Ls i oS oe fi i on LU tio Ba i SE SN ee aay Af, CAT eS , egy LE ite? bie Bip Ly, i) 2 bi p iy Pees, Lae Tee ae i So, ih fy LG a Uf fee < c Nighy f Seite i 5 5 ih PET I Et LEIS a ES ITE oie Ba IR Cornell University Library BOUGHT WITH THE INCOME FROM THE SAGE ENDOWMENT FUND THE GIFT OF Henry W. Saqe 1891 A-W9 411 el EL oe Cornell University Library RC 201.3.D55 1859 w-born child ~ Wii I a DATE DUE GAYLORD PRINTEOINY.S.A. v/) 5)7 THE NEW SYDENHAM SOCIETY. INSTITUTED MDCCCLVIII. VOLUME I. A TREATISE ON SYPHILIS IN NEW-BORN CHILDREN AND INFANTS AT THE BREAST. BY P. DIDAY, SURGEON TO THE HOSPITAL DE L’ANTIQUAILLE, LYONS. TRANSLATED BY .G. WHITLEY, M.D. THE NEW SYDENHAM SOCIETY, LONDON. MDCOCLIX. \\ 49 cay 7 $ A. 4a yl PRINTED BY J. E. ADLARD, BABTHOLOMEW CLOSE. um AUTHOR’S PREFACE TO THE ENGLISH TRANSLATION. Havine learnt accidentally that this work is being translated in England, I have requested the honour of adding a few lines thereto for the purpose of expressing the feelings with which this informa- tion has inspired me. If anything could add to the satisfaction which an author derives from so explicit and spontaneous a token of approval, it might assuredly be found in the circumstance that such approval is accorded by a Society which, in giving it, cannot be suspected either of acting from mere complaisance, or of yielding to solicitation, but which answers only to the calls of a pure love of science. I may perhaps be permitted to observe that, in conferring upon my work this high encomium, the New Sydenham Society will, at the same time, unintentionally have caused a part thereof to redound to their own countrymen. Of the clinical records and theoretic generalisations, the ensemble of which may give some value to my work, none have been furnished me in such great number or of a character so valuable as those by the specialist writers of Great Britam. . Since the publication of my ‘Treatise on the Syphilis of New- born Children and of Infants at the Breast,’ I have not had either to record or to discuss any considerable opposition to the principal points set forth in it. If several explanations which I had myself vi PREFACE. given with every reservation, and rather as probable than demon- strable, have been criticised, the practical facts which I have brought forward have not been contested. The transmission of the poison by the foetus to the mother, denied at that time, has now become admitted, if I may believe the development which this principle has received from various authors; in the first rank amongst whom justice requires that I should mention Mr. Jonathan Hutchinson and Mr. Victor de Méric. The doctrine of transmissibility between nurses and sucklings, plainly enunciated by me, has not been seriously disputed, neither can it, as I conscientiously believe, be disputed by candid prac- titioners. The contagiousness of congenital syphilis is, then, placed beyond doubt ; arid at the same time that it is an accepted principle, so it is one of the most important, as may be seen from an examina- tion of the consequences I have attributed to it (in my recent work") in the explanation of cases of the transmission of constitutional symptoms in adults. All these truths could not remain, and have not remained without influence on practice. Although my position as an author obliges me to allow myself to be judged without developing my means of defence, I cannot, nevertheless, resist the temptation of recom- mending more particularly to my readers the conclusions which I draw (Part V, Chap. I, Section I) concerning the data by which an individual who has had syphilis will be able to recognise whether he is in a state to beget healthy children. No doubt it is a language less reassuring than that held by the earlier writers on syphilis, persuaded as they were of the indispensability and the infallibility of mercury; but my experience and my conscience forbid me to speak otherwise. Upon these various questions, however, light continues to fall from all countries and from all minds. However carefully matured a book may be, it cannot reproduce the scientific movement of its epoch. If it pretend to have fixed this movement, it is in danger ! «Exposition critique et pratique des nouvelles doctrines sur la Syphilis,’ Paris, 1858, 1 vol. en 12, chez J. B. Bailliére et fils. 4 PREFACE. vil of impeding it. Imbued with this truth, I have sought to utilize the relations which my position as a journalist procures me; and, in concert with my honorable friend and colleague, Dr. Rollet, at present head surgeon of the Hospital de lV Antiquaille, I shall pub- lish annually a volume,’ in which will be collated and discussed all the details of progress effected during the year in this branch of medical science, so interesting to those who cultivate it with the love of truth and the feeling of duty. P. DIDAY. Lyons; December 20th, 1858. 1 ¢ Annuaire de la Syphilis et des Maladies dela Peau.’ The first number of this Yearly Miscellany will appear in February, 1859, J. B. Bailliére and Son, Paris, : . , 2.8 pe abet CONTENTS. : PAGE InTRODUCTION ‘ . : F . 3. db PART I—ATIOLOGY. CHAPTER I. Hisroricat Notice ‘ : ‘ : so et CHAPTER II. Derryit1on—Drvision : Concewrran SyPHinis—Acquirep SyPHinis. 14 Section A.—ConcENITAL SYPHILIS ‘ ‘ . I.—Influence of the father’ . ‘ - ‘I4 IL.—Influence of the mother . 22 A. Influence of the mother infected before the ‘moment of conception . - 22 B. Influence of the mother ‘infected after conception - 22 ILI.—Combined influence of both parents ; - 32 Section B.—AcquinepD SYPHILIS . a ‘ - aan T.—Infection during labour. , : . 86 IL.—Infection by lactation . : . . 89 4. By a morbid lesion in the nurse . F . 39 B, By the milk . : 3 ‘ 43 III.—Infection from accidental causes. ‘ - 49 4. By a primary sore in the nurse. - 50 B. By a stranger the subject of a primary hianors - 51 c. Bya person affected on or mene with eee syphilis . . 58 p. By inoculation 3 . . . 54 x CONTENTS. PART IIl.—DESCRIPTION. CHAPTER I. DerarneD and DraGnostic INDICATION OF EACH LESION I.—Primary chancre II.—Buboes IiI.—Exanthemata TV.—Mucous patches A. On the skin i B. On the mucous membranes . V.—Papule and squame Vi—Pustules . VIL—Bulle . ; 3 VIIL—Syphilitic cdryza . : IX.—Onyzis . X.—Lesions of the osseous s system : XI.—Characteristic general appearance ‘ XI1.—Lesions of the viscera : : A ‘ a. Lesions of the lungs . Suppuration of the thymus end . Lesion of the liver Peritonitis bow pe CHAPTER II. PROGRESS OF THE DISEASE L—Period of its appearance i II.—Relation of the iit of the disease to its particular mode of origin . III.—Relation of the progress of the disease to the period of the _ diathesis in the parents at the time of its transmission IV.—On retarded or masked congenital syphilis A. May hereditary syphilis fail to produce its first symptoms until several years after birth? z. Can hereditary syphilis manifest its action by morbid effects other than the characteristic symptoms of venereal disease ? PART IT1.—PROGNOSIS. CHAPTER. I. ZETIOLOGICAL PRoeNoOSIS 97 97 102 109 114 114 119 128 CONTENTS. Rl CHAPTER IL. PAGE SEMEIOLOGICAL PRoeNosis 2 P , . 135 I—Abortion . s ‘ : . 135 IE.—Death after birth . . 139 III.—Gradual diminution of the focticidal action of the poison . 140 IV.—Transmission of syphilis from the feetus to its mother . 146 V.—Transmission of syphilis from the suckling to its nurse . 154 VI.—Transmission of syphilis from the new-born child to indifferent persons . . : aa a - 183 PART IV.—MEDICO-LEGAL BEARINGS. ELEMENTS OF THE JUDGMENT OF AN EXPERT ‘ , . 187 I—Morality . ' : , - 188 IL.—State of health, previous and present : . . 189 A. On the part of the parents . . ; - 189 B. On the part of the nurse. 190 HI—State of health of the persons exposed to contracting sil from the same source: : 191 IV.—Nature of the symptoms . : ‘ . 192 V.—Seat of the symptoms 193 VI.—Comparative date of the apimptoms in the nurse ‘and i in the infant at the breast ‘ : : . 194 VII.—Absence of primary symptoms : : . 195 VIT.—Presence of primary symptoms | : ‘ - 196 TX.—Absence of interested motives é : . 199 Le Conclusion ‘ ‘ F ‘ , . 200 PART V et BES TMNT: "CHAPTER I. PREVENTIVE TREATMENT : 2 F ; . 207 Section I.—To PREVENT A CHILD CONCEIVED, BORN, OR REARED UNDER CONDITIONS WHICH EXPOSE IT To SYPHILIS FROM BEING ATTACKED THEREBY : ‘ . 207 I.—Conditions dependent upon conception ; . 207 First case: before marriage . ; ; - 207 Second case: after marriage . . . - 212 Third case : after conception . : : . 