Hereditary Syphilis
It seems desirable, at this point, to take up the hereditary
transmission of syphilis in advance of the other modes of transmitting
the disease, since it is practically a problem all to itself.
Syphilis is one of the diseases whose transmission from parent to child
is frequent enough to make it a matter of grave concern. It is, in fact,
the great example of a disease which may be acquired before birth. Just
as syphilis is caused only by a particular germ, so hereditary syphilis
is also due to the same germ, and occurs as a result of the passage of
that germ from the mother's body through the membranes and parts
connecting the mother and child, into the child. Hereditary syphilis is
not some vague, indefinite constitutional tendency, but syphilis, as
definite as if gotten from a chancre, though differing in some of its
outward signs.
+Transmission of Syphilis From Mother to Child.+--It is a well-known
fact that the mothers of syphilitic children often seem conspicuously
healthy. For a long time it was believed that the child could have
syphilis and the mother escape infection. The child's infection was
supposed to occur through the infection of the sperm cells of the father
with the germ of syphilis. When the sperm and the egg united in the
mother's body, and the child developed, it was supposed to have syphilis
contracted from the father, and the mother was supposed to escape it
entirely in the majority of such cases. This older idea has been largely
given up, chiefly as a result of the enormous mass of evidence which the
Wassermann test has brought to light about the condition of mothers who
bear syphilitic children, but themselves show no outward sign of the
disease. It is now generally believed that there is no transmission of
syphilis to the child by its father, the father's share of
responsibility for the syphilis lying in his having infected the mother.
None the less, it must be conceded that this is still debatable ground,
and that quite recently the belief that syphilis can be transmitted by
the father has been supported on theoretical grounds by good observers.
+Absence of Outward Signs in Syphilitic Mothers.+--The discovery that
the mother of a syphilitic child has syphilis is of great importance in
teaching us how hereditary syphilis can be avoided by preventing
infection of the mother. It is even more important to understand because
of the difficulty of convincing the seemingly healthy mother of a
syphilitic child that she herself has the disease and should be treated
for it, or she will have other syphilitic children. Just why the mother
may never have shown an outward sign of syphilis and yet have the
disease and bear syphilitic children is a question we cannot entirely
answer, any more than we can explain why all obvious signs of syphilis
are absent in some patients even without treatment, while others have
one outbreak after another, and are never without evidence of their
infection, unless it is suppressed by treatment. Probably at least a
part of the explanation lies in the fact, already mentioned, that
syphilis is a milder disease in women than in men, and has more
opportunities for concealing its identity.
+Healthy Children of Syphilitic Mothers.+--If the mother of a syphilitic
child has the disease, is it equally true that a syphilitic mother can
never bear a healthy child? It certainly is not, especially in the late
years of the disease, after it has spent much of its force. When the
multitudes of germs present in the secondary period have died out,
whether as a result of treatment or in the normal course of the disease,
a woman who still has syphilis latent in her or even in active tertiary
form, may bear a healthy child. Such a child may be perfectly healthy in
every particular, and not only not have syphilis, but show no sign that
the mother had the disease. It is in the period of active syphilis, the
three, four, or five years following her infection, that the syphilitic
mother is most likely to bear syphilitic children.
+Non-hereditary Syphilis in Children.+--Syphilis in children is not
always hereditary, even though the signs of it appear only a short time
after birth. A woman who at the beginning of her pregnancy was free from
the disease, may acquire it while she is still carrying the child as a
result of her husband's becoming infected from some outside source. The
limitation which pregnancy may put on sexual indulgence leads some men
to seek sexual gratification elsewhere than with their wives. The
husband becoming infected, then infects his pregnant wife. There are no
absolute rules about the matter, but if the mother is not infected until
the seventh month of her pregnancy, the child is likely to escape the
hereditary form of the disease. On the other hand, imagine the prospects
for infection when the child is born through a birth-canal filled with
mucous patches or with a chancre on the neck of the womb. Children
infected in this way at birth do not develop the true hereditary form of
the disease, but get the acquired form with a chancre and secondary
period, just as in later life.
