longer than other children, so as to ensure an abundance of animal food
during the first two years of life. Some advise scrofulous mothers not
to nurse their children, lest they should imbibe the scrofulous taint
through the milk. This fear is entirely groundless. We know of no
reason why such a mother should not nurse her offspring, unless it be
that it injures her. The child receives its scrofulous inheritance not
through the mother's milk, but from the ovarian or spermatic cell. Milk
can convey no disease or diathesis except on account of its deficiency
in nutritive properties. If, therefore, there is any special reason why
the mother should not nurse her infant on her own account, it may be
well to turn it over to a healthy wet-nurse; but the temptation to give
an infant raised on the bottle starchy foods prematurely is too strong
generally to be resisted. The numerous infant foods advertised consist
principally of starch, and young infants would infallibly starve on any
or all of them {250} if their venders did not always direct that they
should be taken with a large quantity of cow's milk. If the
circumstances of the parents do not enable them to obtain a wet-nurse,
then good cow's milk constitutes the best food for infants until they
have cut their canine and anterior molar teeth. The custom of weaning
infants at a certain age in every case is a pernicious one. Some
infants are as well developed as to their digestive organs at fifteen
months as others are at thirty, and the eruption of the teeth may
generally be taken as a safe guide as to that question. A moderate
amount of food containing starch after the period indicated may be
allowed, but always with a preponderance of animal food. It is not so
much the starch that acts injuriously upon the nutrition of children as
the excess of that substance; and if the food contains but little
nutrition in proportion to its bulk, it is so much the worse. Even milk
containing too little casein and fat in proportion to the watery
elements may be perhaps quite as injurious as potatoes. And hence if
the mother's milk should be poor in these elements, it ought to be
supplemented with cod-liver oil or other animal fat in small doses.
A practice existed among the Southern slaves (and to some extent also
among the whites) before emancipation which at first I was inclined to
condemn until I saw the excellent effects resulting from it. Within an
hour or so after birth a piece of fat salt pork or bacon was placed
between the child's lips, and it was permitted to suck this at all
times when not nursing. Tied to its wrist by a short string, so as to
prevent swallowing it, this piece of pork furnished both nutrition and
amusement to the infant for many hours while the mother was at work in
field or garden. The children throve well on it, and thus treated we
found them to be as well developed at twelve months as most other
children were at twenty. It was doubtless due in part to this practice
that there was so little scrofula among them.
An abundance of pure air is also a valuable factor in preventing the
establishment of the strumous diathesis. Strict regard, therefore,
should be had to ventilation, and overcrowding should if possible be
avoided. Children over twelve months of age should not even be
permitted to sleep with their parents, but should have in cold weather
a crib, cradle, or other bed to themselves; and in warm weather they
should be put to sleep in a net hammock, which is now so cheap as to be
within the means of almost everybody. This will not only secure to them
a better supply of air, but it will also prevent them from suffering so
much from the heat, which is so potent a factor in the production of
cholera infantum.
Bathing in proper season is also useful as a prophylactic. Sea-bathing
especially has long enjoyed great credit as a remedy for scrofula, but
we think this is often resorted to too soon and practised at improper
times. In warm countries a bath of cold water may be taken every day in
the year, but it should be given at the warmest hour of the day, not
early in the morning. In all climates due regard should be had to the
powers of resistance to cold and the promptness of reaction after the
bath. If children remain cold and pale for a long time after the cold
bath, the practice should be discontinued and tepid water substituted.
In colder climates tepid bathing should be practised once or twice a
day during the winter, and in summer a little lower temperature may be
used. Bathing children under three or four years in the sea at any time
is pernicious, {251} both because the temperature is too low and on
account of the fright which it always causes in these young children.
After four years a child will take to the water almost as instinctively
as a young duck.
Therapeutic.--Almost all of the so-called scrofulous manifestations
belong to the surgeon, dermatologist, or oculist and aurist, and we
shall therefore say nothing about the special and local treatment of
these manifestations, but refer the reader to works upon these several
departments of medicine. But as little success will be had in the
treatment of these special disorders unless due regard is had to the
general condition, and unless the local treatment is supplemented by
constitutional measures, we shall briefly give some directions for this
constitutional treatment of the scrofulous individual.