214 2 INTRODUCTION. mechanism of its first effects, and the circumstance ‘that its usual termination, at this age, is death, have naturally rendered special writers the more assiduous in their researches. Its history also, though somewhat modern as compared with that of general syphilis, is already rich in valuable monographs. A condition inherent in its very nature has hitherto, unfortunately, impeded the study of this disease, and appears to weigh fatally upon its nosological future. Profiting by the necessary obscurities of the subject, dogmatical writers have too often abused the oppor- tunities of bringing forward hypotheses which they boldly urged as proved, simply because it had been impossible to demonstrate their incorrectness. Some have described congenital syphilis as a condition apart; exceptional in its etiology ; exceptional in its capability of destroying the fcetus without leaving any traces of its presence ; exceptional in that its symptoms entirely elude the classification by periods so justly established in the adult; excep- tional in the contagious property of ad the lesions which it engenders, Others, on the contrary, resuscitating the theory of analogues, admit the most perfect identity between the characters of foetal poisoning and those of the diffusion of the poison of a chancre in an adult who has contracted it. In the propagation of the disease from parents to their children, they see only the phenomena of ordinary contagion. They follow, step by step, the transit of the infectious agent through the absorbents, in the embryo as in the adult. In the evolution of disorders which sometimes prove fatal in a few days, they still find time and space to distinguish a secondary and a tertiary phase. Lastly, they deny the transmis- sibility of congenital syphilitic lesions. If both parties had been content to accept experience, consulted freely and without afterthought, as an arbiter, we should rather have had reason to congratulate ourselves upon these dissentions, which, by evoking controversy, stimulate to investigation and accelerate the triumph of the good cause. But it would show great ignorance of our science and our age to imagine that truth could long remain intact in the midst of this conflict of rival opinions. The study of infantile syphilis ought to be an end; and it certainly appeared sufficiently important to satisfy the ambition of investi- gators, sufficiently arduous for all their zeal. Far from this; it has become either a means by which to arrive at a general theory of INTRODUCTION. 3 syphilis, or, in the eyes of some, an obstacle, a stumbling-block for a doctrine, proof, until then, against any serious objection. What has been the result? Animated by discussion, neither party has remained within the bounds of moderation. The solution of this pathological problem having thus degenerated into the proportions of one of those detail theorems intercalated to con- tribute to a main proof, every one has used the weapon in his own way or according to his own interests. As a means, its signification was strained; as an obstacle, men sought to avoid it or to over- throw it. Thus, instead of observing first, and then drawing their conclusions, they boldly took the latter step, and then sought to conform observation to these hastily formed opinions. Thus— common rock, upon which split all systems arrived at the acme of their fortunes—we have seen the best minds, forgetting the laws which they had themselves promulgated to the satisfaction of all, dispute the most adequate diagnostic signs; assume fraud where -ignorance alone is responsible; assert the existence of immorality solely because its opposite is not easily demonstrated; set down, amongst all the instances of fcetal contagion, each of its victims as culpable; repudiate the most respectable evidence, the universal assentment, and the unanimous decision of all the authorities; refuse, in a word, to look at what is shown to them, that they may admit only what they wish to see. The worst effect of this error—one with which each party may equally be reproached—is, that it tends to compromise indefinitely the future of science, by corrupting the sources them- selves at which it might be purified. With this pertinacity in torturing facts—which strips them emulously, on both sides, of what is true in them, to leave them only what appears probable to each party—the elements of an exact history of congenital syphilis are, at the present day, very difficult to collect. Very few con- temporary observations have been collated without the intention of supporting or attacking some theory, and as much precaution is required in the choice of them as discernment in their interpretation. In respect to some, the name of their reporter suffices to give the measure of the confidence they deserve. In others, it will be prudent to correct, by the aid of their indifferent circumstances, the exactness of those which may have been altered or assumed to suit a purpose. In others again, we may take the fact but reject the explanation of it. And it will, in the end, be safer, in disputed 4 INTRODUCTION. questions, to rely by preference upon the experience of the older writers, who, wifettered by the systematic preoccupations of our period, relate simply what they have seen, and not what has been taught them. Thus to defend the rights of observation against the pretensions of theory is the duty of every cultivator of medical science, and one which the practice of our art furnishes us only too many opportunities of fulfilling. But the obligation becomes more imperative and sacred when, as in the case of congenital syphilis, the usurpations of imagination over reality reveal themselves in the form of irreparable injuries to the health, the lives, and the honour of individuals, families, and nations. A man has just been cured of syphilis: how soon can he procreate safely? One, two, three successive pregnancies have terminated before the full time in the expulsion of an atrophied and, as it were, blighted fetus. Is this a sign of venereal disease in the mother—a sufficient reason for subjecting her to specific treatment? A child is born covered with characteristic blots. Can we, without scruple, give it to a healthy woman to suckle? A nurse, previously robust and free from any venereal antecedents, presents ulcerations on the breasts having some resemblance to chancres. One school affirms that they are primary, and cannot be anything else. Must we accept its dictum, and deny that they may have resulted from suckling a syphilitic child, abstaining, consequently, from giving mercury to this woman? ‘These are some of the hundred questions which practice daily evokes. But to these problems, which ask for and com- mand an exact solution, experience often answers in the affirmative —a given doctrine in the negative. It is not surprising, then, that when it beeomes necessary to choose between two such advisers, our choice is always made in favour of the fact against the pretended right. We may take pleasure in the spectacle of the human mind labouring to develop its synthetic creations ; we may ourselves sometimes yield to temptation, and risk some steps on this path. But, in the face of dangers so grave, the interest of a system pales before that of humanity : positivism is no longer the mere desire of the philosopher, it rises to the rank of a social necessity, and everything must be placed in subordination to its laws. Such, at least, is my opinion; such will be my invariable rule of conduct in the course of this work. To embrace in a complete and methodical classification the INTRODUCTION. 5 numerous points connected with the history of syphilis in new-born children, this work has been divided into five parts : The first is devoted to studying the mechanism of the develop- ment of the disease, its different origins, and the respective part played by each of them in its ulterior evolution—tiology. The second comprises the description of the various forms, and’ no less variable progress of the disease—Semeiology. The third treats of the dangers peculiar to syphilis at an early age, of the transmissibility of the lesions which it occasions, and of the mortality which it causes—Prognosis. The fourth is more especially devoted to the discussion of the questions to which cases of this kind frequently give rise in courts of justice—Medico-legal bearings. The fifth explains the treatment in all its details: preventive treatment; curative treatment; treatment direct or indirect; treat- ment of the child, the parents, and the nurse; prophylaxis to be employed by persons having relations with the infected nursling, &c.