April, 1878, p. 103) that "the full weight of Colles's law is to be
estimated in connection with the question whether the child whose
hereditary syphilis is derived from the mother exclusively is capable
of infecting its healthy father; and if no instance of this latter can
be adduced a higher law becomes defined--viz. that the child whose
hereditary syphilis is transmitted by one parent only is incapable of
infecting either." He explains this hypothetical immunity, in which he
seems to believe, by saying that "it is probably due to the fact that
the syphilis-bearing cell-element cannot readily be implanted upon the
soil from which it sprang--a fact illustrated by the infecundity of
consanguineous marriages and the non-auto-inoculability in general of
the primary lesion of syphilis." When, however, we exclude the large
number of cases in which the father is already syphilitic, and remember
that in the others the contact between him and the child is slight,
infrequent, and fleeting--being usually limited to an occasional kiss
or caress--it does not seem strange that no instances of such infection
have been reported; nor does the fact seem at all worthy of being made
the foundation of a general law.]
There can be but one rational explanation of these facts--viz. that the
mothers who have thus acquired an immunity have done so by first
acquiring the disease. It may, in those cases where no secondary
symptoms appear, be in a modified form, due, as suggested by Mr.
Hutchinson, to some heteromorphism or alternation of generations on the
part of a specific fungus, or to the excessively small quantity of the
poison which finds its way from child to mother, or to some other
obscure cause with which we need not now concern ourselves. It is, at
any rate, no more mysterious than the protective influence of vaccine
in small-pox, and when one is rationally explained doubtless the other
will be found to be closely allied in its mode of action. The fact
which interests us at present is that it is in the highest degree
improbable that anything but some form of syphilis itself could afford
this entire protection, and that it is not in the least unreasonable,
but, on the contrary, logical and consistent with all the known facts,
to suppose that while in some cases no observable symptoms might be
produced, in others where the cause was the same, but more active, or
the powers of resistance less, the usual constitutional phenomena would
be developed.
We may conclude, then, that the husband may infect his wife--(1) In the
usual manner or by direct contagion; (2) through the medium of the
child, or at any rate by the production of conception.
The theory upheld by Von Baerensprung, that the syphilis of the mother
is imparted to her at the moment of impregnation, the disease being
impressed upon the fecundated ovule, does not materially conflict with
the above views, conception being in either case the essential factor,
but in the latter instance the intervention of the foetus itself not
being necessary. It has to support it the clinical fact that in those
cases where syphilis appears during pregnancy the outbreak of symptoms
occurs at about the ninth or tenth week after the date of conception,
or a period which closely corresponds to that of the appearance of
general symptoms after exposure to ordinary contagion--allowing about
three weeks for the so-called incubation of the chancre and six weeks
for the secondary incubation.[32]
[Footnote 32: This has been shown not only by Von Baerensprung (_Die
Hereditäre Syphilis_), but also by Diday, whose observations were
intended to prove the possibility of syphilis being derived from the
child by the mother--"choc en retour." In 24 cases the period at which
the first eruption appeared in the mother averaged sixty-five days
after conception; only once did the first signs appear after the fourth
month of pregnancy.]
{265} It may also be said to be rendered probable by the following line
of argument:
Colles's law, which is without exception, demonstrates that every woman
who has had a syphilitic child has been herself infected, even if she
has had no observable symptoms;[33]
Cases are recorded, however, in which a woman having given birth to one
or more syphilitic children, and therefore herself syphilitic, bears
healthy ones in consequence of specific treatment administered to the
father before and during the period of conception, she remaining
untreated;[34]
The determining cause, therefore, of the syphilis of the child is not
the syphilis of the mother, but the condition of the fecundating germ
of the father; and, as a corollary,
The determining cause of the syphilis of mothers in whom the disease
follows conception is not by infection from the foetus through the
utero-placental circulation[35] or otherwise, but is the diseased male
procreative cell which becomes blended with the female ovule.[36]
[Footnote 33: It is obviously no explanation of the law of Colles to
say that "it would seem to indicate that the escape of the mother is
due to some occult, undiscernible change in her system" (Bumstead and
Taylor, _op. cit._, p. 745).]
