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slighter forms of primary syphilitic ulceration, when followed by secondary symptoms, usually precede the eruption or the sore throat but a very short period. Also, that an attack of syphilitic lepra or lichen, or syphilitic iritis, may supervene while the patient is still under the influence of mercury, the primary ulcer being unhealed. cases the interval is longer. into St. Bartholomew's Hospital in June, 1844, with a syphilitic sore John W--, aged twenty, was admitted in the body of the penis; he was treated in the usual way, and dismissed in about a month. In the month of November following, six months afterwards, he was again under treatment for papular eruption over the whole body. He had had no other primary affection between while.
Mr. De Meric refers the varieties of syphilitic eruptions to four heads erythema, papules, vesicles, pustules. Other authors speak of the scaly, papular, pustular, and tubercular eruptions. It matters not which form of classification is adopted; but we cannot agree with the author that the term "scaly" is too vague; it indicates a condition of the integument far more persistent and better marked than the papular, vesicular, or pustular rash, which run so readily one into the other. But it is quite true that some cutaneous affections have a tendency to pass into ulceration, while others do not, although no useful division can be founded on the fact, for generally speaking it is the condition of the patient's health which exerts the unfavourable influence upon the usual course of the disease.
We think that in the works before us there is an evident want of information on the subject of constitutional syphilis. We do not meet with graphic descriptions of those severe ulcerative affections which are so baffling to the surgeon, so erratic and uncertain in their course as regards the patient. The teaching of the School of the Midi appears to us too precise; the venereal disease is divided into stages which do not exist in nature, and the only conclusion to which we can arrive is either that the symptoms and history of the disease are very different on the two sides of the Channel, or that the same series of facts have been very differently interpreted. But when it is borne in mind that the venereal patients of a large hospital are from all countries, that many have been infected by foreign prostitutes, and yet that the phenomena of the disease are the same, we think that the latter explanation is the more probable; and we unhesitatingly assert, that the teachings of the English school appear to be far more faithful to nature, and likely to be verified by future experience, than the ingenious hypotheses which have been so multiplied in the schools of Paris.
We next proceed to the important subject of infantile syphilis"An infant," says M. Diday, "may contract syphilis; firstly, during intrauterine life, through the formative or nutritive elements derived from its parents; secondly, during or after birth by the absorption of the virus from some source or other. Hence we have two classes of phenomena, which we shall study successively under the designations of congenital and acquired syphilis." (p. 14.)
I. Influence of the father.-The father alone being syphilitic, can
he communicate the disease to the child? M. Diday answers in the affirmative, adding, however, that it is difficult to obtain proof, because the father is very rarely affected with the disease without communicating it to the mother before or during pregnancy; and when the child is born with symptoms of syphilis we do not know to which of the parents they are due.
Numerous and precise facts furnish a positive demonstration of the theory. Professor Cederschjold has frequently seen children affected some weeks after birth with copper-coloured spots on the forehead, ulcers about the arms. He adds, 'the mothers were healthy, and there was no reason to suppose that they had been infected.'"*
It is asserted, too, that a man who has had syphilis, but who presents no symptoms of the disease at the moment, may beget a syphilitic child, the mother remaining to all appearance healthy. But we must pause in hastily drawing conclusions, for cases occur in which a woman retains the power of infecting the child under circumstances which might mislead the surgeon.
A healthy-looking woman, aged thirty, presented herself at St. Bartholomew's Hospital, with an infant of a few weeks' old covered with a syphilitic rash. She said that twelve or fourteen years ago she had been on the town, but that to the best of her knowledge she never had had disease. She was married to a respectable man, a widower, the father of several healthy children. Every child to which she gave birth became, however, the subject of syphilis and died, and she entreated the surgeon, in unfeigned grief, to eradicate the disease by any means in his power. Now, it would be possible to quote this as an instance of infection from the father, had he ever suffered from venereal sore; but such was not the case; he was the parent of healthy children by the first marriage; the more probable explanation is, that at some period of the woman's life of prostitution the system had been generally infected, but without any obvious outward manifestation.
