be but little doubt in the minds of most syphilographers that in rare
instances syphilitic children have been born to parents who had long
passed the limits of the secondary period. At least the great majority
of writers upon this subject speak confidently of the exceptional
occurrence of such cases, and assert that syphilis may be transmitted
during any of its stages.[6] If, however, we come to look for positive
evidence in this respect, we will find very little that is entirely
satisfactory. Cases are reported, to be sure, in which eight, ten,
twelve, or even fifteen or twenty, years after the primary sore,
syphilitic patients have become the parents {258} of children who
showed unmistakable indications of the disease. When we examine the
history of the cases, we find usually that many important points are
omitted without which it is impossible to be certain of its true
character. Were both parents originally infected? If not, has a recent
case of syphilis occurred in the one who at first escaped? If they were
both diseased originally, has either been subsequently re-infected?--a
much more frequent accident than has been commonly supposed.[7] On
applying these tests to the cases in question it will be found that few
if any of them are thoroughly convincing. Kassowitz's observations,[8]
made, it must be remembered, upon persons with whom no mercurial
treatment had been employed, seemed to show that the average limit of
transmissibility was about ten years, after which time healthy children
began to be born. His observations were, however, incomplete in many
respects, and, like all such investigations, are of course open to the
suspicion of intentional deception on the part of the patients.[9] Even
these cases, however, show unequivocally, as do all which have ever
been recorded, the steady diminution of the transmissive power under
the influence of time alone.
[Footnote 6: Belhomme et Martin, _Traité de la Syphilis_, p. 413.]
[Footnote 7: Cornil, _op. cit._, p. 20.]
[Footnote 8: _Die Vererbung der Syphilis_, Wien, 1876.]
[Footnote 9: See also Hutchinson, _British and Foreign Med.-Chir.
Rev._, Oct., 1877.]
I have said that the majority of writers seem to have no doubt of the
long continuance of this transmissive power in rare cases. There are,
however, a few notable exceptions. Fournier, whose immense experience
and acuteness of observation entitle his opinion to the utmost
consideration, says that in cases of paternal heredity the duration of
the force of transmission never exceeds at the maximum three or four
years.[10] In no case of the many hundreds he has observed has he known
a syphilitic father to infect a child--the mother being healthy--at a
later period than the one mentioned. And he is equally positive that
the gradual diminution and final extinction of the syphilitic reaction
of the parents upon the children is a veritable pathological law,
"absolutely demonstrated."[11]
[Footnote 10: _Syphilis and Marriage_, Am. ed., p. 87.]
[Footnote 11: _Op. cit._, p. 88. Of course when both parents are
diseased a somewhat longer period of activity is to be expected for the
poison.]
M. Mireur, a careful and accurate observer, records[12] a striking
instance in which in the history of a couple, both syphilitic and
untreated, eight pregnancies occurred. The first resulted in abortion
at fifth month; the second, in abortion at seventh month; the third, in
a stillbirth; the fourth, a syphilitic child dying in one month; the
fifth, in a syphilitic child dying in forty-five days; the sixth,
seventh, and eighth, in living, healthy children. To me the most
interesting fact in the whole relation is that during a portion of the
time, and immediately after the last three pregnancies, which resulted
in the birth of healthy children, both husband and wife manifested
grave tertiary syphilitic symptoms--gummata, tubercles, ulcers, etc.
This is direct evidence of the strongest kind in favor of the view that
syphilis ceases to be transmissible by heredity at the end of a certain
period, as we know that it ceases to be contagious or inoculable.
[Footnote 12: _Essai sur l'Hérédité de la Syphilis_, Thèse de Paris,
1867, p. 91.]
M. Ricord long ago,[13] and even before him Astruc and Doublet,[14] had
{259} promulgated the same theory, Ricord asserting that in the
tertiary stages the only effect of the disease upon the children was so
to modify their organization and temperament as to expose them to
developments of a scrofulous character--a view of the relation between
syphilis and struma which has been so ably supported in our own day by
Professor Gross.