— Treatment. ON SYPHILIS IN NEW-BORN CHILDREN AND IN CHILDREN AT THE BREAST, PART L—ATIOLOGY, CHAPTER JI, HISTORICAL NOTICE, Ir is necessary, before discussing the opinions which actually obtain concerning the various modes of transmission of syphilis to infants, to inquire what foundation these opinions’ have in the views of our predecessors; by what means they have successively become established or discredited in the minds of medical men; and whether those which now, from their early date, appear most respectable, are the result of serious observations or the product of popular prejudices. But this historical notice, which was only touched upon by Mahon and Bertin, presents to us, at the outset, this singular fact, z.: that the truth, caught sight of for a moment and clearly ‘sketched out by the writers of the first period, soon became obscured by the speculative views which sacrificed the study of the objective phenomena of the disease itself to rash inquiries into its primordial cause, so that it afterwards required a complete change in the processes of scientific research to reunite the broken chain of sound traditions, and to place upon a firm basis the etiological determination of congenital syphilis. 8 ON SYPHILIS IN NEW-BORN CHILDREN. According to Mahon, Mathiolus (1536) was the first writer who mentioned the existence of syphilis in new-born infants. How- ever, towards the end of the fifteenth century, Gaspard Torella (1498) wrote: “In pueris lactantibus prima infectio apparet in ore aut in facie; et hoc accidit propter mammas infectas, aut faciem, aut os nutricis, seu alicujus alterius. Solent enim nutrices sepius infantes osculari, et sxpius vidi infantem infectum hoc morbo multas nutrices infecisse.” In this passage he makes no allusion to the doubtful infection by the milk. The expression “ propter mammas infectas” clearly proves that he admits of no transmis- sion except by the contact of a local sore in the nurse with some part of the body of her suckling. Cataneus (1505) believed firmly in the infectious influence of the nurse’s milk, and advised that infants should not be intrusted to such as had had the French disease, even if they were perfectly cured of it; for, he adds, it is very apt to recur. The following very explicit phrase of his has often been quoted: “ Vidimus plures infantulos lactantes, tali morbo infectos, plures nutrices infecisse.” But in comparing it with that which we have just borrowed from Torella, it is evident that Cataneus, if he really observed such facts, confined himself, in the description of them, to copying the text of his predecessor. , George Vella (1508) still believed in contamination by the nurse exclusively. Led by induction, however, he surmised another source of poisoning, and asked himself: “Quare autem parentes non generant prolem infectam, cum materia que subjicitur pro generatione spermatis sit infectaP?” Unfortunately his experience did not yet suffice to mature these doubts, and he was content, in regard to the point at issue, with this negative solution of them: “Nisi esset quod, si subjicitur, non subjicitur immediaté, sed mediaté, et per plures transmissiones purificatur et a malitid ila expoliatur.” Conrad Reitterius (1508), in his ode addressed to the Virgin Mary, to beseech her to arrest the ravages of this malady, confines himself to the mention of infection by nurses : “Non puer tutus teneris in annis, Quem suse lactat genetricis uber.” Paracelsus (1529) was the first who asserted positively the reality of the most usual mode of the propagation of the malady, by spe- ATIOLOGY. 9 cifying that, in certain cases, “fit morbus hereditarius, et transit a patre ad filium.” But almost immediately after the truth had been proclaimed error seems to have resumed its empire, for Nicholas Massa (1532), to whom it was sought to give the credit of this discovery, confines himself to quoting the cases of three children, of the respective ages of three, six, and eleven years, whom he had seen affected with syphilis. And, as he adds that they could not have contracted it either by coitus or suckling, it was no doubt assumed that he concluded that they had inherited it. But besides that such a view is not to be found in any part of his work, the age of these patients alone shows that there could be no question with them of such a mode of propagation; for it is, in general, long before the third year that the symptoms of hereditary syphilis are developed, and it is almost unexampled that they have been delayed until the sixth and eleventh year. Everything seems to prove, therefore, that they had contracted the malady after birth, by contact with persons suffering from communicable forms of syphilis; unless, indeed, these had been instances of the retarded congenital syphilis to be mentioned hereafter. _ Antonius Gallus (154.0) writes, it is true: “Sensere quoque hance labem virgines et infantes,” but it is clear that he does not allude, in this phrase, to congenital syphilis, for infants are only introduced to complete the picture in which he shows the ravages of the ‘disease attacking “tam viros quam foeminas, pueros quam senes, proceres quam mancipia, magistratus quam humilem plebem !” The more we advance, the more does the light acquired lose in brightness. Thus, J. B. Theodosius (1541) merely says that “he fears this malady may be hereditary.” But, to justify these suspi- cions, he has no better proof to offer than the observation of three brothers whom he had seen die of the consequences of the French disease. It appears that, according to his mode of reasoning, they could not all three have contracted it in the ordinary way, and that it was more reasonable to look for the common germ in their parents than in an impure connection on the part of each of them. Montanus (1550) also alludes only to transmission by the nurse’s milk. Musa Brassavole (1553), however, a very learned writer, dis- tinctly records three modes of transmission: I. That in which the lo ON SYPHILIS IN NEW-BORN CHILDREN. child has been infected by actual contact (subagitatus a turpissimo in moribus homine). II. That in which it has been suckled by an infected nurse. III. That in which, being itself infected, it com- municates the disease to its nurse. We see that this description includes everything except the most usual mode of communication, that by generation. Another writer of this period seems to have been on the right track. Augier Ferrier (1553) thus expresses himself: “Cum in utero morbus contrahitur, tanquam hereditarium fit malum, et tanquam corruptum elementum uni cum paterno vel materno semine infunditur; aut si mater a dié conceptionis in morbum inciderit, communicatio foetui, vitiosis infectisque humoribus.” The three modes in which infection may occur during intra-uterine life are here very clearly defined, and modern researches have added nothing to this distinction. Unfortunately, in establishing it, Ferrier appears to have trusted more to its probability than to its reality; for he does not allude to any observation of his own in support of it. An almost equally positive assertion is met with in the work of one of his contemporaries. The following apparently decisive pas- sage may be quoted from P. Haschardims (1554): “Trans- mittitur per generationem, quoniam hic morbus humores vitiat et corrumpit; unde semen corruptum qui sic affecti sunt emittunt, et ex hoc proles vitiata ac corrupta creatur.” But on reading the whole chapter it becomes evident that, far from relying upon facts or even a personal conviction, he has no other basis for this asser- tion than the belief of Hippocrates in the conformity of the semen with the peculiarities of the individual by whom it is secreted. Let us admit, however, that some of the developments of this doctrine appear to be proper to him. Thus, he says, “children are more severely infected when the infection is derived from the mother, because they then acquire the disease from a double source, generation and lactation.” But among these definite assertions, justified though they have been by later experience, we do not meet with a single observation, or even a description! Perhaps, after all, we ought not to be much surprised at the gaps which we meet with in the works of the writers of this period. Where could they have found room for facts in the midst of their interminable disser- tations on the primitive seat of the French disease, which they assume, almost unanimously, to be the liver; on its essential cause, aL 8 ‘ ETIOLOGY. 