[Footnote 34: See foot-note, p. 262.]
[Footnote 35: On account of the absence of cellular elements in the
fluid interchanged.]
[Footnote 36: An elaborate paper by Fraenkel (_Archiv für
Gynaekologie_, 1873, vol. v. p. 1), based on twenty-one cases of
childbirth, was written to prove by the condition of the placenta that
direct infection of the child by the father was possible without the
participation of the mother, and that when the latter became infected
it was through the medium of the child (_choc en retour_). In fourteen
of his cases the specific change in the placenta began in the foetal
portion or affected it exclusively. These cases, however, as analyzed
by Hill and Cooper (_op. cit._, p. 57), are altogether defective in
important particulars. Of course to sustain his theory there should be
indubitable evidence that the fathers were syphilitic, and that the
mothers were not so. So far from this being the case, but one of the
fathers was known to be syphilitic, while two of the mothers had
evidences of constitutional syphilis at the date of childbirth, and
nine others had markedly suspicious histories. The lesions of the
placenta which are thought to be syphilitic consist in the development
of papular or gummatous growths which give rise secondarily to
inflammatory troubles affecting either the placenta itself or the
placenta and the uterine mucous membrane.]
If the premises are admitted the conclusions seem irresistibly to
follow.
There is no proof whatever that the semen of a syphilitic man is
contagious or can transmit the disease in any but the way above
discussed. On the contrary, it has been shown experimentally[37] that
it is entirely innocuous and non-inoculable.
[Footnote 37: Mireur, _Annales de Derm. et Syph._, 1876, p. 77.]
All other theories as to methods of contagion are so entirely
hypothetical and unsupported by trustworthy evidence that we can afford
to disregard them.
We may now consider the ways by which syphilis reaches the child, and
they may be broadly classified into--
1. By descent from the father.
2. By descent from the mother.
3. By direct infection.
As a matter of course, the influence of the father upon the child, so
far as regards heredity, ceases at the moment of conception; or, to be
more exact, no subsequent condition of the male parent, no development
or acquirement of disease, can exert any further effect. That the
existence of active syphilis in the father may result in the
transmission of the malady to the child can hardly be doubted. To be
sure, there are numerous {266} examples of cases where both wife and
child have escaped though the husband showed at the time of conception
very active secondary lesions. These, however, are exceptions, and do
not in the least invalidate the rule that it is possible for a father
to hand the disease directly to his child. There is no other possible
interpretation of the cases already alluded to in which successive
pregnancies in the same woman alternately resulted in healthy or in
syphilitic children according as the father was or was not kept under
specific treatment. Other arguments might be advanced, but that seems
to me conclusive.
The relative effect of paternal as compared with maternal influence may
be considered after we have described the latter.
Descent from the mother may occur theoretically in consequence of--
1. Infection of the mother previous to conception.
2. Infection of the mother at the moment of conception.
3. Infection of the mother during the period of utero-gestation.
As to the first of these methods of transmitting the disease there is
little if any difference of opinion. Even those who claim the most for
paternal influence[38] include among the conditions which may give rise
to syphilis in the child disease of the ovule, and it may be stated as
incontrovertible that recent or active syphilis in the mother at the
time of conception will almost certainly be followed by syphilis in the
child. As a rule, women who have borne syphilitic children, even when
they do not give unmistakable evidence of the disease, fail in health,
become anæmic, and often develop glandular or osseous swellings which,
according to Zeissl,[39] are only relieved by antisyphilitic treatment.
The bearing of Colles's law upon the alleged immunity in many instances
of the mothers of syphilitic children has already been shown (p. 264);
and there is other evidence, not perhaps so conclusive, but strongly
corroborative, of the same view--viz. that their escape is only
apparent, and that syphilis, either latent or active, always affects
such mothers.[40] There can be no manner of doubt that in every
instance at or about the time of childbirth there are not to be found
pathognomonic lesions of syphilis, nor do such lesions always make
their appearance in cases where the period of observation is a short
one; but it is claimed with much show of truth that prolonged and
patient inspection of such patients will in time result in the
discovery of some symptom which betrays the presence of the disease.