[Footnote 13: _Traité pratique des Maladies vénériennes_ Paris, 1838,
p. 644.]
[Footnote 14: Legendre, _Nouvelles Recherches sur les Syphilides_, 1841
(quoted by Belhomme et Martin).]
M. Bazin also[15] denies absolutely that tertiary syphilis is any more
transmissible than it is communicable in other ways, although he fails
to give his reasons for this belief.
[Footnote 15: _Leçons sur les Syphilides_, 1859, p. 35.]
Hill and Cooper state[16] that the transmissive power continues as long
as the secondary eruptions are present, but usually ceases when the
tertiary stage is reached.
[Footnote 16: _Syphilis and Local Contagious Disorders_, London, 1881,
p. 62.]
Van Buren and Keyes[17] believe that fathers with tertiary syphilis
certainly, as a rule, procreate non-syphilitic children; and in
speaking of the fact that when the mother has syphilis the child is
generally infected, they except the later tertiary stages.
[Footnote 17: _Genito-urinary Disease and Syphilis_, 1874, p. 521.]
Bumstead[18] and Taylor say that without mercurial treatment the danger
of transmitting the disease to offspring usually persists up to the
fourth year of syphilitic contagion.
[Footnote 18: _Venereal Diseases_, 1879, p. 739.]
Mr. Lane says:[19] "It is certainly the rule that when the parents have
fully reached the tertiary stage the children born to them are free
from all signs of syphilis."
[Footnote 19: _Lectures on Syphilis_, London, 1881, p. 65.]
Mr. Hutchinson says:[20] "It is almost an acknowledged law that parents
in the late tertiary stages do not transmit taint."
[Footnote 20: _The Med. Press and Circular_, Aug. 2, 1882, p. 85.]
It will be seen from the foregoing extracts, which might be greatly
multiplied,[21] that there is a strong tendency on the part of many
authors to limit more or less strictly the period of transmissibility
of syphilis even when the disease is allowed to progress without
treatment. As to the facts that it becomes milder with time, both in
parents and offspring, that it ceases to be conveyed from husband to
wife or vice versâ, that with each succeeding year after the
termination of the secondary period the chances of escape of the
product of conception increase in a rapidly augmenting ratio,--there is
no difference of opinion whatever. Neither is it seriously disputed
that the length of time during which the disease remains active, as
well as the degree of its activity, may be markedly and beneficially
influenced by the administration of mercurial treatment. Under proper
medication patients who have rashly or disobediently married in the
height of the secondary period have been enabled to escape the danger
of transmission either to spouse or offspring--have, in fact, had
children born healthy and who never subsequently manifested any
symptoms of the disease.
[Footnote 21: M. Diday, _Traité de la Syphilis des Nouveau-nés_, Paris,
1854, p. 183; M. Bertin, _Traité de la Maladie vénérienne chez les
Nouveau-nés_, Paris, 1870, p. 142; M. Bazin, _op. cit._, p. 164; M.
Roger, _L'Union Médicale_, 1865, t. i. p. 147 (quoted by Fournier).]
I may add that my own experience seems to confirm the views which have
thus been set forth. I have notes of all my cases occurring in private
practice in a large city--some of them, I regret to say, among personal
friends or acquaintances, some of them in our own profession--and have
repeatedly {260} given permission to men to marry or to resume marital
relations after three years or three years and a half of mild mercurial
treatment, to which during the last six months or a year had been added
iodide of potassium. In many instances healthy children have been born:
in none, so far as I know, has the wife or mother been directly
infected. There have been a few doubtful cases in which premature
deliveries or stillbirths have occurred, but in nearly every such
instance there seemed to be other and entirely competent causes for the
accident; and in none of them, as I learned from the father or from the
obstetrician in attendance, were the children the subjects of
unmistakable syphilitic symptoms.
