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.