to speak only of recorded cases) eighty-seven observations relative to syphilitic subjects, undoubtedly syphilitic, who, hav- ing married, have never communicated to their wives the least suspicious phenomenon, and, what is more, have begotten — these eighty-seven — a total of one hundred and fifty-six children, absolutely healthy " (page 19). From its great importance, this proposition dominates the whole subject developed in this book. On this ac- count I have judged it indispensable to legitimize it by an expose of the facts from which it is deduced. I can not here relate in extenso these eighty-seven observations, some of which are quite long. But I will at least furnish an abstract of them, assuredly quite concise, but suffi- cient, I think, to fix the conviction of the reader : Case I. — Indurated chancre of the glans ; roseola ; buccal syphilides ; epididymitic sarcocele ; treatment active and pro- longed ; marriage six years after the debut of the syphilis ; wife remaining uncontaminated ; three healthy children, the eldest of whom is now six years old ; gumma of the penis after the birth of the second child ; resumption of treatment. Case II. — Indurated chancre ; roseola ; palmar syphilides ; NOTES AND ILLUSTRATIVE CASES I97 buccal syptilides ; treatment quite long but irregular ; mamage six years after the d^but of the infection ; second marriage some years later ; both wives remaining uncontaminated ; five children from these two marriages, all absolutely healthy ; recurrence of palmar psoriasis after the birth of the first and third child. Case III. — Indurated chancre ; roseola ; buccal syphilides ; recurrence of the roseola in circinate form ; treatment prolonged ; marriage three years after the debut of the syphilis ; wife remain- ing uninfected ; two healthy children, the eldest of whom is now nine years of age ; ulcerated tubercle of the penis nine years after marriage. Case IV. — Indurated chancre ; roseola ; buccal syphilides ; eruption of crusts on the hairy scalp ; palmar and plantar syphi- lides ; recurrence of roseola; treatment quite prolonged ; marriage four years after debut of the syphilis ; wife remaining uninfected ; a healthy child, now seventeen years old ; later, dry, tubercular syphilide (form benign). Case V. — Indurated chancre of prepuce ; roseola ; buccal and genital syphilides ; iritis ; average treatment ; marriage three years after debut of syphilis ; wife remaining healthy ; four healthy, well-developed children. Case VI. — Indurated chancre ; roseola ; buccal syphilides with multiple recurrences ; treatment irregular ; marriage six years after debut of the infection; wife remaining uninfected ; • five healthy children. Case VII, — Indurated chancre of the glando-preputial furrow; immediate 'treatment, active and prolonged ; no other accident than roseola ; marriage after nineteen months of infection ; wife remaining healthy ; a healthy child now aged six years. Case VIII. — Indurated chancre ; papular syphilide ; recur- rence five years later of an erythemato-papular syphilide; consid- erable treatment (pills of proto-iodide during four years, etc.); marriage eight years after d^but of syphilis ; wife remaining healthy ; three healthy children. 14 198 SYPHILIS AND MAREIAOE. Case IX. — Indurated chancre of penis ; papular syphilide. Crusts of hairy scalp ; buccal syphilides with quite numerous relapses ; prolonged methodic treatment ; marriage in the third year ; wife remaining uninfected ; two healthy children. Case X. — Primary accident unperceived ; cutaneous and mucous syphilides ; treatment from six to eight months ; mar- riage after eight years of infection ; wife remaining uninfect- ed ; five healthy children, the eldest of whom is now twelve years old ; tubercular syphilide of the thorax after birth of third child ; gumma of the palatine arch after the birth of fifth chUd. Case XI. — Indurated chancre ; papular syphilide ; crusts of hairy scalp ; tonsillar syphilides ; treatment prolonged ; marriage five years after debut of infection ; wife remaining healthy ; two healthy children. Case XII. — Indurated chancre ; mucous syphilides ; cephalal- gia ; methodic treatment ; marriage eleven years after the debut of the infection ; wife remaining healthy ; a healthy child, at pres- ent nine years of age. Case XIII. — Chancre of the nose ; mucous syphilides ; cervi- cal adenopathies ; treatment for some months ; marriage the third year ; wife remaining healthy ; three healthy children. Case XIV. — Indurated chancre of the penis ; roseola ; buccal ■ and anal syphilides ; prolonged treatment by iodide of potassium, without mercury ; mai-riage six years after the debut of the dis- ease ; wife remaining healthy ; a healthy child ; debut of cerebral syphilis (apoplectiform stroke, hemiplegia, etc.) five months after marriage, four months before the birth of the child. Case XV. — Indurated chancre ; roseola ; buccal syphilides ; short treatment ; marriage nine years after infection ; wife re- maining healthy ; a healthy child. Case XVI. — Indurated chancre ; papular syphilide ; buccal syphilides with multiple recurrences ; five years later, nasal caries; frightful ozsena ; treatment extremely^ energetic during a number NOTES AND ILLUSTRATIVE GASES 199 of years ; marriage nine years after the d6but of the infection ; wife remaining healthy ; a healthy child. Case XYII. — Indurated chancre ; roseola ; mucous syphilides; eighteen months' treatment; marriage eleven years after the debut of the syphilis ; wife remaining healthy ; two healthy children ; papulo-tubercular syphilide and costal periostosis after the birth of the two children. Case XVIII. — Indurated chancre of the thumb ; papular syphilide ; tonsillar syphilides ; cephalalgia ; treatment energetic and prolonged ; marriage four years after debut of syphilis ; wife remaining healthy ; three healthy children. Case XIX. — Indurated chancre ; erythemato-papular syphi- lide ; buccal syphilides ; multiple nervous accidents ; anaemia ; asthenia ; treatment active and prolonged ; marriage six years after debut of syphilis ; wife remaining healthy ; four healthy children ; after the birth of these children, cerebro-spinal acci- dents, very probably of specific origin. Case XX. — Indurated chancre ; roseola ; buccal syphilides ; treatment for six months ; marriage fifteen years after debut of syphilis ; wife remaining healthy ; a healthy child ; one month after the birth of the child accidents of cerebral syphilis ; death. Case XXI. — Indurated chancre ; papular syphilide ; patches on the tonsils ; treatment of about one year ; marriage seven years after debut of syphilis ; wife remaining healthy ; two healthy children (the eldest now about fifteen years old) ; debut of cere- bral syphilis three years after the birth of second child ; death. Case XXII. — Indurated chancre ; various secondary acci- dents ; treatment of one year ; marriage eight years after debut of syphilis ; wife remaining healthy ; a healthy child. Case XXIII. — Indurated chancre ; papulo-crusted syphilide ; ecthymatous syphilide (ecthyma deep) ; rupia ; violent cephalal- gia ; hemiplegia ; recurrence of rupial syphilides ; treatment very energetic, very prolonged ; marriage two years after debut of syphilis ; wife remaining uninfected ; healthy child ; later, diplo- 200 - SYPHILIS AND MARRIAGE. pia ; ephemeral attacks of right hemiplegia ; nasal syphilides ; ecthyma of the legs. Case XXIV. — Indurated chancre ; buccal syphilides ; treat- ment for some months ; marriage eleven years after debut of syphilis ; wife remaining uninfected ; two healthy children. Af- ter the birth of these two children tibial periostosis and specific glossitis. Case XXY. — Indurated chancre ; roseola ; buccal syphilides ; active, prolonged treatment ; marriage fourteen months after debut of syphilis ; wife remaining uninfected ; two healthy chil- dren. Case XX VL — Indurated chancre ; buccal syphilides, multiple and relapsing onyxis ; papulo-squamous circinate syphilide ; peri- ostosis ; tubercle of the glans ; treatment active and prolonged ; marriage nine years after debut of syphilis ; wife remaining unin- fected ; healthy child. Case XXVII. — Indurated chancre ; papulo-squamous syphi- lide ; secondary costal periostosis ; ecthyma ; tibial exostosis ; treatment prolonged ; marriage six years after debut of syphilis ; wife remaining healthy ; one healthy child. Case XXVIII. — Indurated chancre ; slight secondary acci- dents ; prolonged treatment ; marriage four years after debut of syphilis ; wife remaining healthy ; two healthy children. Case XXIX. — Indurated chancre ; roseola; buccal syphilides ; prolonged treatment ; marriage three years after debut of syphilis; wife remaining healthy ; healthy child ; multiple accidents after birth of child ; specific sarcocele, periostosis, nasal ulcerations, tubercular syphilide of the nose ; diabetes. Case XXX. — Indurated chancre of glando-preputial furrow ; papular syphilide ; circumscribed ecthyma ; specific hydrarthrosis ; active treatment ; marriage three years after debut of disease ; wife remaining uninfected ; three healthy children. Case XXXI. — Indurated chancre ; roseola ; cnisted eruption of hairy scalp ; buccal syphilides with multiple relapses ; alopecia ; NOTES AND ILLUSTRATIVE GASES. 201 treatment methodic and prolonged ; marriage three years after debut of syphilis ; wife remaining uninfected ; a healthy child. Case XXXII. — Indurated chancre ; palmar psoriasis ; treat- ment for several months ; marriage six years after debut of syphi- lis ; wife remaining healthy ; a healthy child ; ulcerating laryn- gitis, manifestly specific, three years after birth of child. Case XXXIII. — Indurated chancre; some secondary accidents of benign form ; later nasal osteitis, perforation of the septum ; treatment not prolonged ; marriage after five years of the dis- ease ; wife remaining uncontaminated ; four healthy children ; fatal cerebral syphilis ; the last child was procreated after the debut of the cerebral accidents (epileptiform attacks, psychical troubles). Case XXXIV. — Primitive accident not recognized ; roseola ; eruption of crusts of hairy scalp ; eight to ten months' treatment ; marriage twelve years after debut of the disease ; wife remaining uninfected ; four healthy children ; fronto-parietal exostosis oc- curring a short time after the birth of the fourth child. Case XXXV. — Indurated chancre ; secondary angina ; cervi- cal adenopathies ; mercurial treatment of some months ; marriage eleven years after debut of syphilis ; wife remaining uninfected ; a healthy child ; syphilitic accidents of the cord preceding by one year the birth of the child. Case XXXVI. — Indurated chancre of the penis ; roseola ; ton- sillar, lingual, palatine syphilides ; active treatment ; marriage one year after debut of syphilis ; prolonged treatment after mar- riage ; wife remaining uninfected ; two healthy children. Case XXXVII. — Indurated chancre ; no secondary accidents remarked, except perhaps an anal papule ; mercurial treatment from three to four months ; marriage nine years after debut of syphilis ; wife remaining uninfected ; a healthy child ; some months before the birth of the child, debut of cerebral syphilis. Case XXXVIII. — Indurated chancre ; roseola ; cervical ade- nopathies ; mercurial treatment of six months ; marriage five years 202 SYPHILIS AN'D MARRIAGE. after debut of syphilis ; wife remaining uninfected ; three healthy- children ; exostoses one year after the birth of the third child. Case XXXIX. — Indurated chancre ; papular syphilide ; mu- cous patches of the tongue ; prolonged treatment ; marriage eight years after debut of syphilis ; wife remaining healthy ; healthy child. Case XL. — Indurated chancre ; buccal mucous patches ; treat- ment quite protracted, principally of iodide of potassium ; mar- riage five years after debut of syphilis ; wife remaining unin- fected ; three healthy childi'en (the eldest now aged seven years). Case XLI. — Indurated chancre ; roseola ; buccal syphilides ; prolonged treatment ; marriage five years after debut of syphilis ; wife remaining uninfected ; two healthy children. Case XLII. — Indurated chancre ; cutaneous eruptions ; buccal syphilides ; ecthyma ; treatment quite prolonged ; marriage four years after debut of syphilis ; wife remaining uninfected ; healthy child. Case XLIII. — Indurated chancre of index-finger; erythemato- papular syphilide ; alopecia ; tonsillar, labial, and lingual patches ; multiple adenopathies ; cephalalgia ; neuralgia ; prolonged treat- ment ; marriage four years after debut of syphilis ; wife remain- ing uninfected ; two healthy children. Case XLIV. — Indurated chancre ; no other secondary acci- dents except buccal mucous patches ; treatment prolonged ; mar- riage four years after debut of syphilis ; wife remaining unin- fected ; two healthy children ; after the birth of the last child, cranial exostosis, with incessant relapses. Case XLV, — Parchment chancre of the prepuce ; papular syphilide ; specific icterus ; buccal syphilides ; prolonged treat- ment ; marriage eight years after debut of syphilis ; wife remain- ing uninfected ; two healthy children. Case XLYI. — Indurated chancre ; buccal syphilides ; specific sarcocele ; treatment prolonged ; marriage nine years after d^but NOTES AND ILLUSTRATIVE GASES. 