COLUMBIA LIBRARIES OFFSITE 
 
 HEALTH SCIENCES STANDARD 
 
 HX641 18460 
 C201 .C83 Some aspects of infa 
 
 IRECAPI 
 
 OME Aspects 
 
 OF 
 
 PANTILE 
 
 Syph 
 
 ILIS 
 
 \ A. COUTTS 
 
 RiVINOTON • Percival & C? 
 
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 ^M 
 
 College o! ^i)v^itmn9i anh ^urgeong 
 
INFANTILE SYPHILIS 
 
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SOME ASPECTS 
 
 OF 
 
 f\. INFANTILE SYPHILIS 
 
 BEING THE HUNTERIAN LECTURES 
 
 DELIVERED AT 
 
 THE^OYAL COLLEGE OF SURGEONS 
 IN 1896 
 
 BY 
 
 A. COUTTS, M.B. (Cantab.), M.R.C.P. 
 
 FORMERLY PROFESSOR AT THE COLLEGE 
 
 PH^'SICL-VN TO THE EAST LONDON HOSPITAL FOR CHILDREN 
 
 RIVINGTON, PERCIVAL & CO. 
 
 KING STREET, CO VENT GARDEN 
 
 LONDON 
 
 1897 
 

 aB3 
 
TO MY SENIOR COLLEAGUE, 
 
 DR. EUSTACE SMITH. 
 
 AS HE HAS BEEN MAINLY RESPONSIBLE FOR THESE 
 LECTURES BEING DELIVERED AND REPRINTED 
 
 IN THEIR PRESENT FORM, 
 
 IT IS FITTING THAT HE SHOULD INCUR THE 
 
 ADDITIONAL RESPONSIBILITY OF 
 
 DEDICATION. 
 
PREFACE 
 
 These lectures deal with only a limited 
 portion of the subject of "Infantile SyphiHs." 
 This being the case, I was for some time 
 unwilling to publish them in a permanent 
 form, preferring to await the opportunity 
 of attempting a treatise dealing with the 
 subject in a more complete manner. I 
 have, however, received such pronounced 
 assurance that their publication, even in 
 the present incomplete form, would be 
 useful, that I reluctantly forego my scruples. 
 These lectures, then, remain in practically 
 the same shape in which they were delivered 
 at the Royal College of Surgeons. Their 
 publication at least gives me the oppor- 
 tunity of expressing my indebtedness to 
 my cousin, Dr. A. M. Gossage, for much 
 invaluable help and criticism. 
 
 J. A. COUTTS. 
 
 54, Upper Berkeley Street, W. 
 
LECTURE I. 
 
 Mr. President and Gentlemen, — 
 In the first place I have to acknowledge 
 my indebtedness to the Council of this 
 College for allowing me to occupy this 
 present position. I feel, however, that I 
 can best fulfil the trust imposed on me by 
 not elaborating this acknowledgment, but 
 by proceeding at once to the subject with 
 which I have to deal. 
 
 That syphilis can be transmitted from 
 parents to offspring few will have the hardi- 
 hood to deny at the present day. Long 
 after the recognition of the symptoms of 
 inherited syphilis in the infant, however, 
 there would seem to have been a minority 
 of observers who doubted this transmission. 
 Hunter, it is well known, was induced to 
 deny it ; but in this College we may fairly 
 claim for the great Scotch surgeon that 
 
 B 
 
2 Some Aspects of 
 
 with him "error was but opinion in the 
 making." During his lifetime and for 
 years after his death his teaching was 
 widely accepted and believed in. Further 
 experience and knowledge, and especially 
 the works of Colles, had shown that much 
 of Hunter's writing on venereal disease was 
 erroneous, and I fancied that, with the 
 refutation of his mistake, the non-belief in 
 the parental transmission of syphilis had 
 been universally abandoned. It was then 
 with surprise that I learnt from. Kassowitz 
 that in 1875, more than three centuries 
 after the general acceptation of the fact of 
 hereditary syphilis in the infant, there were 
 still " authorities " who doubted this trans- 
 mission. As late, indeed, as 1882 Her- 
 mann of Vienna published a work in which 
 he endeavoured to prove that the assump- 
 tion of such a complaint as hereditary 
 syphilis was entirely a fallacy. Consider- 
 ing the recent date of this work, and 
 having regard to the manifest differences 
 between the inherited and acquired com- 
 plaints, it needs but slight powers of 
 prophesy to foretell that other "authorities " 
 
Infantile Syphilis. 3 
 
 will in the future come forward to support 
 Hermann and their predecessors in Kasso- 
 witz's time in the denial as to the identity 
 of the disease in parent and infant. It is 
 easy to predict, moreover, that the grounds 
 of their unbelief as to the hereditary form 
 of syphilis will be based on the theory that 
 the latter is a germ disease, and that what 
 is really transmitted from parent to off- 
 spring is not the living germ itself, but 
 merely a toxine or some other product 
 resulting from it. But in the light of our 
 present knowledge doubts as to the trans- 
 mission to the infant are not within the 
 range of practical controversy, and if there 
 still lingers any smouldering scepticism as 
 to this transmission it is of little import, 
 and I feel I can fairly ignore it without 
 further comment. 
 
 I assume, then, as proven the fact that 
 syphilis can be transmitted from a parent 
 to the infant. I feel I may also take as 
 proven that syphilis in the infant can be 
 derived from the complaint in the father 
 alone or the mother alone, or may be a 
 joint heritage from parents who are both 
 
4 Somd Aspects of 
 
 affected. It is true that within compara- 
 tively recent times authorities have doubted 
 the power of the father to transmit except 
 through the previous contamination of the 
 mother, and others who have doubted the 
 pregnancy resulting from a tainted ovum 
 proceeding as far as the birth of a living 
 child. Proofs in abundance, however, are 
 forthcoming where, the father alone being 
 infected, the mother has borne a syphilitic 
 infant without presenting the least sign of 
 the complaint herself, and others where a 
 syphilitic mother has produced a tainted 
 infant and the father undoubtedly been 
 free. Any attempt, then, to refute the 
 views of those who have argued otherwise 
 would be superfluous on my part, and I 
 will proceed to attempt an investigation as 
 to whether there are any differences in the 
 frequency and severity with which the 
 infant is affected dependent on the parental 
 source from which the complaint is derived. 
 Apart from the consideration of disturb- 
 ing elements introduced by such factors as 
 the length of time elapsed from primary 
 infection and the amount of treatment, 
 
Infa7itile Syphilis, 5 
 
 there are other inherent difficulties in the 
 way of estimating the paternal influence as 
 regards the frequency of transmission of 
 syphilis and its severity in the infant. 
 One such difficulty Hes in the fact that 
 the mother may possibly have been affected 
 in the ordinary manner, although she may 
 exhibit no signs of the disease, and then 
 it becomes a matter of impossibility to 
 rightly assign to either parent his or her 
 due share in the production of the com- 
 plaint. Another difficulty arises from the 
 assumption that every mother bearing a 
 syphilitic infant has herself contracted the 
 complaint from the foetus i7i utero — a con- 
 tingency that will be considered later when 
 dealing with the question of " syphilis by 
 conception." On one point bearing on the 
 paternal influence, however, all observers 
 are agreed. This is that a very large pro- 
 portion of the mothers of syphilitic infants 
 exhibit no outward evidences of the com- 
 plaint themselves even after prolonged and 
 careful search. It is only in such cases 
 as these that any estimation as to the 
 paternal influence in syphilitic heredity 
 
6 Some Aspects of 
 
 can be attempted. When writers such as 
 Fournier, who believe in the doctrine of 
 " syphilis by conception," give statistics as 
 to the paternal influence, they simply refer, 
 I take it, to cases where there is certain 
 proof of the disease in the father and 
 where there is an entire absence of the 
 ordinary signs of it in the mother. 
 Fournier's statistics as to the paternal in- 
 fluence, subject to the reservation I have 
 stated, are as follows. From notes of 
 1 1 27 pregnancies in his private practice 
 where the father alone was manifestly 
 syphilitic, he places the mortality amongst 
 infected children at 28 per cent. In his 
 hospital practice, from notes collected by 
 Mademoiselle Krikus, he places the mor- 
 tality where the father alone was syphilitic 
 at as high a figure as 48 per cent., an 
 increase fully accounted for by the differ- 
 ence of surroundings of the parents in 
 private and hospital practices. Kassowitz, 
 who denies the doctrine of syphilis by 
 conception, gives the following figures : 
 out of 105 pregnancies where the father 
 was syphilitic, there were 26 abortions, 21 
 
Infantile Syphilis. 7 
 
 children who died early, and 58 who sur- 
 vived. This gives a percentage of mor- 
 tality of 26*5, a result closely in accord with 
 Fournier's record from private cases. I 
 have collected notes from my out-patient 
 practice at Shad well of 100 families where 
 the mother presented no signs of syphilis 
 and the disease in the infant was pre- 
 sumably derived from the father alone, 
 and a similar number where the mother 
 was unmistakably syphilitic. They are, 
 of course, subject to the disadvantages 
 attaching to notes gathered from patients 
 actually brought for inherited syphilis, and 
 that they refer to infants born at widely 
 differing periods from the times of primary 
 infection. Subject as they are to these 
 sources of vitiation, they are still not with- 
 out interest. In the first set, where the 
 mother was apparently free from syphilis, 
 there had been 563 pregnancies, resulting 
 in 187 abortions, 193 children who died 
 early, and 183 children still living. This 
 gives the high mortality of 56*6 per cent., 
 but poverty and other factors are probably 
 as much responsible for it as syphilis when 
 
8 Some Aspects of 
 
 dealing with East-end babies. But the 
 mortality amongst affected infants by no 
 means adequately gauges the evils of 
 syphilis on the offspring. Its responsi- 
 bility for death of the foetus in utero and 
 the harm wrought by it in infants who 
 survive must also be taken into account in 
 this respect. Fournier, reckoning up the 
 number of abortions and the number of 
 infants attacked by inherited syphilis, and 
 comparing their sum with the total number 
 of pregnancies, has deduced what he terms 
 "indices of harmfulness " {nocivite) for 
 parental syphilis. This "index of harm- 
 fulness " when the father alone is syphilitic 
 he places at 37 per cent. But a true 
 "index of harmfulness" is only to be 
 arrived at by following out the whole of 
 the child-begetting histories of numerous 
 syphilitics ; an opportunity, however, for 
 doing this is never likely to fall to any 
 one observer. Were it possible to gain 
 such statistics I cannot but think that 
 Fournier's " indices of harmfulness " would 
 be materially lowered. 
 
 The marked effect of time in decreasing 
 
Infantile Syphilis. 9 
 
 and annulling the power of the father to 
 transmit cannot be gainsaid. But it is 
 difficult, or rather impossible, to give any 
 definite limit of time beyond which this 
 power of transmission is entirely lost. Mr. 
 Hutchinson is probably right in the main 
 in limiting the time during which the 
 father can infect the mother at five years 
 from the date of his own infection, and 
 also in his statement that such an eventu- 
 ality is rare even after the lapse of only 
 three years. That the power of infecting 
 the offspring, however, may long outlast 
 that of directly infecting the mother cannot 
 be doubted. Kassowitz from his own 
 experience would give the limit of time 
 during which transmission to the offspring 
 is possible at from ten to fourteen years 
 after primary infection, and he also pro- 
 pounds the important aphorism that if 
 there is even a remote chance of the 
 mother being contaminated in such a case 
 inheritance by her offspring is a certainty. 
 That the power of transmission can be 
 retained by the father for a longer period 
 than that assigned by Kassowitz is 
 
lo Some Aspects of 
 
 sufficiently proven. Henoch quotes a case 
 from his own experience where syphilis in 
 the infant was due to disease contracted 
 by the parent more than twenty years 
 before. Dr. George Ogilvie has published 
 a case in which amongst other interesting 
 facts was the one that nineteen preg- 
 nancies, spread over nineteen years from 
 the date of infection of the father, all re- 
 sulted in syphilitic infants or abortions, 
 and this in spite of prolonged and vigorous 
 treatment. Dr. Colcott Fox mentioned 
 at a meeting of the Royal Medical and 
 Chirurgical Society that he had known a 
 case where the transmission from parent 
 to infant took place more than twenty 
 years after primary infection. Dr. Eustace 
 Smith, too, tells me of the following case. 
 A medical man married fifteen years after 
 contracting syphilis ; his wife during the 
 first five years of her married life had 
 several abortions. Dr. Smith saw the first 
 living child, born more than twenty years 
 after the contraction of the disease by 
 the father, and it was deeply syphilitic, 
 although the mother was apparently a 
 
Infantile Syphilis. 
 
 1 1 
 
 strictly healthy woman. I have person- 
 ally known a case where the fourteenth 
 pregnancy, sixteen years after the incur- 
 rence of syphilis, resulted in a tainted 
 infant. Happily, such cases of long reten- 
 tion of the power of transmission are rare. 
 In very exceptional instances, however, it 
 might well be, judging from the cases 
 given, that the power of transmission is 
 only limited by the child-bearing or child- 
 begetting capacities on the part of the 
 parents. 
 
 That time alone, independently of any 
 treatment, may abolish the capability 
 of the father to transmit is undeniable. 
 Before finally annulling the power of 
 transmission lapse of time engenders the 
 quality of rendering transmission less 
 certain. When this stage is reached at 
 which transmission is uncertain, though 
 possible, it becomes a mere matter for 
 surmise what determines the infection of 
 the infant in one case and freedom from 
 it in another. That such infection is 
 dependent upon any fresh outbreak of 
 symptoms in the father is not proven. All 
 
12 Some Aspects of 
 
 the same, I should consider the father 
 more likely to transmit the disease at a 
 time when he had outward manifestations 
 of the complaint than he would at a time 
 when all symptoms are latent. At what- 
 ever period of the disease the father 
 transmits, if he transmit at all, he pro- 
 bably does so with the same intensity as 
 he would do at the beginning of his 
 syphilis when transmission was almost 
 certain. The case of an infant in this 
 respect is identical with that of a woman. 
 When a man late in his syphilis, having 
 reached the stage at which transmission is 
 uncertain, contaminates a woman, there is 
 no proof that such a woman acquires a 
 milder form of the disease than she would 
 have acquired at a time when his syphilis 
 was recent and transference certain. In 
 other words, there is no proof that lapse 
 of time brings with it attenuation of the 
 virus. And so with regard to the infant. 
 When a syphilitic man and a healthy 
 woman bear a succession of infants, I grant 
 the gradual lessening of the severity, 
 and tendency to eradication, of the 
 
Infantile Syphilis. 13 
 
 complaint in each succeeding infant. This 
 diminution of the symptoms in successive 
 infants by the same couple, where the 
 father alone is syphilitic, is not, however, 
 necessarily dependent on the assumption 
 of any progressive increase of attenuation 
 of the virus in the man. In fact, I believe 
 that such lessening severity in the suc- 
 cessive infants is independent of the father, 
 and due entirely to the presence of some 
 product in the mother, this product being 
 by her absorbed from the foetus in utero^ 
 and in amount proportional to the number 
 of syphilitic conceptions she has carried. 
 When a syphilitic man, by the same 
 woman, has begotten a succession of 
 infants in the latest of whom the syphilis 
 has decreased to the vanishing point, we 
 have no proof that, if he still retain the 
 power of transmission, he would not in 
 other women beget infants with syphilis as 
 virulent as that in the initial conception 
 by the first woman. Indeed, such slight 
 evidence as we possess would tend to 
 prove that he would. Plenty of cases are 
 on record where men, many years after 
 
14 So7ne Aspects of 
 
 infection, have begotten infants with 
 syphilis as virulent as in any born within 
 a short period after the primary disease. 
 Diday's law of decreases I hold to be true 
 in the main, but only as regards infants 
 from the same couple. 
 
 The effects of treatment in limiting the 
 power of transmission are still more 
 marked than those of time alone. But 
 again we have no proofs, where the man 
 alone is affected, that treatment any more 
 than time can furnish an attenuated virus ; 
 and, however fully a man may have been 
 treated, if he transmit at all, he probably 
 transmits in full to woman or infant. 
 Obviously such a rule does not apply in 
 the case of the woman, for the mercury 
 taken by her may help to mitigate the 
 disease of the foetus in lUero. What would 
 seem remarkable about mercury is not its 
 power of attenuating the virus transmitted, 
 but its power of temporarily preventing 
 transmission altogether, and especially if 
 it be administered about the times of pro- 
 creation. A case recorded by Fournier is 
 a striking example of this ; " A young 
 
Infantile Syphilis. 15 
 
 man, against the advice of the last-named, 
 married in the first year of his syphilis, 
 but continued his treatment. His wife 
 conceived and bore him a healthy infant. 
 Thinking, by this latter fact, that he was 
 absolutely cured, he left off his mercury ; 
 he then infected his wife, whose second 
 pregnancy resulted in a deeply-infected 
 infant." Diday, too, quotes cases where 
 by the administration or withholding of 
 mercury healthy or infected infants were 
 alternately produced. There, is however, 
 a mathematical precision about some of 
 these cases that makes them difficult of 
 acceptation. All the writers, however, in 
 dealing with this power of mercury describe 
 the infants born under the conditions in 
 question as "healthy," and not as merely 
 suffering from a mitigated form of the 
 disease. 
 