It is important in determining upon the proper treatment in any given
case to bear in mind the division of the scrofulous into the two types
of torpid or lymphatic and sanguine or erethistic already described. It
is true that in many cases it is not easy to determine to which class a
patient belongs, and many possessing some of the characteristics of
both certainly cannot be referred to either. Still, in many cases the
discrimination is easy, and then furnishes very clear and valuable
indications as to treatment. Iodine (and its preparations) has since
the time of Lugol, who first brought it into prominent notice, been
regarded as a useful remedy in scrofula. But burnt sponge (spongia
usta), which contained the iodides of sodium and potassium, had been
used to dissipate goitrous and scrofulous swellings many hundreds of
years before the time of Lugol. It is a valuable remedy in certain
cases, and if it is falling into disuse it is probably for the want of
proper discrimination in the selection of cases. In all cases in which
there seems to be an abundant production of fat, and therefore in
nearly all the cases of coarse struma where there is an indolent
process of assimilation and disassimilation, iodine and its
preparations will be found useful. Indeed, in the form of syrup of
iodide of iron we have rarely failed with it to cause strumous
enlargements of glands to disappear when the remedy was used soon after
their first appearance. Of course, neither iodine nor any other
medicine can have any effect in removing these enlargements after the
glands have become caseous. While good results may be obtained with the
syrup in all forms of scrofula, it is unquestionably in the sanguine
and neutral types that it is most useful. It should be given in doses
of 10 to 30 drops to children under five years of age, and to older
ones ½ to 1 fluidrachm three or four times a day may be administered.
We have given the latter dose to children four or five years of age for
a long time, with the best effect upon their scrofulous manifestations,
and without any injury whatever to their digestive organs.
In the torpid types preparations stronger in iodine should be used.
Here Lugol's solution or iodide of potassium or sodium will be found
very useful, either alone or in connection with the iron preparation
above mentioned. Indeed, as in these cases it seems to be
disassimilation that appears to be specially faulty, even very small
doses of mercury in the form of bichloride or biniodide will be found
useful. Donovan's solution may be prescribed in these cases along with
the active preparations of iodine with good effect, or if the arsenic
in that preparation is objectionable, one-fiftieth of a grain of
bichloride or biniodide of {252} mercury may be substituted. The
mercurial should not, however, be continued longer than one or at most
two weeks at a time, after which it should be suspended and the iodine
continued.
Cod-liver oil, which is too indiscriminately prescribed in all cases,
will be found to be of little use in the lymphatic types, if indeed it
is not actually injurious; but in those cases with pale, thin skin,
with deficient development of fat, and with small muscles--in short,
those in which emaciation or delicacy is prominent--it is a most
valuable remedy. It is almost surprising to see how rapidly
ulcerations, caries, eczemas, catarrhs, etc. occurring in this class of
subjects will disappear under the use of this medicine alone.
The hypophosphites and lactophosphates are also useful in this class of
cases, especially where there is disease of bone or joints, in
connection with the cod-liver oil. We have long been in the habit of
using the following formula, which we have found very useful:
Rx. Pulv. Acaciæ, drachm ij;
Ol. Amygdal. amar., gtt. vj;
Syr. Calcii hypophosphit.,
vel Syr. Calcii lactophos., fluidounce iv;
Ol. Morrhuæ, fluidounce iv;
Ft. mist.
S. Teaspoonful to tablespoonful three times a day according to age.
Syrup of iodide of iron may be added if desirable, though we prefer to
give this by itself.
Gentle exercise, passive or active, pure air, well-ventilated sleeping
apartments, a generous diet--in which wholesome animal food should
predominate--and bathing are of course as necessary and as useful in
the treatment as in the prevention of the scrofulous diathesis.
Alkalies should be given in all cases in which we are trying to
dissipate enlarged lymphatic glands, for the reason that caseation of
these glands occurs because of insufficient alkalinity of the blood to
effect reduction of fat, and because also the strumous almost always
suffer from excessive acidity of the gastric and other secretions. When
the iodides of potash or soda or the hypophosphites of lime and soda
are given, the additional administration of alkalies may not be
necessary; but if not, bicarbonate of sodium or potassium (which have
long enjoyed a good reputation in the treatment of struma) should be
added to the other remedies.