11 which they agree in attributing to an unhappy conjunction of the planets, of which one of them, Grunbeck, 1499, accuses two, Jupiter and Saturn, of having done all the mischief ! Could it have been that, at this period, the transmission of syphilis by generation rarely or never occurred? If the almost universal silence of the writers of the sixteenth century could have given rise to this idea it would have been dissipated by reading the following passage, in which Gabriel Fallopius (1555), after having asserted contagion by the milk, goes on thus; “ Preterea videbitis puerulos nascentes ex foemina infecta, ut ferant peccata parentum, qui videntur semi-cocti.” To his mind, indeed, this proves only that the malady does not always commence in the genital organs, but in the part which has been in contact with an infected channel. Consequently, according to his views, this would only be an instance of what we now call, infection during labour. But the fact obtains independently of his erroneous explanation; and the characteristic expression semi-cocti bears ample testimony, in his day as in ours, to the influence exercised by the ee upon the child during intra-uterine life. J. Fernel (1556) adopts as real all the possible agents of infec- tion, the milk, the saliva, the sweat, and other secretions. The semen and ovum alone are not, perhaps, comprised in his enumera- tion. Rondelet (1560) furnishes us, at last, with a fact. A fact! something precious for that period, despite the brevity of his description. “Ego vidi puerum nasci totum co-opertum (sic) pustulis morbi gallici.’ This is no longer a vague assertion, it is the author who has himself observed it. Zyo vidi... . The interest attached to this case is doubled when we reflect that there is ques- tion not only of syphilis contracted by generation, but also of symptoms existing at birth, a circumstance of which even some modern writers on syphilis deny the possibility. The views of our learned Ambrose Paré (1561) on this subject are not easily determined. If we refer, as Mahon has done, to his thirty-third chapter, on syphilis occurring im young children, we should have no reason to doubt that he had recognised hereditary transmission ; for the chapter begins thus: “ We often see infants who are born with this malady, and on whose bodies numerous pustules appear soon after birth.” But as, previously, when treating of prognosis (chapter V), he declares positively that 12 ON SYPHILIS IN NEW-BORN CHILDREN. “syphilis is never observed to be transmitted from father to son,” his real meaning becomes clearer. When speaking of infants as being born with the disease, he only means, as it appears to me, that they are born with the germ of it; an explanation which the appearance of pustules soon after birth, and not immediately, tends further to confirm. According to his views, therefore, there is question only of infection during labour. Botal (1563) might pass for an advocate of infection by genera- tion, if we argue from what he omits as well as from what he asserts : “Pueri ex infect’ matre editi, inculpatam etatem agent longevam, modo a sana nutrice aliti fuerint.” Leaving out of the question the possibility of infection by the milk of the nurse, must we con- clude, from this phrase, that if, on the contrary, they have not been fed with good milk, the infants will afterwards, in his opinion, suffer from the pathological consequences of infection by the mother. In the seventeenth century we have Guyon-Dolois, who believes in hereditary syphilis, in infection by the milk, and in the érans- missibility of the disease to the nurse. At a later period, Musitanus insisted upon the last-named class of cases. Garnier occupied himself specially with the treatment of syphilitic children. De Blegny, lastly, called attention to the accidental causes of contagion in new-born children, and to the infallible danger of infection by the milk of a nurse affected with the disease. But here we approach that less remote portion of the historical notice which Mahon has treated in as complete a manner as we have ourselves endeavoured to treat that of the earlier periods. In the course of the eighteenth century there appeared, first, the special researches of Boerhaave, who describes the -different sources and varying mechanism of infection. These were followed by Astruc’s work, an erudite and profound dissertation, but confined to recognising and specifying the different share of the father and the mother in the contamination of their progeny, and to, exaggerating the value of indirect treatment. Rosen was the first to call attention more particularly to ‘symptoms, and to render more familiar, by their aid, a disease which ‘had ‘previously been studied almost exclusively in reference to its causes. -Levret was chiefly occupied in demonstrating the power of ‘mercury when administered at the proper time. Fabre, with as little of proof as of order, multiplied his divisions and subdivisions of the aticlogy ATIOLOGY. 13 of the disease. And lastly, the exaggerations of Sanchez, who saw syphilis everywhere in new-born infants, even to the greenish colour of the excrements, no less than the bold negations of Hunter, threatened to retard the study of this disease which was still so little advanced, when a special hospital was founded. at Vaugirard, in 1780, for the reception of pregnant women affected with syphilis, and their infants. From that moment the possibility of observing the disease more closely on a larger scale, and of comparing the results of different modes of treatment, gave an impulse to the study of congenital syphilis, which has not since abated. The names of Faguer, Doublet, Bertin, Mahon and Cullerier are closely connected with this revival, of which they were the chief promoters, and which they established on the most solid foundations. But if we pursued the inquiry further in this form, history would incroach inconveniently upon the domain of pathology. The authors whose doctrines still remain to be explained, and the facts upon which they based them, will be mentioned in the course of this work. It sufficed for our present purpose to refer to their first origin the opinions which have successively obtained as to the various modes of infection in children, and to show under what patronage, in spite of what hesitations, and on what proofs they have taken their rise, their development, and lastly their right of citizenship in science. CHAPTER II. DEFINITION.—DIVISION. Tae generality of special writers employ indifferently, in the designation of this disease, the terms hereditary syphilis, congenital syphilis, syphilis by generation, infantile syphilis, and syphilis of new-born children. These denominations, however, are not synonymous ; some express a genus, others a species, others again, according to certain writers, only a simple variety. We must be careful, therefore, not to apply them indiscriminately to the various etiological modifications of an affection which presents, in this par- ticular respect, so much diversity. An infant may contract syphilis: firstly, during intra-uterine life, through the formative or nutritive elements derived from its parents; secondly, during or after birth, by the absorption of the virus from some source or other. Hence we have two classes of phenomena which we shall study successively, under the designations of congenital and acquired syphilis. Srction A. CONGENITAL SYPHILIS. To determine how much is real in the different influences to which this kind of transmission of syphilis has been attributed, we must take the problem to pieces. We shall examine them one after the other, as well in reference to their derivation from each of the two parents, as to their being exercised before or after the moment of fecundation. I.—JInfluence of the Father. The father alone being syphilitic, can he communicate the disease to the child? If this question has been put doubtfully; if many ATIOLOGY. 