 Time and treatment are concerned in 
 another question of great practical import- 
 ance — viz., the date at which marriage 
 should be sanctioned in a man after 
 the incurrence of syphilis. A definite 
 answer, applicable to all cases, is, I think 
 
1 6 Some Aspects of 
 
 impossible and unadvisable. The age at 
 which the disease was contracted, the vary- 
 ing degrees of severity of the symptoms, the 
 amount of treatment and the lapse of time 
 over which it has been spread, are all 
 factors which must largely qualify the 
 answer in every instance. As it may be 
 of interest, I will give the dates after 
 primary infection at which some modern 
 authorities consider a man is justified in 
 marrying, with a fair prospect of not trans- 
 mitting the complaint to wife or offspring. 
 Schuster of Aix-la-Chapelle, who has 
 written a h'ochure on the subject, places 
 the date at two years after primary in- 
 fection. Mr. Hutchinson finds the same 
 period, and says he has only once had to 
 regret his sanction to marriage after this 
 interval. This is, perhaps, more a tribute 
 to the results of his treatment than a 
 warrant of justification for others to follow 
 his example in sanctioning marriage at so 
 early a date. Mr. Hutchinson, however, 
 is emphatic on the point. " Probably," he 
 writes, "in the vast majority of cases the 
 risk of transmission to children is over 
 
Infantile Syphilis. 17 
 
 long before the end of two years." With 
 this favourable view of the matter I cannot 
 but think that he will find many autho- 
 rities to disagree. Mr. Cooper would allow 
 marriage three years and Fournier and 
 Otis four years after first infection. Kopp 
 and Lesser would extend the time to as 
 long as five years. Personally I am in 
 most cases in favour of the longer interval. 
 The responsibility of sanctioning a marriage 
 with any risk of imparting syphilis to 
 others is not to be lightly undertaken. 
 Diday's sarcasm, ''that the extreme cau- 
 tion displayed by some authorities on the 
 matter would soon depopulate the earth," 
 I think can be ignored. If treatment has 
 been thorough, and delay of marriage in 
 any way detrimental, I would shorten the 
 interval to one of two years after the dis- 
 appearance of all active symptoms, or to 
 one of three years after primary infection. 
 In no case would I sanction marriage until 
 at least three months after the disappear- 
 ance of active symptoms, no matter how long 
 a time had elapsed between their appear- 
 ance and the incurrence of the complaint. 
 
 C 
 
1 8 Some Aspects of 
 
 That syphilis in the mother can be 
 transmitted to her infant when the father 
 is healthy is now placed beyond all manner 
 of cavil of doubt. It was the mother alone 
 that Hunter accredited with the trans- 
 mission of the complaint in the days 
 whilst he yet believed in the reality of 
 hereditary syphilis. As the father is the 
 introducer of syphilis into the household 
 in the vast majority of instances, it is 
 somewhat difficult to meet cases of here- 
 ditary syphilis where there is a positive 
 guarantee of the mother's sole responsi- 
 bility for the transmission, and on this 
 point I have to rely on the statistics of 
 others. Fournier has recorded the cases 
 of 13 syphilitic women whose husbands 
 were free, and 28 pregnancies in these 
 women resulted as follows : 7 children 
 living, 4 syphilitic; 15 infants died at 
 birth or soon after ; and 6 abortions. 
 Fournier gives the percentage mortality 
 amongst infants born alive of syphilitic 
 mothers as 60, but it reaches as high as 68" i 
 if calculated from the figures last given. 
 Kassowitz records the results from his 
 
Infantile Syphilis. 19 
 
 own practice of 40 pregnancies where the 
 mother alone was syphilitic, and they gave 
 18 abortions, 5 children died early, and 17 
 living children. This gives a percentage 
 mortality of only 227 as compared with 
 Fournier's 60, but the percentage of abor- 
 tions is incomparably higher in Kassowitz's 
 figures than in Fournier's. Elsewhere, too, 
 Kassowitz gives the mortality amongst 
 syphilitic infants, inheriting from the 
 mother alone, as 80 per cent. Fournier's 
 index of harmfulness for maternal syphilis 
 is 84 per cent. ; but as he probably formed 
 it on statistics drawn from mothers bear- 
 ing infected infants, it is in all likelihood 
 much too high if intended as applying 
 to the whole community of infected 
 mothers. Two other questions concerned 
 with syphilis in the mother — the effect on 
 her offspring, of her contamination during 
 pregnancy and " syphilis by conception " 
 — I purpose dealing with later. 
 
 In attempting to estimate the influence 
 of syphihs in both father and mother upon 
 the offspring, the disturbing elements of 
 time and treatment have redoubled force, 
 
20 Some Aspects of 
 
 as here they have to be reckoned with in 
 each parent instead of one only. Fournier, 
 from statistics gathered under conditions 
 as identical as the case permits of, places 
 the mortality of infants where both parents 
 are syphilitic at 6% per cent, as against 28 
 where the father alone and 60 where the 
 mother alone is syphilitic. Kassowitz, out 
 of ']6 pregnancies where both parents were 
 affected, found 28 abortions, 24 infants that 
 died early, and 24 infants that survived, 
 this giving a mortality of 50 per cent. 
 The same author, however, in another 
 series found the mortality as high as 69 
 per cent. From my notes of 100 families 
 where the mother was syphilitic, and in 
 the vast majority the father syphilitic also, 
 I gather the following statistics. In these 
 100 families 539 pregnancies resulted in 
 189 abortions, 203 infants who died early, 
 and 147 living children. This gives a 
 mortality of exactly 58 per cent, a result 
 not differing greatly from that obtaining 
 in my cases where the father alone was 
 affected. Fournier's index of harmfulness 
 rises to 92 for the mixed type of inheritance. 
 
Infantile Syphilis. 21 
 
 Statistics such as I have given as to the 
 parental influences in transmission are 
 subject to many faults and discrepancies. 
 For a due and reliable estimation of these 
 influences, and their effect upon the progeny, 
 we want more detailed statistics than have 
 as yet been furnished us. Thus, it would 
 be of value if we had the result of preg- 
 nancies tabulated according to the number 
 of years elapsing from the dates of primary 
 infection. As an example of this, Kasso- 
 witz gives the figures for 90 pregnancies 
 of women contaminated by their husbands 
 and conceiving in the first year of their 
 syphilis, and these resulted in 50 abortions, 
 38 infants who died early, and only 2 
 infants who survived. Further statistics 
 of a like character and others giving details 
 as to successive pregnancies, independently 
 of the times elapsed from infection, might 
 be of great practical utility and interest. 
 Rough and imperfect as the statistics are 
 that I have given, I think that they indu- 
 bitably show that maternal syphilis is more 
 deleterious as regards the offspring than a 
 paternal one, and that the mixed type is 
 
2 2 Some Aspects of 
 
 the most serious of the three. The extra 
 seventy of the one type over the other, 
 however, is, I believe, entirely exercised 
 upon the foetus in utero and has no 
 influence after birth. The greater severity 
 upon the foetus of a maternal syphilis over 
 a paternal one is due, probably, to the 
 reason unusually assigned for it, the dele- 
 terious influence of the vitiated maternal 
 fluids upon the foetus in utero ; and the 
 slight increase in the mixed parental type 
 over the maternal one is possibly owing to 
 a greater certainty and frequency of trans- 
 mission. Mr. Hutchinson writes : "There 
 is no reason for believing that the infection 
 from the mother (germ transmission) pro- 
 duces more serious results than sperm 
 transmission, or that the child who inherits 
 from both parents suffers more severely 
 than he would if one were free." Excep- 
 tions to this rule, he admits, occur in cases 
 *' in which children are born with syphilitic 
 lesions actually present or with traces of 
 intra-uterine disease." If I interpret these 
 sentences correctly, Mr. Hutchinson would 
 seem to agree with me as to the extra 
 
Infantile Syphilis. 23 
 
 severity of one form of inheritance over 
 another being entirely exercised during 
 intra-uterine existence. As a practical 
 point, in any infant brought at the usual 
 age for treatment, I know of no facts that 
 would justify any qualification of prognosis 
 depending on the parental source from 
 which its syphilis might be derived. 
 
 I turn now to a subject of practical 
 importance and interest, the effect upon 
 the foetus of a syphilis contracted by a 
 mother during her pregnancy. For many 
 years one set of authorities strongly asserted 
 that in this contingency the foetus was 
 usually infected, and another set as strenu- 
 ously denied it. Even at the present day, 
 in fact, it cannot be claimed that the dis- 
 pute is settled to the satisfaction of all, 
 although the possibility of infection of the 
 foetus is commonly accepted. Diday, who 
 is much quoted on the point, lays down 
 the curious rule, and defends it on the 
 anatomical relations of the placenta, that 
 if a mother is infected during the first forty 
 days, or after the seventh month of her 
 pregnancy, the child will escape, but the 
 
24 Some Aspects of 
 
 latter will be syphilitic if the mother be 
 infected in the interval between these 
 times. Kassowitz justly asks, however, if 
 a mother infected during the first forty 
 days of her pregnancy is not syphilitic 
 also in the interval during which Diday 
 claims transmission is probable ? Ricord 
 writes : " If the infection of the mother 
 takes place during the last three months, 
 it is not certain that transmission is 
 possible." Mr. Hutchinson, again, doubts 
 whether a woman would be likely to go to 
 the end of her pregnancy who had suffered 
 from constitutional syphilis in the early 
 part of it. Most of the facts in his own 
 personal knowledge occurred in cases in 
 which the disease was incurred by the 
 mother late in pregnancy. There is, then, 
 great discrepancy among authorities as to 
 the time during pregnancy when infection 
 of the mother can occur with the produc- 
 tion of a syphilitic infant. Fournier, who 
 believes in the infection of the infant 
 through a syphilis incurred by the mother 
 during pregnancy, follows Cazenave and 
 Diday in adopting the name of "congenital 
 
Infantile Syphilis. 25 
 
 syphilis " for the type of complaint in the 
 infant under these conditions, restricting 
 that of " inherited syphilis " for the class 
 of cases originating at times of conception. 
 He, moreover, claims that the symptoms 
 of this " congenital syphilis " are easily 
 distinguishable from those of inherited 
 syphilis. Mr. Hutchinson will not admit 
 of any possible differentiation of symptoms 
 in the two classes, and throws the onus 
 of proving any difference between them 
 on those who assert it. There is, then, 
 as great a contention amongst leading 
 authorities as to the symptoms in the 
 infant as there is regarding the times 
 of pregnancy at which a mother can be 
 infected with transmission to the infant. 
 Kassowitz and other German authorities 
 deny the transmission to the infant at 
 whatever period of pregnancy ]a mother 
 may be infected. There is no proof, 
 Kassowitz argues, that in any one of the 
 cases where a mother was infected during 
 pregnancy and produced a syphiHtic infant 
 that such syphilis was not derived from 
 the father at the time of conception. But 
 
26 Some Aspects of 
 
 if he admitted the possibility of the carry- 
 ing of a syphilitic foetus for several months 
 in her uterus, and the subsequent con- 
 tamination of the mother, Kassowitz in 
 this way allowed the possibility of what is 
 in reality an equivalent of a breach of the 
 first part of Colles' law, a deduction from 
 his belief that would seem to have escaped 
 this astute observer. Personally, I have 
 no experience in the matter ; but in all 
 the cases of this nature, under the care of 
 my friends, the infants escaped. I have, 
 moreover, met with twins born of a syphi- 
 litic mother, where the one infant was 
 deeply affected and the other apparently 
 free, and I know of similar cases under 
 my colleagues. This circumstance would 
 seem to show that there is no imperative 
 necessity for the inoculation of the foetus 
 by a syphilitic mother's blood, and also 
 that infection of the foetus is probably 
 most often effected through the ovum. 
 Henoch has never known a case of a 
 mother contaminated during her preg- 
 nancy, but he deems transmission to the 
 infant likely under such conditions. Birch 
 
Infantile Syphilis, 27 
 
 Hirschfeld knew three instances where a 
 mother was infected during pregnancy. 
 The infants born from these pregnancies 
 died soon after birth from some complaint 
 other than syphilis, and the necropsies 
 revealed no trace of the last disease, not 
 even the characteristic changes so gene- 
 rally found in the epiphyseal cartilages. 
 Birch Hirschfeld, nevertheless, believes that 
 transmission is possible to the infant under 
 the conditions in question, but that such 
 transmission is not possible so long as 
 the integrity of the endothelial barrier 
 between the maternal and foetal circula- 
 tions is maintained. He claims to have 
 proved that any affection of this endo- 
 thelial barrier, permitting of the passage 
 of micro-organisms from the mother to 
 the foetus, is secondary to serious vascular 
 disease in the maternal portion of the 
 placenta. If his views are correct, then 
 contamination of the foetus under the con- 
 ditions in question must be allowed as 
 possible, but abortion or the entire escape 
 of the foetus would seem much the most 
 probable result. When writers like Mr, 
 
28 So7ne Aspects of 
 
 Hutchinson and Fournier cite cases where 
 the infant has inherited the disease in- 
 curred by its mother during her pregnancy, 
 I take for granted that they have satisfied 
 themselves as to the freedom of the father 
 at the times of conception, and I accept 
 the possibility of the transmission to the 
 infant. Nevertheless, I believe that what 
 is possible has unwittingly been exalted 
 into what is probable. To thoroughly 
 settle several of the points concerned in 
 the question, we want the publication of 
 further cases giving details as to the free- 
 dom of the father at the time of concep- 
 tion, the date of infection of the mother 
 in her pregnancy, and a full description 
 of the symptoms in the child. 
 
 The converse of the preceding question, 
 the effect upon the mother of the blood 
 returned to her through the placenta from 
 a syphilitic foetus, may appropriately be 
 taken here. This, amongst others, involves 
 the much-debated subject of '' syphilis by 
 conception." First prominently promul- 
 gated by Ricord and Diday, the doctrine 
 of "syphilis by conception" has been 
 
Infa7itile Syphilis, 29 
 
 alternately advanced and denied by every 
 eminent writer on syphilis since their time. 
 Some of the uncertainty and contention 
 on the subject has undoubtedly arisen 
 from a want of due appreciation of what 
 is really implied by '' syphilis by concep- 
 tion." It is not very uncommon to find 
 the term used in connection with the 
 disease in the infant — a strange confusion 
 of ideas. Under these circumstances I 
 trust it will not be deemed superfluous if 
 I define what is implied by the term. 
 " Syphilis by conception " is the syphilis 
 supposed to be acquired by a healthy 
 mother by means of the tainted blood, 
 returned to her through the placenta, from 
 a syphilitic foetus infected by the sperm of 
 the father — a "syphilis by return shock," 
 as Diday calls it. The term, of course, 
 implies an escape of direct infection of the 
 mother by the father, and that her syphilis 
 is solely and entirely due to the fact of 
 her conceiving. It is claimed by many 
 eminent authorities that if a woman co- 
 habit with a man incapable of directly 
 contaminating her, but who is still capable 
 
30 Some Aspects of 
 
 of transmitting to the foetus, such cohabi- 
 tation may be harmless to the woman 
 unless she conceives, but that this last con- 
 dition of necessity leads to her impregna- 
 tion with syphilis. More than this, the 
 syphilis, such writers allege, which had 
 lost much of its virulence in the man, is, 
 merely from the fact of conception on the 
 part of the woman, regenerated in her with 
 all its initial virulence — ^^ vires acqiiirit 
 eundoy'* as Diday quotes. Such are some 
 of the principles underlying the theory of 
 " syphilis by conception." It is a syphilis, 
 its upholders claim, agreeing with one ac- 
 quired in the ordinary way in all secondary 
 manifestations and sequelae, but never- 
 theless possessing certain characteristics 
 peculiar to itself. Fournier, the most able 
 advocate of the doctrine at the present 
 day, has styled it a *' syphilis decapitee," 
 inasmuch as with it there is an entire 
 absence of primary chancre and enlarge- 
 ment of the corresponding glands, and the 
 periods of primary and secondary incuba- 
 tions are abolished. For the establish- 
 ment of " syphilis by conception " in any 
 
Infantile Syphilis, 31 
 
 particular Instance, its upholders allow that 
 proofs of the following essentials must be 
 forthcoming: (i) That the father was free 
 from any innoculable lesion at a time 
 when the date of the mother's syphilis was 
 consistent with the direct acquirement from 
 him ; and (2) that the mother has always 
 been free from any primary chancre and 
 any enlargement of glands resulting from 
 the presence of one. The first requisite 
 for the establishment of " syphilis by con- 
 ception/' the absence of innoculable lesion 
 in the father, is absolutely incapable of 
 proof in any instance. It is impossible for 
 any one of us to guarantee the freedom of 
 any patient in this respect at all times and 
 seasons. In many of the published cases, 
 too, of syphilis by conception, it is recorded 
 that sores on the scalp, palmar psoriasis, 
 and such like trifles were missed ; and, this 
 being so, how much more readily might a 
 slight abrasion of the penis be passed 
 over by a layman ? Such a lesion might, 
 moreover, be easily missed by a medical 
 man even with ample opportunities of 
 examining his patient. The history, then. 
 