203 of syphilis ; wife remaining uninfected ; two healthy children (the eldest now aged nine years). Case XL VII. — Two indurated chancres of the sulcus ; ery- themato-papular syphilide ; buccal syphilides ; ecthymatous syph- ilide of the legs ; ulcerating syphilide of the palate ; marriage in the course of the third year after debut of the infection ; treatment very energetic and protracted ; wife remaining unin- fected ; healthy child ; dry tubercle of the penis some months after birth of child. Case XL VIII. — Indurated chancre ; buccal syphilides ; alope- cia ; circinate syphilides of the tongue ; treatment active and prolonged ; marriage four years after debut of syphilis ; wife remaining uninfected ; healthy child ; some months after birth of child, palmar and plantar syphilides of papulo-squamous form. Case XLIX. — Indurated chancre ; roseola ; palmar psoriasis ; buccal syphilides ; iodide treatment ; no mercury ; marriage four years after debut of the malady ; wife remaining uninfected ; two healthy children ; after birth of second child patient infects his wife from a buccal syphilide ; a pi'egnancy, happening the follow- ing year, terminates in an abortion. Case L. — Two indurated chancres ; eruptions of crusts of hairy scalp ; secondary angina ; choroiditis ; buccal syphilides ; treatment protracted ; marriage four years after debut of syphilis ; wife remaining uninfected ; healthy child. Case LI. — Seven indurated chancres ; roseola ; impetiginous syphilide of hairy scalp ; treatment quite long ; marriage after seven years of the malady ; wife remaining uninfected ; two healthy children ; after the birth of second child, ecthymatous syphilide and gumma of palatine arch. Case LII. — Parchment chancre of prepuce ; roseola ; buccal syphilides ; cephalalgia ; digital psoriasis ; prolonged treatment ; marriage in the third year of the disease ; wife remaining unin- fected ; healthy child. Case LIII. — Indurated chancre ; papular syphilide ; gummous 204 - SYPHILIS AND MARRIAGE. sypbilide of pharynx ; diplopia ; treatment from eight to ten months ; marriage ten years after debut of infection ; wife re- maining uninfected ; healthy child ; one year after birth of child, d6but of cerebral syphilis. Case LIV. — Indurated chancre ; circinate syphilide of hairy scalp, papulo-crusted ; prolonged treatment ; marriage in the fourth year of the malady ; wife remaining uninfected ; two healthy children. Case LV. — Indurated chancre ; buccal syphilides ; alopecia ; papular syphilide ; treatment of several months ; marriage four years after debut of disease ; wife remaining healthy ; healthy child ; one year after birth of child, debut of cerebral syphilis. Case LVI. — Indurated chancres ; roseola ; acneiform syphi- lide ; buccal syphilides with frequent recurrences ; tibial exosto- sis ; prolonged treatment ; marriage four years after debut of syphilis ; wife remaining uninfected ; two healthy children. Case LVII. — Indurated chancre ; buccal syphilides ; super- ficial sclerotic glossitis ; prolonged treatment ; marriage in the third year of the disease ; wife remaining uninfected ; healthy child. Case LVIII. — Indurated chancre ; no secondary accidents re- marked ; iodide treatment ; gummous syiDhilides of the palatine arch and pharynx ; frightful phagedena of the arch, the pillars, the tonsils, the pharynx ; energetic treatment, prolonged several years ; marriage five years after debut of syphilis ; wife remain- ing uninfected ; healthy child. Case LIX. — Indurated chancre ; roseola ; buccal syphilides ; cephalalgia ; papular circinate syphilide ; treatment prolonged ; marriage six years after debut of syphilis ; wife remaining unin- fected ; healthy child. Case LX, — Indurated chancre ; buccal syphilides ; crusts of hairy scalp ; treatment prolonged ; marriage eight years after de- but of syphilis ; wife remaining uninfected ; healthy child. Case LXI. — Indurated chancre ; buccal syphilides ; ecthyma NOTES AND ILLUSTRATIVE GASES 205 of the foot ; treatment of some months only ; marriage three years afer debut of syphilis ; wife remaining uninfected ; healthy child. Case LXII. — Indurated chancre ; roseola ; cephalalgia ; buc- cal syphilides ; psoriasiform syphilide ; treatment prolonged ; mar- riage four years after debut of syphilis ; wife remaining uninfect- ed ; healthy child. Case LXIII. — Indurated chancre ; roseola ; buccal syphilides ; cephalalgia ; treatment prolonged ; marriage four years after de- but of syphilis ; wife remaining uninfected ; healthy child. Case LXIV. — Indurated chancre ; roseola ; buccal syphilides ; treatment very protracted ; marriage five years after debut of syphilis ; wife remaining uninfected ; healthy child. Case LXV. — Indurated chancre ; roseola ; buccal syphilides ; treatment of about one year ; marriage in fourth year of the disease ; wife remaining uninfected ; healthy child ; specific sar- cocele at the moment of birth of child. Case LXVI. — Indurated chancre ; cutaneous and mucous syphilides ; several months' treatment ; marriage eight years after debut of syphilis ; wife remaining uninfected ; three healthy children ; twelve years after marriage, paralysis of the sixth pair of nerves. Case LXVII. — Indurated chancre ; no other secondary acci- dents remarked besides buccal syphilides ; treatment of one year ; marriage in the second year of the disease ; wife remaining unin- fected ; three healthy children ; afterward, sclerous glossitis. Case LXVIII. — Indurated chancre ; roseola ; ecthymatous syphilide of the legs ; treatment quite prolonged ; marriage four years after debut of syphilis ; wife remaining uninfected ; two healthy children. Case LXIX, — Indurated chancre ; roseola ; buccal syphilides; prolonged treatment ; marriage ten years after debut of syphilis ; wife remaining uninfected ; healthy child. Case LXX. — Indurated chancre ; papular syphilide j buccal 206 . SYPHILIS AND MARRIAGE. and anal syphilides ; iritis ; treatment prolonged ; marriage five years after debut of syphilis ; wife remaining uninfected ; two healthy children. Case LXXI. — Indurated chancre ; buccal syphilides ; erup- tion on hairy scalp ; treatment quite prolonged ; man-iage eight years after debut of syphilis ; wife remaining uninfected ; a healthy child. Case LXXII. — Indurated chancre ; buccal syphilides ; palmar psoriasis ; four months' treatment ; marriage five years after de- but of syphilis ; wife remaining uninfected ; healthy child ; after- ward, gumma of the palatine arch. Case LXXIII. — Indurated chancre ; diverse secondary acci- dents ; treatment of some months ; six years later, palmar psori- asis ; resumption of treatment ; marriage thirteen years after debut of syphilis ; wife remaining uninfected ; two healthy chil- dren. Case LXXIV. — Indurated chancre ; buccal syphilides ; pal- mar psoriasis ; energetic treatment ; marriage in the course of the second year of the disease ; wife remaining uninfected ; healthy child. Case LXXY. — Indurated chancre ; cutaneous and mucous syphilides ; treatment irregular, still suflBciently prolonged ; mar- riage four years after debut of syphilis ; wife remaining unin- fected ; a healthy child ; two years later, papulo-crusted syphilide of circinate form. Case LXXVI. — Indurated chancre ; cutaneous syphilides ; treatment of some months ; marriage five years after debut of syphilis ; wife remaining uninfected ; two healthy children ; four years after birth of second child, debut of cerebral syphilis. Case LXXVII. — Indurated chancre ; roseola ; buccal syphi- lides ; ecthyma of the leg ; treatment prolonged ; marriage two years after debut of syphilis ; wife remaining uninfected ; a healthy child. Case LXXYIII. — Indurated chancre ; no secondary accidents NOTES AND ILLUSTRATIVE GASES. 207 remarked ; mercurial treatment for six months ; marriage three years after debut of syphilis ; wife remaining uninfected ; three healthy children ; after the birth of the third child, debut of lo- comotor ataxia. Case LXXIX. — Labial chancre ; cutaneous syphilides ; no treatment ; marriage seven years after debut of syphilis ; wife remaining healthy ; healthy twin children ; after the birth of these two children, palatine gumma, tertiary ulcerations of the nasal fossse, cephalalgia. Case LXXX. — Indurated chancre ; cutaneous and mucous syphilides ; palmar psoriasis ; prolonged treatment ; marriage four years after debut of syphilis ; wife remaining uninfected ; a healthy child. Case LXXXI. — Indurated chancre ; papular syphilide ; buc- cal and genital syphilides ; treatment prolonged ; marriage six years after debut of syphilis ; wife remaining uninfected ; two healthy children. Case LXXXII. — Indurated chancre of glans ; marriage al- most immediately after cicatrization of chancre ; various second- ary accidents, buccal syphilides, palmar psoriasis ; treatment prolonged ; the patient avoiding any fecundating connection during five years ; the following year a healthy child ; wife remaining uninfected ; consecutive to the birth of the child, tibial periostosis ; cerebral syphilis. Case LXXXIII. — Primary accident not recognized ; roseola in 1866 ; buccal syphilides ; prolonged treatment ; marriage six years after d^but of syphilis ; wife remaining uninfected ; healthy child. Case LXXXIV. — Indurated chancre ; buccal syphilides ; pro- longed treatment ; marriage fourteen years after debut of dis- ease ; wife remaining uninfected ; a healthy child. Case LXXXV. — Indurated chancre ; roseola ; palmar psori- asis ; treatment prolonged ; marriage seven years after debut of syphilis ; wife remaining uninfected ; a healthy child. 208 SYPHILIS AND MARRIAGE. Case LXXXVI. — Indurated chancre ; various secondary ac- cidents ; treatment for fourteen weeks, composed principally of iodide of potassium ; but little mercury ; marriage five years after debut of syphilis ; wife remaining uninfected ; a healthy child, at present fifteen years old ; fifteen years after marriage, tuberculo-ulcerative syphilide of nose. Case LXXXVII. — Indurated chancre ; papular syphilide ; buc- cal syphilides ; genital syphilid es ; treatment prolonged ; marriage nine years after debut of disease ; wife remaining uninfected ; a healthy child. Independently of the principal demonstration fur- nislied by the preceding statistics, they bring into promi- nence a most important fact, viz., that syphilitic subjects may be inoffensive in marriage to their wives and chil- dren, even while they remain under the power of the diathesis, and are destined to undergo new attacks. And, in effect, these statistics embrace no less than tMrty-five cases of this order, in which various accidents of a nature incontestably specific occurred after marriage, without, however, the wives and the children of these different patients having suffered the least bad result medically. This fact is certainly reassuring. Nevertheless, one should not exaggerate the importance of these statistics, nor attach to them a signification of which they do not admit. While it is true that the patients in question have trans- mitted, hereditarily, nothing to their offspring, and have communicated nothing to their vdves (which is explained by the situation or the character of their accidents), they have no less been, a certain number at least, very preju- dicial to their families on account of the personal conse- quences of their disease. Many, for example, hsive died ; others have only survived with functional troubles, more NOTES AND ILLUSTRATIVE GASES. 