[Footnote 38: Bumstead and Taylor, _op. cit._, p. 745. Hutchinson in
Reynolds's _System of Medicine_, Am. ed., vol. i. p. 431: "In a large
proportion of the cases met with in practice the taint is derived from
the father only." (On this point see foot-note to p. 270.) If there
were any doubt as to the fact that syphilis in the mother only may be
transmitted to the child, it would be removed by the cases of Bardicet
and others mentioned in _Nouv. Dict. de Méd. et Chir._, vol. xxxiv. p.
688. In these cases nurses who had contracted the disease from their
sucklings subsequently became pregnant (without having infected their
husbands) and gave birth to syphilitic children.]
[Footnote 39: _Jahrbuch_, vol. ii. p. 303, 1872.]
[Footnote 40: Zeissl, Sigmund, Oewre, Flindt, Woodman, and others are
quoted by Hill and Cooper to this effect. Woodman, for other purposes,
gave the histories of 200 cases of infantile syphilis. In all of these
the mothers had suffered from typical secondary lesions.]
The cases in which treatment of the father has resulted in healthy
children, whereas without treatment he procreated only syphilitic
children, the mother being without either symptom or treatment, have
been urged as evidence of the direct descent of syphilis from the
father to the child without the intervention or participation of the
mother. Doubt {267} has been thrown upon them by those who uphold the
contrary view;[41] but after looking into them carefully I am
constrained to admit that some of them, notably those of Kassowitz[42]
and R. W. Taylor,[43] are convincing of the facts--(1) that treatment
of the father controlled the condition of the child, and (2) that there
was no evidence that the mother had syphilis. But we have seen that the
only proof of the universal infection of mothers of syphilitic children
is the law of Colles, and that in many cases the disease is for a long
time latent or unrecognizable. Let us admit that this was the condition
in the cases in question; it does not at all follow, necessarily, that
because the mother has latent or hidden syphilis she must infect her
child. Every case even of active syphilis in the parents is not handed
down to the children, a certain proportion of whom escape even when
both parents are in the height of the secondary stage at the time of
conception.[44] But the activity of the disease in the children, and
even more the likelihood of its reaching them, are in direct proportion
to its activity in the parents.[45] A mother, therefore, who under the
influence of active syphilis in her husband has given birth to two or
three syphilitic children, and has herself shown no symptoms of the
disease, may nevertheless have it in the latent form and have no strong
tendency to transmit it. Consequently, treatment of the father will
result in the procreation of healthy children, because it removes the
active and efficient cause of their infection. To take any other view
of these cases is to assume that every syphilitic parent must hand down
the disease to the children--an assumption which is not in consonance
with numerous well-attested clinical facts.
[Footnote 41: Hill and Cooper, _op. cit._, pp. 52, 53.]
[Footnote 42: "Die Vererbung der Syphilis," _Stricker's Med. Jahrb._,
1875, p. 391.]
[Footnote 43: _Archives of Clinical Surgery_, New York, Sept., 1876.]
[Footnote 44: Fournier, _op. cit._, pp. 35-37.]
[Footnote 45: Hutchinson, _op. cit._, p. 431.]
Leaving this interesting question, however, we may consider the other
methods by which syphilis descends from the mother to the child, having
seen already that it is beyond doubt that it may be handed down by
disease of the ovule due to syphilis acquired previous to conception,
and having seen that there is a high degree of probability that the
mother herself rarely, if ever, escapes the disease. The second method,
or that in which the mother becomes syphilitic at the moment of
conception, has already been sufficiently discussed. It is really,
strictly speaking, an example of paternal heredity, as the resulting
germ is syphilitic--not because the ovule of the mother was infected,
but on account of the disease of the spermatozoid of the father.
There remains for consideration the influence upon the child of a
syphilis acquired by the mother during some period of utero-gestation.