32 So7ne Aspects of 
 
 of the freedom of the father from innocu- 
 lable lesion is in no case a partial proof 
 of the possibility of syphilis by conception. 
 The second requisite — the establishment 
 of the absence of a primary chancre and 
 enlargement of the corresponding glands 
 in the mother — stands on an equally un- 
 satisfactory basis as the preceding one. 
 In a large number of syphilitic women 
 who have never been pregnant the site of 
 the primary lesion is impossible to locate. 
 There are admitted difficulties in this 
 respect applying to women that do not 
 obtain in men. But even in men a careful 
 observer like Mr. Hutchinson has to admit 
 that " in not a few cases he has been 
 unable to ascertain the original site of 
 innoculation." The absence of proof, too, 
 of any glandular enlargement is not con- 
 clusive of its non-existence or of that of 
 a primary sore. Where the latter is high 
 in the vagina or on the cervix uteri the 
 demonstration of enlargement of the corre- 
 sponding glands may be physically im- 
 possible. How, then, can it ever be proven 
 that the syphilis of a pregnant woman is 
 
Infantile Syphilis, 
 
 00 
 
 acquired through the agency of conception 
 when there are such insuperable difficulties 
 in establishing her non-acquisition by the 
 ordinary channels ? 
 
 If we turn to the descriptions furnished 
 by the upholders of the doctrine, we find 
 a marked discrepancy amongst them as 
 regards the times of onset of the complaint 
 after conception. Fournier would seem- 
 ingly place the time at as early a date as 
 three weeks after this latter. He gives 
 the case of a young woman who developed 
 syphilis soon after marriage, and in whom 
 he could find no primary chancre or trace 
 of moculable lesion in her husband At 
 the woman's monthly period, however 
 shortly preceding her syphilis, the men- 
 strual flow was attended with more pain 
 and some firmer clotting than usual 
 J^ournier gravely argues from this that as 
 there was no proof of primary contagion 
 this undue clotting and pain were owin- 
 to the expulsion of a three weeks' fcetus" 
 and that the short sojourn of this last in 
 utero was sufficient to account for a 
 syphilis in the mother. Most of us ^o^x\6 
 
 XJ 
 
34 Some Aspects of 
 
 I fancy, however, find a less subtle expla- 
 nation of such a syphilis. If Fournier is 
 correct in his interpretation, and syphilis 
 by conception can manifest itself after so 
 short a period as three weeks after impreg- 
 nation, then in other cases the pregnancy 
 should never be far advanced before the 
 appearance of symptoms. Diday, however, 
 who is chiefly responsible for the doctrine 
 of " syphilis by conception," suggests par- 
 turition, or shortly after, as the time at 
 which symptoms of such a syphilis are 
 most likely to appear. There is, then, 
 seemingly a most marked disagreement 
 amongst the upholders of the doctrine 
 on one of its most vital points. Diday is, 
 however, quite clear in his teaching as to 
 the frequency of such a syphilis. " If a 
 woman bear a syphilitic infant," he writes, 
 '' I say she has had the complaint herself." 
 Fournier is equally emphatic. According 
 to him, pregnancy with a tainted foetus, 
 however short a time it may last, implies 
 the certain acquisition by a woman of 
 " syphilis by conception." If there are 
 none of the outward signs of syphilis in 
 
Infantile Syphilis. 35 
 
 such a woman, then, according to Fournier, 
 she has it in a latent form. As a proof 
 of the reaHty of this last condition, cases 
 have been instanced where women have 
 borne infected infants by syphilitic hus- 
 bands, and although presenting no early 
 symptoms of the disease themselves, have 
 in later years appeared with tertiary ones. 
 That such cases do occur will be readily 
 granted, but they are not restricted in 
 occurrence to fertile women. Cases of 
 sterile women, and of men also, in whom 
 the presence of tertiary symptoms is 
 accompanied by an absolutely negative 
 history as regarded primary and secondary 
 manifestations, are far from rare. Charrier's 
 case of this nature, quoted by Fournier, 
 Messrs. Cooper and Cotterell, and others, 
 is to me an ordinary one of a woman in 
 whom, owing to the mildness of the 
 secondary symptoms, the complaint had 
 been missed until the supervention of 
 gummata. Such cases, were they infinitely 
 more common than they are, go but a 
 slight way to prove the reality of " syphilis 
 by conception," latent or manifest. 
 
36 Some Aspects of 
 
 The preceding are not all the arguments 
 that can be adduced against the theory of 
 "syphilis by conception." Diday, as I 
 have already stated, is generally credited 
 with being the founder of the doctrine. 
 Most of those, however, who have accepted 
 his teaching on the point would seem to 
 pass unnoticed the deductions he drew 
 from it. This is what he terms the " law 
 of increases," and it would seem to me a 
 fairly logical outcome from the establish- 
 ment of this "syphilis by conception." By 
 this law, Diday asserts, every conception 
 on the part of a woman by a syphilitic 
 partner adds to her syphilis, and these 
 additions tell in their turn upon the foetus, 
 and thus each succeeding pregnancy results 
 in a product more syphilitic than the pre- 
 ceding one. The " law of decreases," the 
 lessening severity upon the foetus in each 
 successive pregnancy, only applies, he 
 asserts, to cases where the mother or both 
 parents are affected. When the father 
 alone is affected, which applies to by far 
 the greatest number of cases of inherited 
 syphiHs, this " law of increases " condemns 
 
Infantile Syphilis. 37 
 
 each successive infant in a family as more 
 syphilitic than the last — a dreadful state 
 of things to contemplate if true. But 
 fortunately, I think, all experience proves 
 its falsity and that of the theory that gave 
 it birth. It is repulsive enough that a 
 woman should be compelled to bear syphi- 
 litic infants against her will. This repul- 
 siveness would be vastly increased if 
 " syphilis by conception " were proven, and 
 that such a woman could be tainted from 
 her unborn infant. The one slight tittle 
 of evidence in favour of the possibility of 
 " syphilis by conception " is that afforded 
 by Ricord and Diday, and Henoch quotes 
 Fournier and Mr. Hutchinson to the same 
 effect, that they have known women to 
 have lived long with syphilitic partners 
 and escaped contamination as long as they 
 remained sterile, but conception brought 
 syphilis in its train. But cases such as 
 these, where proof of infection by the 
 ordinary methods is wanting, are not 
 sufficient in number to free them from 
 the class dependent on mere coincidence. 
 I have stated my disbelief in the theory 
 
38 Some Aspects of 
 
 of " syphilis by conception '* and have 
 given the reasons for that disbelief. The 
 theory no doubt arose from the immunity 
 to syphilis displayed by mothers bearing 
 affected infants. That such mothers do 
 enjoy immunity, partial or complete, would 
 seem almost universally accepted at the 
 present day. But immunity to syphilis 
 by no means entails the necessity of having 
 passed through an attack of the disease 
 itself. In accordance with all modern 
 teaching there is every justification for 
 the supposition that syphilis is a disease 
 dependent upon a specific micro-organism. 
 It is true that hitherto attempts at identi- 
 fication and cultivation of the responsible 
 organism have not met with a success 
 universally acknowledged. Notwithstand- 
 ing the failures, or perhaps partial successes, 
 of Lustgarten, Klebs, and others, the 
 prevalent opinion that syphilis is a germ 
 disease has not been shaken. If, then, 
 syphilis be a germ disease, the termination 
 of an attack in the individual is brought 
 about by the evolution by the germs 
 themselves of some chemical principle 
 
Infantile Syphilis. 39 
 
 antagonistic to their own growth and exist- 
 ence. By analogy with other complaints this 
 chemical product is possibly an antitoxin, 
 the syphilitic equivalent of that occurring 
 in diphtheria. Now, if the syphilis in an 
 infant, inherited from the father, is ever a 
 contagious disease, this last of necessity 
 implies the transference of active micro- 
 organisms from the father to the foetus. 
 Once implanted in the foetus, the evolution 
 of these micro-organisms could be as active 
 in utero as in extra-uterine life, and with 
 their growth would ensue a corresponding 
 production of the " syphilitic antitoxin." 
 Now, the possibility of the passage of such 
 a substance as this " antitoxin " into the 
 maternal circulation no one would contest, 
 although many would do that of the germs 
 themselves, with the consequent syphiliza- 
 tion of the mother. Chauveau has recorded 
 some observations with a close bearing on 
 this point. He claims to have proved that 
 when gravid sheep are inoculated with 
 " symptomatic anthrax " the lambs they 
 drop are immune to that complaint. This 
 immunity, too, Chauveau states, is not due 
 
40 Some Aspects of 
 
 to the direct passage of the anthrax germs 
 themselves to the lambs, but to that of 
 some product generated in the mother and 
 absorbed by her progeny by means of the 
 placental vessels. In an exactly analogous 
 manner to this last, although the direction 
 of the stream is reversed, I would suggest 
 that a mother may absorb the antitoxin 
 from her syphilitic foetus and so gain 
 immunity for herself, partial or complete. 
 In this way such a mother, without having 
 incurred the actual complaint herself, may 
 ave gained the position of one who has 
 passed through and recovered from an 
 attack of syphilis. In this last deduction 
 from the germ theory of syphilis I am 
 seemingly supported by many. For a 
 further deduction — a wild speculation it 
 may be called — I fear I must charge 
 myself with the sole responsibility. It has 
 occurred to me that if the immunity in the 
 mother has been gained by the absorption 
 of some " antitoxin " from the foetus, this 
 substance may in its turn beneficially react 
 upon the foetus in utero. In the case of a 
 first conception the absorption of the 
 
Infantile Syphilis, 41 
 
 " antitoxin " by the mother, and its conse- 
 quent diffusion through the two circula- 
 tions, may be detrimental to the foetus 
 and to some extent explanatory of the 
 more untoward results of first syphilitic 
 pregnancies. But in succeeding pregnancies 
 the mother's " antitoxin " would act upon 
 the foetus from the start and with much 
 more marked effect. With each pregnancy 
 the amount of antitoxin in the mother 
 would be increased, and it may be that its 
 accumulation would be sufficient to cure 
 the disease in later conceptions, although 
 all the time the father transmit in full. 
 Such a theory would seem to me fairly 
 explanatory of the extra severity of the 
 complaint in the first infant in a family, 
 the lessening severity in each successive 
 infant, and the final disappearance of the 
 complaint in the latest ones. It would 
 also account for the greater severity in 
 utero of a mixed parental or maternal 
 syphilis over a paternal one. By the 
 theory, too, the later infants in a syphilitic 
 family, although presenting no signs of 
 the complaint, should be immune to it. 
 
42 Some Aspects of 
 
 and possibly also the earlier infants by a 
 second husband, who is free, of a woman 
 who has borne infected infants by a former 
 partner. In conclusion, I would suggest 
 that if the serum treatment of syphilis is 
 deemed worthy of further trial, such serum 
 should be taken from mothers who have 
 borne affected infants and themselves 
 remained free, rather than from persons 
 broken down with tertiary symptoms. 
 
hifantile Syphilis. 43 
 
 LECTURE II. 
 
 Mr. President and Gentlemen, — 
 In my last lecture I dealt with the parental 
 sources of inherited syphilis. I now pro- 
 ceed to treat of the symptoms of the 
 complaint in the infant. These symptoms 
 are so numerous and varied and affect so 
 many parts of the body, either separately 
 or simultaneously, that any elaborate 
 treatment of any single one of them is 
 incompatible with the time at my disposal. 
 In fact, I feel that instead of attem.pting to 
 deal with such a controversial subject as 
 infantile syphilis in its entirety, it will be 
 well to restrict myself to a more thorough 
 consideration of a selected number of the 
 chief manifestations of the complaint. 
 Even as it is I must pass over many parts 
 of the subject, not on account of their 
 lacking either consequence or clinical 
 interest, but because time will not allow 
 
44 Some Aspects of 
 
 me to deal with them in a manner at all 
 commensurate with their importance. 
 Some others of the less debatable points I 
 also ignore, lest I incur the charge of 
 " demonstrating the obvious and expatiat- 
 ing on the commonplace." 
 
 That the symptoms of inherited syphilis 
 may be apparent in the dead-born foetus 
 or in the living child at birth must now, I 
 think, be conceded by all. The word of 
 obstetricians, who are the only persons 
 with any great opportunities of experience 
 on these points, is unanimous in this 
 respect. It is true that such symptoms 
 as maceration of the foetus and the like — 
 a necessary consequence of its retention 
 in utero after death — were formerly too 
 often and falsely ascribed to syphilis. The 
 proof that such symptoms were not neces- 
 sarily dependent upon syphilis, however, 
 in nowise detracts from the testimony of 
 the better informed, who have found un- 
 controvertible evidences of syphilis in the 
 viscera, bones, and other organs of still- 
 born infants. It is unnecessary, how- 
 ever, to dwell upon such cases ; equally 
 
Infantile Syphilis. 45 
 
 unnecessary, too, Is it, I consider, to linger 
 on the cases of infants presenting signs 
 of unmistakable syphilis at birth. Such 
 infants, in the vast majority of instances, 
 are only foredoomed to die after the 
 briefest span of life, even under the most 
 skilful treatment and care. If recovery 
 has taken place in infants presenting 
 unequivocal signs of syphilis at birth, such 
 recoveries are so exceedingly exceptional 
 that any lengthy discussion on them would 
 be unprofitable at the present place and 
 time. 
 
 I have just said that infants born with 
 unmistakable signs of syphilis speedily die. 
 So short is their existence that few, if any, 
 find their way to children's hospitals and 
 kindred institutions. There is, however, 
 one symptom of syphilis often present or 
 commencing at birth that may appropri- 
 ately be dealt with now. This is the 
 marasmus or wasting that forms such a 
 prominent feature in many cases of in- 
 herited syphilis. Now, marasmus in a 
 new-born child is far from being a certain 
 proof that such a child is syphilitic. More 
 
46 Some Aspects of 
 
 than this, as a rule it does not manifest 
 itself in syphilitic infants before other 
 symptoms have cleared up the diagnosis, 
 and in many syphilitic infants marasmus 
 may never supervene. But still wasting 
 may be the earliest symptom of inherited 
 syphilis in the infant. I have known 
 numerous infants brought to me at the 
 East London Hospital for Children for 
 wasting dating from birth develop other 
 unmistakable evidences of syphilis whilst 
 under observation. These infants have 
 almost invariably died. Other marasmic 
 infants whom I fancied were syphilitic 
 have died before unequivocal signs of 
 syphilis had possibly had time to develop. 
 With these facts before my eyes, I have on 
 numerous occasions placed infants, in whom 
 wasting was the only objective sign, on a 
 course of mercury, where the family history 
 was suggestive of syphilis. This treatment 
 has, I think, been attended in some cases 
 with success, although the measure of 
 success is not a great one. Some of these 
 infants both gained flesh and developed 
 syphilitic manifestations under the mer- 
 
Infantile Syphilis. 47 
 
 curial treatment. Others, whilst improving 
 under mercury, developed no further syphi- 
 litic symptoms, owing possibly, I thought, 
 to their abeyance under treatment. But 
 early marasmus in syphilitic infants is of 
 such grave import that treatment, let this 
 be as early as it may, can claim but few 
 successes. 
 
 The marasmus I have just mentioned 
 is that present at birth or commencing 
 soon after it. Such cases form but a small 
 minority of those where marasmus plays a 
 prominent part in inherited syphilis. Most 
 syphilitic infants are plump and well 
 nourished at birth and usually exhibit no 
 trace of their complaint until a month or 
 so later ; then marasmus is apt to develop 
 simultaneously with snuffles and rash. 
 These last may disappear under mercury, 
 but the marasmus is prone to persist, and 
 death may result from it at a period when 
 all the more characteristic symptoms of 
 syphilis have passed away. In other cases 
 of undoubted syphilis, a fatal marasmus 
 may delay its appearance until months 
 after that of the specific symptoms proper. 
 
48 Some Aspects of 
 
 It is in hand-fed infants, however, that 
 marasmus has its most frequent and pro- 
 nounced occurrence. Breast-fed infants, if 
 specifically treated, usually escape it. It 
 is only in such marasmic infants, I am 
 inclined to agree with Henoch, that the 
 peculiar cafe-mt-lait tint of skin appears 
 which Trousseau described as characteristic 
 of cases of inherited syphilis in general. 
 With Henoch and some other writers, too, 
 I am at one in regarding marasmus as the 
 most important factor in prognosis in the 
 complaint. Other points that have been 
 laid stress upon by some authorities, such 
 as the early appearance, amount, and 
 character of the eruption, the extent of 
 the involvement of the viscera in the com- 
 plaint, are, in my opinion, but seldom of 
 the same prognostic significance as wasting. 
 Henoch practically sums up the question 
 of prognosis with the assertion that wasting 
 infants die, but well-nourished ones recover. 
 Many wasting syphilitic infants, if they do 
 not actually die from an obstinate and 
 progressive asthenia, are very apt to do so 
 from some intercurrent disease, such as 
 
Infantile Syphilis, 49 
 
 collapse of the lung or diarrhoea, which 
 they might have escaped or recovered from 
 had they possessed greater vitality.-^ 
 
 Thus far, except when it was present at 
 birth, I have only treated of marasmus in 
 connexion with syphilis in cases where the 
 diagnosis of the latter was confirmed by 
 the more unequivocal symptoms of the 
 complaint. Cases where these last can be 
 adduced in confirmation, however, in my 
 opinion are far from being the only ones 
 where an association between infantile 
 syphilis and wasting can be traced. I 
 have seen numerous infants in whom the 
 only objective sign has been an obstinate 
 wasting, and where the family history alone 
 has been inferential of syphilis. Such 
 cases occur in infants of any age, from that 
 of three or four months upwards. The 
 question arises as to how far it is justifiable 
 to regard such cases of wasting as syphilitic 
 
 ^ In connection with this part of the subject, I may 
 mention that my colleague, Dr. Dawson Williams, has 
 made the important observation that the mortality 
 amongst the later children of syphilitic families is unduly 
 and excessively high, even when such children have not 
 exhibited any of the ordinary signs of the inherited 
 complaint. 
 