209 or less important, with serious infii-mities, etc., and that to the great detriment of the social community constituted by marriage. On the other hand, note it well, the preceding statistics have neither for object nor for result, from the point of view of the protection of wives and children, the estab- lishment of numerical relations between the subjects who marry after a sufficient depuration and those who contract marriage in conditions precisely opposite. This relation necessarily escapes us, and will always escape us. In effect, we only take cognizance of those patients who come to us on account of various accidents, and these are always certain to find a place in our statistics ; while the others remain unrecognized by us, for the excellent reason that, having no further manifestations of syphilis, they have no occcasion to claim our services. Finally, the preceding statistics show us certain exam- ples of syphilis particularly grave, which have, never- theless, remained inoffensive in marriage, at least so far as relates to the dangers incurred by the wife and the children. Case XXIII is a type of this class. This, assuredly, was one of the cases in which every prudent physician would have considered it his duty to interdict marriage, by reason of the multiplicity and the threat- ening character of the manifestations (profound ecthym- atous syphilide with multiple recurrences, rupia, the most violent cephalalgia, hemiplegia, etc.). The result, however, has not justified the apprehensions which the gravity of the symptoms was calculated to excite. NOTE 11. SYPHILIS. — SEVEN ABOETIONS OR PREMATURE ACCOUCHE- MENTS. X , aged forty years, seamstress, entered the Lour- cine Hospital, June 16, 1870. She is a woman of tall figure, who aj)pears to have formerly had a robust constitution, but who has become, according to her statement, very much enfeebled by work, grief, and numerous pregnancies. She has always enjoyed excellent health. She even boasts that she has never suffered, apart from her con- finements, the least indisposition. Married at nineteen years of age, she, first of all, had three ''superb children," two of which are still living and in excellent health. The third, which was likewise well developed, died in infancy, and appears to have suc- cumbed to some incidental malady of an acute form (probably pneumonia). At the age of twenty-nine years, this woman contracted syphUis from her husband, who had himself contracted it quite recently. At the same time she became enceinte. This pregnancy was termi- nated by an abortion in the fifth month. As accidents of syphUis, the patient states that she had, at first, an indurated chancre of the vulva ; then, soon afterward, an eruj)tion of small red spots, which rajDidly covered the body, the limbs, and the lower portion of the face. NOTES AND ILLUSTRATIVE CASES. 211 Later she had new papules on the skin, erosions in the mouth, and, especially, a very tenacious eruption on the palms of the hands. This eruption had been called psori- asis by a physician. It continued not less than a year. On account of these various accidents the patient twice entered the Hospital St. Louis, in tihe service of Dr. Gfibert. The second time she remained nearly six months. She remembers having been treated by a mercurial syrup, then by a solution of iodide of potassium. Since then she has not had any treatment, although at times she has experienced new accidents, notably ulcerations in the mouth, violent pains in the arms and in the back, diffused neuralgias, and a very characteristic sciatica. She has not been better treated, she says, because she has scarcely ceased being enceinte since that time. And, in reality, from that date until 1867, she has had no fewer than six pregnancies, which all terminated disastrously, as follows : Fifth pregnancy: premature accouchement at seven months and a half ; child sickly, stunted, dying on the fifteenth day. Sixth pregnancy : accouchement almost at term ; child stiU-born. Seventh pregnancy : premature accouchement at seven months and a half ; child stUl-born. The patient' s mother, who assisted at the confinement, said to her that the child's skin "was quite black and came off in pieces." Eighth pregnancy: premature accouchement; child still-born. Ninth pregnancy : abortion at three months and a haK. Tenth pregnancy : abortion at six weeks, accompanied with considerable haemorrhage, and followed by several metrorrhagias. 212 SYPHILIS AND MARRIAGE. To recapitulate, tlien : ten pregnancies, of which the three anterior to the syphilis resulted, at term, in healthy- children, and the seven posterior to the syphilis termi- nated in four premature accouchements and tliree abor- tions. Within the last two years new accidents again ap- peared, viz. : "a tumor " at the level of the left clavicle, quite voluminous and very sensitive to pressure ; an eruption of crusts on the hairy scalj) ; an abundant loss of hair, etc. These various accidents brought the patient to Lourcine, where she was treated (service of Dr. Pean) with mercurial pills and the iodide of potassium. She left cured ; even her hair had almost entirely grown in again. Outside, the patient continued the medication for sev- eral months, returning from time to time to the hospital for consultation, where we saw her for the first time. Finally, about a month ago, she felt two lumps, "like two kernels," which were formed in the tongue. A third kernel soon formed in the neighborhood of the two others. Then all three became ulcerated, and on this account she came to ask our care. To-day, we find upon the extremity of the tongue three well-circumscribed ulcerations, with borders adhe- rent and clearly cut, with grayish bottom, the base en- gorged and renitent. In aspect, they are types of gum- mous lesions. No symptomatic adenopathy. No other accidents. Treatment : iodide of potassium, in a daily dose of from three to five grammes, progressively increased ; painting twice a day with the tincture of iodine ; gargles of infu- sion of marsh-mallow, and pulverizations of iodide solu- tion upon the tongue. Rapid cure. NOTE III. HEEEDITAEY II^FLUElSrCE OF MATERNAL SYPHILIS. "It may be said very positiyely, and without any ex- aggeration, that the syphilitic influence of the mother is veritably pernicious for the foetus." (Page 63.) The following statistics, collected from different sources, and which, for reasons above mentioned, I intentionally give separately, go to establish this with a numerical evi- dence unfortunately too complete : I. , The first relates to syphilitic women observed in this city, in private practice. It comprises eighty-five cases of pregnancy, which, considered only in their result, the most direct and the least subject to error, viz., the deatTi or the surmval of the child, have furnished me with the following figures : Cases of survival 27 Cases of death (abortions, premature accouchements, still-born infants, infants dead within a short time after delivery) . . 58 Total 85 Here are the details of these different cases : Case I. — X , nineteen years old ; indurated chancre of the 16 214: ■ SYPHILIS AND MARRIAGE. lip, misunderstood as to its nature ; papulo-squamous syphilide ; no treatment ; miscarriage at third month,* Case II. — Twenty-one years ; contagion at beginning of mar- riage ; roseola ; papulo-erosive syphilides of the vulva and anus ; mercurial treatment for some months ; pregnancy ; accouche- ment at about seven months ; child very miserable, dying on fifth day. Case III. — Twenty-five years ; debut of syphilis unknown ; pregnancy ; mercurial treatment of short duration ; accouchement at term ; child syphilitic ; energetically treated and surviving (now nine years old). Case IV. — Twenty-eight years ; debut of syphilis unknown ; various secondary accidents ; prolonged treatment (mercury and iodide of potassium); pregnancy six years after first accidents ; accouchement at term ; child healthy and surviving ; two years after birth of child, superficial syphilides of the tongue. Case V. — Thirty-one years ; contagion at date of marriage ; treatment very irregular and of short duration ; four pregnancies in five years ; first pregnancy : accouchement at seven and a half months, child very small, cachectic, born with a specific eruption, and dying in some hours ; the three other pregnancies were ter- minated by abortion. Case VI. — Twenty-five years ; husband syphilitic ; pregnancy from beginning of marriage ; syphilis by conception ; papulo- squamous syphilide ; vulvar and buccal syphilides ; mercurial treatment for some Aveeks ; accouchement before term ; child bom with a syphilitic eruption ; dying on eleventh day. Case VII. — Twenty-one years ; infected soon after marriage (syphilis by conception at least probable) ; specific treatment long time continued ; first child syphilitic, surviving ; second pregnancy * I shall only mention here, be it well understocd, miscarriages absolutely sponta- neous — I mean happening without an accidental cause, and which could not reason- ably be imputed to specific influence. I have rigorously excluded from these statis- tics all cases where there existed the least suspicion of the possible action of any cause whatever outside of syphilis. NOTES AND ILLUSTRATIVE CASES. 215 terminates by abortion (accidental causes alleged); third and fourth pregnancies terminating at term ; children healthy and living. Case VIIL— (See page 117.) Case IX. — Infected by her husband in the last months of first pregnancy ; vulvar chancre ; roseola ; cephalalgia ; specific treat- ment quite prolonged ; accouchement at term ; child syphilitic, dying in a few hours ; second pregnancy : accouchement at eight months ; child presenting syphilitic spots at birth ; dying in half an hour ; third pregnancy : accouchement at term ; child healthy in appearance, dying suddenly of convulsions at seven months ; fourth pregnancy : accouchement at term ; child healthy ; surviv- ing; fifth pregnancy : accouchement before term ; child dying in a few hours ; sixth pregnancy : abortion ; seventh pregnancy : accouchement at term ; child healthy ; surviving. Case X. — Twenty-three years ; date of origin of syphilis un- known ; various secondary accidents ; treatment of some weeks ; accouchement at term ; child syphilitic, infecting its nurse, and dying at the age of one month ; second pregnancy five years later, after prolonged treatment ; child healthy ; surviving. Case XI. — Infected by her husband ; various secondary acci- dents ; treatment of short duration ; three pregnancies ; first child dying at six weeks ; second child dying in three hours ; third child still-born ; at this time specific treatment, which is prolonged sev- eral years ; fourth pregnancy : child healthy ; surviving. Case XII. — Twenty-one years ; syphilis dating back several months ; papulo-squamous syphilide ; lingual syphilides ; onyxis ; treatment two or three months ; abortion. Case XIII. — Twenty-eight years ; infected by her husband ; treatment of fifteen days ; first pregnancy giving a syphilitic child, which dies in a few hours ; the husband and wife then sub- mit themselves to a specific treatment, which is pursued during two years ; second pregnancy three years later ; child healthy ; surviving. 216 SYPHILIS AND MARRIAGE. Case XIV. — Seventeen years ; vulvar chancre ; papular sypli- ilide ; palmar psoriasis ; cephalalgia ; treatment short, in very feeble doses ; pregnancy in the second year of the disease ; ac- couchement before term ; child dying in three weeks, in a state of frightful consumption. Case XV. — Twenty-seven years ; syphilis in 1869 ; confluent syphilides of vulva ; buccal syphilides ; treatment of a few weeks ; premature accouchement in 1870 of dead child ; premature ac- couchement in 1871 ; child dead. Case XVI.