That under these circumstances the child can become infected has been
and is still absolutely denied by some very respectable
authorities.[46] All that is {268} necessary for proof of its
occurrence is, however, (1) freedom of both parents from syphilis at
the time of conception, or, in other words, syphilis must have been
acquired by both--not alone by the mother--after the beginning of
pregnancy; (2) that the syphilis of the child be unmistakably
pre-natal--that is, not acquired by some accident during or after
birth.
[Footnote 46: Bumstead and Taylor, _op. cit._, pp. 742, 744. They base
their denial, first, on the physiological fact (?) that no interchange
of cellular elements between mother and father is possible, and next on
the absence of satisfactory evidence of the occurrence of infection
during pregnancy. Zeissl's case seems sufficient answer to the last
assertion, and there is strong evidence that the first is without good
foundation. "The placenta is penetrated by the virus, and does not play
the part of a filter for the elementary particles of matter which, so
far as we know, represent the true active contagion of the disease. In
the absence of direct experiments, which it would be almost impossible
to institute, we may argue from the facts known to exist in certain
acute infectious diseases in which there are very interesting points of
resemblance.
"It has been known for a long time that small-pox occurring in the
mother may be transmitted to the product of conception enclosed in the
uterus, and it is supposed that the virulent particles traverse the
walls of the maternal vessels in order to penetrate the circulating
apparatus of the foetus. But what is only a supposition in the case of
small-pox seems to have been actually demonstrated in symptomatic
charbon (Arloing, Cornevin, and Thomas), bacteridian charbon, and
recurrent fever, in which the poisonous element is easily recognized.
The recent experiences of Strauss and Chamberland (1882) have shown
that the foetus participates in the 'infection charbonneux' of the
mother. Albrecht has shown (1880) the presence of numerous spirochoetæ
in the blood of the heart of a child born at seven months of a woman
with a second attack of relapsing fever. It may be supposed, therefore,
though not demonstrated, that the transmission of syphilis takes place
by the same method as that of relapsing typhus or of charbon" (_Nouveau
Dict. de Méd. et de Chir._, pp. 682, 683).]
The following case,[47] reported by a most accurate observer, seems to
combine both these requisites. Zeissl the younger reports that O. X.,
thirty-six years old, never having had syphilis, left his wife, to whom
he had been married two years, to go a journey on July 15, 1877. The
wife was then in the second month of her first pregnancy. On July 24th
O. X. had extra-marital intercourse. About twenty-one days after this
coitus he observed a small lump on the inner surface of the foreskin,
and on Aug. 22d he consulted Zeissl the elder. On Sept. 23d a
maculo-papular eruption of the skin with erythema faucium appeared.
Under treatment these symptoms completely disappeared. On Oct. 29th he
went home to fetch his wife to Vienna for her lying-in, and had
intercourse with her soon after his return, notwithstanding Zeissl's
strict prohibition. At the beginning of December a hard sore developed
on the left nympha of the wife, who was then in the seventh calendar
month of her pregnancy. At the end of December a maculo-papular
eruption spread over the body and was treated with mercury. On Feb. 14,
1878, a well-grown and apparently healthy female child was born at full
term. When eleven days old[48] a pustulo-scaly eruption came out on the
child's soles and toes, and soon afterward a maculo-papular eruption
over the body generally. A few days later the child died. No
post-mortem examination was permitted. In July, 1878, the wife had
iritis, and after that gummata on the leg. She miscarried in July,
1878, at the third month, and again in February, 1879, at the second
month.
[Footnote 47: Quoted by Hill and Cooper, _op. cit._, p. 60.]
[Footnote 48: Of course much too early for constitutional symptoms if
the disease had been acquired during or after birth.]
There seems to be no reasonable escape, after reading this carefully,
from the conclusion that in some manner the poison of syphilis found
its way from the mother to the child. The old idea that the latter was
directly infected in utero from the semen of the father is altogether
without foundation. Other cases equally satisfactory and complete have
been reported, and, unless the intelligence or the truthfulness of the
observers be impugned, establish without doubt the possibility of
infection during utero-gestation.