15 writers believe that the power of the father, in this respect, is much more limited than that of the mother; and if some others, as Vassal and Bouchut, still contest the reality of this power, we must attribute it to a circumstance peculiar to facts of this kind. The father, in fact, is very rarely affected with the disease without communicating it to the mother before or during pregnancy. And when the child is born with symptoms of syphilis, we do not know to which of the parents they are due. But since the mother,—the last to be infected, and, moreover, often ill-cared for on account of the obstacles which gestation opposes to treatment,—is most frequently at the time of her confinement the only one affected, it is in her that the symptoms are then observed, and it is she who is accused of having transmitted them. However, despite these inherent difficulties in establishing the paternal influence, there are few specialists who have not been able to do so. I have been astonished, therefore, to see Trousseau, (Gazette des Hép., 1846, p. 571), impute to Ricord the opinion, “That it is not possible for a syphilitic father to communicate the disease to the child, unless he has previously given a chancre to the mother.” The illustrious surgeon of the hospital Du Midi has explained himself too clearly on this point, in various writings, to allow of our interpreting the prudent reserve which he is fond of exercising on the delicate questions of paternity as a denial of the infecting influence of the real agent. Moreover, numerous and precise facts furnish a positive demon- _Stration of this theory. Professor Cederschjold! has frequently seen children affected, some weeks after birth, with copper-coloured spots on the forehead, ulcers about the arms, &c. He adds, “The mothers were healthy, and there was no reason to suppose that they had been infected.” Swediaur? quotes the case of a dragoon affected with venereal ulcer of the throat, whose child presented the same symptom. ‘The mother, he adds, has never had any venereal affection, and is still in perfect health.” Bertin, in his thirteenth observation,? relates the case of a woman, free from syphilis, and having had four very healthy children by her first husband, who married a second, who was affected with the disease, and gave birth, though 1 «Tidscrift for Lakare,’ b. vii, No. 10, 1840. 2 «Tr, comp. des Mal. vénér. ou syphil.,’ t. ii, p. 11. 3 «Tr, de la Mal. vénér. chez les Enf. nouveau-nés,’ p. 163. 16 ON SYPHILIS IN NEW-BORN CHILDREN. herself perfectly healthy, both at the time and afterwards, to a little girl who had venereal ulcers of the mouth at the age of six weeks. Depaul? recognised symptoms of syphilis in a new-born infant whose father had had an indurated chancre two months before fecundation. The mother asserted that she had never had any symptoms of venereal disease, “nor was any trace of such to be found upon any part of her body.” The recent work of Bertherand ? contains the history of a similar case, in which the child, very severely affected, recovered under the administration of bichloride of mercury. Haase? speaks of a child which presented evident symptoms of syphilis at birth, which were soon communicated to the nurse. The mother, who had already had three, healthy children, was not syphilitic. The father had had some venereal affection a short time before. : Finally, if any doubts still remained, they would, I think, be dissipated by the perusal of the two following observations, in which all the precautions necessary for ensuring the special health of the mother appear to have been taken. V. Cl. Guérard+ mentions a woman of good family and excellent reputation, who gave birth to a child which was covered with yellow spots, and had ulcers, situated chiefly on the fingers and toes, which were unanimously recognised as syphilitic. The woman had uever had any affection of this kind, not even Jeucorrhcsa. The author examined her, and did not find any suspicious appear- ances. The husband confessed that while on a journey, a short time before begetting this child, he had contracted a chancre. On examination he was found to have copper-coloured spots on the forehead, feet, and sternal region, and to be suffering from pains in the bones. He was cured by bichloride of mercury, and the child by Hahneman’s soluble mercury. Beehr® knew a Mr. W—, who got a chancre, of which he was cured by mercury. Some time after his cure his wife joined him; she soon became pregnant, and during the whole period of gestation showed no indication of syphilitic infection. She gave birth to a female child, which she suckled. When three weeks old the child was covered with deep, corroding ulcers on the buttocks, arms, and Jabia majora, and with copper-coloured spots on the calves of the legs. It also had coryza, with crusts of a peculiar character. The author administered mercury to the child, and its disease, which had resisted all means previously employed, began at once to improve, and was speedily cured. ‘Gaz. méd. de Paris,’ 1851, p. 399. Page 33]. ‘ Allgemein. mediz. Annal.,’ Feb., 1829, p. 194. ‘Journ. de Siebold,’ t. x, § 553. ‘Journ. der pract. Heilkunde,’ 1836. nm © Mo ZTIOLOGY. 17 These are not the only facts which I could have collected, but they suffice to prove that the syphilis of the child very frequently acknowledges no other cause than syphilis in the father. This point being settled, another more practical and not less important question arises : Will a man who has had syphilis, but who presents no symptom of the disease at the moment, beget a syphilitic child? This pro- blem, which involves the most serious considerations of aptitude for marriage and procreation, has been variously solved. It seems natural to admit that a diathesis which does not yet manifest itself, or no longer manifests itself by sensible effects, should be less marked, and consequently less capable of transmis- sion than one of which the symptoms are actually present. This opinion is the most general one; Rosen,! amongst others, formally avows it, and it is supported by several examples. The following is one which I have met with: In June, 1849, a young man, Mr. D—, came into my consulting-room in’ tears. He was to marry, twelve months afterwards, a young person to whom he had been engaged from childhood, and he had contracted a chancre a month previously. The chancre being an indurated one I treated it with the proto-iodide of mercury, and as my patient was fearful, above all, that he might not be cured by the time fixed, I readily yielded to his repeated wishes, and did not spare the medicine or limit the period of the specific treatment. A fortnight or three weeks after his first visit a papular eruption appeared, accompanied by a tubercular ulceration of the tonsils. He took mercury, under my direction, for six months, so as to affect the gums slightly several times. Being still uneasy about himself, he wished for a consultation between my worthy col- league, Dr. Bottex, and myself. For the sole purpose of satisfying the patient, Dr. B., thinking he was quite cured, advised the use of Van Swieten’s drops for three weeks. 3 Mr. D— married, and his wife soon became pregnant. About the third month of her pregnancy he went to the baths at Aix, and was very much alarmed, during the use of them, by the return of a well-marked papular eruption, accompanied by some mucous patches about the anus, which symp- toms I had the opportunity of observing. He therefore looked forward to his wife’s confinement with the greatest anxiety, as he feared to see the child covered with pustules. His fears were, fortunately, uot realised. The child is at present two years old, and has always been perfectly healthy. But if the immunity of the foetus, under such circumstances, be possible, we should deceive ourselves, to the great prejudice of families, in believing it to be certain. Cullerier, surgeon to 1 «Rosen, 1778, p. 541. 18 ON SYPHILIS IN NEW-BORN CHILDREN. VOurcine, has told me that he believes this unfortunate power of transmitting syphilis to their children, although no traces of the disease are present at the moment of procreation, belongs to the mother alone, and not to the father. But this dangerous paradox of such a shrewd observer must be answered by facts only. The following are decisive ones : Professor Cederschjold, whose authority I have already invoked, says that the fathers of the children which he had seen born with syphilis, although the mother was healthy, “had been treated shortly before cohabitation for primary symptoms; but that from this time they had remained free from any venereal affection, and suffered only from debility.” Mr. T~ married after having had syphilis four times, for which he had been imperfectly treated. He was weak, but did not show any specific taint. A year afterwards, his wife, who had continued to enjoy good health, gave birth to a child which was to all appearance strong and healthy, but which, when three weeks old, had a well-marked pustular syphilitic eruption. It sank at the age of eleven months.’ But this condition of syphilitic diathesis without external manifes- tations presents two very different periods: either the individual affected has been, at the moment of procreation, between two succes- sive outbreaks of constitutional symptoms ; or else he has been in the interval which occurs between the first appearance of a primary sore and the first outbreak of secondary symptoms. Js he equally capable, in the latter case as in the former, of transmitting syphilis by the semen? The following cases leave us no ground for doubting this: A young man had a chancre for the first time in the beginning of the sum- mer of 1839. He was under mercurial treatment for seventy days, and married in the month of October of the same year, without having had any symptoms of constitutional syphilis. His wife became pregnant in January, 1840. In March the husband had some mucous patches upon the tonsils, for which he again took mercury. The child was born in September, 1840. On the third day it presented patches of a dull coppery-red colour, which spread over the whole body. These were accompanied by intense coryza. The child became gradually weaker, and sank in fifteen days.? In 1823, Campbell, of Edinburgh,* attended a lady who miscarried at the 1 Troncin, ‘De l’Extinct. de la Mal. vénér.,’ p. 50. 