Since the appearance of Niemeyer's _Handbook of Clinical Medicine_ the
proper treatment of scrofulous glands that have undergone the caseous
degeneration has been a moot question. Some recommend the ablation of
these glands by the knife, some advise spooning out the caseous matter
through a small opening, while others prefer to await the natural
process of softening and the discharge of the caseous matter by
suppuration. There can be no question that the removal of these glands
by the knife, when this can be done without serious risk, will leave
behind a less unsightly scar, and will be attended with less fever and
consequent deterioration of the general health, than usually attends
suppuration. Spooning out the caseous matter will perhaps leave no
extensive cicatrix, but we can never be sure that by this operation we
have removed all the caseous matter, and it must certainly be more
painful than the knife. Mothers will generally object to either of
these {253} operations, and as the risks of infection by absorption of
the caseous pus during the suppurating process do not seem to be very
great, it is perhaps best to leave these glands to nature, unless the
vitality of the patient is so low as to give reasonable ground for fear
that the child may succumb to the effects of the natural process. If
any surgical interference is deemed necessary, we are decidedly in
favor of removing the caseous gland entire by the knife.
{254}
HEREDITARY SYPHILIS.
BY J. WILLIAM WHITE, M.D.
About a half century ago Mr. Abraham Colles, who had just resigned the
professorship of the Theory and Practice of Surgery in the Royal
College of Surgeons in Ireland, the duties of which, in the opinion of
the college, he had discharged for thirty-two years in an "exemplary
and efficient manner," wrote the following introductory paragraph to
his remarkable chapter on "Syphilis in Infants:" "Perhaps there is not
in the entire range of surgical diseases any one the contemplation of
which is more calculated to arrest our attention or to excite our
interest than syphilis infantum."
Although it was not then, and is not at the present day, strictly
relegated to the domain of surgery, hereditary syphilis, like its
parent disease, was generally treated of by the practitioner of that
branch of medicine. And yet in the great majority of instances the
management of such cases, especially as regards their family relations,
the relations of husband and wife, the management of the latter during
pregnancy, the delivery and subsequent care of the child, the necessary
attention to the safety of other members of the family--in fact, all of
the most weighty responsibility--falls upon the ordinary medical
attendant. It is therefore in every way proper that the condition
should receive some notice in a system of general medicine.
A proper presentation of the subject of hereditary syphilis involves a
consideration of the vexed question as to the mode by which the disease
is conveyed from parent to offspring. That it may be so transmitted has
been generally believed since the doctrine was first announced by
Torella at the end of the fifteenth century; and the facts in its
support are so numerous and convincing that, in spite of a few
distinguished opponents--among whom John Hunter was the most
conspicuous[1]--it has been unhesitatingly accepted by the profession
down to the present day. As regards the manner of transmission,
however, controversy has been and still is rife. Opposing theories have
been constructed and ardently supported, differing radically as to
essential points, often resting upon exceptional or anomalous, and
still oftener upon imperfectly observed, cases.[2]
[Footnote 1: _Works of John Hunter_, vol. ii. p. 383.]
[Footnote 2: Parrot, in a clinical lecture on syphilitic abortion (_Le
Progrès Médicale_, Nov. 3, 1877, p. 798), says: "The infection of
children was known, but its true origin was not suspected. The belief
of Gaspard Torella (1498) and Matthioli (1536) that it came from the
nurses through the milk was generally accepted."
{255} According to Diday, Paracelsus (1529) was the first to plainly
state the heredity of syphilis: "Fit morbus hereditarius et transit a
patre ad filium."
Others attribute the original announcement to Augier Ferrier (1553),
and it seems certain that he was first to specify the three modes of
infection of the product of conception: "La semence du père, celle de
la mère, et la contamination de la mère durant la grossesse."
Fallopius in a posthumous treatise on the Mal Français (1566) adds the
authority of his name to this view: "Præterea videbitis puerulos
nascentes ex foemina infecta, ut ferant peccata parentum, qui vedentur
semi cocti."