As to the exact time at which it is safe to permit marriage, and as to
the proper treatment before and after that event, it is hardly possible
in an essay like this to enter into many details. Yet so much is
involved in the answer to our first question that it may not be
altogether out of place here to indicate briefly the views of the
writer as to general methods of treatment. This is the more proper
because in every case of suspected syphilis in a new-born child, in
every case of threatened or actual abortion or miscarriage in the wife
of a man who has at some time in his life had syphilis, these questions
will present themselves, and the answers to them will greatly influence
not only the diagnosis and prognosis, but even the treatment, of such
cases.
1. In the first place, then, the diagnosis of syphilis should have been
assured. No venereal sore can with certainty be pronounced to be
syphilitic before the occurrence of general constitutional symptoms,
either the early cutaneous eruptions or at least the general glandular
involvement. Treatment begun prior to these developments leaves the
whole case open to the suspicion of mistaken diagnosis.[22]
[Footnote 22: "It is unsafe to predict confidently that any venereal
ulcer, even a soft sore attended with suppurating bubo, will entail no
further consequences. There is a strong probability that an indurated
sore will prove infecting; and there is a probability, though not
nearly so strong, that a soft suppurating sore will not; but exceptions
to both these general rules will be met with, and there is really no
absolute proof of the infecting nature of any given sore but the fact
of infection itself" (_Lectures on Syphilis_, James S. Lane, London,
1881, p. 23).]
2. The drug which should at once be begun when the character of the
case is fully recognized is mercury in one of its various forms. It may
be given by the mouth, by inunction, by vaporization, by hypodermic
injection, according to the preferences of the physician or patient;
but, however administered, it should be given in sufficient
quantity--_i.e._ in each case the full physiological dose of that
particular patient should be employed. To ascertain this the amount
used should have been gradually increased until commencing symptoms of
salivation are produced, when it should be diminished about one-half.
3. The quantity which has been thus determined should be given
continuously, or stopping only for the management of intercurrent
complications, for at least eighteen months. If during this time new
syphilitic symptoms make their appearance, the dose should be
temporarily raised until they have vanished, when it should be brought
down again to the original amount.
4. At the end of eighteen months or two years small doses of iodide of
potassium should be added to the mercurial, and this mixed treatment
should be persevered in for six months or a year longer, or should be
{261} still further prolonged if during that time any evidence of
syphilis is seen.
5. At the end, then, of from two to three years, if no symptom has been
seen for six months or a year, treatment may be stopped and the patient
kept under observation for a year; and if during that time no symptom
develops he may consider himself as in all probability cured. Any
course of treatment less thorough than this should be set down as
insufficient to afford any reasonable presumption of further immunity
from the disease.
There is evidence to prove, on the other hand, that this plan of
treatment, rigidly carried out, results in the majority of cases in
curing the disease, or at any rate in putting the patient in such
condition that he may with safety marry and may expect to have healthy
children.
To recapitulate: Syphilis after a certain period, not extending much
over four years where the disease is allowed to run its own course, and
probably much reduced by treatment, ceases to be a contagious disease;
and at about the same time or some time after loses, in the majority of
cases, its capability of being transmitted.
As there are probably exceptions to the rule that this power of
transmission disappears spontaneously within any specified time, it is
never safe to trust altogether to the unaided efforts of nature, but a
vigorous and sufficient specific treatment must be employed.
Given, however, the lapse of a sufficient time--say from three to four
years as a minimum--the history of a proper and continuous plan of
treatment, and the absence for a year or more of any specific symptoms
whatever, and the risks of marriage are so reduced as probably to
warrant a careful physician in permitting it.[23] And conversely, of
course--and this constitutes the reason for introducing the foregoing
matter into a paper on hereditary syphilis--in any doubtful case where
such a history can be elicited, and where all these precautions have
been observed, it is improbable that any taint of syphilis has been
transmitted.
[Footnote 23: This refers, of course, to an ordinary case of syphilis.