 E 
 
50 Some Aspects of 
 
 where there are no direct evidences of that 
 complaint beyond, possibly, the family 
 history. The majority of authorities would, 
 I believe^ protest against such an assump- 
 tion as unjustifiable from the absence of 
 the more characteristic symptoms, and as 
 unduly and unnecessarily extending the 
 domains of syphilis to unknown limits. 
 Accordingly, whilst in most descriptions 
 of inherited syphilis wasting is mentioned 
 in connexion with other symptoms, it is in 
 but few that it is treated as possibly the 
 only manifestation of the complaint. For 
 my part I can see nothing unreasonable in 
 the diagnosis of syphilis in many wasting 
 infants in whom there is an entire absence 
 of specific symptoms, and in this conten- 
 tion I am happy in being supported by the 
 majority of my colleagues. Snuffles and 
 rash and other symptoms may be very 
 evanescent, occasionally missed, and even 
 when marked may disappear with doses of 
 mercury totally inadequate for the cure 
 of the complaint. Again, the first appear- 
 ance of specific symptoms may not occur 
 for many months later than the majority 
 
Infantile Syphilis. 5 i 
 
 of text-books allow. Nowadays, moreover, 
 we are even told that the manifestations of 
 inherited syphilis n^ay be retarded until 
 puberty or many years later still. In 
 numerous ways, then, it may well happen 
 that one may be frequently called upon to 
 treat a case of syphilis in an infant in whom 
 the only noticeable symptom is obstinate 
 wasting, and in whom there is a totally 
 negative history as to more unequivocal 
 manifestations both in the present and the 
 past. Dr. Donkin is, as far as I know, 
 the only writer who has deemed such 
 cases worthy of separate description, and 
 he has done it so graphically that I need 
 not go over the ground again. These 
 cases of syphilitic atrophy are peculiar, he 
 considers, in that they are not attended by 
 any noticeable amount of diarrhoea or 
 vomiting, and I agree with him in this and 
 in his estimation of them as a large and 
 important class that has not received 
 sufficient attention at the hands of the 
 profession. 
 
 The result of specific treatment cannot 
 be applied as any fair test as to the 
 
52 Some Aspects of 
 
 syphilitic nature of such cases. Syphilitic 
 infants with atrophy generally die, whether 
 such atrophy date from birth or many 
 months later, and whether treated with 
 mercury or not. In some few cases I 
 think I have succeeded in checking the 
 wasting by means of that drug. In one 
 or two younger infants, moreover, the use 
 of mercury seemed to bring out other and 
 more certain signs of syphilis beyond the 
 wasting. The improvement in nutrition 
 produced by the drug appeared to allow 
 the production of these other syphilitic 
 symptoms in infants previously too reduced 
 in vitality for their manifestation, but 
 their appearance with the administration 
 of mercury may have been mere coinci- 
 dence. The failure of mercury in infantile 
 syphilis where atrophy is a prominent 
 feature is readily accounted for by the 
 post-mortem revelations in such cases. 
 These show that the atrophy is by no 
 means limited to the external parts under 
 observation, but that it involves the internal 
 organs at the same time. In many such 
 cases the small intestine is found to be 
 
Infantile Syphilis. 53 
 
 almost practically deprived of its mucous 
 and muscular coats, being little more, in 
 fact, than a semi-transparent tube of peri- 
 toneum. To a less degree the stomach 
 and large intestine suffer from the same 
 destructive change. With this atrophy of 
 the secretive and absorptive surface of the 
 intestinal tract it is evident that no satis- 
 factory digestive processes could possibly 
 take place. The liver, too, in many 
 instances is found markedly fatty, and this 
 probably assists in maintaining the failure 
 of nutrition. The condition of intestine 
 I have just alluded to is found in other 
 cases of atrophy besides those arising from 
 syphilis, but it is in these latter, I believe, 
 that it finds its most frequent and pro- 
 nounced appearance. Dr. Donkin alludes 
 to it in his work on Children's Diseases, 
 but I know of no satisfactory account of it 
 in the leading pathological treatises.^ Here 
 I may say that this is the only abnormal 
 
 * Since this was written, Dr. Soltan Fenwick has 
 published an interesting article on " The Pathology of 
 Infantile Marasmus " in the British Medical Journal o{ 
 September 26, 1896, in which atrophy of the intestine is 
 dealt with at some length. 
 
54 Some Aspects of 
 
 condition of intestine that I am personally 
 acquainted with in inherited syphilis. At 
 numerous necropsies I have seen nothing 
 resembling the gummatous indurations of 
 the mucous and muscular coats or of the 
 condylomata and ulcerations occurring in 
 Peyer's patches, described by Oser, Jurgens, 
 and others. The atrophic condition I 
 have mentioned is amply sufficient to 
 account for the mortality in such cases. 
 Mercury may be capable of combating the 
 syphilitic diathesis accountable for the con- 
 dition, but it cannot replace the wasted 
 glandular intestinal structures on which 
 nutrition depends. 
 
 In an apparently healthy infant, present- 
 ing as yet no signs of the parental disorder, 
 I think it will be admitted that a mercurial 
 course as a preventive or precautionary 
 measure is inadvisable, if not unjustifiable. 
 This being so, then the limit of time of 
 possible onset of symptoms is no unimpor- 
 tant question, not only on account of 
 relieving parental anxiety, but of releasing 
 the infant from the stricter forms of medical 
 supervision. A great diversity of opinion 
 
Infantile Syphilis. 55 
 
 as to the limits of time in which initial 
 symptoms are possible occurs amongst 
 authorities. On two points, however, all 
 observers are agreed, these being that in 
 the majority of cases symptoms appear 
 in the second month of life, and that their 
 primary manifestation is exceptional after 
 the third month has expired. All experi- 
 ence agrees on these points and statistics 
 amply confirm them. Kassowitz, indeed, 
 would seem to doubt whether the primaty 
 manifestation of symptoms is ever deferred 
 beyond the third month. Dr. Radcliffe 
 Crocker asserts that the initial symptoms 
 are never delayed beyond the sixth month. 
 Henoch writes : '' After the second, or still 
 more after the third month, it is rare for 
 them to appear for the first time ; and 
 when they occur still later it is always 
 doubtful whether it is not a case of recur- 
 rence or of direct transmission." With 
 these last-named writers I cannot agree. 
 I have not infrequently seen infants where 
 snuffles and rash had primarily manifested 
 themselves much later in the first year of 
 life than the sixth month, and one or two 
 
56 Some Aspects of 
 
 where symptoms had been delayed until 
 the second year. Of course, I may be 
 told that such cases were those of a relapse, 
 and that the first appearances of the com- 
 plaint had been missed. Such an assertion 
 is equally easy to make as hard to dis- 
 prove. I would only say that in my 
 experience relapses of the skin affection 
 are somewhat rare in the later months of 
 infancy, the common expressions of a 
 relapse at such times being the presence of 
 mucous tubercles or condylomata. If we 
 may believe, moreover, in the reality of a 
 "syphilis tarda," so commonly accepted 
 now, then I can see no inherent improba- 
 bility in the first manifestations of the 
 complaint occurring at a much later infan- 
 tile age than is usually taught. Dr. Donkin 
 has already written to the same effect, and 
 I gather that others are now inclined to 
 extend the limit of time during which 
 initial symptoms are possible to at least 
 twelve months from birth. 
 
 The first obvious manifestation of in- 
 herited syphilis is usually the well-known 
 snuffles. This generally precedes any 
 
Infantile Syphilis. 57 
 
 affection of the skin, and in only a small 
 minority of cases is the skin eruption 
 simultaneous with, or anterior to, the 
 snuffles. It is only in very exceptional 
 instances, too, that the swelling of the 
 nasal membrane causes distress and diffi- 
 culty in sucking before the snuffling 
 develops. Snuffles, which usually precedes 
 all other symptoms, may also long outlast 
 them. A few doses of mercury may cause 
 the disappearance of all skin eruptions, 
 but snuffles may persist for many months 
 as the sole evidence of the complaint. 
 
 The prominence of snuffles in hereditary 
 syphilis has often led, I fancy, to an 
 erroneous diagnosis of that complaint from 
 the presence of this one symptom alone. 
 When it is marked and persistent in cha- 
 racter I would admit a justification for the 
 suspicion of syphilis in a large majority of 
 cases in which it occurs. But the extreme 
 sensitiveness of the nasal mucous membrane 
 in infants leads to a minor degree of 
 snuffling from many causes in cases where 
 syphilis is out of the question. This 
 sensitiveness of the nasal membrane 
 
58 Some Aspects of 
 
 persists for about' the first year of life, and 
 any undue exposure to cold may bring on 
 a greater or slighter degree of snuffles in 
 many infants. Its temporary character 
 and the absence of other signs ought to be 
 sufficient to dispel the suspicion of syphilis 
 in the majority of such cases. There is, 
 however, one complaint peculiar to infants 
 where the presence of marked snuffling 
 may mislead even the more wary. This is 
 what Henoch has aptly named the ''acute 
 coryza of infants." In this an infant, 
 generally after exposure to cold wind, is 
 suddenly seized with high temperature and 
 acute nasal obstruction, followed shortly, 
 in most cases, by laryngitis or bronchitis. 
 If seen for the first time towards the end 
 of an attack, when all acute symptoms 
 have subsided, the combination of hoarse- 
 ness or voicelessness along with intense 
 snuffling is very apt to lead to a confident, 
 although erroneous, diagnosis of syphilis. 
 The acute nature of the attack ought to 
 prevent mistakes in any one acquainted 
 with Henoch's description of the complaint. 
 In one case of this kind I knew dire offence 
 
Infantile Syphilis. 59. 
 
 given by an incautious catechising of the 
 father which a short delay would have 
 served to prevent. 
 
 The syphilitic affection of the nasal 
 structures in infancy responsible for the 
 snuffles generally leads to some broadening 
 and depression of the root of the nose, 
 more apparent, perhaps, than real. In 
 most cases this is entirely recovered from, 
 and the child grows up with a nose as well 
 shapen as in those who are non-syphilitic. 
 In a minority, however, a nasal deformity 
 incurred in infancy persists throughout 
 life. I have never in such cases noticed 
 any undue foetor in the nasal secretion 
 suggestive of active bone destruction, nor 
 have I ever learnt of the discharge of 
 palpable portions of bone and cartilage 
 which Diday and others write about. The 
 explanation of the permanent nasal defor- 
 mity incurred in infancy lies rather, I 
 think, in changes occurring in the cartilage 
 which interfere with its nutrition, and this 
 defective nutrition is followed by arrested 
 development. But beyond infancy there 
 is no doubt that active destruction of the 
 
6o Some Aspects of 
 
 nasal bones can occur from inherited 
 syphilis, and the usual time for this is 
 generally from the age of four years to 
 that of puberty. Not very infrequently, 
 I believe, cases treated for strumous ozoena, 
 with bone destruction, have their origin 
 in inherited syphilis rather than struma, 
 and I have known mercury and iodide suc- 
 cessful in such cases where other measures 
 have failed. In one interesting case I saw 
 through the kindness of Dr. Julius Jacob- 
 son, active nasal bone trouble occurred as 
 late as the age of thirty-four years in a 
 woman who was undoubtedly the subject 
 of inherited syphilis. 
 
 The affection of the nasal membrane has 
 little, if any, tendency to spread to neigh- 
 bouring parts, and in the early stages of 
 infancy the pharynx generally appears per- 
 fectly normal. Diday dissents from this, 
 as he states that repeated examinations 
 only resulted in his finding insuperable 
 difficulties in the way of pronouncing with 
 any certainty as to the freedom of the 
 pharynx in very young infants. At any 
 rate, his repeated examinations did not 
 
Infantile Syphilis, 6i 
 
 enable him to find any frequent affection 
 of the pharynx in such cases. What has 
 been said as to the pharynx applies equally 
 to the mouth in very young infants. Any 
 shallow ulcerations of the mouth found in 
 them are generally due to aphthous con- 
 ditions, which are common enough in 
 babies with no suspicion of syphilis. 
 Henoch agrees with this, and gives useful 
 warning against mistaking ulcers along the 
 middle line of the palate in young infants 
 for specific manifestations. Although in 
 early infancy the mouth and throat are 
 free, yet in infants some months old, 
 whether with a relapse or not, the tonsils, 
 fauces, palate, and buccal membranes may 
 be the sites of a few scattered ulcers un- 
 mistakably specific in character. These 
 affections of the mouth only occur in a 
 minority of cases, and the infants in whom 
 they appear are seldom less than four 
 months old, and generally some months 
 older than this. Fissuring of the lips, too, 
 is a later symptom than some of the text- 
 books allege. The infrequency of sores 
 about the mouth and their late appearance 
 
62 Some Aspects of 
 
 in the disorder have, I believe, important 
 bearings on the spread of the disease from 
 infants to others. 
 
 Along with the sores in the mouth I 
 have usually found mucous tubercles at 
 the angles of the lips and often on other 
 parts of the body where there is a com- 
 bination of moisture and warmth. These 
 mucous tubercles have been often de- 
 scribed as one of the earliest symptoms 
 of inherited syphilis, but this I am certain 
 is a decided fallacy. Their real place is 
 amongst the later signs that may occur 
 in infancy. They are the commonest 
 symptoms of all in relapses, and may 
 recur from time to time, as the sole 
 evidence of the disease, until the child is 
 five or six years old. Henoch has pointed 
 out the much greater luxuriance of the 
 growth of mucous tubercles and condylo- 
 mata in the acquired syphilis of children 
 than in the inherited form, and in this 
 my experience fully tallies. I have seen 
 cauliflower masses of condylomata in 
 acquired syphilis in children such as I 
 have never seen approached in inherited 
 
Infantile Syphilis. 63 
 
 cases. These mucous tubercles afford the 
 surest evidence of syphih's where other 
 signs are doubtful. I quite agree with 
 Mr. Hutchinson that one well-formed 
 mucous tubercle or condyloma is patho- 
 gnomonic and an incontrovertible proof 
 of the complaint. 
 
 The skin eruptions have been so fre- 
 quently and fully dealt with by others 
 more competent than myself that I feel 
 any lengthy description of most of them 
 uncalled for. My former colleague, Dr. 
 Radcliffe Crocker, whose experience was 
 largely gained from the same sources as 
 my own, has indeed rendered any attempt 
 in this direction superfluous on my part. 
 All I would propose to do, then, is to take 
 the arrangement and classification laid 
 down in Dr. Crocker's treatise on Diseases 
 of the Skin, and to briefly deal with the 
 different eruptions with such comments as 
 personal observation may seem to warrant. 
 The most frequent sites of the eruption 
 are admittedly the buttocks and adjacent • 
 parts, the chin and upper lip, the eye- 
 brows, and the skin behind the ears. In 
 
64 Some Aspects of 
 
 exceptional and generally fatal instances 
 the eruption may be universal over the 
 body. Of the parts mentioned the but- 
 tocks and their neighbourhood are those 
 most frequently affected, and very com- 
 monly, indeed, the only ones. I cannot 
 recall a case where there was any very 
 decided eruption where the buttocks re- 
 mained free. These parts are usually also 
 the first to show the eruption, and are 
 the ones most deeply affected even when 
 it is fully developed on numerous other 
 places. Next in frequency to the buttocks 
 as sites for the eruption come the upper 
 lip and chin. It has been assumed that 
 the reason for these situations being the 
 commonest ones for the syphilitic eruption 
 is that they are the ones most subject 
 to irritation from contact with wet napkins 
 and saliva or mucus. To this view I 
 have never altogether assented. Some of 
 the other parts commonly affected by the 
 syphilitic eruption are subject to no irrita- 
 tion that would explain their prominence in 
 this respect over others of the body. In 
 the acquired syphilis of infants, moreover. 
 
Infantile Syphilis. 65 
 
 the eruption shows no preference for 
 the parts most affected in the inherited 
 form, although the sources of irritation are 
 the same in each. Other eruptions, too, 
 confessedly owing their origin to some 
 source of irritation, show no special prefer- 
 ence for the sites most commonly affected 
 in inherited syphilis. I cannot help think- 
 ing, then, that there is some selective 
 influence at work beyond mere irritation 
 that determines the eruption to its favourite 
 sites, the reason of the selection lying 
 deeper than our present knowledge can 
 explain. 
 