In the above case the contagion of the mother occurred in the seventh
{269} month of pregnancy; and this, I believe, is as late as it has
ever been known to be communicated to the child. The exact date at
which it becomes impossible so to transmit it is unknown, but as a
general rule it may be said that the earlier a mother is infected
during gestation the less likely is it that the child will escape.
Treatment of the mother--as of the father in cases where he is at
fault--very greatly modifies the whole problem and adds immensely to
the chances that the child will not be infected.
Direct infection of the child during birth could not properly come
under the head of hereditary syphilis. There is no possible reason why,
when the mother has contagious lesions of the genitals, acquired too
late to infect the child in utero, this should not occur, but as a
matter of fact no such case has ever been recorded. One explanation of
this circumstance may be found in the protective covering of vernix and
mucus which coats the infant's body and lessens greatly the risk of
absorption. This hardly accounts satisfactorily, however, for the
entire absence of such cases from medical literature, and it is fair to
suppose that in all but those cases in which the primary sore is
acquired during the last month of gestation--which for obvious reasons
are excessively rare--the infant acquires some immunity which protects
it from its mother, and is similar to that which, under Colles's law,
operates in her favor. In other words, even though apparently free from
syphilis at birth--a not uncommon event, as we shall see--it has a
latent or modified syphilis which protects it from contagion.
We may now briefly restate the conclusions at which we have thus far
arrived:
1. After a certain interval, not less than four years, and after
thorough specific treatment, a person who has contracted a syphilis not
especially severe or malignant in its type may be permitted to marry.
The assent to marriage will then be based on a belief in the curability
of syphilis or the cessation of its contagiousness, its inoculability,
and, in the vast majority of cases, its transmissive power at the end
of the secondary stage.
2. It may be inherited from either parent or from both, and the
probability that this will occur increases in a direct ratio with the
nearness of the time of conception to the date of their infection with
the disease. The severity of the inherited disease in the child
increases in the same proportion.
3. It is undoubted that, the father being healthy and the mother
syphilitic, the child may, and in all probability will, have the
disease.[49]
[Footnote 49: Dr. Sturgis, who disbelieves altogether in the
possibility of paternal heredity, concludes, after examining the
subject carefully, that (1) a mother begets non-syphilitic children as
long as she is not infected, even though the father is syphilitic; and
(2) the moment she is diseased the children are inevitably so (Paper on
"The Etiology of Hereditary Syphilis," _New York Medical Journal_,
July, 1871). This doctrine was previously supported by M. Cullerier,
whose views gave rise to the remarks of M. Voillemier (quoted by
Fournier) that if they were accepted "the father would be only the
accidental occasion of a child; one would be, in reality, the child of
his mother only." Cullerier's cases are invalidated by the fact that
the syphilitic fathers who had healthy children had been subjected to
mercurial treatment (_Mém. de la Société de Chirurgie_, Paris, 1854,
quoted by Taylor in _Archives of Clin. Surg._, vol. i. p. 83). The
theory is a very old one. Vassal has sustained this idea as long ago as
the end of the last century. Kostum (1804), and after him Hufeland,
were of the same opinion. Cullerier (1857) wrote: "In order that a
child acquire syphilis hereditarily it is necessary that the mother is
or has been {270} syphilitic." Notta, Follin, Charrier, Mireur (1867),
and Langlebert (1873) support this theory more or less earnestly. Oewre
wrote (1873): "Paternal influence is nil as regards hereditary
syphilis." Isseff (1879) wrote: "Where a man suffers or has suffered
from syphilis he cannot transmit the disease to his descendants without
infecting his wife; that is to say, in fewer words, there is no
infection from the father." Sigmund says: "The heredity of syphilis is
derived in its last analysis from the mother" (_Nouveau Dict. de Méd.
et Chir._, vol. xxxiv. p. 689).]
4. It is probable, but less so,[50] that, the mother being healthy and
the father syphilitic, the child will be infected.