If the symptoms have been unusually grave, if the deeper tissues or the
viscera have been seriously involved, if cerebral or spinal
complications have occurred, the situation is of course much more
grave, and no step should be taken without the most thoughtful
deliberation. The work of Fournier already alluded to (_Syphilis and
Marriage_) furnishes an admirable guide under these circumstances.
Mr. Frederick Lowndes, surgeon to the Liverpool Dock Hospital
(_Lancet_, July 8, 1882), says: "Each case must be judged on its own
merits. When the constitution is good, and there has been sufficient
specific treatment, marriage may be permitted within a much shorter
period than M. Fournier suggests, and with safety. Syphilis alone and
syphilis combined with scrofula are two very different foes to contend
with, and if our patient be of a scrofulous temperament a delay even
longer than M. Fournier's may be desirable."
He quotes Dr. Thomas Edward Beatty in an address at the annual meeting
of the British Medical Association at Leeds in 1869: "Mercury given to
the man when first diseased would, I firmly believe, have prevented
this terrible calamity--_i.e._ the syphilitic infection of the wife;
and I would now humbly suggest to all who undertake the treatment of
venereal disease that if they have a certainty that their patients will
remain celibate all their lives, they may heal up their sores and
dispel their eruptions and sore throats in any manner they like, but
that they have no right to expose the pure, innocent, high-minded
females of society to contamination by marrying men treated without
mercury."]
Beyond this in positiveness of assertion it is not safe to go. There
may be exceptions to these as to most other hygienic or therapeutic
rules, but they will surely be of excessive rarity.
{262} Before considering the methods by which syphilis can reach the
child from one or the other of its parents, it may be well to mention
the modes in which they can infect each other.
The father can derive syphilis from the mother only in the usual
way--_i.e._ by contagion through a breach of surface permitting of the
direct absorption of the poison, the development of the disease being
attended by the usual phenomena--chancre, lymphatic enlargement, skin
eruptions, etc. The woman may--and in the vast majority of cases
does--acquire the disease from the husband in a similar manner. But
there seems to be good reason for believing that she may also become
infected through the medium of the child, who receives its syphilis
directly from the father, the mother up to the time of conception
having escaped contagion. More than this, it appears to be highly
probable[24] that no woman ever bears a syphilitic child and remains
herself absolutely free from the disease.
[Footnote 24: The strongest argument against the theory that every
woman who has had a syphilitic child has herself been infected lies in
the existence of cases like the following, several of which have been
observed: The wife of a man having active but untreated syphilis gives
birth to one or two syphilitic children, she herself developing no
symptoms. Later, the husband is placed on mercurial treatment. She then
conceives and gives birth to a healthy child. He stops treatment, and
she again bears a syphilitic child, which on his resuming his mercurial
course is followed by another healthy infant. Such cases certainly
indicate that the syphilis of the mother, if any exists, is incapable
of transmission to the child, as the effect of the treatment of the
father is too direct and unvarying to admit of doubt.]
The existence of this form of infection--syphilis by conception--has
been vehemently denied by many authors[25]--by some on the theoretical
grounds that as the essential elements or carriers of the syphilitic
virus have been shown to be cells or protoplasmic particles, and as,
after conception, the embryo is supplied with serum, but not with cells
of any kind, it is impossible that syphilis can be conveyed either to
or from it;[26] by others on reported observations of numerous cases in
which mothers who have been delivered of syphilitic children have shown
no evidences of the disease.
[Footnote 25: Kassowitz, Von Baerensprung, Bidenkap, and others.]
[Footnote 26: Bumstead and Taylor, _op. cit._, p. 742.]