+Effect of Syphilis on the Child-bearing Woman.+--What does syphilis
mean for the woman who is in the child-bearing period? In the first
place, unlike gonorrhea, which is apt to make women sterile, syphilis
does not materially reduce the power to conceive in most cases. A woman
with active syphilis alone may conceive with great frequency, but she
cannot carry her children through to normal birth. The syphilitic woman
usually has a series of abortions or miscarriages, in which she loses
the child at any time from the first to the seventh or eighth month. Of
course, there are other causes of repeated miscarriages, but syphilis is
one of the commonest, and the occurrence of several miscarriages in a
woman should usually be carefully investigated. The miscarriage or
abortion occurs because the unborn child is killed by the germs of the
disease, and is cast out by the womb as if it were a foreign body.
Usually the more active the mother's syphilis, the sooner the child is
infected and killed, and the earlier in her pregnancy will she abort.
Later in the disease the child may not be infected until well along, and
may die only at the ninth month or just as it is born. In other words,
the rule is that the abortions are followed later by one or more still
births. This is by no means invariable. The mother may abort once at the
third month, and with the next pregnancy bear a living syphilitic child.
The living syphilitic children are usually the results of infection in
the later months of the child's life inside its mother, or are the
result of higher resistance to the disease on the part of the child or
of the efficient treatment of the mother's syphilis.
+Variations on the Rule.+--It should never be forgotten that all these
rules are subject to variation, and that where one woman may have a
series of miscarriages so close together that she mistakes them for
heavy, irregular menstrual flows, and never realizes she is pregnant,
another may bear a living child the first time after her infection, or
still another woman after one miscarriage may have a child so nearly
normal that it may attain the age of twenty or older, before it is
suspected that it has hereditary syphilis. Again a woman with syphilis
may remain childless through all the years of her active infection, and
finally, in her first pregnancy, give birth to a healthy child, even
though she still has the disease in latent form herself. Still another
may have a miscarriage or two and then bear one or two healthy children,
only to have the last child, years after her infection, be stillborn
and syphilitic. The series of abortions, followed by stillborn or
syphilitic children, and finally by healthy ones, is only the general
and by no means the invariable rule.
+Treatment of the Mother.+--For the mother, then, syphilis may mean all
the disappointments of a thwarted and defeated maternity, and the
horrors of bearing diseased and malformed children. She is herself
subject to the risk of death from blood poisoning which may follow
abortion. But here, as in all syphilis, early recognition and thorough
treatment of the disease may totally transform the situation. In the old
days of giving mercury by mouth and without salvarsan, there was little
hope of doing anything for the children during the active infectious
period in the mother. Now we are realizing that even while the child is
in the womb the vigorous treatment of the mother may save the day for
it, and bring it into the world with a fair chance for useful and
efficient life. More especially is this true when the mother has been
infected while carrying the child, or just before or as conception
occurred. In these cases, salvarsan and mercury, carefully given, seem
not only not harmful to mother and child, but may entirely prevent the
child's getting the disease. For this reason every maternity hospital or
ward should be in a position to make good Wassermann blood tests,
conduct expert examinations, and give thorough treatment to women who
are found to have syphilis. There does not seem to be any good reason
why a Wassermann test should not be made part of the examination which
every intelligent mother expects a physician to make at the beginning
of her pregnancy. Such a test would bring to light some otherwise
undiscovered syphilis, and protect the lives of numbers of mothers and
children whose health and happiness, not to say life, are now sacrificed
to blind ignorance.
+Effect of Hereditary Syphilis on the Unborn Child.+--In the effect of
hereditary syphilis on the child, we see the most direct illustration of
the deteriorating influence of the disease on the race. Here again we
must allow for wide variation, dependent on circumstances and on
differences in the course of the disease. This does not, however,
conceal the tragedy expressed in the statement that, under anything but
the most expert care, more than 75 per cent of the children born with
syphilis die within the first year of life. Good estimates show that
more often 95 per cent than fewer of untreated children die. Such
figures as those of Still are not at all exceptional--of 187 children of
syphilitic parents, born or unborn, 113 were lost, whether by
miscarriage, still-birth, or in spite of treatment after they were born.
It is estimated that not more than 28 per cent of syphilitic children
survive their first year. Those that survive the first year seem to have
a fighting chance for life. Statistics based on over 100,000 cases show
that about one child in every 148 from two to twelve years of age has
hereditary syphilis. Realizing the difficulty in recognizing the disease
by examination alone, it is entirely safe to suppose that the actual
figures are probably higher. The statistics given at least illustrate
how few syphilitic children survive to be included in such an estimate.