2 Barserean, ‘Tr. des Affections de laPeau. Symptém. de la Syphilis, 1852, p. 540. 3 ‘Lond. and Edinb, Monthly Journal,’ 1844, p. 514, ZETIOLOGY. 19 sixth month, The same thing had happened to her in a former pregnancy, and occurred for the third time in 1824. The husband was a young medical man, and acknowledged having had, six months before marriage, a sore which had been diagnosed as a chancre by himself and by some of his medical acquaintance. No other symptom manifested itself up to the time of his marriage. Campbell could not detect any evidence of syphilis in either of the parents. He placed them both under the influence of mercury. The lady soon became pregnant again, and gave birth at the full time to a well-formed male child, which lived without having syphilis. Besides the very positive answer which these observations furnish to the last question, I shall draw from them two practical conclu- sions. The first is, that mercurial treatment, although commenced on the first appearance of a primary sore and long continued, neither prevents nor corrects with certainty the special perversion which the generative function has undergone. The second, to judge, at least, from the facts just mentioned, is, that the fetus does not appear to be infected less severely hy a father in the incubation period of syphilis than by one in whom the disease is fully developed. I shall also refuse, for the present, ta accept the opinion which Prieur! quotes from Ricord’s lectures: “The con- ditions transmitted are those of the parents at the moment of procreation ; if the syphilitic affection he recent, the influence is less than if severe symptoms had gone before.” Nor is it necessary, after the preceding observations, to combat the opinion of those who sustain that a father cannot transmit syphilis to his child, because the semen of an individual so affected is incapable of causing fecundation. The responsibility of such an opinion must be left to the speculative writers of the last century, by whom it was advocated. I cannot quit this part of the subject without some words on a question which has been raised by Hunter and Nisbett: Can a man who is affected with syphilis and has connexion with a pregnant woman, communicate the disease directly to the fetus, without infecting the mother ? Strange as this question may appear to be, it is nevertheless necessary to discuss it, as it has been seriously enter- tained by several writers on syphilis. As early as 1698, de Blegny? remarked, that “we frequently see children born with syphilis, although the semen which had induced conception was pure, because the mothers had cohabited during pregnancy with men imperfectly 1 «Théses de Paris,’ 1851. 2 Page 101. 20 ON SYPHILIS IN NEW-BORN CHILDREN. cured of the same disease.” Hunter! says that “the contagious matter may, without setting up any syphilitic action in the tissues of the mother, be conveyed to the fetus in the same state in which it has been absorbed, and develop in it the same morbid action which it would have developed in the mother.” Nisbett also thinks that “the venereal poison which circulates in the general mass may infect the foetus without affecting the mother.” This idea of an influence exercised by the father upon the already-formed feetus is so general, that barbarous nations believe in its continuance beyond the moment of birth. Amongst the Caraibans, as we are told by M. Lucas,? the father, immediately after the delivery of the mother, “keeps his bed and abstains for six months from eating birds or fish, for fear the new-born infant should participate in the defects natural to those animals.” Moreover, this action of a poison capable of affecting the foetus without compromising the mother, is rendered more than probable by daily experience. If smallpox may be present in the fetus, whilst the mother remains exempt, instances of which have been observed by Mead,? Deneux,* Piednagel,5 Lebert, Depaul,® and Simpson,’ why may not a very analogous agent, the poison of syphilis, possess the same property, and produce its effects in the product of conception alone? Lawrence, arguing from this analogy with smallpox, thinks that the father may, without communicating the disease to the mother, transmit syphilis to the foetus with which she is pregnant. The following is a case published in support of this theory : A mani affected with primary syphilis had connexion with his wife when she was in the sixth or seventh month of pregnancy. She was not infected. At the full time she was delivered of an infant which presented, soon after birth, weli marked syphilitic pustules, and died in nine days. The father soon afterwards had symptoms of constitutional syphilis, and was cured of them by mercurial inunctions.® 1 «Traité de la Mal. vénér.,’ 1852, p. 564. 2 «Tyaité de l’Hérédité,’ t. ii, p. 12. 3 «Traité de la petite Vérole,’ chap. iv, p. 337. 4 *Gaz. Méd. de Paris,’ 1852, p. 14. 5 ‘Gaz. des Hop.,’ 1845, p. 304. 6 «Gaz. Méd. de Paris,’ 1849, p. 252. 7 ‘Edinb. Month. Journ. of Medical Science,’ April, 1849. 8 Albers, ‘Ueber Erkenritniss und Kur der Syphilis, Hautkrankheit,’ p. 19. ZETIOLOGY. 21 In facts of this kind we must distinguish between appearance and reality, between the improbable inference drawn from them and the rational explanation of which they admit. Serious men will surely regard as fabulous the hypothesis of an influence exercised by the vitiated semen of a man upon a fetus of some weeks or months. Between two such beings no direct relation is possible, But may not the organism of the mother serve as a mode of communication from the one to the other? May not her circulating system be capable of so circumscribing and isolating the poison, as to transmit it from the man with whom she cohabits to the infant which she bears in the womb, without allowing it to be developed in and to infect herself? Numerous analogies forbid an absolutely negative answer to this question. From the observations of Mayo, Giles, Guérin, Devay, Gillivray, Allen Thompson, d’Olgive, and Fournet, on the transmission of certain characteristics in animals, and of certain diseases in the human race, it cannot be doubted that a healthy widow, who takes for her second husband a man whose sanitary condition is unexceptionable, may from this source have children tainted with a defect inherent in the former husband. But what else is this than the transmission of a morbid influence . directly from the father to the child through the organic system of the mother, acting as a simple conductor, and not as a participating medium? I shall quote, in reference to the kind of morbid influence here specially in question, an instance which proves this mode of transmission. A man had intractable syphilis, for which he was treated at the Hospital du Midi, and of which he died. While he was suffering from this disease his wife gave birth to a female child, which had, at the age of two months, ulcerations about the vulva, and died without having had any remedy administered, - The wife asserted that she had never, at any period of her life, had syphilis. Eighteen months after her first confinement, she married a healthy man, and had a child by him which presented spots upon the genitals and forehead similar to those of the child by her former marriage. Not being able to get it cured, she went into l’Oureine with it. At the age of four months and a half this child had well-marked syphilitic tubercles on the forehead, mouth, thighs, buttocks, and scrotum. A careful examination of the woman gave no evidence of any present or previous venereal affection. On the fore part of the neck a small patch of granular redness was observable. 