It would appear, however, that, setting aside arguments based on
theoretical considerations, the weight of clinical evidence is
altogether in favor of the frequent, if not the invariable,
contamination of the mother through the medium of the foetus. No
physician of large experience in this class of cases can fail to have
seen some in which the husband, having had syphilis and having married
after an insufficient interval or an imperfect course of treatment, has
infected his wife with the disease, although at the time no
discoverable symptom is to be found upon his body--no abrasion, sore,
mucous patch, no lesion of continuity or suspicious point of any
description. An equally careful inspection of the woman will also in
such cases be attended by negative results--no initial lesion, no spot
of induration, no adenopathy being at all discoverable--and yet she
will be found with unmistakable evidences of constitutional
syphilis.[27] There is a clue to all such cases which will immediately
resolve the difficulty. In every instance, providing that no mistake
has {263} been made and that both husband and wife are really free--the
one from any contagious lesion, the other from any evidence of a
present or previous primary sore--it will be found that pregnancy has
occurred; that the woman has either been delivered of a syphilitic
child or has had an abortion or miscarriage at some time before the
outbreak of the symptoms of syphilis. Although I am firmly convinced
that this is a statement of facts based upon careful clinical
observation, and although this view has received the unqualified
endorsement of no less an authority than Fournier,[28] it is yet
strongly combated by many excellent authorities. They say in reply to
the above arguments that the reported cases are open to just criticism,
that trifling and unnoticed lesions of the father--chafes or abrasions
almost microscopic--suffice to transmit it on his part; while as an
explanation of the supposed absence of the primary lesion in the mother
they plead the well-known difficulty of discovering it in women under
any circumstances.
[Footnote 27: For a typical case see _Colles's Works_, New Sydenham
Society, London, 1881, p. 253. From that date to this hundreds of such
cases have been observed, and it would be idle to refer to them.]
[Footnote 28: _Op. cit._, pp. 26-30. He confesses to complete ignorance
as to the precise method by which this contagion takes place, whether
by poisoning of the fecundated ovule at the moment of conception (the
theory of Von Baerensprung) or by exchanges of the utero-placental
circulation, and regards the various hypotheses upon these points as
without practical value.]
Another argument, however, which seems to me to be unanswerable lies in
the application to the case in question of the well-known "law of
Colles," which from the date of its first enunciation by its
distinguished expounder in 1837 down to the present day has been found
to be absolutely without exception. I know of no other statement in
reference to disease which is at once so sweeping and comprehensive in
its bearings and so completely substantiated by clinical experience. It
may be given in his own words: "One fact well deserving our attention
is this: that a child born of a mother who is without obvious venereal
symptoms, and which, without being exposed to any infection subsequent
to its birth, shows this disease when a few weeks old,--this child will
infect the most healthy nurse, whether she suckle it or merely handle
and dress it; and yet this child is never known to infect its own
mother, even though she suckle it while it has venereal ulcers of the
lips and tongue."[29]
[Footnote 29: _The Works of Abraham Colles_, edited by Robert
McDonnell, the New Sydenham Society, London, 1881, chap. xiii. p. 287.]
As to the absolute and unvarying truth of this law there is no excuse
for a shadow of doubt. To quote Mr. Hutchinson: "It has received the
assent of every authority who has written on the subject since it was
announced. It has attracted attention both at home and abroad, and I am
not aware that a single exception to it has been recorded.[30] We have
all of us seen chancres on the nipples of wet-nurses. They are, indeed,
not very infrequent. We have, however, none of us seen such on those of
the mothers of infected children. Let us remember that it is very
unusual to put a syphilitic infant out to wet-nurse--a thing which no
prudent physician would ever permit--and that, probably, for one so
nursed a hundred are suckled by their mothers, and we can appreciate
the weight which this entire absence of proof that mothers ever suffer
{264} bears. It amounts, I think, to all but proof that they are
absolutely insusceptible."[31]
[Footnote 30: The cases of Cazenave (1847), Cocchi (1858), Müller
(1861), Ranke (1878), Guibout (1879), Scarenzio (1880), and Zingalès
(1882), are defective in important particulars, the first two so much
so as to render them valueless. Ranke's case is by far the strongest
yet recorded, but lacks fulness and rests upon his unsupported
testimony. (See Hill and Cooper, _op. cit._, p. 55, and _Nouveau Dict.
de Méd. et de Chir._, vol. xxxiv. p. 687.)]