A man who is affected with syphilis and has connexion with a pregnant woman may, according to the author, communicate the disease directly to the fœtus without infecting the mother. But then, what is meant by "not infecting the mother?" Is it not true that there are many cases in which a mother brings forth, after connexion with an infected person, an unhealthy child at each subsequent pregnancy, although the parentage may be different? and should we not regard this in itself as an indication of general syphilitic taint. Cases have presented themselves before us, to show that during the period of uterogestation secondary symptoms, which are latent at other periods, often burst into full activity. It is difficult, therefore, to say how far the mother is free from taint, although there may be no present manifestation.
II. The influence of the mother.-It is unnecessary to speak of the influence of the mother infected before the moment of conception; but we shall proceed to inquire up to what period of pregnancy can syphilis, then first contracted by the mother, be communicated to the
* Tidschrift for Lakare, Band vii. No. 10. 1840.
fœtus? In other words, is there a period of pregnancy after which syphilis contracted by the mother, can no longer be transmitted to the foetus? "Until the sixth month," said M. Ricord to his class, in 1847, the mother may transmit constitutional syphilis acquired during gestation; but if the infection of the mother take place during the last three mouths, it is not certain that transmission is possible. M. Diday says, "Madame B——, a patient of my own, suffered from syphilitic contagion at the commencement of the seventh month. The child, born at the full time, died at the end of five months." (p. 31.) But new and varied observations are required for the definite solution of these questions.
III. Combined influence of both parents.-M. Diday thinks the conclusion, "that in such a case the foetus has no chance of escaping," has been made too hastily, and that so serious a sentence demands more conclusive evidence. "At the worst," he says, "the infection of both parents can only expose it to two noxious influences instead of one. But if the disease be slight in each of the parents, may it not be the case that this double chance is less serious than the single one, with which only one of the parents, being severely affected, would have threatened its future health?" (p. 32.)
Acquired Syphilis.-I. Infection during labour. II. Infection by lactation. III. Infection from accidental causes.
Of the first, we agree with both Diday and Ricord, "it is without doubt rare, but not impossible."
Of infection by lactation some assert, with Ricord, that the nurse was the subject of a primary sore, and communicated one to the child. Others, adhering to the older opinions, believe that the disease is communicated in a secondary form. Each of these explanations has its difficulties. Diday believes that congenital syphilis may be accidentally engrafted upon an adult-as by an infected child upon a nurse with an excoriated nipple; and that the sore then formed may transmit the disease in its secondary form to a healthy child.
As regards the influence of the milk, M. Diday, after collecting different opinions, leaves the matter in abeyance, experience not having given sufficient support to its suggestions.
Accidental causes of infantile syphilis are mentioned and supported by cases. But hospital experience would show that such cases are very rare.
In the description of the disease, M. Diday draws especial attention to morbid changes as they occur in the viscera, particularly the lungs and liver. Indurations are met with in the substance of the lung; when cut into, they are found to be composed internally of a compact yellowish tissue, in the centre of which is a cavity containing a seropurulent fluid. The microscope reveals in it the most marked characters of pus. (p. 88.)
In the liver, the distinct appearance of its two substances has completely vanished. On a uniform yellowish ground, a more or less close layer of small, white, opaque grains is seen, having the appearance of
grains of semola, with some delicate arborescences formed of empty blood vessels. On pressure no blood is forced out. (p. 92.)
Further observations are required before the syphilitic character of these morbid appearances can be accepted.
"The transmission of the poison by the foetus to the mother, denied formerly, has now become admitted," says M. Diday, “if I may believe the development which this principle has received from various authors, in the first rank among whom justice requires that I should mention Mr. Jonathan Hutchinson and Mr. Victor De Meric." (p. vi.)
We are glad to read in M. Diday's work a refutation of that great error which Ricord has promulgated, namely, "that if a new-born child transmit syphilis to its nurse, it is because it had itself a primary chancre;" and as a counterpart, "that if only hereditary syphilis, constitutional lesions exist, it will not transmit any disease to its nurse." He brings forward a mass of interesting information; and in speaking of the glandular affections which not uncommonly present themselves in the axilla of the nurse, remarks, "It is only one of the applications of this great result of observation, viz., that the poison of syphilis, when it involves the organism of an individual, always determines a process of reaction in the first gland which it meets with in its course, manifested externally by the enlargement of that gland." (Op. cit. p. 18.)