 Syphilitic roseola, far and away the 
 most common form of eruption in adult 
 acquired syphilis, is extremely rare in the 
 inherited disease. I have never seen an 
 example of it in the latter. Cases are, 
 however, related by Bassereau, Cullerier, 
 Dr. Crocker, and others. The record of 
 single cases by these last-named is suffi- 
 cient testimony to the rarity they place 
 upon it. Although I have never seen this 
 form of eruption in inherited syphilis, I 
 have several times seen it in the acquired 
 
 F 
 
66 Some Aspects of 
 
 variety in both infants and elder children. 
 When seen in these last, it differs in no 
 respect either in situation or appearance 
 from that occurring in adults. 
 
 Although syphilitic roseola is extremely 
 rare, another of the erythematous erup- 
 tions is the commonest of all in the in- 
 herited disease. The following account 
 by Dr. Crocker so graphically describes 
 it that I prefer to give it in his own words : 
 " It consists of erythematous patches of 
 various sizes which usually commence on 
 the buttocks and round the anus. They 
 may be well or ill-defined at the edge, 
 bright coppery or yellowish red, tending 
 to coalesce into large sheets of eruption, 
 but generally patchy on the borders. 
 This erythema may extend uniformly on 
 the back and inner side of the legs quite 
 down to the feet, including the soles, 
 which are bright red and peeling. On 
 the front and outer side it is still generally 
 patchy, upwards it often extends to the 
 loins and abdomen, and in a few cases 
 all over the body in patches which coal- 
 esce ; the whole surface is then red and 
 
Infantile Syphilis, 67 
 
 desquamating on the dry parts, while on the 
 buttocks or where it is exposed to moisture 
 the scales are soaked off and the surface 
 is left raw or brightly glistening. These 
 generalized cases are very likely to die." 
 As to the fatal nature of these cases with 
 extensive erythema, my experience fully 
 tallies with that of Dr. Crocker, and 
 Henoch writes to the same effect. 
 
 A papulo - squamous eruption corre- 
 sponding to that of acquired syphilis is 
 the next most common one in the in- 
 herited complaint. The following descrip- 
 tion, like the preceding one, is taken from 
 the same source, the work of Dr. Crocker. 
 "It consists of round superficial patches, 
 from one-eighth to half an inch in diameter, 
 very slightly raised above the surface, 
 delicately scaly, with a pink or reddish- 
 brown colour at first, but after a few days 
 of a pale fawn tint. It may be limited 
 to one or more regions, such as the limbs, 
 forehead, or round the mouth, or occupy 
 the whole body surface, usually in discrete 
 patches, and commencing upon the but- 
 tocks, where the superficial ulceration is 
 
68 So77te Aspects of 
 
 apt to occur from the irritation of the 
 urine and faeces. A variety of this is a 
 crescentic squamous eruption with a raised 
 border, which in one of my cases began 
 on the buttocks a week after birth and 
 then spread over the thighs and then all 
 over the body, forming map-like outlines 
 on the skin, most marked on the lower 
 part of the body and legs." 
 
 Besides this last Dr. Crocker describes 
 three small papular forms of eruption — 
 the acuminate, convex, and flat. The first 
 two may be crowned with a scaly cap, a 
 small bead of pus, and less seldom with 
 a clear vesicle. All these forms occupy 
 the usual sites of the other eruptions, run 
 the usual course, and are not significant 
 of any particular import in prognosis or 
 severity of the disease. 
 
 Vesicular eruptions are rare in inherited 
 syphilis, and are usually preceded by other 
 forms of eruption. The skins of syphilitic 
 infants, too, are more prone than those of 
 others to respond to external irritation. 
 In this way eczema and other inflammatory 
 eruptions may break out in syphilitic 
 
Infantile Syphilis. 69 
 
 infants independently of the constitutional 
 complaint. 
 
 Pustular eruptions are much more 
 common than the vesicular, but, like the 
 last, are seldom the primary ones in the 
 complaint. Any of the previously men- 
 tioned forms under continued irritation are 
 liable to take on a pustular character. 
 Besides these, however, others may be 
 pustular from the onset. Thus ecthymatous 
 sores are far from uncommon, covered with 
 a greenish crust, concealing sharp-edged 
 spreading ulcers or simple excoriations. 
 They show no preference for any part of 
 the body, and are seldom numerous ; but 
 they generally denote a profound cachexia, 
 and are of bad prognosis. 
 
 One of the pustular forms is deserving of 
 further notice. This was first described, I 
 believe, by Dr. Barlow, and is known as 
 the " syphilitic furuncle," although a more 
 appropriate name could possibly be found 
 for it. It is of importance as being often 
 the sole manifestation of the later stages of 
 inherited syphilis, and its significance in 
 this respect is, to my personal knowledge, 
 
7o Some Aspects of 
 
 only too often overlooked. In its typical 
 form it consists of an elevation of the 
 epidermis of the size of half a hazel nut, 
 the raised epidermis being generally of a 
 deep purple colour. There is very slight 
 hardening of the surrounding and under- 
 lying skin, and under the purple epidermis 
 is a scanty secretion of ill-formed pus. 
 If left to itself it may persist for long 
 without the skin giving way, but under 
 mercurial treatment it rapidly disappears 
 without scarring. Without treatment it is 
 apt to leave a small nodular thickening in 
 the subcutaneous tissue, with a correspond- 
 ing slight depression in the overlying 
 epidermis. The same small nodular thick- 
 ening in the subcutaneous tissue may 
 occasionally be found preliminary to the 
 formation of the cutaneous pustule. These 
 "syphilitic furuncles" are most common, 
 perhaps, in children two or three years old, 
 and are rare before the eighth or ninth 
 month. They may appear anywhere on 
 the body, but are most frequent, in my 
 experience, on the upper and outer aspects 
 of the thighs. As an indication of syphilis. 
 
Infantile Syphilis. 71 
 
 when other signs are wanting, I consider 
 them of prime importance. On two occa- 
 sions my diagnosis of syphilis from their 
 appearance alone was confirmed by the 
 discovery of unsuspected mucous tubercles. 
 At one time I looked upon them as patho- 
 gnomonic of syphilis, but in one case I 
 came across " furuncles," undistinguishable 
 from those described, where syphilis could 
 with certainty be excluded. They indicate 
 syphilis, however, in the majority of 
 instances, and the non-recognition of their 
 significance by many observers is matter 
 for regret. 
 
 Bullous eruptions are more common in 
 inherited than in acquired syphilis. Pem- 
 phigus is one of the best recognized forms 
 of eruption in the former. It is usually 
 either present at birth or commences a few 
 days later, seldom later than the first week. 
 Dr. Crocker, however, mentions a case 
 where it first appeared in an infant a fort- 
 night old. It is usually confined to the 
 hands and feet, and here more especially 
 attacks the palms and soles. The nail 
 beds, too, are generally affected with 
 
72 Some Aspects of 
 
 destruction of the nails. The situation 
 of the eruption, mainly the palms and 
 soles, is sufficient to distinguish it from 
 another infantile form of pemphigus, arising 
 from bad hygienic surroundings, which 
 shows no preference for these sites. The 
 bulls, too, in the syphilitic variety are 
 flaccid, and contain pus or blood ; in the 
 other variety they contain clear serum. 
 The almost fatal prognosis attaching to 
 pemphigus in inherited syphilis is disputed 
 by none, and I have never known a case 
 recover. Pemphigus in the later stages of 
 infancy is not uncommon, but when occur- 
 ring then has no connection with syphilis 
 in particular. 
 
 Although gummata are not, of course, 
 confined to the skin, yet they may appro- 
 priately be dealt with now, as completing 
 what I have to say on the cutaneous 
 eruptions. All observers are agreed as to 
 the rarity of gummata in the skin in 
 inherited syphilis. My personal experience 
 is limited to perhaps half a dozen cases. 
 In only two of these did they break down, 
 forming the well-known characteristic 
 
Infantile Syphilis. 73 
 
 ulcers, and even in these two there was a 
 doubt in the history as to whether the 
 syphilis was inherited or acquired. In 
 the others they persisted for a long time, 
 in spite of treatment by iodide, and this 
 increased resistance to that drug would 
 seem, in my limited experience of them, 
 one of the peculiar features of gummata in 
 the inherited form of the disease. The 
 youngest of my patients was about two 
 and a half years old, and the rest several 
 years older than this. What has been said 
 as to the rarity of gummata in the skin 
 applies equally to gummata elsewhere in 
 the inherited complaint. The cases I have 
 seen of older children with destructive 
 lesions of the palate and adjacent parts are 
 not more numerous than the ones where 
 gummata occurred in the skin. In more 
 than one of these, again, the history was 
 doubtful, and I was uncertain whether the 
 disease was inherited or acquired. Gum- 
 matous infiltrations of the skin are of 
 interest as being, in the opinion of Dr. 
 Crocker and others, the only skin eruption 
 found in the latest stages of inherited 
 
74 Some Aspects of 
 
 syphilis. Of this nature are probably the 
 lupus-like conditions described by Mr. 
 Hutchinson as occurring along with inter- 
 stitial keratitis and allied disorders. These 
 later skin eruptions are certainly rare, but 
 I have seen one or two examples of this 
 syphilitic '' lupus " in children near the age 
 of puberty. 
 
 One peculiarity about all the skin erup- 
 tions in early infancy is the rapidity with 
 which they disappear under treatment, and 
 the little tendency they have to recur 
 provided this last have been at all adequate. 
 Mr. Hutchinson writes : " If an infantile 
 eruption due to inherited syphilis have 
 once disappeared under treatment, it but 
 seldom, in my experience, shows any 
 tendency to recur. The relapses so fre- 
 quently seen in adults who have acquired 
 the disease find no place in infants." With 
 this opinion of Mr. Hutchinson I agree, 
 provided) as I have said, that the treatment 
 be efficient. During the first year I should 
 not consider it very uncommon for the skin 
 eruptions to disappear and relapse where 
 the treatment had been little or none. 
 
Infantile Syphilis. 75 
 
 After the first year, however, eruptions of 
 any kind, except mucous tubercles or 
 condylomata, are exceedingly exceptional 
 under any circumstances whatever. 
 
 One of the most marked characteristics 
 of inherited syphilis, as compared with the 
 acquired form, is the early and frequent 
 involvement of the viscera in the former, 
 leading to their enlargement. The recog- 
 nition of the affections of the abdominal 
 viscera in inherited syphilis is not of 
 modern origin, many of the older writers 
 being as fully cognisant of them as those 
 of the present time. The viscera most 
 affected are admittedly the liver and spleen. 
 It is, indeed, in only a minority of cases 
 in my experience that the latter is of 
 normal size. In 100 cases of inherited 
 syphilis under my care I found the spleen 
 enlarged in 62, and in 19 others its size 
 was probably above the normal. Dr. Gee, 
 however, only found the spleen enlarged 
 in 45 per cent, of his cases. The splenic 
 enlargement generally dates from birth, 
 and may certainly exist before any other 
 symptom has manifested itself. In 92 
 
']6 Some Aspects of 
 
 examinations of macerated syphilitic 
 foetuses, Mewis, cited by Mr. Hutchinson, 
 found the spleen enlarged in 72 — i.e. about 
 78 per cent. The fact of its occurrence 
 in utero accounts for the early enlargement 
 of the spleen to be found in living infants. 
 In some few cases I have found the spleen 
 enlarged in later months where I was 
 unable to do so in the earlier ones, so 
 that I am not inclined to regard the affec- 
 tion as necessarily a congenital one. The 
 enlargement of the spleen in inherited 
 syphilis is, I should say, very rarely carried 
 to any great extent. In uncomplicated 
 syphilis I have never known the hyper- 
 trophy of the spleen so great, at least in 
 the first year of life, as to suggest any 
 connection between it and an associated 
 condition of blood change, although such a 
 connection has been described by others. 
 But anaemia is so common in inherited 
 syphilis — and, indeed, in infants generally 
 of the age in question — that it can seldom 
 be necessary to assume any causation for 
 it in the splenic affection. The profound 
 anaemia and changes in the blood and 
 
Infantile Syphilis. 77 
 
 bones which are sometimes found along 
 with splenic enlargement in syphilitic 
 infants in their second year are, in my 
 opinion, more fairly ascribable to rickets, 
 which almost invariably complicates the 
 former complaint at that period. It is 
 only in exceptional instances, moreover, 
 that the hypertrophy from syphilis persists 
 beyond the first year. 
 
 As far as present knowledge attains, 
 there is nothing specific in the changes 
 in the splenic tissues that lead to its 
 hypertrophy. The resulting pathological 
 condition is a simple hyperplasia of all 
 the splenic elements, and there is nothing, 
 microscopical or otherwise, serving to dis- 
 tinguish this hyperplasia from that occur- 
 ring in rickets and other infantile disorders. 
 There may be, perhaps, some greater 
 tendency in the syphilitic affection for 
 thickening of the capsule to accompany 
 the other splenic changes. Any conditions 
 allied to gummata I have never seen in 
 the spleen in syphilis. It is true that 
 in one or two post-mortem examinations 
 in children I have seen scarring of the 
 
y^ Some Aspects of 
 
 splenic surface, but this fact in no way 
 necessarily implies the former existence 
 of anything like gummata in the organ. 
 
 After the spleen the liver is the viscus 
 most frequently affected. The difficulties 
 attaching to the recognition of the slighter 
 degrees of enlargement of the liver may 
 possibly lead to an under-estimation of 
 the frequency of its affection. Writers 
 of the time of Diday would seem to have 
 regarded it as of almost universal occur- 
 rence, the las't-named, indeed, somewhat 
 fancifully suggesting that induration of the 
 liver in the inherited form corresponded to 
 the primary chancre of acquired syphilis. 
 Mewis, in the statistics before referred 
 to, in 92 syphilitic foetuses found the 
 liver diseased in 52 instances. The fre- 
 quency with which it is found in the dead 
 foetus would suggest its early occurrence 
 in the living subject, and most cases of 
 syphilitic affection of the liver, I believe, 
 date from birth. The changes in the 
 organ are those of an interstitial hepatitis. 
 Along with the increase of the interlobular 
 tissue there is a certain am.ount of atrophy 
 
Infantile Syphilis. 79 
 
 of the cells with destruction of the blood- 
 vessels and thickening of the capsule. 
 The interstitial, hepatitis, as a rule, affects 
 the whole organ, but in some cases certain 
 lobes, or parts of them, entirely escape or 
 are less affected than the rest. Even with 
 extensive disease of the organ gummata 
 of the liver are exceedingly rare, if not 
 unknown, in infancy. In older children 
 I have seen them post mortem, and in 
 two cases have known them diagnosed 
 during life with some degree of certainty. 
 Considering what an important part the 
 functions of the liver play in infancy, it 
 is reasonable to suppose that such a 
 marked change in its structure as this 
 interstitial hepatitis entails cannot be 
 without serious detriment to the patient. 
 The older writers, then, were possibly 
 right in the importance they placed on 
 the digestive disturbances arising from 
 syphilitic liver disease in infants, and it 
 may be that we do not sufficiently regard 
 them. Marked enlargement of the liver 
 and spleen is certainly an unfavourable 
 factor in prognosis. But symptoms directly 
 
8o Some Aspects of 
 
 chargeable to the affection of the liver are 
 extremely rare. A case recorded by 
 Depasse is, as far as I know, the only 
 one where ascites was clearly connected 
 with syphilitic disease of the liver in an 
 infant. Jaundice is much more frequent, 
 but still a rarity, considering how fre- 
 quently the liver is diseased. Such jaun- 
 dice, I believe, almost invariably dates 
 from birth, and is generally slight in 
 amount, but if the bile vessels be involved 
 in the liver changes may attain a high 
 degree of intensity. Whether slight or 
 intense, jaundice in infants arising from 
 inherited syphilis is generally fatal. I 
 have known several instances of it, all 
 fatal, and Henoch records others where, 
 along with the jaundice, he found haemor- 
 rhage into the stomach from obstruction 
 of the portal vein. Henoch, too, mentions 
 the case of a syphilitic woman who bore 
 three infants, who all died soon after birth 
 from congenital jaundice. As the effect 
 of treatment, or independently of it, the 
 enlargement of the liver disappears or 
 largely diminishes during the first year 
 
Infantile Syphilis. 8i 
 
 of life. In some instances, however, the 
 enlargement lasts for years. I have known 
 two children eight or nine years old, with 
 a clear history of inherited syphilis, in 
 the East London Hospital for Children, 
 in whom there were ascites with the 
 enlargement of the liver, and where what 
 were taken to be gummata in the latter 
 could be felt through the abdominal wall. 
 One case required repeated tapping, but 
 both finally recovered under treatment 
 with mercury and iodide. 
 