+Moral Effect on the Parents.+--The real extent of the damage done by
the disease as a cause of death in infancy is scarcely appreciated from
figures alone. There is something more to be reckoned with, which comes
home to every man or woman who has ever watched for the birth of a child
and planned and worked to make a place for it in the world. The loss or
crippling of the new-born child jars the character and morale of the
father and mother to the root. When the object of these ideals dies,
something precious and irreplaceable is taken from the life of the
world. The toll of syphilis in misery, in desolation, in
heart-breakings, in broken bonds and defeated ideals can never be
estimated in numbers or in words.
+Course of Hereditary Syphilis in the Infant.+--The course of syphilis
in the child tends to follow certain general lines. The disease, being
contracted before birth, shows its most active manifestations early in
life. The stillborn child is dead of its disease. The living child may
be born with an eruption, or it may not develop it for several weeks or
months. It is thought by some that these delayed eruptions represent
infections at birth. Hereditarily syphilitic children are filled with
the spirochetes, the germs of the disease. They are in every tissue and
organ; the child is literally riddled with them. In spite of this it may
for a time seem well. The typical syphilitic child, however, is thin,
weak, and wasted. Syphilis hastens old age even in the strong. It turns
the young child into an old man or woman at birth. The skin is
wrinkled, the flesh flabby. The face is that of an old man--weazened,
pinched, pathetic, with watery, bleary eyes, and snuffling nose. The
mother often says that all the baby's trouble started with a bad cold.
The disease attacks the throat, and turns the normal robust cry of a
healthy infant into a feeble squawk. The belly may become enormously
distended from enlargement of the internal organs, and the rest of the
child dwindle to a skeleton. The eruptions are only a part of the
picture and may be absent, but when they occur, are quite
characteristic, as a rule, especially about the mouth and buttocks, and
do not usually resemble the commoner skin complaints of infants. It is
important to remember here that a badly nourished, sickly child with a
distressing eczema is not necessarily syphilitic, and that only a
physician is competent to pass an opinion on the matter. Syphilitic
children in a contagious state are usually too sick to be around much,
so that the risk to the general public is small. On the other hand, the
risk to some woman who tries to mother or care for some one else's
syphilitic child, if the disease is active, should be thoroughly
appreciated. Women who are not specially trained or under the direction
of a physician should not attempt the personal care of other people's
sick children.
+The Wet Nurse.+--This is also the proper place to introduce a warning
about the wet nurse. Women who must have the assistance of a wet nurse
to feed their babies should, under no circumstances, make such
arrangements without the full supervision of their physicians. There is
no better method for transmitting syphilis to a healthy woman than for
her to nurse a syphilitic child. Conversely, the healthy child who is
nursed by a syphilitic woman stands an excellent chance of contracting
the disease, since the woman may have sores about the nipples and since
the germs of syphilis have been found in the milk of syphilitic women.
The only person who should nurse a syphilitic child is its own mother,
who has syphilis and, therefore, cannot be infected. A Wassermann blood
test with a thorough examination is the least that should be expected
where any exchanges are to take place. Nothing whatever should be taken
for granted in such cases, and the necessary examinations and questions
should not give offense to either party to the bargain. Syphilis is not
a respecter of persons, and exists among the rich as well as among the
poor.
+Hereditary Syphilis in Older Children.+--Hereditary syphilis may become
a latent or concealed disease, just as acquired syphilis does. None the
less, it leaves certain traces of its existence which can be recognized
on examination. These are chiefly changes in the bones, which do not
grow normally. The shin bones are apt to be bowed forward, not sideways,
as in rickets. The skull sometimes develops a peculiar shape, the joints
are apt to be large, and so on. Syphilis may affect the mental
development of children in various ways. Perhaps 5 per cent of children
are idiots as a result of syphilis. Certain forms of epilepsy are due to
syphilitic changes in the brain. On the other hand, syphilitic children
may be extraordinarily bright and capable for their years. Some are
stunted in their growth and develop their sexual characteristics very
late or imperfectly. It is one of the wonders of medicine to see a
sickly runt of a child at fifteen or sixteen develop in a few months
into a very presentable young man or girl under the influence of
salvarsan and mercury. A few syphilitic children seem robust and healthy
from the start. The signs of the disease may be very slight, and pass
unrecognized even by the majority of physicians. Some of them may be
splendid specimens of physical and mental development, but they are
exceptional. The majority are apt to be below par, and nothing shows
more plainly the insidious injury done by the disease than the way in
which they thrive and change under treatment. Even those who are
mentally affected often show surprising benefits.