— (See page 118.) Case XVII. — Twenty-two years ; syphilis by conception ; erythemato-papular syphilide ; tonsillar syphilides ; cephalalgia ; treatment of some months ; accouchement at seven months ; child healthy in appearance ; dies suddenly after some days. Case XVIII. — Twenty-two years ; syphilis by conception ; secondary accidents toward the fifth month of pregnancy ; mercu- rial treatment ; accouchement at seven and a half months ; child affected with grave syphilis ; energetically treated, it survives. Case XIX. — Thirty years ; syphilis in 1872 ; chancre not rec- ognized ; vulvar and buccal syphilides ; alopecia ; treatment of some months ; abortion in 1875. Case XX. — Twenty-five years ; infected from the data of marriage ; vulvar chancres ; syphilides ; four months of treat- ment ; two miscarriages in the first two years succeeding mar- riage ; the fifth year, child syphilitic ; surviving ; contamination of the nurse. Case XXI. — Twenty-nine years ; cutaneous syphilides ; vul- var syphilides ; treatment of some months ; pregnancy in the first months of the disease ; abortion. Case XXII. — Thirty years ; debut of syphilis unrecognized, manifesting itself in the course of pregnancy ; papular syphilide ; palmar psoriasis ; onyxis ; treatment of few weeks ; accouchement at term ; child dead fifteenth day. Case XXIII. — Twenty-nine years ; d^but of syphilis unknown ; NOTES AND ILLUSTRATIVE CASES. 217 no treatment ; papular syphilide ; buccal syphilides ; abortion ; afterward, periostosis and accidents of cerebral syphilis. Case XXIV. — Twenty-two years ; accidents of secondary syphilis in the course of pregnancy ; roseola ; cephalalgia ; in- tense neuralgias ; retiuo-choroiditis ; treatment of some months ; abortion. Case XXV. — Twenty-five years ; indurated vulvar chancre ; roseola ; lingual syphilides ; treatment of some weeks ; pregnancy six months after debut of disease ; abortion. Case XXVI. — Twenty-three years ; infected from the d6but of her marriage and became enceinte simultaneously ; treatment of some months ; accouchement of a dead child at eight months ; three pregnancies the three following years ; treatment of some months in the course of each pregnancy ; second child syphilitic ; dead at two months ; third child syphilitic ; treated energetically, it survives ; fourth child healthy ; entirely well. Case XXVII. — Twenty-two years ; indurated chancre of the buttock in 1870 ; papular syphilide ; vulvar and buccal syphilides ; frontal periostitis ; ten months of regular treatment (mercury and iodide of potassium) ; accouchement at term, in December, 1872 ; child healthy. Case XXVIII. — Twenty years ; contagion in sixth month of pregnancy ; indurated vulvar chancre ; tonsillar syphilides ; treat- ment only commenced at eighth month; five days after, accouche- ment of a macerated foetus. Case XXIX. — Nineteen years ; secondary accidents appear- ing in the first months of pregnancy ; erythemato-papular syphi- lide ; vulvar syphilides ; cephalalgia ; treatment of ten months ; accouchement of a dead child. Case XXX. — Twenty years ; secondary accidents appearing in third month of pregnancy ; treatment of some months ; abor- tion ; afterward, mercurial and iodide treatment long time pur- sued ; second pregnancy two years later ; accouchement at term ; healthy child ; onyxis consecutively to accouchement. 218 . SYPHILIS AND MARRIAGE. Case XXXI. — Twenty-seven years ; secondary accidents ap- pearing in the course of pregnancy ; ti'eatment of some months ; abortion ; second pregnancy : premature accouchement ; child dead on fifteenth day ; third pregnancy : accouchement at term ; child syphilitic ; treated ; surviving. Case XXXII. — Twenty-five years ; debut of syphilis unknown ; not treated ; pregnancy three to four months ; papulo-squamous syphilide ; ulceration of the tonsils ; alopecia ; abortion. Case XXXIII* — Twenty-seven years ; debut of syphilis un- known ; no treatment ; pregnancy from fourth month ; tonsillar syphilides ; osteocopic pains ; abortion. Case XXXIV. — Twenty-three years ; secondary accidents ap- pearing in the course of pregnancy ; no treatment ; abortion. Case XXXY. — Twenty-six years ; syphilis transmitted by catheterism of the Eustachian tube, and remaining for a long time unrecognized ; herpetiform syphilide ; ecthyma, cephalalgia, neu- ralgias ; treatment of some months ; abortion. Case XXXVI. — Twenty-five years ; syphilis of unknown debut and not treated ; various secondary accidents ; first pregnancy ; child still-born ; second pregnancy : child dying fifteenth day ; consecutively, tubercular syphilide. Case XXXVII.-^Twenty-four years ; roseola ; papular syphi- lide ; buccal syphilides ; treatment from five to six months ; pregj- nancy in second year of disease ; abortion. Case XXXVIII. — Thirty-one years ; syphilis not recognized ; cicatrices clearly specific ; no treatment ; abortion ; some years later, syphilis of the brain ; death. Case XXXIX. — Twenty-seven years ; infected at beginning of marriage ; treatment of few months ; two pregnancies, termi- nating by abortion ; afterward, gumma of palatine arch and per- foration of palate. Case XL. — Twenty-five years ; contagion in third month of pregnancy ; indurated chancre of labia minora ; papular syphi- lide ; treatment of one month ; accouchement at term ; child NOTES AND ILLUSTRATIVE GASES. 219 eyphilitic ; treated ; dying at eight months ; treatment regular and prolonged after accouchement ; three years later,' second preg- nancy ; child healthy, surviving. Case XLI. — Twenty-three years ; debut of syphilis unknown ; papulo-crusted syphilide ; buccal syphilides ; irregular treatment ; pregnancy five years after infection ; accouchement almost at term ; child syphilitic, soon dying ; two miscarriages the two fol- lowing years. Case XLII. — Twenty-two years ; infected in second month of pregnancy ; chancre parchemAn'e, of the vulva ; vulvar syphilides ; mercurial treatment until the end of pregnancy ; accouchement at term ; child surviving, never having presented but a slight erup- tion, nature of which remains doubtful. Case XLIII. — Twenty-three years ; syphilitic infection and pregnancy from debut of marriage ; no treatment ; abortion at second month. Case XLIY. — Twenty-two years ; pregnancy from debut of marriage ; accidents of secondary syphilis appearing from the third or fourth month of gestation ; treatment of some months ; accouchement at term ; child syphilitic ; treated ; surviving. (This child infected its nurse, who has transmitted the syphilis — 1. To her child ; 2. To her husband.) Case XLV. — Twenty-three years ; secondary accidents making invasion in fifth month of pregnancy ; mercurial treatment ; ac- couchement at term ; child syphilitic ; treated ; surviving ; con- tagion transmitted to the nurse. Case XLYI, — Twenty years ; infected from debut of mar- riage ; treatment for some weeks ; two abortions in the first year ; recommencement of treatment, which is continued two and a half years ; pregnancy four years later ; accouchement at term ; child healthy (at present five years old). 220 SYPHILIS AND MARRIAGE. II. Our second statistics have been recorded of patients observed in hospital practice, for the most part at the Lourcine, some at the Saint Louis. It has furnished us the following results : Cases of survival of infant 23 Cases of death of infant (abortions, premature accoucliements, still-born, children dead shortly after the accouchement) . . 145 Total 167 • Here are the cases which have furnished the elements of these statistics : Case I. — Twenty-seven years ; syphilis of unknown origin ; roseola and vulvar syphilides in 1872 ; no treatment ; in 1875, accouchement at seven months ; child still-born ; in 1879, tuber- cular syphilide, taking on a phagedenic form. Case II. — Thirty years ; syphilis in 1868 ; cutaneous erup- tions ; syphilides of the mucous membranes ; alopecia ; very short treatment ; in 1869, accouchement at term of a dead child ; in 1875, miscarriage at three months ; in 1878, enormous gumma of the sternal region. Case III. — Twenty-five years ; syphilis of unknown origin, but of certainly recent date ; papulo-hypertrophic syphilide of the vulva ; crusts of the hairy scalp ; very irregular treatment ; abor- tion at fourth month. Case IV. — Thirty-five years ; in 1877, syphilis occurring in the course of pregnancy ; papulo-hypertrophic syphilides of the vulva and the peringeum ; treatment for some months ; accouche- ment at term ; child dying of convulsions when one month old ; second pregnancy in 1878 ; abortion. Case V, — Twenty-one years ; pregnancy eight months ad- vanced ; genital and peri-anal syphilides ; no treatment until en- NOTES AND ILLUSTRATIVE CASES. 221 trance to hospital ; mercurial treatment ; accouchement at term ; child syphilitic ; dying in five months. Case YI. — ^Twenty-seven years ; syphilis probably hereditary ; tuberculo-ulcerative syphilide of phagedenic form, having com- menced when she was eight years old, and still persisting nineteen years later. This lesion has traversed the entire extent of the in- ferior limb, affecting a serpentine course ; cured quite rapidly by specific treatment. Five pregnancies. First pregnancy, child dy- ing at two and a half years ; second pregnancy, child dying at six months ; third pregnancy, child affected " with an immense sore, which involved the entire chest " — dying at three years ; fourth pregnancy, child hydrocephalic, dying at five months ; fifth preg- nancy, child dying suddenly, and " without disease," at the age of three months. Case VII. — Thirty-nine years ; syphilis unrecognized ; in 1877, gummous syphilide destroying the nasal septum and its base, multiple and very large cicatrices disseminated over the whole body. The lesions which produced these cicatrices date back fifteen years. Two pregnancies in 1867 and 1868. First child dying at one year (cause unknown) ; second child dying at three weeks, in a state of consumption. Case VIII, — Syphilis at twenty-five years ; roseola ; mucous patches, alopecia, osteocopic pains, febrile attacks ; later, ulcer- ating syphilides leaving deep cicatrices ; treatment irregular. First pregnancy at thirty years ; child syphilitic, surviving ; sec- ond pregnancy the following year, child surviving ; five years later, rupia. Case IX. — Twenty -three years ; in 1874, pregnancy, in the course of which appeared mucous and cutaneous syphilides ; ac- couchement at term ; child dying at three months (cause unknown) ; second pregnancy in 1875 ; abortion at three months ; third preg- nancy in 1876 ; abortion at seven months ; treatment always irregular. Later, in 1878, ulcerating syphilide of the vulva. Case X. — Twenty-five years ; syphilis unknown ; gumma of 222 ■ SYPHILIS AND MAIiRIAGB. pharynx in 1878 ; the same year, accouchement before term, child dying of convulsions on eighth day. Case XI. — Twenty -nine years ; syphilis unknown ; buccal and vulvar syphilides ; alcoholism ; pregnancy ; child submitted to an energetic treatment, surviving. Case XII. — Twenty -two years ; accidents of secondary syphi-. lis in the course of pregnancy ; treatment very short ; premature accouchement ; child still-born. The following year, second preg- nancy ; accouchement at term, child dying in six weeks. The fol- lowing year, third pregnancy ; accouchement at term, child dying first day. Later, papulo-squamous syphilide of circinate form. Case XIII. — Twenty-one years ; syphilis in 1875 ; contagion in the course of pregnancy ; indurated chancre of the vulva ; sec- ondary angina ; neuralgias ; alopecia ; no treatment ; abortion ; second pregnancy ; premature accouchement of a still-born child. In 1878, tibial periostosis. Case XIY. — Twenty years ; accidents of secondary syphilis appearing in course of pregnancy ; mercurial treatment of two and a half months ; premature accouchement ; child syphilitic ; dying on tenth day. Case XV. — Twenty-two years ; pregnancy ; contagion at de- but of pregnancy ; chancre of neck of uterus ; roseola ; vulvar syphilides ; crusts of the hairy scalp.; mercurial treatment not prolonged ; accouchement before term ; child still-born. Case XVI. — Eighteen years ; contagion at debut of preg- nancy ; chancre of neck of uterus ; vulvar syphilides ; roseola ; palmar psoriasis ; treatment of a few weeks ; abortion at third month. Case XVII. — Twenty-two years ; pregnancy at five and a half months ; indurated chancre of the vulva ; roseola ; ti'eat- ment of a few weeks ; premature accouchement ; child still-bom. Case XVIII. — Nineteen years ; syphilis in 1869 ; chancre of the uterine neck ; cephalalgia ; cranial periostoses ; no regular treatment ; pregnancy in 1871 ; abortion. NOTES AND ILLUSTRATIVE CASES 223 Case XIX. — Twenty years ; accidents of secondary syphilis in 1872 ; papulo-erosive syphilides of the vulva ; treatment of few weeks ; in 1875, pregnancy ; accouchement at term ; child prob- ably syphilitic ; dying in four months. Case XX. — Twenty-seven years ; debut of syphilis unknowTi ; vulvar syphilides ; abortion three weeks before entrance into hos- pital. Case XXI. — Seven abortions or premature accouchements (vide case in detail, p. 210), Case XXII. — Twenty years ; pregnancy, in course of which appeared various secondary accidents (roseola, vulvar syphilides, eruptions of crusts of hairy scalp, alopecia) ; treatment of a few weeks ; abortion at six and a half months. Case XXIII. — Twenty years, at the time of entrance into hospital ; pregnancy at eighth month ; papulo-hypertrophic vul- var syphilides ; roseola ; emaciation ; alopecia ; asthenia ; treat- ment by mercurial frictions and iodide of potassium ; accouche- ment at term ; child syphilitic ; dying at six weeks, in state of cachexia. Case XXIV. — Eighteen years ; contagion contemporary with debut of pregnancy ; papular syphilide ; vulvar syphilide ; treat- ment of six weeks ; abortion at six and a half months. Case XXV. — Twenty - two years ; pregnancy at seventh month ; debut of syphilis unknown ; confluent vulvar syphilides ; alopecia ; febrile attacks ; mercurial treatment ; accouchement at term ; child dying of convulsions at five weeks. Case XXVI. — Twenty-six years ; secondary syphilis of recent prigin ; no treatment ; abortion at fourth month. Case XXVII. — Seventeen years ; pregnancy of seven months ; papulo-ulcerative syphilides of the vulva ; mercurial treatment of four weeks ; accouchement at eighth month ; child still-born. Case XXVIII. — Twenty-six years ; pregnancy of six months ; syphilis appearing to date from four months ; vulvar, peri-vulvar, anal, genito-crural, and buccal syphilides ; circinate roseola ; treat- 224 SYPHILIS AND MARRIAGE. ment of few weeks ; accouchement at eighth month ; child etill- bom. Case XXIX. — Twenty-two years ; pregnancy of five and a half months ; debut of syphilis unknown ; papulo-squamous syph- ilide ; cephalalgia ; rheumatoid pains ; specific fever ; frontal peri- ostosis ; enteritis ; emaciation ; imminence of cachexia ; tonic and specific treatment ; accouchement at eight months, child living only two hours. Case XXX. — Eighteen years ; pregnancy of seven months ; indurated chancre of upper lip ; tonsillar syphilides ; mercurial treatment ; accouchement at term ; child living, healthy. Case XXXI. — Twenty-one years ; indurated chancre of vulva at fourth month of pregnancy ; mercurial treatment ; abortion at six months. Case XXXII. — Eighteen years ; pregnancy of two months ; roseola ; crusts of hairy scalp ; cephalalgia ; mercurial treatment ; abortion at three months. Case XXXIII, — Twenty-four years ; syphilis dating from five years ; treatment quite short ; ulcerating syphilides of the vulva ; pregnancy ; accouchement at term, child dying second day. Case XXXIV. — Twenty-three years ; syphilis in 1869 ; treat- ment of two to three months ; in 1871, pregnancy ; simple chan- cres and suppurating buboes ; papulo-squamous syphilides ; vul- var syphilides ; accouchement at term ; child syphilitic, dying on the fifteenth day. Case XXX'^^. — Eighteen years ; syphilitic chancre in May, 1868 ; roseola ; no treatment ; accouchement at term, in June| 1868, child living only five hours. Case XXXVI. — Twenty-four years ; pregnancy ninth month ; indurated vulvar chancres ; cephalalgia ; alopecia ; accouchement at term, two days after entrance into hospital ; child syphilitic ; dying at fourth month. Case XXXVII. — Twenty-two years ; pregnancy ; contagion NOTES AND ILLUSTRATIVE OASES. 225 during eiglith month ; syphilitic chancre of the vulva ; mercurial treatment ; accouchement almost at term ; child small but sur- viving (lost sight of when six weeks old). Case XXXVIII. — Twenty-nine years ; secondary accidents in the course of pregnancy ; treatment irregular, brief ; accouche- ment at eight months, child dying in six days. Case XXXIX. — Seventeen years ; debut of secondary syphi- lis unknown ; no treatment ; abortion at fourth month. Case XL. — Twenty-one years ; pregnancy, two to three months ; papulo-erosive vulvar syphilides ; two months' treatment ; accouchement at term ; child syphilitic ; dying at fourth week. Case XLIc — Thirty years ; syphilitic chancre at fifth month of pregnancy ; roseola ; alopecia ; buccal syphilides ; two months' treatment ; accouchement at seven and a half months ; child still- born. Case XLII. — Twenty-five years ; pregnancy, fifth month ; syphilis of unknown origin ; no treatment ; roseola ; vulvar syphilides ; abortion the second day after entrance into hospital. Case XLIII. — Twenty - two years ; pregnancy of eight months ; debut of syphilis unknown ; genital syphilides ; cu- taneous syphilides ; treatment of three weeks ; accouchement at term, child dying in five days. Case XLIV. — Twenty-two years ; accidents of secondary syphilis manifesting themselves in the course of pregnancy ; vul- var syphilides ; no treatment ; abortion at five and a half months. Case XLV. — Twenty -two years ; pregnancy of eight months ; roseola ; vulvar syphilides ; mercurial treatment ; accouchement at term ; child small, emaciated, dying at fifth day. Case XLVI. — Thirty years ; pregnancy of eight months ; secondary accidents manifesting themselves in the second half of pregnancy ; vulvar syphilides ; temporal periostosis ; cephalalgia ; asthenia ; emaciation ; premature accouchement ; child dying at fourth day. Case XL VII. — Twenty - eight years ; pregnancy of eight 226 SYPHILIS AND MARRIAGE. months ; secondary accidents happening during pregnancy ; papu- lar syphilides ; cephalalgia ; neuralgias ; analgesia ; no serious treatment ; accouchement at term ; child dying day of its birth. Case XLVIII. — Twenty-six years ; accidents of secondary syphilis occurring in second half of pregnancy ; vulvar syphilides ; treatment of a few weeks ; accouchement at seven and a half months ; child miserable, dying in a few hours. Case XLIX. — Twenty-seven years ; debut of secondary syph- ilis unknown ; cutaneous syphilides ; vulvar and buccal syph- ilides ; no serious treatment ; accouchement almost at term ; child syphilitic, dying fifteenth day. Case L. — Twenty-three years ; debut of syphilis unknown ; vulvar syphilides ; treatment of few weeks ; abortion at six and a half months. Case LI. — Nineteen years ; accidents of secondary syphilis appearing in the earlier months of pregnancy ; mercurial treat- ment and iodide in small doses ; accouchement at term ; child probably syphilitic, dying at one month. Case LII. — Nineteen years ; indurated chancre of vulva in fourth month of pregnancy ; vulvar syphilides ; specific treat- ment ; accouchement at term ; child dying in four days. Case LIII. — Twenty years ; debut of syphilis unknown ; mul- tiple secondary accidents ; no treatment ; accouchement at seven months ; child dying at two months (probably syphilitic). Case LIV. — Twenty-two years ; syphilis in 1869, toward the end of first pregnancy ; treatment of fifteen days ; child healthy, surviving ; in 1872 second pregnancy ; abortion at six months ; later, gummous syphilide. Case LV. — Twenty-five years ; debut of syphilis unknown ; secondary accidents ; pregnancy ; hydramnios ; accouchement at seven months ; child still-born. Case LVI. — Twenty years ; accidents of secondary syphilis coincident with debut of pregnancy ; vulvar syphilides ; crusts of NOTES AND ILLUSTRATIVE CASES. 227 hairy scalp ; treatment of two montlis ; accouchement at term ; child small, miserable, dying in twenty-four hours. Case LVII. — Twenty-one years ; debut of secondary syphilis unknown ; pregnancy of seven months ; treatment of few weeks ; accouchement of dead child. Case LVIII. — Nineteen years ; pregnancy of five months ; secondary syphilis appearing to date from two to three months ; treatment of a few weeks ; abortion. Case LIX, — Twenty years ; pregnancy of seven and a half months ; debut of syphilis unknown ; vulvar and tonsillar syphi- lides ; cephalalgia ; neuralgiform pains ; pigmentary syphilide of the neck ; treatment of a few weeks ; accouchement at term ; child dying in few hours. Case LX. — Twenty-four years ; pregnancy of eight months ; debut of syphilis unknown ; vulvar syphilides ; no treatment ; child still-born. Case LXI. — Twenty-four years ; pregnancy of eight months ; syphilis appearing to date back three months ; vulvar syj)hilides ; febrile attacks ; treatment of one month ; accouchement at term ; child syphilitic, treated, surviving. Case LXII. — Twenty-three years ; pregnancy in fourth month of syphilis ; vulvar syphilides ; cephalalgia ; no treatment ; pre- mature accouchement ; child still-born. Case LXIII. — Twenty-two years ; pregnancy of six months ; contagion during pregnancy ; roseola ; confluent syphilides of the vulva, of the perinseum, of the anus, of the genito-crural fold ; emaciation ; no treatment ; abortion. Case LXIV. — Twenty years ; pregnancy of from four to five months ; debut of syphilis unknown ; confluent syphilides of the vulva, of the anus, of the mouth ; chloro-an£emia ; cephalalgia ; analgesia ; treatment very short and irregular ; accouchement at seventh month ; child dying in twelve days. Case LXV. — Twenty years ; pregnancy of six months ; sec- ondary accidents appearing during pregnancy ; confluent syphi- 228 SYPHILIS AND MARRIAGE. lides of the vulva ; palmar psoriasis ; papulo-squamous syphilide ; active mercurial treatment (from five to twenty grammes of the proto-iodide daily during three months) ; accouchement at term ; child living, apparently healthy (lost sight of when twelve days oia). Case LXVI. — Twenty years ; secondary syphilis of recent date ; syphilides of the vulva and of the throat ; pregnancy ; no treatment ; accouchement almost at term ; child syphilitic, dying of convulsions when three weeks old. Case LXVII. — Forty-four years ; syphilis coinciding with debut of pregnancy ; papulo-hypertrophic syphilides of the vulva and of the anus ; buccal syphilides ; alopecia ; papulo-squamous syphilide, herpetiform at several points ; no treatment ; abortion at six months. Case LXVIII. — Twenty-two years ; syphilis appearing at the debut of pregnancy ; multiple secondary accidents ; treatment of two to three months ; accouchement at term ; child still- born. Case LXIX. — Nineteen years ; appearance of secondary acci- dents in the third month of pregnancy ; no treatment ; accouche- ment at seven months ; child still-born. Case LXX. — Twenty-six years ; indurated vulvar chancre ap- peai'ing at third month of pregnancy ; treatment of from two to three months ; accouchement at seven and a half months ; child still-born. Case LXXI. — Twenty years ; pregnancy of five months ; d6- but of secondary syphilis unknown ; vulvar syphilides ; syphilitic fever ; costal periostitis ; treatment of a few months ; accouche- ment at term ; child still-born. Case LXXII. — Twenty-one years ; contagion at third month of pregnancy ; indurated chancre of the vulva ; vulvar syphilides ; treatment of a few weeks ; abortion. Case LXXIII. — Nineteen years ; debut of syphilis unknown ; papulo-squamous syphilide ; alopecia ; tonsillar syphilides ; treat- ROTES AND ILLUSTRATIVE OASES. 