Ambroise Paré also acquiesced in the theory, saying, "Souvent on voir
sortir les petits enfants hors le ventré de leur mère, ayant ceste
maladie, et tost après avoir plusieurs pustules sur leur corps;
lesquels étant ainsi infectés, baillent la vérolle à autant de
nourrices qui les allaictent."
Subsequently, Mauriceau, Boerhaave, and Astruc sustained the same view,
which, with the single exception of Hunter, had no prominent
antagonist.
It was not, however, until the eighteenth century that it was described
with any attempt at detail or exactness by Rosenstein, and his essay is
loaded with errors. It was in the foundling hospitals of Paris at the
end of the last century, in the wards of Salpétrière and Bicêtre, and
in the hospitals of Vaugirard and in the Capucin convents of the Rue
Saint Jacques, where pregnant women and nurses attacked with syphilis
were admitted, that methodical and trustworthy observations were made
(1780-1810) by Colombier, Despenières, Doublet, Mahon, Cullerier, and
Bertin. Since then the history of the disease has been the history of
syphilis itself.]
A full consideration of these, or even a recapitulation of the
respective arguments pro and con, would far exceed the limits allotted
to the present article, and we will confine ourselves simply to stating
the questions which most nearly concern the practical physician, and
the conclusions which the accumulated observation and experience of the
profession seem to justify. The points bearing upon the general subject
of hereditary syphilis which exercise an important influence upon
advice or opinions of the utmost gravity as regards the happiness and
well-being of the individual or family may be enumerated as follows:
1. Is syphilis in all its stages transmissible (_a_) to the wife or
husband, (_b_) to the offspring? Or, in other words, is it ever proper
to consent to the marriage of a person who has had syphilis? If so,
under what circumstances?
2. By what means or through what channels can the disease of the
parents reach the child?
3. What are the pathology and symptoms of hereditary syphilis?
4. What is the treatment--(_a_) prophylactic, applied to the parents,
and (_b_) curative? We may now take these up seriatim.
No more important questions can be submitted to a medical man than
those pertaining to the marriage of syphilitics. Involving as it does
the welfare of many individuals, modifying or fixing the conditions or
circumstances of one or more lives, his opinion should be exceptionally
definite and well grounded. The responsibility of advising or
consenting to the marriage of a person who has once had syphilis is
undoubtedly great; the responsibility of prohibiting it is, however, no
less so. Matrimony is the natural condition for the majority of people.
Enforced celibacy, especially in males, brings with it not infrequently
a long train of attendant evils, moral and physical. It will not do to
assume that professional duty is properly discharged by telling all
patients to be on the safe side and to remain single for fear of
inoculating wife or offspring, unless it can be clearly shown that
there is a definite and unavoidable risk in every case, which continues
throughout life.[3]
[Footnote 3: "The surgeon who, on account of past syphilis, forbids
marriage to an otherwise {256} eligible man must remember that he
forbids it at the same time to some woman, who, possibly, if well
informed as to her risks, would willingly encounter them.... Respecting
a malady so common as syphilis, while it is often our duty to warn, it
is also not unfrequently our duty to encourage" (Mr. Hutchinson,
preface to the English translation of Fournier's _Syphilis and
Marriage_, p. vii.)]
There are two distinct methods of arriving at an answer to the question
under discussion: first, by considering the probabilities in regard to
the essential nature of syphilis; and, second, by carefully weighing
the clinical evidence in the matter. It seems evident that belief in
any particular theory of syphilis assigning it to this or that class of
disease must have an important influence in determining the opinion
which is held as to its curability, or at least as to its indefinite
transmissibility.
If the late symptoms, the so-called tertiary outbreaks of the disease,
are held to be evidences of the presence in the system of the specific
virus, which has simply remained for a long period, perhaps for many
years, latent or quiescent, and which is thus again manifesting its
power; if syphilis is believed, accordingly, to be a practically
unlimited disease, conforming to no known law as regards its duration,
corresponding to no other infectious or contagious malady in having a
period of termination--more or less delayed perhaps, or more or less
indefinite, but still invariably present--at which time either the
particular poison or the susceptibility of the system to its influence
has become exhausted;--if tertiary syphilis, in other words, is
regarded as simply a continuance or recurrence of the disease,
differing in no essential respect, except as to the particular tissues
involved, from the same disease in its early stages, it is difficult to
see how marriage can ever be conscientiously recommended to a person
who has once contracted it.