1 This case is reported by Vidal (‘ Gaz. des Hép.,’ 1841, p. 545). He con- siders the grazular reduess of the neck as sufficient evidence of the existence of 22 ON SYPHILIS IN NEW-BORN CHILDREN. These details are exact and of a nature, as it appears to me, to bring conviction. But, since the vitiated semen of a first husband may leave behind it in his wife an impression capable of infecting her subsequent children, the offspring of another than himself, why may it not make this same impression in the case of an infant recently engendered, and which has still to undergo, for six or seven months, the influence of nutrition through the placenta? I have no wish to deny the differences which exist between the two cases; but are they so wide that, the one being now acknowledged as almost proved, we are justified, without further evidence, in regarding the other as improbable or absolutely impossible ? We may draw, as a practical conclusion from the foregoing data, an inference opposed to most of the doctrines now in vogue, viz. that when a man, affected with syphilis, has had connexion with a pregnant woman, especially if she have not been pregnant long, we must not, even if she remain healthy, calculate with certainty that the child will be exempt; and that it will be prudent to watch it carefully during the first months of its life. IL.—Jnfluence of the Mother. A woman suffering from constitutional syphilis may affect the - feetus in two different ways: either by throwing off a vitiated ovum, or by furnishing it, during pregnancy, with elements of nutrition imbued with the specific diathesis. Hence arise two pos- sible infecting conditions in her: either she had syphilis at the moment of conception, or she contracted it subsequently, Let us study these two different cases one after the other. A. Influence of the mother infected before the moment of conception. —This influence is clear, patent, and undeniable. Founded upon reason, supported by innumerable facts, no author has ventured to doubt it, and I know of no writer, except Cazenave,’ who has described it as less potent than that exercised by the father. a syphilitic diathesis in this woman. But can a lesion so slight, and so evidently the result of pure and simple inflammation, legitimately be made to bear such a signification? And shall we not be interpreting the case more correctly if we place it amongst the number of those which prove the power possessed by the economy of the mother of transmitting (without becoming itself implicated) the poison of syphilis from the father to the child ? 1 ¢Traité des Syphilides,’ p. 134. ZTIOLOGY. 23 However, without wishing to dispute the conclusions from daily experience, I must observe that the proof of this apparently so simple fact is almost inevitably subject to a grave cause of error. A woman affected with syphilis gives birth to a syphilitic child. The paternity appears clear, and the mother is accused—the mother who is before our eyes with symptoms or traces significant of the disease. But who shall answer for the father, who is absent, or unknown, or cured at the time of delivery? Who shall prove that it is not by his act that the diathesis has been transmitted to the product of conception? How can we know whether he has not at least had a share therein ; or whether, without the mterven- tion of vitiated semen, the woman, although diseased, might not have thrown off a healthy ovum, and borne it as such to the full term of gestation? The fact is the more difficult to verify, because it is most frequently the same man who has communicated the disease to the woman who becomes the father of her children. To solve this problem, therefore, it will not suffice to accumulate promiscuously cases in which a syphilitic child has been born of a syphilitic mother, but we must rather profit by those rare cases in which, the influence of the father being accidentally annihilated, it is possible to determine more exactly the part played by the mother. ¢ If, for instance, a woman who has contracted syphilis from her first husband becomes a widow and marries another man free from such antecedents, and if the children which she has by this second marriage present manifest symptoms of syphilis, does it not appear evident that they can have derived it from the mother alone? And this concatenation of circumstances is frequently met with. The following history furnishes a proof sufficiently circumstantial to deserve notice. The Widow C— consulted M. Vassal in September, 1779 (sce, 1799), on account of two buboes and sixty venereal warts about the vulva and perineum. He gave her mercury for three months. She married again, and became preg- nant in 1801. The child, given to nurse to a woman of whose healthy state the author had convinced himself, presented some moist pustules about the: genital organs after the expiration of thirty-five days. About the same time the husband died of fever, without ever having had any symptom of syphilis. She married once more, 1804, and gave birth to two weakly, wrinkled chil- dren, whose skin peeled off, and who were attacked by jaundice on the fifth day. One sank on the ninth, the other on the twelfth day. In 1807 she became pregnant for the fourth time. The child, entrusted to a healthy nurse, had, at 24 ON SYPHILIS IN NEW-BORN CHILDREN. the expiration of thirty-two days, thick crusts on the forehead and at the roots of the hair, with copious fetid suppuration. It was treated with mercury and recovered. The mother, although she had for along time had no traces of syphilis, and had never communicated the disease to any of her husbands, deter- mined, for the sake of her possible future children, to go through a course of mercury. , Many observations of this kind might be quoted; but, as proofs of the exclusive infecting power of the mother, they would always remain open to one serious objection, For nothing forbids the supposition that here, as in the cases mentioned in the preceding chapter, it is the influence of the former father which, persisting in the organism of the mother, has alone conveyed the venereal taint to her subsequent children. We must examine the question, there- fore, under different conditions. But, to clear up this difficulty, the best means is the history of cases in which syphilis has been communicated by lactation. Thus, a woman, previously healthy, begins to suckle a syphilitic child, and the disease is communicated to her. She then becomes preg- nant, and is delivered of a syphilitic child. This series of pheno- mena evidently contains the proof I was in search of, for the husband of the nurse has remained out of the field of the succession of syphilo-genetic phenomena; he has had only an irreproachable share in the procreation of his child. The mother alone was dis- eased, and that recently, and in a manner which leaves neither doubt, nor suspicion, nor mystery. To her alone, therefore, must we impute the infection of the child to which she has given birth. Examples of this succession of events are by no means rare, but it will only be necessary to quote a few such to show that they have been recognised by the most competent observers. A healthy nurse had suckled with good effect for three months the female child of M. de B—, when she took a second child to nurse, which, fifteen days after birth, had mucous patches about the vulva and mouth, and died in three months. The woman, three months after the death of the latter child, observed, on her own body, a great number of mucous patches about the genital organs. Six months afterwards, having been delivered of a female child, her infant, which at birth had every appearance of health, and which she suckled also, presented, 1 Vassal, ‘Mém. sur la transmiss. du virus vénér. de la Mére & |’Enfant,? Paris, 1807, p. 40. . JZTIOLOGY. 25 at the age of two months and a half, about thirty mucous patches on the vulva perineum, and upper part of the thighs. Lallemand? relates the case of Madame de C—, the wife of a colonel who had had syphilis several times, and who had communicated the disease to her. Their children presented all the symptoms of this disease, of which the first three died. The fourth child had the same symptoms—copper-coloured spots on the skin and pustules about the anus. The nurse to whom it was entrusted had’ ulceration of the breast, and was imperfectly treated. She then became pregnant and gave birth to a weakly, emaciated child, which lived only five days. At the expiration of fifteen months she had a second child, which continued healthy for three months, but then presented brown spots and tubercles about the lips and fundament, which M. de C— recognised as exactly similar to those which had appeared in his own children. ‘allemand subjected this woman to a methodical and complete course of treatment. She has since borne a child which, says the author, is now eighteen months old, and has never exhibited the least trace of venereal affection. Bertherand? relates the case of a healthy nurse, whose antecedents were good, and to whom the child of a Mrs. O— was given to nurse. Soon after- wards she suckled another child, which had syphilitic tubercles in the groins and a purulent discharge from the mouth and nose, and died in three months. The nurse had mucous patches about the vulva. She ultimately became preg- nant and was delivered, says Bertherand, of a syphilitic child. Lastly, Bardinet* gives the history of a woman, Fra —, who, having taken to nurse a child affected with hereditary syphilis, had, at the end of two months, specific ulcers on the breasts. Becoming pregnant afterwards, she was delivered of a still-born child. Some time afterwards she again became pregnant, and gave birth to a child in which were developed, about the third month, mucous pustules at the margin of the anus, and ulcers in the throat. But a still more convincing proof in this respect is that observed by Bergeret, in which the child of a woman C—, died of constitutional syphilis at the age of seven weeks. But the woman, C—, had herself contracted the disease from a nursling, to which it had been communicated by a neighbour, the woman N—, who had taken it from a nursling infected from being s 1 M. Cazenave, ‘Revue Méd. de Paris,’ 1852, p. 409. 