229 ment for several months ; accouchement at term ; child syphilitic, dying in three weeks. Case LXXIV. — Twenty-six years ; debut of syphilis un- known ; papular syphilide ; vulvar syphilides of circinate form ; cephalalgia ; pregnancy ; treatment not prolonged ; abortion. Case LXXV. — Twenty years ; pregnancy of four or five months ; debut of syphilis unknown ; secondary accidents ; treat- ment of a few weeks ; premature accouchement ; child dying at five days. Case LXXVI. — Twenty-two years ; contagion in the first months of pregnancy ; vulvar, anal, and tonsillar syphilides ; cepha- lalgia ; mercurial treatment prolonged several months ; accouche- ment at term ; child healthy (lost sight of when six weeks old). Case LXXYII. — Twenty years ; pregnancy ; debut of syphi- lis unknown ; pustulo-crustaceous syphilide ; no treatment ; ac- couchement at seven months ; child dying when five days old. Case LXXYIII. — Twenty-one years ; syphilis dating from eighteen months ; mercurial and iodide treatment quite regularly followed and long protracted ; accouchement at term in the second year of the disease ; child living and healthy. Case LXXIX. — ^Twenty-two years ; debut of syphilis un- known ; no treatment ; abortion at two months. Case LXXX. — Twenty-eight years ; syphilis dating from eleven years ; treatment very insufiicient ; three pregnancies since the debut of the disease ; three abortions — at six weeks, at six months, at seven months. Case LXXXI. — Twenty-four years ; debut of secondary syph- ilis unknown ; vulvar syphilides ; cephalalgia ; no treatment ; abortion at two months. Case LXXXII. — Twenty-two years ; secondary accidents making invasion in the course of pregnancy ; cutaneous and mu- cous syphilides ; mercurial treatment of several months ; accouche- ment at term ; child syphilitic, dying at two months. Case LXXXIII. — Twenty-five years ; pregnancy of three to 16 230 SYPHILIS AND MARRIAGE. four months ; debut of syphilis unknown ; roseola ; palmar psori- asis ; vulvar and peri-vulvar syphilides ; cephalalgia ; neuralgic pains ; febrile attacks ; treatment of a few months ; premature accouchement ; child still-born. Case LXXXIV. — Nineteen years ; pregnancy ; debut of syph- ilis unknown ; confluent vulvar syphilides ; papulo-squamous syph- ilide ; cephalalgia ; nervous troubles ; no treatment ; accouche- ment at seven months ; child still-born. Case LXXXV. — Thirty-five years ; debut of syphilis not known, certainly dating back from a distant period ; multiple gummous tumors ; five pregnancies ; four children dying, all soon after birth ; last child surviving. Case LXXXVI. — Twenty-two years ; pregnancy of seven months ; secondary syphilis, debut unknown ; cutaneous syphi- lides ; vulvar and buccal syphilides ; analgesia ; treatment, nature unknown, regularly followed during several months ; accouche- ment at term ; child dying on fifteenth day. Case LXXXVII. — Twenty-two years ; pregnancy of four to five months ; syphilis dating from fourteen months ; vulvar syph- ilides ; treatment of some months ; accouchement at term ; child dying at twenty days. Case LXXXVIII. — Eighteen years ; accidents of secondary syphilis coinciding with debut of pregnancy ; treatment of one month ; papulo-hypertrophic syphilides of the vulva ; accouche- ment at term ; child still-born. Case LXXXIX. — Twenty-four years ; secondary syphilis, d^- but unknown ; no treatment ; abortion. Case XC. — Twenty-seven years ; secondary accidents appear- ing toward the sixth month of pregnancy ; no treatment ; ac- couchement at term ; child still-bom. Case XCI. — Nineteen years ; secondary syphilis, debut un- known ; no treatment ; abortion at five months. Case XCII. — Twenty-eight years ; secondary syphilis, debut unknown ; pregnancy of five months ; no treatment ; abortion. NOTES AND ILLUSTRATIVE CASES. 231 Case XCIII. — Twenty-three years ; pregnancy of six months ; secondary syphilis, debut unknown ; vulvar and anal syphilides ; treatment of some months ; accouchement at term ; child still- born. Case XCIV. — Thirty-three years ; pregnancy of three months ; vulvar syphilides ; papulo-squamous syphilide ; palmar psoriasis ; no treatment ; abortion at six months. Case XCV. — Twenty-two years ; secondary accidents appear- ing toward the fifth month of pregnancy ; vulvar, peri- vulvar, and anal syphilides, etc.; palmar psoriasis ; alopecia ; treatment of a few months ; accouchement at term ; child living, lost sight of when fifteen days old. Case XCVI. — Nineteen years ; secondary syphilis, debut un- known ; ulcerating syphilides of the vulva ; palmar psoriasis ; no treatment ; abortion at six months. Case XCYII. — Twenty years ; syphilitic chancre of the vulva in the fifth month of pregnancy ; roseola ; buccal syphilides ; in- terdigital syphilides ; cephalalgia ; mercurial treatment of four months ; accouchement at term ; lost sight of after four or five weeks. Case XCVIII. — Twenty-four years ; pregnancy of three to four months ; debut of syphilis unknown ; vulvar, anal, and buccal syphilides ; treatment of some months ; accouchement at term ; child syphilitic ; lost sight of when two months old. Case XCIX. — Twenty-two years ; pregnancy of about five months ; syphilis dating from one year ; vulvar, peri-vulvar, and anal syphilides ; treatment of several months ; accouchement at term ; child syphilitic, surviving. Case C. — Twenty-eight years ; contagion during pregnancy ; vulvar syphilides ; alopecia ; treatment not prolonged ; accouche- ment at term ; child dying at two months. Case CI. — Twenty-three years ; secondary syphilis, debut un- known ; no treatment ; abortion at two and a half months. Case CII. — Twenty -nine years ; secondary syphilis appearing 232 - SYPHILIS AND MARRIAGE. in the second half of pregnancy ; papulo-squamous syphilides ; buccal and vulvar syphilides ; febrile attacks ; mercurial treatment until the end of pregnancy ; accouchement at term ; child syphi- litic; treated, surviving. Case CIII. — Twenty years ; secondary syphilis, debut un- known ; vulvo-anal and buccal syphilides ; treatment, nature un- " known ; accouchement at term ; child surviving. Case CIV. — Twenty-one years ; accidents of secondary syphi- lis appearing in the second half of pregnancy ; vulvar and buccal syphilides ; treatment of fifteen days ; accouchement at term ; child still-born. Case CY. — Twenty-four years ; pregnancy of eight months and a half ; debut of syphilis unknown ; palmar psoriasis ; treat- ment for several months ; child healthy, surviving. Case CVI. — Twenty years ; pregnancy of three months ; indu- rated chancre of the vulva ; papular syphilide ; genital syphilides ; febrile attacks ; treatment of from two to three months ; abortion. Case CVII. — Twenty-one years ; syphilis dating from eight months ; pregnancy of four months ; erythemato-papular syphi- lide ; vulvo-anal syphilides ; treatment of ten days ; abortion at five and a half months. Case CVIII. — Twenty-three years; pregnancy of three months; syphilis dating from two years ; papular syphilide ; vulvar and buccal syphilides ; irregular treatment ; accouchement at eight months ; child dying in seventeen hours. Case CIX. — Twenty-two years ; syphilitic chancre of the neck of the uterus in the seventh month of pregnancy ; mercurial treat- ment ; accouchement at terra ; child healthy (at least up to its exit from the hospital, six weeks old). Case CX. — Twenty years ; infected from the d^but of mar- riage ; indurated chancre of the lip ; roseola ; vulvar and buccal syphilides; cephalalgia ; neuralgic pains ; treatment of several months ; accouchement at term (ten months after marriage) ; child syphilitic, dying at one month. NOTES AND ILLUSTRATIVE CASES. 233 Case CXI. — Twenty-three years ; debut of pregnancy and sec- ondary accidents of syphilis ; roseola ; buccal syphilidfes ; treat- ment very irregular ; accouchement at eight months ; child still- born. Case CXII, — Twenty-live years ; secondary syphilis, debut unknown ; vulvar syphilides ; palmar psoriasis ; pregnancy of four months ; treatment of six weeks ; abortion. Case CXIII. — Twenty years ; contagion toward the third month of pregnancy ; syphilitic chancres ; roseola ; cephalalgia ; nervous phenomena ; analgesia ; peripheric algiditis ; losses of consciousness ; febrile attacks ; mercurial and iodide treatment, very active and prolonged during the entire pregnancy ; accouche- ment at term ; child healthy ; six months after accouchement the mother presented some papulo-circinate syphilides upon the legs. Case CXIV. — Twenty years ; pregnancy ; debut of syphilis unknown ; cutaneous and mucous syphilides ; treatment of some weeks ; abortion at three months ; one year later second preg- nancy ; child syphilitic, dying at five months. Case CXV. — Twenty-two years ; pregnancy of six to seven months ; debut of syphilis unknown ; vulvar and buccal syphi- lides ; roseola ; analgesia ; two or three months' treatment ; ac- couchement at term ; child syphilitic ; treated, surviving ; con- tamination of the nurse by the child ; syphilis of the nurse very severe. Case CXYI. — Twenty-two years ; chancre of the breast trans- mitted by a syphilitic nursling ; cutaneous syphilides ; viilvar and buccal syphilides ; treatment of some weeks ; pregnancy a few months later ; accouchement at term ; child syphilitic, dying at five weeks. Case CXVII. — Nineteen years ; infected in the first months of marriage in the course of pregnancy ; treatment of a few weeks only ; abortion. Case CXVIII. — Twenty-one years ; syphilis by conception ; secondary accidents ; treatment of some weeks ; accouchement at 23-i SYPHILIS AND MARRIAGE. term ; child probably syphilitic ; dying of convulsions when one month old. Case CXIX. — Thirty-one years ; two children living and healthy, born before the contagion ; contagion in the course of the third pregnancy ; treatment of some weeks at its debut, and since then no medication ; child still-born ; afterward four pregnancies, from year to year ; three giving children still-born, or dying after a few days ; of the fourth only, child surviving, feeble, but ap- pearing to have never been affected with specific accidents. Case CXX. — Twenty-eight years ; contagion one year after marriage ; multiple secondary accidents ; cutaneous and mucous syphilides ; crusts of the hairy scalp ; alopecia ; neuralgic pains ; cephalalgia, etc. ; treatment insignificant ; six pregnancies in four years ; six abortions. Case CXXI. — Twenty-nine years ; pregnancy of five to six months ; debut of syphilis unknown ; secondary accidents ; treat- ment of some weeks ; accouchement at eight months ; child still- born. Case CXXII. — Seventeen years ; syphilis recent, and preg- nancy of two or three months ; vulvar, anal, perineal, and ton- sillar syphilides ; crusts of the hairy scalp ; no treatment ; abor- tion a few days after entrance into hospital. Case CXXIII. — Twenty-one years ; pregnancy of five months ; debut of syphilis unknown ; papular syphilide ; vulvar and buccal syphilides ; treatment of two to three months ; accouchement al- most at term j child syphilitic, dying at three weeks. Case CXXIV. — Thirty years ; chancre in the fourth month of pregnancy; cutaneous syphilides; alopecia; vulvar syphilides; treat- ment of some weeks ; accouchement before term ; child still-bom. Case CXXV. — Twenty-seven years ; debut of syphilis un- known ; palmar psoriasis ; tonsillar syphilides ; vulvar and peri- neal syphilides ; alopecia ; treatment very irregular ; four preg- nancies in two years succeeding invasion of syphilis ; four abor- tions from two to four months. NOTES AND ILLUSTRATIVE GASES. 235 Case CXXVI. — Twenty-five years ; syphilis dating from seven months ; pregnancy of five months ; cutaneous syphilides ; no treatment ; abortion two days after entrance into hospital. Case CXXYII. — Twenty-two years ; syphilis contracted at beginning of marriage ; no treatment ; abortion at three months ; secondary accidents ; papular syphilide ; buccal syphilides ; vulvar syphilides ; treatment of a few weeks ; the following year, abor- tion at five months. ISrOTE IV. SYPHILIS COISTTEACTED BEFORE MARRIAGE, AND MAKING ITS FIRST APPEARANCE AFTER MARRIAGE. The ordinary period of syphilitic incubation some- times exemplifies the curious fact of a syphilis which, contracted lief ore marriage, does not make its first inva- sion until after marriage. Cases of this kind are naturally quite rare. But, nevertheless, I have the records of four which are quite authentic. The following will serve as an example : M , aged twenty-eight years ; good constitution ; had typhoid fever at the age of fourteen years. Nothing else, besides this, than passing indispositions. In the way of venereal accidents, had two blenorrhagias, at twenty- two and twenty-four years of age ; perfectly cured. Fifteen days before the date fixed for his marriage, M gave a large supper to his friends, under the pretext of bidding adieu to bachelor life. Stupefied by copious libations, he allowed himself to be induced to spend the night with a former mistress. This woman was at the time under treatment for accidents of secondary syphilis, and still presented certain ^'■houtons^^ on the vulva, which her physician had characterized (I subse- quently learned) as mucous patches. Afterward, I had occasion to see this patient several times, and observed undoubted accidents of syphilis upon her. NOTES AND ILLUSTRATIVE GASES. 