 Since Dubois first described a syphilitic 
 affection of the thymus gland in 1850, 
 many, if not most, writers have concurred 
 with him in recognizing a similar disease 
 of that viscus in inherited syphilis. It 
 is claimed by some that the thymus gland 
 is the earliest of the viscera to be attacked, 
 and that it may even be the only one to 
 show the syphilitic taint. Dubois described 
 two varieties, or rather grades, of this 
 syphilitic affection of the thymus. In 
 the first the organ is but little, if at all, 
 enlarged. On section it is found studded 
 with cavities varying in size from that 
 
 G 
 
82 Some Aspects of 
 
 of a pin's head to that of a pea, from 
 which a yellow, pus-like fluid exudes. In 
 other cases no visible cavities are found, 
 but the sarae fluid can be made to exude 
 in drops by squeezing the gland. In the 
 second class of cases the organ is con- 
 siderably enlarged, and cavities as large 
 as a walnut may be found containing the 
 same yellow fluid as in the first class. 
 This fluid, Diday states, had been care- 
 fully analyzed, and was found to bear all 
 the physical properties and microscopical 
 tests of pus. Without at all wishing to 
 deny a syphilitic affection of the thymus, 
 I would beg to state that a further proof 
 of its reality is needed than that furnished 
 by Dubois and his successors. I have 
 seen the condition of thymus described 
 by Dubois in syphilitic infants, but more 
 often in infants in whom there was no 
 reason to suspect such complaint. In one 
 infant who died from croupous pneumonia, 
 and who had been perfectly healthy until 
 the commencement of the fatal illness, I 
 saw the thymus immensely enlarged and 
 containing a cavity filled with about half 
 
Infantile Syphilis. ^t^ 
 
 an ounce of the yellow fluid. I have never 
 analyzed this fluid, but to me the naked- 
 eye appearances of it are not identical 
 with those of ordinary pus. Since pre- 
 parations of the thymus, too, have found 
 a therapeutic use, I hear that the manu- 
 facturers have to reject a fairly large 
 percentage of the glands supplied to them 
 owing to the presence of these fluid- 
 containing cavities. It is in cases of 
 inherited syphilis, possibly, that necropsies 
 on very young infants are most often 
 performed, and where special attention is 
 paid to the state of the thymus. Were 
 necropsies as regularly made on very 
 young infants dying from other causes 
 than syphilis, and equal attention paid m 
 them to the state of the thymus, I have 
 a suspicion that the cavities m question 
 would be found as often in these cases 
 as in the syphilitic ones. On these 
 grounds, then, I feel justified in my 
 belief that up the present the involvement 
 of the thymus in inherited syphilis is 
 at least not proven. 
 
 What has been stated as to the thymus 
 
§4 Some Aspects of 
 
 applies also to the pancreas. Many 
 writers describe a syphilitic affection of 
 this latter in the inherited forms of the 
 complaint. As far as I can gather, the 
 chief reason for the belief in such an 
 affection has been an unnatural hardness 
 in the pancreas. Now, I have seldom 
 attended a necropsy on an infant a few 
 months old without being struck with the 
 much firmer consistence of the pancreas 
 than that obtaining in the case of older 
 children. It is, I believe, a physiological 
 and not a pathological condition, and due 
 to the active developmental and functional 
 changes taking place in the viscus in early 
 infancy. Before assuming, then, the reality 
 of a syphilitic affection of the pancreas, I 
 consider that further evidence is necessary 
 beyond a mere increase in the consistency 
 of the organ. 
 
Infantile Syphilis. 85 
 
 LECTURE III, 
 
 Mr. President and Gentlemen,— 
 The lesions of the osseous system in in- 
 herited syphilis are of great clinical 
 interest. The due appreciation of their 
 frequency and importance may fairly be 
 claimed for modern observers. As late, 
 indeed, as 1858, Diday writes that "the 
 annals of science offer at most five or 
 six well-authenticated instances of them." 
 These words of Diday and the reticence 
 on the subject by the authorities of his 
 day would seem inexplicable, in the face 
 of our present experience, did it not appear 
 by their writings that almost the sole 
 affection of the osseous system Diday's 
 contemporaries regarded as syphilitic was 
 the presence of suppurating nodes on the 
 long bones. Now, nodes on the long- 
 bones, whether leading to suppuration or 
 
86 Some Aspects of 
 
 not, are rarities in infants with inherited 
 syphilis, and the non-discovery of them 
 no doubt led to the erroneous impressions 
 of Diday and others. Mr. Hutchinson 
 states that he met with a few instances of 
 nodes on the long bones in infants early 
 in his career, and, I gather, does not regard 
 them as so very uncommon. Other writers, 
 too, describe them as not infrequent, but 
 that, being evanescent, they are often over- 
 looked. This is as it may be, but careful 
 and prolonged search has not enabled me 
 to come across an instance of them in a 
 child younger than eighteen months. In 
 older children they are occasionally found 
 in association with Hutchinsonian teeth 
 and interstitial keratitis. They usually 
 occupy the same situations as the nodes 
 of the adult acquired form, but have 
 seemed to me less tractable to the in- 
 fluence of iodide than these last. 
 
 If nodes are rare on the shafts of the 
 long bones, they are far from being so on 
 the bones of the skull, for the researches 
 of Parrot have clearly established the peri- 
 osteal origin of the well-known cranial 
 
Infantile Syphilis. 87 
 
 bosses occurring In inherited syphilis. 
 These may appear in many places on the 
 skull, but are certainly more frequent on 
 the frontal and parietal bones, close to the 
 margins of the anterior fontanelle. With 
 regard to the contention as to what really 
 constitutes a syphilitic type of skull in 
 infants, I would state my conviction that 
 the natiform skull of Parrot, with the four 
 bosses closely surrounding the anterior 
 fontanelle, is undoubtedly syphilitic, and 
 in this I am happy in being confirmed by 
 Dr. Eustace Smith. The subsequent 
 changes in the skull brought about by 
 rickets being superadded to syphilis have 
 led, I believe, to a confusion amongst 
 observers. But the cranial bosses in rickets 
 are confined to accentuations of the frontal 
 and parietal eminences. Mr. Macnamara 
 has, moreover, in his interesting work on 
 the bones and joints, shown that in exten- 
 sive syphilitic disease of the bones of the 
 skull the frontal and parietal eminences 
 are the only parts that escape. In early 
 cases, then, we have the means of dis- 
 tinguishing the syphilitic from the rachitic 
 
88 Some Aspects of 
 
 type of skull. But rickets is so frequent 
 a complication of inherited syphilis that 
 after the age of six months we are apt to 
 get a mixed type of skull, with correspond- 
 ing difficulties as to the part played by the 
 different factors in its causation. If I 
 ventured to criticize the classical descrip- 
 tion by Mr. Hutchinson of the later stages 
 of inherited syphilis, it would be that the 
 type of skull he associated with this com- 
 plaint is really due to rickets following 
 upon it. The cranial bosses in syphilis do 
 not often last beyond the first year of life, 
 and leave no traces of their former presence, 
 and, moreover, do not affect the situations 
 of the frontal and parietal eminences. 
 
 As with the type of skull, the connection 
 between inherited syphilis and rickets has 
 been one of discussion. The explanation 
 of the frequent association of the two com- 
 plaints would seem to me a natural and 
 simple one. Rickets is a disease of mal- 
 nutrition which may own many causes for 
 its production. Amongst these, possibly, 
 no factor is more powerful in this way 
 than syphilis, and thus the vast majority 
 
Infantile Syphilis. 89 
 
 of syphilitic infants incur a greater or less 
 degree of subsequent rickets. The con- 
 tention of Parrot, that every case of rickets 
 has a foundation in syphilis, is to me, as 
 with most others, inexplicable and utterly 
 untenable. In only one case have I seen 
 suppuration ensue upon a node on the 
 skull. Here a tender swelling over the 
 frontal bone occurred in a syphilitic infant 
 about six months old, with redness and 
 infiltration of . the overlying skin. The 
 skin gave way in a short time, and the 
 bone beneath rapidly necrosed away, 
 opening up the cerebral membranes ; 
 mercury, iodide, and the cautery alike 
 failed to arrest the progress, and the child 
 died from abscess of the adjacent brain. 
 Dr. Barlow lately mentioned that he had 
 seen two cases of a like formidable cha- 
 racter, but I am not aware whether he has 
 published them or not. 
 
 By far the most important and frequent 
 osseous affection in inherited syphilis is 
 the inflammatory one occurring in the 
 epiphyses and in the junctions between 
 them and the rest of the bones. First 
 
go So7ite Aspects of 
 
 described by Wegner in 1870, his researches 
 have been confirmed and extended by 
 Taylor of New York, Dr. Barlow, Dr. Lees, 
 and many others. According to Wegner, 
 there is found in the bones of new-born 
 syphilitic infants and young children a 
 morbid process taking place at the point 
 of junction of the cartilage of the epiphysis 
 with the diaphysis. This consists of a pro- 
 liferation of the cells of the cartilage along 
 with a retardation of ossification in its 
 already calcified structure. At the same 
 time this proliferation of the cartilage cells 
 interferes with the existing blood-vessels, 
 and the formation of new ones takes place 
 imperfectly or is altogether arrested. As 
 a consequence of this interference with the 
 blood-vessels, the cartilage cells themselves 
 suffer in their nutrition and undergo atrophy 
 or fatty change. The result of this morbid 
 process is seen on section as a narrow, 
 somewhat jagged line of yellowish or 
 orange colour running along the line of 
 the epiphyseal cartilage. This appearance, 
 according to Wegner, is due to necrotic 
 tissue separating the diaphysis from the 
 
Infaittile Syphilis, 91 
 
 epiphysis, and a further suppurative com- 
 plication may lead to a complete detach- 
 ment of the latter from the shaft of the 
 bone. Taylor of New York confirms this 
 appearance, but he — and in this he is 
 supported by Waldeyer and Kobner — re- 
 gards the yellow zone, not as a necrobiosis 
 due to deficient vascularity, but as a 
 gummatous process due to the enormous 
 proliferation of new cells, which by com- 
 pressing the vessels lead to the destruction 
 of the intervening tissues and the conse- 
 quent separation of the epiphysis from the 
 diaphysis. Whether Wegner's or Taylor's 
 is the correct interpretation of the epi- 
 physeal change is of minor moment ; both 
 are agreed as to the frequency and im- 
 portance of the result produced. Along 
 with the other changes just described, the 
 ossification of the epiphyseal cartilage 
 proceeds irregularly, and the cartilage 
 cells, which in health are arranged in rows, 
 are disarranged, or are completely disin- 
 tegrated and replaced by groups of smaller 
 cells. 
 
 Such, in brief, is a summary, mainly 
 
92 Some Aspects of 
 
 from Henoch, of the pathological dis- 
 turbances occurring in the epiphyseal 
 cartilages upon which most modern 
 German writers lay especial stress. It is 
 claimed that the morbid process always 
 appears in several places simultaneously, 
 particularly often at the lower end of the 
 femur, in the bones of the legs and fore- 
 arms, and in the ribs ; sometimes in all 
 the long bones together. It is not neces- 
 sarily confined to the larger bones, how- 
 ever, for it is now known that syphilitic 
 dactylitis in reality commences with disease 
 of the epiphyseal ends of the phalanges. 
 Wegner, who first described this epiphyseal 
 disorder, says it is almost constant in the 
 bodies of infants suffering from inherited 
 syphilis. Kassowitz, who admits its ex- 
 treme frequency, had nevertheless met 
 with a few cases where it was absent. 
 Waldeyer, Kobner, and Frankel describe 
 it as being present without exception in 
 every case of inherited syphilis, and the 
 first two state that even when there are 
 no naked-eye changes in the epiphyses, 
 these may be recognized with certainty by 
 
Infantile Syphilis, 93 
 
 the microscope. Birch Hirschfeld, too, 
 writes as if the absence of epiphyseal dis- 
 order were the surest proof of the freedom 
 of the infant from syphilis. Most of the 
 modern German authorities, in fact, would 
 seem to regard this affection of the epi- 
 physes as pathognomonic and distinctive 
 of inherited syphilis, and to regard its 
 non-discovery as conclusive evidence of 
 freedom from it. In the English text- 
 books much less attention is paid to it. 
 This possibly arises, however, from the 
 subject not having received the general 
 notice that its importance deserves, owing 
 to a non-appreciation of its prevalence. 
 
 Whether it be as frequently present as a 
 pathological condition as some German 
 writers allege or not, there is a consensus 
 of opinion that this epiphysitis only calls 
 for consideration as a clinical symptom in 
 exceptional instances. In its milder forms 
 it can sometimes be diagnosed by the 
 pain elicited by pressure over the epi- 
 physes of the long bones, more especially 
 the lower ones of the humeri and bones 
 of the forearms. But pain is no necessary 
 
94 Some Aspects of 
 
 accompaniment of syphilitic epiphysitis ; 
 and there may be considerable swelling of 
 the epiphyses of several bones with no 
 obvious sensory disturbance. This swelling 
 of the epiphyses, with or without pain, as 
 the lesion giving rise to it is a congenital 
 one, may appear in infants of any age. 
 When the enlargement of the epiphyses is 
 of any considerable size, however, it usually 
 occurs in infants of from three to six 
 months old, but is rare after the latter 
 age. Some writers give criteria by which 
 syphilitic enlargements of the ends of the 
 bones are to be distinguished from rachitic 
 ones in the same situation, but I cannot 
 think confusion between the two conditions 
 can often occur. The younger age of the 
 syphilitic patients, the want of symmetry 
 in the distribution of the bony lesions, the 
 greater prevalence of the lesions in the 
 bones of the upper extremity, and even 
 here very often a predominance in one side 
 over the other, along with the presence of 
 other signs of syphilis, ought to be sufficient 
 to prevent errors of diagnosis. Still, in 
 children over the age of six months syphilis 
 
Infantile Syphilis. 95 
 
 and rickets may occur together, and here 
 it may perhaps be an impossible matter to 
 duly apportion to each disease its share 
 in the causation of the epiphyseal swellings. 
 Suppuration as a result of epiphyseal 
 disease of the long bones is rare in infants 
 under a year old, and I have only known two 
 or three examples of it. In older children 
 suppuration over the ends of the long 
 bones is, perhaps, commoner than in young 
 infants, owing possibly to walking and 
 other uses of the limbs proving prejudicial 
 to a previous epiphysitis not entirely 
 cleared up. A symmetrical suppurative 
 epiphysitis in children between one and 
 three years old is to me sufficient to 
 warrant a strong suspicion of syphilis for 
 its causation. In contradistinction to the 
 case of the long bones, suppuration arising 
 from epiphysitis of the phalanges, ''syphi- 
 litic dactylitis," is not very rare. Like Mr. 
 Hutchinson, I have only seen it in con- 
 nection with the bones of the fingers, never 
 with those of the toes. Dr. Colcott Fox 
 has, however, published a case where it 
 occurred in the foot. On all these points 
 
96 So7ne Aspects of 
 
 regarding suppuration I speak with some 
 diffidence, as such cases come more appro- 
 priately under the care of the surgeon than 
 that of the physician. Like suppuration, 
 separation of the epiphyses of the long 
 bones is rare, and my experience of such 
 cases is an extremely limited one. Dr. 
 Barlow has lately called attention to the 
 deformities of the limbs that may result 
 from it owing to the awkward angles at 
 which the epiphyses may rejoin the 
 shafts. 
 
 By far the most interesting condition 
 associated with epiphysitis is the anomalous 
 one known as syphilitic " pseudo-paralysis," 
 in which one or more of the limbs lie cold, 
 wasted, and flail-like by the sides of the 
 body. I have associated this ''pseudo- 
 paralysis " with epiphysitis because the 
 generality of writers have ascribed the 
 muscular wasting to disuse, owing to 
 the pain ensuing on motion from the 
 presence of epiphyseal swellings. Henoch 
 has thrown doubts on this origin of the 
 disorder, however, and with these I agree. 
 It is quite possible to have marked wasting 
 
Infantile Syphilis. 97 
 
 and complete immobility of the limbs in 
 a syphilitic infant without any obvious 
 epiphyseal swellings and with an entire 
 absence of pain. In two cases of "pseudo- 
 paralysis," moreover, having a perhaps 
 exaggerated fear of epiphyseal separation, 
 I had the affected arms confined in splints. 
 Under the use of mercury the infants con- 
 cerned recovered power and muscular tone, 
 although their arms were rigidly fixed. I 
 cannot, then, hold mere disuse accountable 
 for the muscular wasting and paresis. As 
 a possibility I would suggest a peripheral 
 nerve origin for this "pseudo-paralysis" 
 due to the epiphyseal disease, and its being, 
 perhaps, akin to the nervous disorder Dr. 
 Ord has shown may arise from primary 
 joint trouble. Bednar, who would seem to 
 have been exceptionally fortunate in meet- 
 ing with "pseudo-paralysis," for he found 
 it in nineteen out of sixty-eight cases of 
 inherited syphilis, ascribed it to a syphilitic 
 myositis. It is essentially a complication 
 of the earlier stages of inherited syphilis, 
 the limits of age during which I find re- 
 cords of its occurrence being one week and 
 
 II 
 
98 Some Aspects of 
 
 eight months. At the first-mentioned age 
 it was noted in a case under Dr. George 
 Ogilvie's care, and at the latter in one 
 under Henoch's care. It is possible, how- 
 ever, that more careful search would enable 
 me to find it recorded at a later age than 
 the one mentioned. My own cases, amount- 
 ing to perhaps a dozen, all occurred in 
 infants under the age of three months, 
 most of them, indeed, in infants less than 
 six weeks old. In several the paralysis 
 was the earliest symptom of inherited 
 syphilis, and preceded the more unequi- 
 vocal ones by an appreciable interval. In 
 all my cases the arms alone were affected, 
 and in only three did the complaint attack 
 both limbs ; in these three, moreover, the 
 one arm was affected before the other. 
 In Bednar's nineteen cases the arms were 
 affected sixteen times, the legs once, and 
 all the limbs twice. All observers are 
 agreed as to the special tendency for the 
 arms to suffer, and that these suffer first 
 even in the cases where other limbs are 
 subsequently affected. What other fac- 
 tors besides syphilis are necessary for its 
 
Infantile Syphilis, 99 
 
 production and its pathology are still 
 problems requiring solution.^ 
 
 Turning from the symptoms of the in- 
 herited to those of the acquired forms of 
 syphilis in infancy is to enter upon a 
 subject about which there have been the 
 most ardent debate and controversy. That 
 accidental syphilis is rare in infants, as 
 they are not exposed to the ordinary 
 channels in which infection is incurred in 
 adults, will not be denied. Much of the 
 uncertainty and contention reearding- its 
 manifestations undoubtedly arise from the 
 lack of clinical material necessary for form- 
 ing more definite conclusions. No one 
 observer has seen a sufficient number of 
 cases to entitle him to speak dogmatically 
 on the question. Notwithstanding this, 
 there has been dogmatism more than 
 sufficient on the part of most writers on 
 
 ' Cases of relapse of this "pseudo-paralysis" are 
 extremely rare ; indeed, good authorities have dogmati- 
 cally stated that such relapses never occur. Dr. Gossao-e 
 has, however, published a case of relapsing syphilitic 
 "pseudo-paralysis" in vol. x. of the Westminster 
 Hospital Reports; but, as far as I know, this is the only 
 one on record. 
 