It is unfortunately true that in no given instance is it safe to assure
a patient of further complete immunity from the disease. In any case,
however mild in its course or under whatever treatment, there is always
an element of doubt as to the development of subsequent symptoms. The
probability of their appearance may be reduced to a minimum, the
character of the case and the thoroughness of the treatment may both
seem to give assurance that a cure has been completed, and yet both
patient and physician may be mortified and annoyed by an outbreak of
tertiary lesions. This, I think, would be admitted by every one of
large experience with the disease, and indeed furnishes the chief
argument to those who deny or are sceptical as to its curability. If,
then, it were impossible to predict with any sort of certainty that the
contagious and highly transmissible stage of syphilis would terminate
during the life of the individual, it would manifestly be unwise to
permit marriage, with its risk of inoculating the innocent partner and
the consequent double risk to the offspring.
If, however, syphilis is, as taught by Mr. Hutchinson,[4] one of the
exanthemata, having, like them, a period of outbreak, a period of
efflorescence or eruption, and a period of subsidence, and followed,
like them, by certain non-contagious sequelæ, which we call the
tertiary symptoms, but which are merely relapses or degenerations of
parts affected during the secondary stage, it becomes evident that the
risk of transmission to wife or husband or children _after the lapse of
a certain interval_ becomes greatly reduced or almost nil. No one
thinks of forbidding marriage on {257} account of a previous attack of
small-pox or scarlet fever or typhoid fever, even although there are
unpleasant consequences which sometimes follow these diseases.
[Footnote 4: _The London Lancet_, Feb. 5, 1876; Reynolds's _System of
Medicine_, Am. ed., p. 423.]
Or if another and still more plausible theory of syphilis is adopted,
and we look on the tertiary period as one of contraction or
obliteration of lymphatics due to long-continued irritation by the new
cell-growths of the secondary stage, which from the very onset affect
those vessels, our views will be materially modified. During the
primary period, then, when the new cells, which either constitute the
poison of syphilis or are its carriers, are accumulating at the site of
original inoculation, constituting the induration of the chancre, or
are slowly finding their way into the general system through the
lymphatic vessels, proliferating in their walls and thickening and
hardening them, or during the secondary period, when they are rapidly
multiplying in all the tissues of the body, the risk of inoculation or
transmission would be manifestly great. When, however, by destructive
metamorphosis and degeneration, either with or without the aid of
drugs, they have been eliminated from the body, the contagious element
disappears with them; and although here and there throughout the body
some important lymphatic trunk may have undergone irreparable injury,
and may have been contracted or obliterated, permitting of the
accumulation of waste products until the node or gumma or tubercle
which we call a tertiary symptom makes its appearance, yet the disease
has lost much of its terror, and has become dangerous only to the
patient himself.[5]
[Footnote 5: _Clinical Lectures on the Physiological Pathology and
Treatment of Syphilis_, by F. N. Otis, M.D.; _Syphilis_, by V. Cornil,
Am. ed., 1882, pp. 17-27.]
These theories are only alluded to by way of elucidation of the
statement that belief in one or the other of them has an important
bearing on the relation of syphilis to marriage, and because, whichever
is thought to be the most plausible, they equally lessen or altogether
do away with a certain proportion of the danger formerly thought to
surround the marriage of a syphilitic even after a most protracted
interval. It is not necessary to accept either the one or the other
implicitly. The essential point is the recognition of the fact that
modern syphilographers, as a rule, regard the tertiary or late symptoms
as indicative of damage done during the active period--as relapses or
sequelæ, and not as fresh outbreaks, of a highly contagious and
transmissible disease. Their time of appearance, their entire want of
symmetry, their non-contagiousness, their non-inoculability, all favor
this view, and we may now see what evidence corroborative of it may be
obtained from clinical facts.