237 M marries in a perfect condition of health. Fifteen days after his nuptials, he observes upon the glando-preputial furrow a slight redness, somewhat ero- sive. He gives it no further attention, believing it to be "an excoriation from intercourse with his wife." His sexual relations are not interrupted. Still, the erosion exists ; it becomes enlarged, and seems to become tume- fied at its borders. Cauterization with mnaigre de Bully, and continuation of his sexual relations. Some days later only does M become uneasy, and consult his phy- sician, who expresses to him the liveliest fears as to the nature of the accident. Frightened, he rushes to me, and I note the following condition : Upon the glando-prepu- tial furrow a superficial erosion, oval-shaped, of the di- ameter of a lentil ; surface smooth, reddened, gray in the center, lardaceous, pseudo-membranous ; borders adhe- rent, slightly elevated ; base renitent, hard, of a dry hard- ness, almost characteristic. A single ganglion in the corresponding groin, hard and indolent. I confirm the diagnosis of my confrere, and I consider myself author- ized in declaring to the patient that the lesion with w^hich he is affected is a sypMUtic chancre, resulting from a contagion dating back several weeks. The following days, the characteristics of this lesion become more accentuated. The sore extends, and the induration, especially, becomes exuberant, cartilaginous. Several glands become implicated, constituting a verita- ble inguinal pleiad. The syphilitic infection is then ab- solutely manifest. I^^ot until this tmie does the patient avow to me his experience, and bring the woman to me with whom he had connection several days before his marriage. The veri- fication of the syphilis in this woman and the details 238 SYPHILIS AND MARRIAGE. wliicli she gives in regard to her disease complete and confirm the diagnosis of my patient's lesion. Six weeks later, the patient's body is covered with a roseola. Afterward, tonsillar syphilides, crusts of the hairy scalp, slight alopecia, cervical adenopathies ; mer- curial treatment ; disappearance of the accidents. The wife of this patient would not at first consent to an examination which her husband had suggested under some pretext or other. Consequently, I did not see her until about two months and a half after her marriage. At this time there remained no trace of vulvar accidents. But the patient stated that she had had a slight "excori- ated pimple " some weeks previous, which had ]produced "some swelling" of the labia; and on examination there was found in the groin, on the same side as this lesion, a ganglionic pleiad very markedly accentuated, and leaving scarcely a doubt of a syphilitic infection of recent date. A fortnight later, the patient complained of general lassitude, headache, vague pains in the limb. Then, a roseola soon manifested itself, which dissipated all uncer- tainty as to the situation. Subsequently, palmar psoriasis, tonsillar syphilides, alopecia. To recaioitulate, then : 1. Fifteen days hefore mamage, connection with a wo- man affected with vulvar syphilides. 2. Marriage in apparently perfect condition of health. 3. Fifteen days after marriage, appearance of a syph- ilitic chancre, followed by secondary accidents, after the normal incubation. 4. Contamination of the young wife from the chancre of the husband, the nature of which chancre was unrecog- nized at its origin. NOTES AND ILLUSTRATIVE GASES 239 My other three cases are, so to speak, reproductions of the one just narrated. They all relate to chancres break- ing out after marriage, as a consequence of a contagion preceding the marriage from eight to seventeen days. Three times in four, the young wives contracted the con- tagion, and the fourth only escaped, thanks to the acci- dent of a quite prolonged indisposition, which suspended all intercourse. In every case, in iine, the long duration of the incubation deceived the husbands as to the nature of the accidents, and exposed them to the risk of infecting their wives. ( NOTE V. PREMATURE MARRIAGE OF A SYPHILITIC SUBJECT ; FIVE CASES OF SYPniLIS ORIGHSTATING FROM THE SYPHILIS OF THE HUSBAIfD ; DEATH OF A STRANGE NURSLING. The f oEowing case is interesting in two respects : On the one hand, it shows in a general way what may be the consequences of a premature marriage in syphilis ; on the other hand, it illustrates the dangers incidental to the raising of a syphilitic infant, when this infant has been committed to a nurse instead of being suckled by its mother. I. ]Sr contracts syphilis. At first he is treated by a pharmacist, who gives him pills of a "secret" com- position. Four months later he comes to consult me, and I observe the following accidents upon him : papular syphilide covering the thorax and the limbs ; tonsillar syphilides ; crusts of the hairy scalj) ; alopecia ; cervical adenopathies. Mercurial treatment. Disapi^earance of the accidents in a few weeks. Afterward recurrence of a papulo-squamous syphilide, affecting the scrotum. Mercurial treatment is resumed ; later, iodide of potassium. The patient is treated regularly during five or six months, after which I lose sight of him. I have since NOTES AND ILLUSTRATIVE GASES. 241 learned from him that, believing himself cured, he no longer followed any medication after this time. Two years after the debut of his syphilis, he marries, without taking counsel of me or of any other physician. He was, nevertheless, far from being cured at this time, as was demonstrated by the reappearance of various acci- dents in the following years : cutaneous syphilides, buccal erosions, onyxis, periostosis, etc. II. Some months after his marriage, the wife of N commenced to complain of neuralgias of the head, of intense pains in the limbs, of insomnia, of general malaise, of febrile attacks, etc. These various symptoms were at first treated with the sulphate of quinine, but without success. Soon a confluent eruption covered the body, and enlightened the physician as to the nature of the anterior accidents which had, until then, resisted his medication. At this time this woman was brought to me, and I noted upon her accidents of a nature incontestably syphilitic : generalized papulo-squamous syphilide, palmar psoriasis, crusts of the hairy scalp, with scattered alopecia, tonsillar erosions, cervical adenopathies, etc. In addition, about this same date, she became pregnant. Mercurial treatment : rapid disappearance of the acci- dents ; accouchement, at term, of a fine child, which, con- trary to my express recommendations, was committed to a nurse at some distance from the citj. III. I had lost sight of these two patients for a cer- tain time, when, one day, 1^ summoned me to his house, to present to me at the same time — 1. His diseased infant ; 2. The nurse of this infant infected by it ; 3. The husband of this nurse infected by his ^ife. And, in fact, a long interrogation, followed by a care- 242 SYPHILIS AND MAREIAOE. fill examination revealed to me the following series of results : 1. The infant remained exemj)t from every morbid symptom during the first four or five weeks. After that time its body was covered with pimples, especially around the buttocks, its mouth was ulcerated, its nose " ran pro- fusely." It became thin, emaciated, and they had fears for its life during several months. Nevertheless, it grew better, thanks to the treatment which was prescribed for it by the physician of the locality (mercurial frictions, baths of the sublimate, iodide of potassium, etc.). It now presents various specific accidents : erosive syphilides at the buccal commissures ; papulo-ulcerous syphilides of the margin of the anus, etc. 2. Some weeks after the invasion of these accidents upon the nursling, the nurse's breast became "ulcerated." She was not told the nature of the lesion on her bosom, but she says that she was treated with mercurial pills at this time. Besides, some weeks later, she suffered from sore-throat and an inflammation of the vulva, with "ex- coriated pimples " ; her body was covered -with a red erup- tion, and her hair fell out to such an extent that she "thought she would become absolutely bald." I observed upon her, at the time of my visit, undoubted traces of a squamous syphilide, cervical adenopathies, a severe alo- pecia, and pigmentary macules scattered upon the neck. 3. The infant of this woman (which she nursed at the same time as the infant of N ) had been healthy from its birth, and it had continued to "thrive" during several weeks. But two months ago it suddenly commenced to waste away. Its body became covered with a papular erux)tion, its mouth became ulcerated, its legs became swollen ; it then died in a state of consumption. The at- NOTES AND ILLUSTRATIVE OASES 243 tending physician, I was informed, had no doubt that the child succumbed to a syphilis contracted after its birth. 4. Finally, the husband of this woman, a man of regu- lar habits and of irreproachable morality, became diseased some months after his wife. He commenced by i^resent- ing several ^^'boidons^'' upon the penis, then he was af- fected with a confluent eruption, with pains in the head, with sore-throat, etc. I found him, at the time he came under my observation, in an active condition of secondary syphilis : erythemato-papular syphilide, eruption of crusts of the hairy scalp, cervical adenopathies, buccal syphilides, etc. In addition, I found, on the glando-preputial furrow, two cicatricial indurations with a double inguinal pleiad, which were unquestionably the remains of the primitive infection. To recapitulate, then : 1. Premature marriage of a syphilitic subject. 2. Contagion transmitted from the husband to his wife. 3. Birth of a syphilitic child, which is committed to a nurse, in defiance of medical advice. 4. Contagion transmitted by this child to its nurse. 5. Contagion transmitted by this nurse to her own child, which becomes emaciated, wastes away, and dies. 6. Contagion transmitted by this same nurse to her husband. That is to say, five cases of syphilis and one death resulting from the premature marriage of a man mth a syphilis not yet extinct. NOTE VI. FATHER SYPHILITIC .; CHILD SYPHILITIC ; MOTHER SEEM- ING AT FIRST EXEMPT, BUT PRESENTING, SIX YEARS LATER, AN ACCIDENT OF TERTIARY SYPHILIS. " In 186- I had under my care Madame Z during the last six months of her pregnancy, which, moreover, was complicated with frequent nausea and occasional vomiting. The 6th of April this woman gave birth to a little gui, well developed, healthy in appearance, weighing three kilogrammes one hundred and fifty-two grammes. The delivery was completed naturally, twenty minutes after the accouchement. The placenta was healthy. The after-results of the accouchement were favorable. "About the tenth day the child had a little fever, green stools, erythema of the buttocks. On the fifteenth day an eruption showed itself on different portions of the surface. It soon took on the characteristics of a syph- ilitic ecthyma. The 15th of May, mucous patches, as manifest and as typical as possible, appeared around the anus and on the vulva. A treatment, consisting of baths of the sublimate and frictions with mercurial ointment, soon caused the disappearance of these various accidents. "Nevertheless, the mother continued, and has since continued, to nurse her child. She has not ceased to be perfectly weU, and, notably, she has never presented any symptom which could be attributed to syphilis. I will NOTES AND ILLUSTRATIVE CASES. 