TOO Some Aspects of 
 
 the subject, and I fear that only recently 
 I may have laid myself open to the same 
 charge. In what follows, then, I should 
 preliminarily state that any conclusions I 
 may draw have been formed on a limited 
 experience of eight cases of acquired 
 syphilis in infants under a year old, 
 although this experience has been supple- 
 mented to some extent by a larger one ^ 
 of acquired syphilis in children of older 
 age. It may well be, then, that further 
 opportunities may lead me to largely 
 modify my present views concerning the 
 acquired forms in infancy. The only 
 difference Colles recognized between the 
 acquired and inherited forms in infancy 
 was the liability of the mother, as well as 
 the nurse, to contract the former. In fact, 
 he gives cases where healthy infants were 
 contaminated by infected nurses, and 
 makes no distinction between the syphilis 
 so acquired and that inherited from the 
 parents. Most writers before and since 
 his time have concurred in making no dis- 
 tinction between the acquired and inherited 
 forms in infancy. Diday, however, would 
 
Infantile Syphilis, loi 
 
 seem to have recognized a difference in 
 the two forms, for he writes : " Congenital 
 syphilis does not assume either the be- 
 haviour, the progress, or the concatenation 
 of symptoms of the syphilis of adults. A 
 little observation suffices to show that we 
 have here two diseases, analogous but not 
 identical ; that if their prognosis differ, it 
 is less on account of the age of the subjects 
 they attack than from the nature and cha- 
 racter peculiar to each of them. Producing 
 previous to any characteristic symptom a 
 kind of atrophy or stunted condition of 
 the whole economy, breaking out after- 
 wards at a hundred points at the same 
 moment, accompanied from the first by 
 visceral lesions foreign to acquired syphilis, 
 contagious by its slightest symptoms, con- 
 genital syphilis can only be compared to 
 itself, and it is from its energy, much more 
 than from the weakness of its victims, that 
 we must ask the secret of the special 
 dangers which it involves." Further, again, 
 Diday writes : " Syphilis, so often fatal in 
 new-born children when inherited from 
 their parents, scarcely ever compromises 
 
I02 Some Aspects of 
 
 their existence when it has been acci- 
 dentally innoculated from a primary 
 chancre in an adult." Whilst not agreeing 
 with Diday as to the special virulence of 
 infection attaching to congenital syphilis, 
 I am at one with him regarding the differ- 
 ences between it and the acquired form, 
 and especially so as to the much-diminished 
 constitutional disturbance in the acquired 
 form in infancy. Mr. Hutchinson has no 
 separate description of the symptoms of 
 the acquired form in infants, possibly be- 
 cause he deemed it unnecessary, but in 
 writing of the inherited variety he says : 
 "Excepting in the addition of 'snuffles,' 
 these secondary symptoms are much the 
 same as those observed in the acquired 
 disease." It is not a just assumption from 
 this last that Mr. Hutchinson denies the 
 presence of "snuffles" in the acquired 
 syphilis of infants, as his description of 
 the acquired disease was drawn from that 
 presenting in adults. If, however, his de- 
 scription be intended as universally appli- 
 cable to the acquired form, whether in 
 adults or infants, then the absence of 
 
Infantile Syphilis. 103 
 
 snuffles in the last must be considered as 
 a valuable criterion in differentiating them 
 from cases of the inherited variety, where 
 " snuffles " plays such a frequent and con- 
 spicuous part. According to Dr. Radcliffe 
 Crocker, " Acquired syphilis in children 
 and infants presents much the same 
 symptoms and runs much the same course 
 as in the adult, except that in very young 
 children the bones at the junction of the 
 epiphyses to the shaft are very likely to 
 be the seat of inflammation." With regard 
 to the similarity of the acquired form in 
 infants to that in adults, Kassowitz is in 
 accord with Dr. Crocker, although he goes 
 further in this direction than I gather the 
 latter is inclined to follow. "When a 
 healthy infant," Kassowitz writes, "is in- 
 fected shortly after birth, its syphilis 
 does not differ from that of an adult, but 
 does so most markedly from that of a child 
 of the same age with the inherited complaint. 
 The difference betiveen them, then, one not 
 merely dne to age'' Kassowitz has tabu- 
 lated the differences between the inherited 
 and acquired forms in infancy, and his 
 
I04 Some Aspects of 
 
 enumeration is briefly as follows : i. In 
 the inherited form there is early involve- 
 ment of the abdominal viscera, which 
 involvement is often intra-uterine, and 
 may precede the skin eruption by months. 
 In the acquired form any affection of the 
 viscera is always a late symptom and 
 seldom occurs. 2. In inherited syphiHs 
 there is a peculiar and characteristic affec- 
 tion of the calcifying cartilage and growing 
 bone ; this " epiphysitis " occurs early, and 
 may be intra-uterine. The early appear- 
 ance and extensive distribution of this 
 " epiphysitis " in inherited syphilis have no 
 analogy in the acquired complaint. 3. In 
 inherited syphilis there is frequently diffuse 
 infiltration of the skin, especially of the 
 face, soles, and palms. In acquired syphilis 
 there is no such infiltration observed either 
 in infancy or later age. 4. In inherited 
 syphilis there is a peculiar characteristic 
 appearance and distribution of eruption 
 different from those obtaining in acquired 
 syphilis in infancy. 5. In inherited syphilis 
 vesicular eruptions are frequent, but are 
 never observed in the acquired form. 6. In 
 
hifantile Syphilis. 105 
 
 inherited syphilis prodromal coryza is 
 almost universal, but is absent in the 
 acquired complaint. Such are mainly the 
 criteria by means of which, such a judicious 
 and experienced writer as Kassowitz 
 asserts, a distinction can be clearly made 
 between the inherited and acquired forms 
 in infancy. With most of the distinctions 
 drawn by Kassowitz between the two 
 forms of the complaint in infancy I per- 
 sonally agree. As minor details, however, 
 I cannot regard a vesicular eruption as a 
 common occurrence in the inherited form ; 
 nor can I, after reading Dr. Crocker's 
 cases, lay the same stress as Kassowitz 
 does on the difference between the mani- 
 festations of " epiphysitis " in the two 
 varieties of the complaint. As far as my 
 experience goes, the commonest eruption 
 in acquired syphilis in infants, as in adults, 
 is the well-known roseola and its usual 
 distribution, the same at all ages, viz. the 
 front of the chest, the abdomen, and to 
 a less degree the flexor aspects of the 
 limbs. This syphilitic roseola, admittedly 
 rare in inherited cases, was the form of 
 
Jo6 Some Aspects of 
 
 eruption in seven out of my eight case?. 
 In the remaining one, an infant that had 
 acquired a chancre on the back of the 
 neck from kissing by a syphilitic aunt, 
 and that had in its turn given its mother 
 a chancre on her breast, a universal small 
 pustular eruption broke out all over the 
 body. Along with the rash, too, in most 
 of my cases I found a condition of throat 
 identical with that occurring in adult 
 syphilis ; this is in marked contrast with 
 what happens in the inherited form, where 
 the throat remains, as a rule, unaffected. 
 The chief peculiarities of the symptoms, 
 however, in acquired syphilis in infancy are 
 the scantiness and evanescent nature of 
 the eruption, which may be easily missed, 
 and the subsequent early and luxuriant 
 growth of condylomata. These peculiari- 
 ties of acquired syphilis in children were 
 pointed out by Henoch, who apparently 
 did not deem its manifestations identical 
 with those of the inherited form. Dn 
 Barlow informs me that he has found a 
 difference in the appearances and distribu- 
 tion of the eruption in acquired syphilis 
 
Infantile Syphilis. 107 
 
 in infants from that occurring in the in- 
 herited variety, and that his experience 
 tallies with that of Henoch with regard 
 to the appearance of condylomata in the 
 former complaint. My colleague, Mr. 
 R. W. Parker, too, emphatically asserts 
 the resemblance of the acquired form in 
 infancy to that in adult age, and the mani- 
 fest points of difference in the symptoms 
 to those occurring in the inherited form. 
 In very rare instances it may be that the 
 eruption of inherited syphilis may imitate 
 that of the acquired form, so that a reliable 
 opinion as to which of the two is concerned 
 must be formed from other considerations 
 than the mere rash and its distribution. 
 In contrast to this, in no instance have 
 I seen or learnt of the symptoms of the 
 acquired complaint approximating to those 
 of the typical ones of the inherited variety. 
 I would freely admit, however, in spite of 
 the evidence and authorities I have given 
 as to the differences between acquired and 
 inherited syphilis in infancy, that there is 
 perhaps no one single symptom which 
 would serve as an absolute mark of 
 
io8 Some Aspects of 
 
 distinction between the two complaints. 
 When all the symptoms are, however, 
 taken into consideration, I would contend 
 that sufficient criteria exist in most cases 
 to prevent confusion between them. 
 
 Of the primary chancre, a fundamental 
 necessity for the existence of acquired 
 syphilis in infants, I have as yet said 
 nothing, preferring an attempt to point 
 out the differences between the complaint 
 and the inherited form apart from its 
 consideration. There is, of course, no 
 need to insist upon a chancre as the 
 primary factor in the acquired syphilis of 
 infants, as in adults, before my present 
 audience. Only too often, however, within 
 my personal knowledge, owing to reckless 
 charges against public vaccinators and 
 others, has occasion arisen for the insistence 
 of a chancre and of the necessary incuba- 
 tory periods in acquired syphilis in infants. 
 When the fact is firmly grasped that such 
 syphilis in infants runs the same course, 
 both in its primary and secondary mani- 
 festations, as in adults, most of such 
 charges will cease to be brought or 
 
Infantile Syphilis. 109 
 
 seriously entertained. The vast majority 
 of chancres in infants must, from the 
 nature of the case, be situated on the skin 
 or other external part of the body, and 
 present the same conspicuous features in 
 them that chancres do in adults in the 
 same situations. With the minute ex- 
 aminations that infants undergo for "spot 
 or blemish," usually twice a day, there is 
 small chance in them for a chancre to be 
 passed over by even the most careless 
 mother, no matter how frequently they 
 may be missed in adults. Even when a 
 chancre has passed away, moreover, it 
 leaves visible and tangible traces of its 
 former presence, lasting for months or 
 perhaps years, which are generally easy 
 to find in an infant's tender skin. The 
 sticklers for the rigidity of Colles' law 
 universally allege, when supposed excep- 
 tions to it are brought forward, that such 
 exceptions are cases of acquired syphilis 
 in which the primary chancres have been 
 missed. It is to me a remarkable coinci- 
 dence that it is mainly in such cases, where 
 a presumption of acquired syphilis is made 
 
1 lo Some Aspects of 
 
 to uphold the law, that such conspicuous 
 objects as infantile chancres are missed, 
 and leave no traces behind them, and that 
 there is a total lack of evidence as to the 
 source of infection. In each one of my 
 eight cases there was no difficulty in ascer- 
 taining the original site of inoculation. 
 
 Another special point about acquired 
 infantile syphilis is its power of infection. 
 This I propose to leave until I have dealt 
 with the infectiousness of inherited syphilis, 
 which I now proceed to do. 
 
 On no other point in syphilis has there 
 been more contradictory teaching than on 
 that of the infectious nature of the lesions 
 of the inherited form. Whilst some authori- 
 ties have described inherited syphilis as 
 exceptional in the contagious property of 
 all the lesions it engenders, others have 
 denied the contagiousness of inherited 
 syphilis at all. Since the works of Diday, 
 however, his teaching has apparently been 
 accepted as the standard one, and the 
 extreme virulence of the contagion of in- 
 herited syphilis has been promulgated by 
 most writers, many of whom I suspect in 
 
Infantile Syphilis. 1 1 1 
 
 this instance were more influenced by the 
 authority of accepted doctrine than by 
 the result of their personal experience. 
 The opinions of the older writers on the 
 point are difficult to gauge, as they classed 
 cases of transmission from infant to nurse 
 with those of transmission from nurse to 
 infant, and seemingly deemed any dis- 
 crimination between the two classes as 
 of little moment. Hunter, in the days 
 when he still believed in the reality of 
 inherited syphilis, denied the possibility 
 of transmission from the infant to another 
 person. The elder CuUerier and most 
 authorities up to the time of Colles would 
 seem to have agreed with Hunter on this 
 point. When Colles, however, published 
 his book in 1837, he rudely upset the 
 prevalent belief in the non-contagiousness 
 of inherited syphilis. It was, according 
 to him, the peculiar virulence of the con- 
 tagion of infantile syphilis that distin- 
 guished this last from the adult type. It 
 was not necessary, he wrote, for a woman 
 to suckle a syphilitic infant to acquire the 
 complaint from it — it was sufficient for 
 
T 1 2 Some Aspects of 
 
 any one to do so merely to dress, handle, 
 kiss, or fondle such an infant. In fact, he 
 would seem to have imagined the mere 
 presence of such an infant as a menace to 
 the unprotected, and to have believed in 
 a real " aura syphilitica " emanating from 
 it. More than this, he again writes : " The 
 members of the nurse's family may also 
 contract the disease, and more easily than 
 she, for this disease seems to acquire more 
 force the further it becomes removed from 
 its first origin." Most of Colles' personal 
 observations are of little value now, as he 
 indiscriminately mixed up cases of acquired 
 and inherited syphilis in infants, and drew 
 deductions from them as though they were 
 of identical nature. He did not, moreover, 
 acknowledge a primary chancre as a neces- 
 sary part in the contraction of syphilis by 
 an adult. For him to diagnose syphilis in 
 a woman suckling an infected child, it was 
 sufficient that she had ulcers or other sores 
 about the nipples, and he remarks the 
 curious fact that in such cases the disease 
 often limited itself to these manifestations 
 on the breasts. Diday, following in the 
 
Infantile Syphilis. 113 
 
 same steps as Colles, went even beyond 
 the last, if possible, in his estimation of 
 the power of contagion of inherited syphilis. 
 "I have already stated," he writes, **and 
 hope to prove it, that the lesions of con- 
 genital syphilis differ from those of ordinary 
 syphilis by an infinitely greater power of 
 contagion. And what is at the same time 
 remarkable and deleterious in them is that 
 they transmit the same property to the 
 person who receives the disease from 
 them." He considers this virulence of 
 contagion so well established that, if he 
 saw a woman presenting signs of con- 
 stitutional syphilis transmit them to her 
 husband, the suspicion would at once arise 
 in his mind that they were congenital in 
 character, and derived from a child with 
 inherited syphilis nursed by her. If, more- 
 over, he learnt that a nurse had given 
 syphilis to several men, he would consider 
 that there were sure reasons that she had 
 acquired the disease, not by coitus, but 
 from suckling an infected nursling. He 
 writes of the infection of nurses as being 
 of daily occurrence, of thousands of 
 