2 © Journ. Univ.,’ t. xxvii, p. 132. 3 ¢ Précis des Mal. vénér., 1852, p. 336. * Bardinet (‘De la Syphilis héréditaire et de sa transmissibilité’?). This remarkable monograph, destined especially to prove the communicability of hereditary syphilis by lactation, was presented to the Academy of Medicine in Paris, on the 28th December, 1852. The author placed this work at my dis- posal before its publication, with a readiness for which others besides myself have cause to be grateful. But whatever interest my readers may feel in the observations which I have felt authorised to borrow from him, it cannot ap- proach the impression which this work, so rich in facts and so powerful in its deductions, cannot fail to make when known in its entirety. 26 ON SYPHILIS IN NEW-BORN CHILDREN. suckled by the woman P—, which latter individual had herself been infected by a strange nursling.! From this fearful series of transmissions we will, at this moment, infer nothing beyond the possibility of the infection of a child by means of an influence which has acted exclusively upon the mother. It must be added, however, that before she was attacked by syphilis the woman C— had had five children, all of robust constitution and excellent health. To resume my subject, the cases of syphilis transmitted to a child by a mother who had been infected by her husband are so numerous as to have sufficed to bring conviction of the reality of infection by an ovum tainted with this poison. To me, however, they render the fact probable rather than certain; but if we accord their true value to those last mentioned, I cannot think that the theory to which they have reference will any longer be dis- puted. B. Influence of the mother infected after conception.—Several writers have restricted the name of congenital syphilis to the affec- tion which depends upon this cause, giving that of hereditary to that which is communicated by parents suffering from consti- tutional syphilis previous to fecundation. Of these two varieties they make two species, as different in regard to the progress, symp- toms, and importance of the disease, as in reference to its etiology. We shall see, further on, when treating of the evolution of this affection, what is to be thought of sucha theory. At the present moment we must occupy ourselves with a single object, viz., to establish the existence of this cause of infection, and to determine the conditions under which it realises its effects. Thad collected a certain number of instances of fcetal syphilis resulting from an infection communicated to the mother ulteriorly to conception, but as no one now doubts the fact, it seemed entirely superfluous to swell my work with these proofs. Who now dis- putes this influence exercised upon the chila oy the impure materials of nutrition thus furnished to it by the circulation of the mother ? Another question in reference to this subject is of more direct practical interest: Up to what period of pregnancy can syphilis, then first contracted by the mother, be communicated to the Satus ? In other words: Is there a period of pregnancy after which syphilis contracted by the mother can no longer be transmitted to the Soetus ? 1 «Le Moniteur des Hopitaux,’ Noy. 29, 1853. ATIOLOGY, 27 On examining more closely the relations which exist between the embryo and its mother, and the successive modifications which these relations undergo, we learn that the more gestation advances the more do these bonds become loosened. After the formation of the blastoderm, the nutritive fluids pass directly through the mem- branes of the ovum. From the third week to the fortieth day the umbilical vesicle contributes to the vegetative existence of the embryo, by means of the omphalo-mesenteric vessels. As it dis- appears it is replaced by the allantois, the first commencement of the circulation between the mother and her fetus, At a later period the allantois, pushing back the chorion, becomes covered with villosities at the point where the latter adheres to the uterus, and then the placental circulation is established with its principal organ. With the placenta, which holds blood in reserve, with a heart which throws blood into all parts of its body, the foetus has attained a position already less dependent, in anticipation of the moment when the exercise of its digestive functions and the play of its lungs shall permit it to fulfil its own requirements. Thus the ovum, at first simply a portion of an organ of the mother, is nou- rished, as it were, by imbibition; it then becomes the seat of a new vascular development; it soon acquires two sets of vessels, and, subjecting the blood which is sent to it to a certain degree of elaboration, finally leads an organic life more and more inde- pendent, until it becomes entirely separated from the being upon which it had been grafted. Tn these transformations we easily recognise four very distinct periods in reference to the dependence of the embryo upon the mother. At first it is but a portion of her substance; in the second place, and during some time, it subsists and grows exclu- sively at the expense of the albuminous matter by which it is surrounded in the fallopian tube, and of the vitelline membrane. Hence I am convinced that if a woman contracted syphilis two or three days after conception, and was rapidly cured, the child would not show any symptoms of the disease. It is true, indeed, that this hypothesis is not of a nature ever to receive the sanction of positive experience, but I believe that it furnishes a logical explana- tion of more than one case in which, from our not admitting it, we are surprised to see a woman who has contracted syphilis during the first weeks of her pregnancy afterwards give birth to a healthy child. 28 ON SYPHILIS IN NEW-BORN CHILDREN. At a third period of gestation the two vascular currents, that of the embryo and of the mother, unite, and the relations become more intimate and direct. It is then that transmission by the blood—true contagion, whatever may be said otherwise—becomes possible, and actually occurs, At this period, if the mother be really the subject of the diathesis, we cannot well understand how the foetus can escape this source of poisoning, this forced influence, so to speak, which is constantly distilling, drop by drop, as it were, a poison into its veins, against the introduction of which nature has not furnished it with any means of defence. The fourth period has no fixed limit, or at least no distinct starting point, being connected by a gradual transition with the preceding one. The fetus frees itself more and mare from the maternal envelope, and abortion at this period, from causes affecting the mother, becomes much more rare. But at what moment does this independence reach a point at which the foetus is no longer subject to syphilitic disease, then first contracted by the mother ? This we do not know ; but what is certain, and what the opinions of the best observers and daily experience confirm is, that during the last months of pregnancy this influence becomes weakened and eventually annihilated. I am glad to be able to invoke in support of these laws, deduced clearly from physiological data, an authority so decisive on such questions as that of Ricord. Led probably by the same reasoning, he has arrived at the same conclusions concerning the independence of the ovum in the earlier periods of pregnancy. “ When it is the mother who infects the foetus,” he wrote to me on the 16th of March, 1849, “