245 add that a careful interrogatory, as minute as possible, into tlie antecedents of this woman did not enable me to discover anything specific in her history. When she ceased nursing her "infant (fourteen months later), she was a little anaemic, and complained of a persistent pain be- tween the shoulders. She improved rapidly, and without any medication, as soon as she ceased nursing. " The father, interrogated by me as to his antecedents, had confessed to me that he had contracted an infecting chancre four months before his marriage, and that even at the moment of conception he was still affected with vari- ous secondary accidents (mucous patches at the anus, mucous patches on the tonsils, and disseminated crusts of the hairy scalp). " I found myself in the presence then — 1. Of a syph- ilitic father, still presenting syphilitic accidents at the moment of the conception of his child. 2. Of a syphilitic child commencing to present undoubted manifestations of syphilis on the fifteenth day after its birth. 3. Of a mother not infected, and appearing to have never suf- fered any specific accident before her accouchement, and having nursed her syphilitic infant during fourteen months without contracting the least contagious symp- tom from it. " This fact overturned all my beliefs upon syphilitic heredity, and notably my cardinal conviction, viz., that, if a child be born tainted with syphilis, the mother must certainly have been infected. In my opinion, as I had established in a previous memoir, pas de syphilis de V en- fant sans syphilis de la mere. "During six years, I was privileged to look after the health of this family, and I can testify that — 1. The child, submitted to the above-mentioned treatment, has survived. 17 246 , SYPHILIS AND MARRIAGE. Although somewhat lymphatic, it has never ceased to en- joy very good health. 2. The father, vv^ho has followed a rigorous and prolonged treatment, has presented no more specific manifestations. 3. The mother, scrupulously ob- served, has not ceased to continue well, apart from certain passing indispositions. " I confess that this case (followed up by me from day to day, so to speak) very much disturbed my former con- victions. I was even preparing to publish it, when, in the month of October, 188-, Madame Z came to consult me in regard to a tumor on her right arm. This tumor, situated beneath the skin, immediately above the olecranon, was of the volume of a pigeon's e^g. Its circumference and base were hard, but its central portion was soft. It had never given rise to pain, and it still remained indo- lent, even on palpation and pressure. The integument around the portion in process of softening presented a brownish-red color. I examined this tumor A\ith great care, and I arrived at the conclusion that it could only be constituted by a sypMlitic gumma. Ten days later, an abscess formed in the tumor, and opened at its central portion. It gave exit to a liquid which was composed of tv/o distinct portions, one transparent and gelatinous, simi- lar to dissolved gum, the other purulent. The tumor once opened, I perceived that the base of the abscess was gray- ish, as if putrilaginous. The opening rapidly enlarged, presenting a sinuous contour, with borders neatly and per- pendicularly cut. The base of the tumor stUl remained indurated. These characteristics, this evolution, tended to confirm me in my first impression. I diagnosticated a gummous tumor, and I do not indeed believe that any other diagnosis could have been arrived at. ''Treatment by iodide of potassium, doses at first in- NOTES AND ILLUSTRATIVE GASES. 247 creasing, then decreasing ; rapid improvement of the le- sion ; cnre in less than three weeks. "The evidence was, then, conclusive. Besides, what other diseases could this tumor be confounded with ? With an anthrax ? With an abscess ? But the absence of pain, the absence of inflammatory phenomena, the objective aspect of the lesion, the morbid evolution, all exclude such hypotheses ; and, more, the rapid cure effected by the iodide of potassium completely demonstrates, at least in my opinion, that it was a lesion of tertiary syphilis. "It is certain, then, that Madame Z had been in- fected at some previous date, either before or during her pregnancy. Her syphilis had been obscure, fugacious. This syphilis had passed unrecognized both by the patient and myself. Finally, it did not reveal itself in a manifest shape until six years later, by the outbreak, quite unex- pected, of a lesion of the tertiary order. "Altogether, this case, which at first seemed as if it must of necessity overturn the theory which I for a long time had sustained (in accord with that of M. CuUerier, M. Notta, and other observers), viz., that eTiery syphilitic child is horn from a syphilitic mother — this case, I say, has, on the contrary, furnished an additional argument for the theory in question, and confirms it absolutely." — (Dr. A. Charrier.) NOTE VII. INAPTITUDE FOR LIFE, AS AIST HEREDITARY CONSEQUENCE OF PATERNAL SYPHILIS. A CARDINAL fact Wiiicli I have endeavored to place in strong relief in tliis work relates to tlie most serious of tlie hereditary consequences of paternal syphilis. I have asserted, and I think demonstrated, that the child procreated by a syphilitic father is very often stamped with a sort of inaptitude for life. In other words, this child is liable to die early, either in utero, or within a short time after accouchement. I can not reproduce here all the facts which have served to establish my conviction upon this point ; but I think that I ought to place a certain number under the eyes of the reader as illustrative cases : Case I. — Indui-ated chancre of the penis ; roseola ; palmar psoriasis ; tonsillar syphilides ; treatment from six to eight months, but irregularly followed ; marriage five years after the d6but of the syphilis ; wife perfectly healthy, remaining abso- lutely exemjDt ; four pregnancies ; four abortions ; * at this time * I specify, once for all, that in this case, as in the following cases, abortion or premature accouchement could not possibly have been due to any cause, either accidental or constitutional, depending upon the wife. We have here to deal only with cases (I have selected them designedly) where after careful examination, after searching for and excluding every other cause, the death of the foetus re- mains exclusively imputable to the syphilis of the husband. NOTES AND ILLUSTRATIVE CASES. 249 the patient is subjected to a new treatment (mercury and iodide of potassium for about a year) ; four pregnancies afterward ; four accouchements at term ; children living and healthy (the eldest is at present twelve years old). Case II. — Indurated chancre ; buccal syphilides ; insignificant treatment of a few weeks' duration ; married fifteen months after debut of syphilis ; wife remaining absolutely exempt ; nine preg- nancies ; five abortions ; three accouchements before term, infants living from a few hours to three days ; ninth pregnancy at term, resulting in a living infant, which, fifteen days later, was covered with syphilides. Case III. — Indurated chancre, followed by some secondary accidents ; treatment from six to eight months ; ocular paralysis three years later ; marriage seven years after the debut of the syphilis ; tertiary accident (exostosis) the same year ; treatment resumed with vigor, wife remaining exempt ; four pregnancies from year to year ; first pregnancy terminated by abortion ; sec- ond pregnancy : accouchement at eight months of a dead infant ; third pregnancy : accouchement at term, infant dying in a few hours ; fourth pregnancy : accouchement at term, child surviving and healthy. Case IV. — Indurated chancre ; cutaneous and mucous syphi- lides ; treatment for about a year ; marriage four years later ; the first pregnancy is terminated by an accouchement at term ; child living and healthy ; two years later, reawakening of the di- athesis ; tuberculo-ulcerative syphilide, rebellious and recurring ; sclerous glossitis ; gumma ; ecthyma ; this crop of accidents is prolonged during three years, despite an energetic treatment ; it coincides with three pregnancies which all terminate in abortion ; wife uncontaminated. Case V. — Indurated chancre, followed by a few very slight secondary accidents ; mercurial treatment during two months ; the following years, small doses of iodide of potassium from time to time ; marriage fourteen years after debut of syphilis, wife re- 250 SYPHILIS AND MARRIAGE. maining uninfected ; two pregnancies in the course of the two years succeeding marriage ; the first terminating by accouchement at term of a dead infant ; the second producing a syphilitic infant, which dies in three weeks ; consecutively, husband has recurrence of tertiary accidents. Case VI. — Syphilis ; indurated chancre of the penis ; two to three months mercurial treatment in feeble doses ; no secondary accidents remarked ; marriage four years later, wife remaining exempt ; three jiregnancies terminated by three abortions ; at this time accidents of tertiary form ; treatment energetic, and pro- longed w^ith mercury and the iodide of potassium ; a fourth preg- nancy happening a year later results in a child at term, living and healthy. Case VII. — Indurated chancre of the prepuce ; confluent rose- ola ; mercurial treatment for several months ; afterward lingual syphilides ; marriage five years after the debut of the disease ; wife uninfected ; three pregnancies terminating in the following manner : one abortion ; two accouchements before term, infants dead ; consecutively, the husband affected with a psoriasiform syphilide. Case VIII. — Chancre of the lip ; cutaneous syphilides ; buccal patches ; onyxis, mercurial treatment for several months ; mar- riage one year later, wife remaining exempt ; three pregnancies in three years ; the first two infants still-born ; the third is born syphilitic, and dies in three months ; consecutively the husband affected with a psoriasiform syphilide of the hands. Case IX. — Indurated chancre ; secondary accidents ; mercu- rial treatment of one month only ; marriage two years later, wife remaining exempt ; two pregnancies terminate by abortion ; third pregnancy, infant at term, cachectic, dying in a few weeks ; after- ward husband is reattacked with ulcerative syphilides of the penis. Cask X.— Labial chancre ; roseola ; tonsillar syphilides ; mer- curial treatment of three months ; marriage ten years later, wife remaining exempt ; four pregnancies ; two abortions ; tAvo infants NOTES AND ILLUSTRATIVE CASES 251 born at term, hydrocephalic, soon dying ; consecutively the pa- tient is affected with cranial osteitis ; symptomatic encephalitis ; death. Case XL — Indurated chancre of the prepuce ; papular syphi- lide ; buccal syphilides ; onyxis ; cervical adenopathies ; tibial periostosis ; treatment of six months ; marriage three years later, wife remaining exempt ; four pregnancies ; the first two termi- nate by abortion ; the third brings a syphilitic infant to term, which dies the second day ; resumption of treatment ; fourth preg- nancy : child syphilitic, surviving. Case XII. — Indurated chancre of the sheath ; roseola ; anal and buccal syphilides ; treatment of four weeks by mercury, then treatment of two months with iodide of potassium ; marriage in the second year of the disease, wife remaining exempt ; two mis- carriages ; third pregnancy, giving a syphilitic infant (syphilides, pemphigus, osseous lesions), which soon dies. XIII. — Indurated chancre ; secondary syphilides of the skin and mucous membranes ; iritis ; treatment for some months ; mar- riage two years later, wife remaining uninfected ; four pregnan- cies, three quite near each other ; the first two terminate by abortion ; the third gives a syphilitic infant, which survives, thanks to an energetic treatment ; the fourth produces an infant which has never to this day presented specific accidents. XIV. — Indurated chancre ; some secondary accidents ; treat- ment for several months ; marriage four years later ; wife remain- ing exempt ; two abortions ; third infant syphilitic, dying when four weeks old. THE END, provided Uy "^ ^_==r======* the Ubranan m en** & .^^=====r C28(»46>M'°° V^t.i\^