From experiments conducted by Mr. Savory it would appear that the mother may be poisoned by means of the blood circulating in the yet unborn fœtus. He administered chloroform to a pregnant bitch so as to produce complete insensibility, and then opening the uterus, he drew out one of a litter of pups, taking care not to injure the umbilical cord. After separating the pup carefully from all surrounding parts except the umbilical cord, he immersed it in water of the temperature of 100° Fahr., the normal degree of heat in the pregnant uterus. Then upon injecting a solution of strychnine into the pup, he noticed the phenomena of poisoning in the mother, the other pups remaining free from any ill effects. Now, as Mr. Savory very justly remarks, all that this experiment proves is the possibility of the mother being contaminated by poison emanating from the unborn fœtus; it serves to show that the conclusion of Mr. Hutchinson and others— namely, that a healthy female may become affected with constitutional syphilis, without even having a primary sore, by means of a fœtus infected with syphilis through the exclusive agency of the father-is not a doctrine physiologically impossible. But it leaves untouched and unsolved the problem whether the poison can be conveyed to the foetal germ and there deposited, to become so blended with the formative cells as to affect intra-uterine life, and to contaminate the maternal circulation, without in the first place contaminating the mother by means of the ovary. And when we recollect that a woman apparently healthy, who has once given birth to a syphilitic child, will, in many instances, give birth to other children similarly affected, though the parentage be different, we must confess that the reasoning does not appear to us to be quite conclusive.
A modern author* draws the following conclusions from very considerable experience in a public lying-in hospital, on the subject of syphilitic infection as between parent and offspring:
1. If the syphilitic poison is once in the body, and carried into the circulation, it may remain an indefinite time in the organism, and, under favourable circumstances, even when no external sign betrays its presence, may again make its appearance, and develop itself in various secondary forms, known as lues venerea.
2. The lues, latent or visible, can be conveyed from person to person, and the poison taken up thus second-hand can be transmitted to the third or fourth time, &c.
3. Infection is generally effected by the genital organs. Nevertheless, syphilis can be introduced as a blood-disease by any other channel, through which certain secretions, or perhaps the blood of an infected person, can be conveyed into the circulation of another; so by means of the mouth, the nipple, a denuded spot of skin, vaccination, or the uterine blood destined to the nourishment of the foetus.
4. A woman infected in such a manner bears in her, although there may be nothing externally to observe, nine times out of ten, specific marks of disease in the organs of generation. The author constantly found the uterus diseased; and there are few surgeons who have not remarked upon the vaginal discharge which persists even after delivery in women who have borne a syphilitic infant.
We must be permitted to doubt whether experience justifies us in asserting much more than Mr. Whitehead has here laid down. But credit is undoubtedly due to those who still persevere in their endeavours to unravel the difficulties in which this interesting subject is involved.
There remains for us only the pleasing duty of recommending these works to the attention of the profession. Mr. De Meric's lectures are well and concisely written, and explain the views of which he is the supporter, so clearly, that much fuller information is obtainable from them than from works of a more imposing appearance. We strongly recommend the pamphlet. The work of M. Diday is of great merit; it contains all that has been written on infantile syphilis; and he puts the whole subject in a well arranged form for further investigation, as well as present use. Mr. Maunder has translated Ricord's lectures faithfully; but the author is somewhat wordy and diffuse; still, those desirous of learning M. Ricord's opinions may here find them well reported. We do not agree with him; indeed we think that the subject of syphilis has suffered under the handling which it has received from the very questionable experiments of inoculation. But the cause is one which boasts of ardent supporters either way; and we doubt not that the controversy will prove advantageous to the cause of truth.
James Whitehead: On the Transmission from Parent to Offspring of some Forms of Disease, and of Morbid Taints and Tendencies. 1851.