 I 
 
114 Some Aspects of 
 
 examples of it being readily adducible, and 
 he gives accounts where the presence of 
 a single case of inherited syphilis has pro- 
 duced in healthy rural communities out- 
 breaks of syphilis that can only be described 
 as "volcanic," from the suddenness of their 
 incidence and the numbers that were 
 attacked. Notwithstanding the confidence^ 
 and dogmatism with which Diday wrote, 
 there were even in his own time authorities 
 who differed strongly from him, and Ricord, 
 the younger Cullerier, Bassereau, and 
 others would seem to have regarded the 
 contagion of inherited syphilis as a chimera. 
 Maissoneuve and Montanier, too, declare 
 that " doubt is no longer permitted " as to 
 the non-contagiousness of inherited syphilis. 
 Diday quotes all these last named, and, in 
 the face of their writings, it is difficult to 
 appreciate the following remark of his : 
 "All observers have pointed out the pro- 
 pagation of the symptoms by the slightest 
 contact with the new-born child to the 
 nurse, and it is not uncommon to see two 
 or three families victims to the presence 
 of a single syphilitic suckling." As to the 
 
Infantile Syphilis, 1 1 5 
 
 reliance and value to be placed on Diday's 
 opinion on the point, the following con- 
 troversy is both instructive and interesting : 
 "Remark well," Ricord writes, ''that I do 
 not absolutely reject this mode of trans- 
 mission from the foster-child to the nurse, 
 and from the nurse to the foster-child. I 
 only say, without leaving the field of strict 
 observation, and of the exact analysis of 
 facts, that this mode of transmission is 
 not yet proved." Diday rejoins, " I have 
 no difficulty in acknowledging with him 
 (Ricord) that among the clinical facts ad- 
 vanced in proof of this mode of contagion 
 there is not one which is thoroughly de- 
 monstrative, there is not one in which the 
 daily observations of the symptoms — on 
 the one hand in the nurse, her relations, 
 and those around her, on the other, in the 
 child, its father and mother — render it 
 evident that symptoms really constitutional 
 have passed from the one to the other ; 
 but — and in this I regret to differ from 
 Ricord — I am inclined to think that if the 
 conclusive fact be wanting, probable facts 
 abound, and that to such an extent as to 
 
ii6 Some Aspects of 
 
 make up by their number for the absence 
 of the former." In the face of his ** thou- 
 sand histories of infectious lactations fur- 
 nished daily by experience," Diday's 
 inability to adduce one single conclusive 
 example is both startling and inexplicable. 
 His evidence of the conveyance of syphilis 
 by nurslings, too, is not convincing in the 
 light of our present knowledge. "Primary 
 chancres/' he writes, "exist in a very small 
 minority of cases of nurses infected by 
 infants. Mucous tubercles form the earliest 
 symptom in each." It is significant, too, 
 in his cases, as in those of Colles, that the 
 syphilis contracted by nurses from infected 
 infants very often remained confined to the 
 affected breast, and never manifested itself 
 by symptoms elsewhere. But the disparity 
 between the dogmatism of Diday on the 
 virulence of the contagion of inherited 
 syphilis and the proofs he adduces for it 
 is only one amongst many inconsistencies 
 that are to be found in his writings. It 
 may be said that, feeling as I do regarding 
 some portions of these writings, I have de- 
 voted too much time to their consideration. 
 
Infantile Syphilis. 117 
 
 But as Diday's views are still commonly 
 held, and he is largely quoted, no one 
 can afford to lightly ignore him. I will 
 proceed to discuss at less length some more 
 recent opinions on the important point at 
 issue. 
 
 Henoch considers the occasional trans- 
 ference from infant to nurse as proven. In 
 his own vast experience, however, he had 
 never known an instance of it. Fournier 
 writes as if the contraction of syphiUs from 
 cases of the inherited disease were ex- 
 tremely common and of daily occurrence. 
 An infant with this complaint, he asserts, 
 would not infect its mother, but would 
 almost infallibly infect a healthy nurse. 
 In fact, Fournier would seem to be a living 
 exponent of Diday's views as to the viru- 
 lence of the contagion of inherited syphilis. 
 Mr. Hutchinson says that if an infant suf- 
 fering from inherited syphilis be suckled 
 by a nurse free from taint, " the risk is 
 great that a nipple chancre will result." 
 But as he further says that he has only 
 known " perhaps half a dozen " nipple 
 chancres altogether, his words would seem 
 
ii8 Some Aspects of 
 
 to me to exaggerate the risk incurred, 
 more especially when his large experience 
 is taken into consideration. Most latter- 
 day writers are in accord with Mr. Hut- 
 chinson, and in recent text-books inherited 
 syphilis is described as '' eminently con- 
 tagious," or in kindred words to the same 
 effect. 
 
 At the present time there would seem 
 to be a growing opinion that the virulence 
 of contagion of inherited syphilis has been 
 vastly exaggerated both in text-books and 
 by authorities, and that the contraction of 
 the complaint by a healthy person from a 
 tainted infant is an extremely rare occur- 
 rence. Some two years back I published 
 a case of supposed exception to Colles' 
 law, the weak points in which were justly 
 and forcibly dealt with by Dr. George 
 Ogilvie. His latest description of it as 
 " not absolutely conclusive " I think a 
 decidedly appropriate one for the case. If 
 this case be rejected, however, and the sup- 
 position that the infant was really suffering 
 froin acquired and not inherited syphilis 
 be maintained, then I have personally 
 
Infantile Syphilis. 1 1 9 
 
 never known an instance where syphilis 
 was contracted from an infant with the 
 inherited complaint ; and this in spite 
 of many thousands of healthy children 
 and adults having been exposed to infec- 
 tion from cases under my care. To ascer- 
 tain if my experience was in any way 
 exceptional in this respect, I have made 
 inquiries of present and former colleagues 
 at the East London Hospital for Children, 
 all of whom have had a large acquaintance 
 with cases of inherited syphilis. The re- 
 sults of my inquiries are so much at 
 variance with prevalent belief that I feel 
 it incumbent upon me to give the names 
 of the gentlemen I consulted, and this, I 
 may state, is done with their full consent. 
 My senior medical colleague, Dr. Eustace 
 Smith, has only known one instance where 
 syphilis was contracted from an inherited 
 case, and this was one where an infant 
 infected its own mother. The case was 
 seen by the late Mr. Berkeley Hill, who 
 demonstrated to his own satisfaction, but 
 not to that of Dr. Smith, that the infant 
 was suffering from acquired and not 
 
I20 Some Aspects of 
 
 inherited syphilis. Dr. Smith still believes 
 that the case was one of exception to 
 Colles' law, and apart from it has never 
 known syphilis contracted from the in- 
 herited disease. Dr. Donkin, Dr. Dawson 
 Williams, Dr. Arnold Chaplin, and Dr. 
 J. A. Hayward have ne\^er known an 
 instance where an infant with inherited 
 syphilis has infected another person. Dr. 
 Johnstone Campbell has known one case 
 of exception to Colles' law, which he pro- 
 poses to publish when at greater leisure, 
 but no other example of infection from 
 inherited syphilis has come under his 
 notice. Dr. Radcliffe Crocker has known 
 one instance where an infant with inherited 
 syphilis contaminated its foster - mother 
 and her daughter. Mr. R. W. Parker has 
 stated that he had seen a case of exception 
 to Colles' law, but no other example of 
 infection from inherited syphilis. Messrs. 
 L. A. Dunn, W. H. Battle, and H. Betham 
 Robinson have never known syphilis con- 
 tracted from a case of the inherited disease, 
 and present and past resident medical 
 officers — Messrs. P. C. Phillips, Scott 
 
Infantile Syphilis, 121 
 
 Battams, and Dr. E. E. Ware — reply to 
 the same effect. Now, the experience at 
 the East London Hospital for Children 
 of the gentlemen I have named added to 
 my own represents a joint experience of 
 some thousands of cases of inherited 
 syphilis. These syphilitic babies in the 
 East of London, too, are indiscriminately 
 suckled by other women besides their own 
 mothers, and are freely kissed and fondled 
 by numerous persons, who thus expose 
 themselves to infection from this pre- 
 sumedly eminently contagious disease. 
 That the sole result, as far as could be 
 ascertained, of many thousands of ex- 
 posures to infection should be only five 
 examples of the incurrence of syphilis, and 
 that of these four should assume the form 
 of exceptions to Colles' law, seems to me 
 noteworthy and surprising in the extreme. 
 If, as usually happens, these four examples 
 of exception to Colles' law be curtly re- 
 jected as unreliable, then I can learn only 
 one instance where syphilis has been con- 
 tracted from a case of the inherited com- 
 plaint at a large children's hospital where 
 
122 Some Aspects of 
 
 inherited syphilis is rife amongst the in- 
 fantile patients, and where adult women 
 are frequently treated for the acquired 
 disease. I have no reason, either, to suspect 
 that our experience at Shadwell is peculiar. 
 Dr. Barlow and many others of large ex- 
 perience tell me that they have never 
 known the contraction of syphilis by any 
 one from an infant suffering from the in- 
 herited complaint. Lately I have pestered 
 all my friends with questions on this point, 
 and as the outcome I have learnt of two 
 other solitary examples of its occurrence. 
 My friend. Dr. John Thomson of Edin- 
 burgh, tells me he knows a case where a 
 lady contracted a chancre upon her lip 
 from kissing a grandchild with inherited 
 syphilis, the father of the infant having 
 incurred the disease about three years 
 before marriage. Dr. W. S. Colman, too, 
 tells me he knows a case where a baby 
 with inherited syphilis infected its nurse. 
 But three cases go but a little way to 
 justify the descriptions usually applied 
 to the power of contagion of inherited 
 syphilis, especially when the experience 
 
Infantile Syphilis. 123 
 
 and standing in the profession of those 
 from whom I inquired are taken into 
 account. That inherited syphilis is occa- 
 sionally contagious is certain, but it is 
 equally certain, I would contend, that the 
 virulence of such contagion has been grossly 
 and vastly over-estimated. It is impossible 
 to reconcile the experience of certain 
 French writers in this respect with our 
 experience in this country, even when the 
 greater frequency of wet nursing in France 
 is fully admitted. 
 
 There are certain reasons, or sugges- 
 tions rather, by which I think the infre- 
 quency of the contraction of syphilis from 
 infants suffering from the inherited com- 
 plaint can be partially explained. The 
 syphilis in such infants, it must be remem- 
 bered, dates from conception and not from 
 birth, and at the age at which symptoms 
 appear such a syphilis is generally of 
 about a year's standing, and may have 
 lost some of its pristine virulence during 
 both uterine and extra-uterine existence. 
 If the views I expressed in my first 
 lecture, too, be considered as worthy of 
 
124 Some Aspects of 
 
 any consideration, then it may be that 
 some product absorbed by the mother 
 during her first pregnancy may influence 
 the succeeding conceptions, and thus 
 largely modify the disease in the infants 
 resulting from them and its power of 
 contagion. In this way I should expect 
 a first infant more likely to convey the 
 disease to others than succeeding ones, 
 and I have a general impression that the 
 histories of recorded authentic cases of 
 such infection confirm this opinion. That 
 the power of infection is possibly in some 
 measure confined to the first infants in 
 a family may help to partially explain 
 the rarity of infection. Another reason, 
 and a much weightier one, for the infre- 
 quency of infection from inherited syphilis 
 is the rarity of specific sores about the 
 mouths of infants, a fact which has been 
 pointed out by Dr. Colcott Fox, Henoch, 
 myself, and others. Even when such 
 sores do appear they are a comparatively 
 late manifestation, seldom occurring before 
 the age of six months, and by this period, 
 in the vast majority of instances, both 
 
Infantile Syphilis. 125 
 
 treatment and time have probably so 
 modified the complaint that conveyance 
 to others is either in abeyance or annulled. 
 It may be that the nasal secretion and 
 that of mucous tubercles are infectious, 
 but as the latter are a late manifestation 
 the same reasoning applies to them as 
 to sores in the mouth, and there are 
 obvious reasons why the nasal secretion 
 is not often encountered. The reasons 
 I have given are, I admit, totally inade- 
 quate for a full explanation of the extreme 
 rarity of infection from inherited syphilis ; 
 and, whilst I consider that rarity estab- 
 lished, other grounds for it than those I 
 have suggested are still to be sought. 
 
 In marked contrast to the rarity of 
 infection from inherited syphilis is its 
 frequency from the acquired form in 
 infants. Only one instance is within my 
 personal knowledge where a syphilis ac- 
 quired by an infant was not communicated 
 to one or more persons brought into con- 
 tact with the child. Numerous instances 
 are on record, from the time of Ambroise 
 Pare onwards, where infantile acquired 
 
126 Some Aspects of 
 
 syphilis has been the cause of severe 
 outbreaks amongst relatives and friends. 
 Recently I learnt of one in the East of 
 London where acquired syphilis in a child 
 spread to five others in the same family 
 besides strangers. Some of the best 
 authenticated cases, too, recorded by Colles 
 and Diday, who contended for the greater 
 virulence of the inherited form, occurred 
 where numerous persons contracted the 
 disease from an infant with the acquired 
 disease. In fact, it would seem to me 
 that what these writers really contended 
 for was more the extra virulence of in- 
 fantile syphilis generally than for any 
 difference between those of the acquired 
 and inherited forms. Although the pre- 
 sence of acquired syphilis in an infant 
 is the more dangerous to the community 
 at large, there is, I need hardly say, no 
 difference in virulence between such a 
 syphilis and that acquired by an adult. 
 But the presence of the dread disease 
 in an innocent-looking baby is so seldom 
 suspected that generally one or more 
 persons are contaminated before the truth 
 
Infantile Syphilis. 127 
 
 is discovered — a condition of affairs that 
 does not often occur in the case of adults. 
 So nearly constant, however, is the in- 
 fection from an infantile acquired case, 
 and so extremely rare that from one of 
 the inherited form, that, in the lack of 
 criteria, a diagnosis between the two 
 varieties might almost be made from the 
 presence or absence of infection in most 
 instances. 
 
 The few minutes remaining at my dis- 
 posal I will devote to some brief con- 
 siderations of Colles' law. This law in 
 reality consists of two separate parts, the 
 one that the mother of an infant with 
 inherited syphilis cannot contract the dis- 
 ease from her own child, and the other 
 that such an infant would almost infallibly 
 contaminate a healthy wet-nurse. The 
 fact of the inclusion of this second pro- 
 position is generally forgotten by writers 
 contending for the absolute validity of the 
 law. In dealing with the contagiousness 
 of inherited syphilis, I endeavoured to 
 show that this part of the so-called law 
 is far from true. It may well be, then, 
 
128 Some Aspects of 
 
 that the main safety of the mother lies 
 in the little liability of the infant to 
 transmit the disease rather than in some 
 protective quality residing in herself, due 
 to the fact of her having borne a syphilitic 
 infant. For my part I think both such 
 factors possibly conduce to the safety of 
 the mother. Is the first part of Colles' 
 law absolute? Has an infant with in- 
 herited syphilis never contaminated the 
 mother.'* In Colles' own practice, and in 
 those of others since his day, cases have 
 from time to time occurred which were 
 apparently exceptions to the law. Some 
 of these cases are so imperfectly recorded 
 that discussion of them is hardly called 
 for. Others, on the contrary, Dr. George 
 Ogilvie writes, " are as conclusive as any 
 recorded clinical facts can be." Fournier, 
 somewhat grudgingly it would seem to 
 me, admits the validity of some such cases, 
 and he would appear to regard the subject 
 of exceptions to Colles' law as of little 
 practical importance on account of the 
 extremely exceptional character of such 
 exceptions. Mr. Hutchinson has lately 
 
Infantile Syphilis, 129 
 
 stated that he not only admits the possi- 
 bility but the probability of these excep- 
 tions. I am the more pleased at this 
 admission in that it places him in accord 
 with Fournier and other authorities in the 
 matter, and that it is also in some sense 
 a further justification for the belief m 
 myself and others that we have actually 
 met with exceptions to Colles' law. Mr. 
 Hutchinson's sole contention is, I believe, 
 that as yet no exceptions have been re- 
 corded worthy of trust. I am unwilling 
 to differ from him, but I must state my 
 conviction that Dr. George Ogilvie's ad- 
 mirable paper at the Royal Medical and 
 Chirurgical Society is conclusive on the 
 point. Granted the possibility of excep- 
 tions to Colles' law, ought such eminently 
 infrequent occurrences to largely modify 
 our practice in allowing apparently healthy 
 mothers to suckle tainted infants? Per- 
 sonally, I should say decidedly not. In 
 my second lecture I emphasized the impor- 
 tance of maintaining the nutrition of the 
 infant, and for this purpose no factor is 
 more essential than the mother's milk. 
 
 K 
 
130 Infantile Syphilis, 
 
 If ever legislation for the many to the 
 detriment of a limited few is justifiable, 
 the case in question calls for it. Following 
 in the same path as Henoch, the only 
 limitations I would place on suckling by 
 mother or wet-nurse would be the presence 
 of excoriations on her nipples, and that of 
 ulceration or fissures about the moiith of 
 the infected infant. 
 
 In conclusion, I have to apologize for 
 the disjointed and fragmentary character 
 of these lectures. In reality they deal 
 with only a very limited portion of the 
 subject of infantile syphilis. Important 
 questions, such as diseases of the nervous 
 system, vaccinal syphilis, prognosis, treat- 
 ment, and many others, I have preferred 
 to altogether omit rather than to attempt 
 to treat in a perfunctory manner. In 
 fact, my selection has been manifestly 
 based on controversial grounds rather 
 than any other. 
 
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