+Destructive Changes, Bones, Teeth, Etc.+--Syphilis in children, since
it is essentially late syphilis, may produce gummatous changes of the
most disfiguring type, fully as extreme as those in acquired syphilis
and resulting in the destruction or injury of important organs, and the
loss of parts of bones, especially about the mouth and nose. Certain
changes in the teeth, especially the upper incisors in the second set,
are frequent in hereditarily syphilitic children, but do not always
occur. These peg-shaped teeth are called Hutchinson's teeth. Individuals
with hereditary syphilis who survive the early years of life are less
likely to develop trouble with the heart, blood vessels, or nervous
system than are those with acquired syphilis.
+Eye Trouble--Interstitial Keratitis.+--Two manifestations of
hereditary syphilis are of obvious social importance. One of these is
the peculiar form of eye trouble which such children may develop. It is
known as interstitial keratitis, and takes the form of a gradual, slow
clouding of the clear, transparent convex surface of the eyeball, the
cornea, through which the light passes to reach the lens. While the
process is active, the child is made miserable by an extreme
sensitiveness to light, the eye is reddened, and there is pain and a
burning sensation. When the condition passes off, the child may scarcely
be able to distinguish light from dark, to say nothing of reading,
finding its way about, or doing fine work. A certain amount of the
damage, once done, cannot be repaired, although cases improve
surprisingly if the process is still active and is properly treated. The
course is slow, often a matter of years, and only too many patients do
very poorly on the sort of care they can get at home. One eye case in
every 180 has interstitial keratitis, according to reliable figures.[9]
Of 152 with this trouble, only 60 per cent recovered useful eye-sight
and the remaining 40 per cent were disabled partly or completely.
Forty-three out of 71 persons lost more or less of their capacity for
earning a living. In practically all cases it means the loss of months
or years of school between the ages of five and ten and a permanent
handicap in later life. These patients would belong in school-hospitals,
if such things existed, where they could get the elaborate treatment
that might save their eyes, and at the same time not come to a
stand-still mentally. Any chronic inflammatory eye disease in children
urgently needs early medical attention, and those who know of such cases
should do what they can to secure it for them.
[9] Iglesheimer, quoted by Derby.
Blindness in hereditary syphilis may, of course, take the same form that
it does in the acquired disease, resulting from changes in the nerve of
sight (optic nerve). This form is entirely beyond help by treatment.
+Ear Trouble--Nerve Deafness.+--The second important complication of
hereditary syphilis is deafness. This occurs from changes in the nerve
of hearing and may be present at birth or may come on many years later.
The deaf infant is usually recognized by its failure to learn to talk,
although it may seem perfectly normal in every other way. Again, the
child may hear well at birth and deafness may come on in later life,--as
late as the twentieth year,--suddenly or gradually, and become complete
and permanent. It is often ascribed to colds or to falls and accidents
that happen to occur at the same time. If syphilitic deafness comes on
before the age of ten years, it is very apt to result in the child's
forgetting how to talk, and becoming dumb as well. It goes without
saying that children whose syphilis made them deaf at birth never learn
to talk at all, and are therefore deaf and dumb. Very little is known
about how many of the inmates of asylums for the deaf are hereditary
syphilitics, but there is reason to suspect the percentage to be rather
large. Deafness in hereditary syphilis is practically uninfluenced by
treatment.
+Accident and Injury in Hereditary Syphilis.+--It is a matter of great
importance to realize the large part played by accidents, injury, poor
health, or lowered resistance in bringing a hidden hereditary syphilis
to the surface. A child may show no special signs of the disease until
some time during its childhood it has a fall which injures or bruises a
bone or breaks a limb. Then suddenly at the place where the injury was
done a gumma or tertiary syphilitic change will take place and the bone
refuses to heal or unite or a large sore may develop which may be
operated on before the nature of the condition is realized. In the same
way a woman with hereditary syphilis may seem in perfect health, marry,
and suddenly after the birth of her first child, even as late as her
twenty-fifth year, may develop syphilitic eye trouble. It must be
realized that hereditary syphilis is as treacherous as the acquired
disease, and can show as little outward signs before a serious outbreak.
It is part of the duty of every person who suspects syphilis in his
family or who has it himself to let his physician know of it, for the
sake of the help which it may give in recognizing obscure conditions in
himself or his children.
+Marriage and Contagion in Hereditary Syphilis.+--In general it may be
said that, in the matter of marriage, persons who have hereditary
syphilis and live to adult life with good general health can, after
reasonable treatment, marry without fear of passing on the disease.
Hereditary syphilis apparently is not transmitted to the children as
acquired syphilis is. Hereditary syphilis practically is not contagious
except during the eruptions and active manifestations in infancy, such
as the nasal discharge and the other sores in the mouth and about the
genitals. As adults they can enter into the intimate relations of life
without risk. Many of them, while perhaps having positive blood tests
while the disease is active, later become negative without treatment.
Some of them even recover from the disease to the extent that they can
acquire it again, since there is no absolute immunity.
+Syphilis in Adopted Children.+--A word might well be said at this point
on the adoption of children with hereditary syphilis. In all probability
this is not a common occurrence, certain factors tending to diminish the
risk. A child adopted after its second year will not be so likely to
have the disease, since most syphilitic children die before this age is
reached. Agencies which arrange for the adoption of children are now
much more careful about the matter than formerly, and a Wassermann test
on the mother and also on the child, as well as a careful history in the
case of the mother, is frequently available. The information in regard
to the mother is quite as important as that about the child, since the
child may have a negative test while the mother's may be positive.
Children who have hereditary syphilis, even in latent form, should not
be offered for adoption, and should become a charge upon the state.
Families in which it later develops that an adopted child was syphilitic
should not, however, be needlessly alarmed for their own safety, since,
from the standpoint of infectiousness, the late forms of hereditary
syphilis are not dangerous to others. The agency from which the child
was adopted should assume responsibility for the child if the family
cannot meet the situation. The state of Michigan has been a pioneer in
this country in legislation which provides for the welfare of these
children among others. A law has been enacted making it possible to
provide for their medical treatment for an indefinite period in the
state hospital at Ann Arbor, at the cost of the state.
+Treatment of Hereditary Syphilis.+--The question of the treatment and
cure of a person with hereditary syphilis is in many respects a
different one from that in an acquired case. The foothold which the germ
has in the body in hereditary syphilis is stronger even than in an
untreated acquired case. Many of the changes produced by it are
permanent, and the prospects of completely eradicating it are
correspondingly small. On the other hand, the child who survives
hereditary syphilis has probably an enormous resistance to the disease,
which in a measure compensates for the hold which it has on him.
Treatment in hereditary syphilis becomes an extremely difficult problem
because it must in many cases be carried out during infancy, and for
that reason the coöperation of the patient cannot be secured. By
treating the mother, we now know that we can accomplish a great deal for
the unborn child. Once the child is born, its salvation will depend on
unremitting care and labor. If it is skilfully treated and kept at the
breast, it is estimated that it has even as high as ninety chances in
one hundred of surviving to a useful life. Salvarsan can be given to
even very small babies, and mercury also is employed with excellent
results. Persistence and skill are essential, and for that reason, if
possible, hereditary syphilis in active form in later childhood should
have the advantage of occasional or prolonged treatment in special
hospitals or sanitariums where the child could go to school while he is
being built up and cared for. This is not like trying to salvage
wreckage. Many syphilitic children are brilliant, and if treated before
they are crippled by the disease, give every sign of capacity and great
usefulness to the world. Welander, who was one of the greatest of
European experts on syphilis, has left himself an enduring monument in
the form of the so-called Welander homes, which have been established by
cities like Copenhagen, Berlin, and Vienna to provide for such children
the combined benefits of the school and the hospital. We cannot be too
prompt in adopting similar provision for such cases in this country.
There can be little excuse, eugenic or otherwise, for not doing the
utmost that modern medical science is capable of for their benefit.