shown that these plastic nodules were not lobular pneumonia, but truly a specific lesion, which is only found with other syphilitic phenomena in the child or its parent, and that it must be looked upon in the light of a specific change, belonging to constitutional syphilis. M. Depaul, in forming this conclusion, relies, moreover, upon the important fact, that these changes are only observed in infected children, or in those born of parents who have had syphilis. This coincidence is with him a criterion of certainty. A distinguished accoucheur, M. Cazeaux, in a very elaborate treatise, has objected to this conclusion, which, according to his opinion, is too strict, and he has thought that these changes might as probably partake of the nature of inflammation not of a specific kind, as be the result of syphilis. But M. Cazeaux appears to me to have far too much sacrificed the probabilities in favour of this exigency of the bare anatomical facts. He demands that a lesion should exhibit the nature of its first cause, whilst he himself knows very well that lesions, the result of constitutional syphilis, are not absolutely and always recognizable at first sight. If we reasoned in this way, we should return to the dark age of Broussais, when every disease, even syphilis, was classed under the title of inflammation. We must not, then, tax anatomical facts too far, for fear of injuring them in the estimation of surgeons, and when they have no absolute signification, it is to the antecedent and concomitant circumstances to which we must look to determine their true nature. This M. Depaul has done; he has often noticed suppurating pulmonary nodules accompanying hereditary syphilis; he concluded that one might be the cause of the other, and ed, he was right.

In the liver, a special and specific alteration takes place, which was first noticed and written upon by M. Gubler.

It consists of a fibro-plastic induration of the liver. It may be general or only partial. In the first case, which is very rare, the hepatic gland is, throughout, hypertrophied, indurated, elastic; its colour is pale yellow; its tissue semi-transparent; the distinction between the two substances has disappeared, and its surface only presents some small whitish opaque granulations, which may be compared to grains of semolina.

Generally, the change is partial, and in some respect circumscribed. It appears in the form of a yellowish, clear, semi-transparent nodule, varying in size, and well distinguished by its colour from the other brown parts of the liver. This nodule of induration presents at other times the general physical characters of fibro-plastic induration. (The finest injections do not penetrate the indurated tissue, and microscopical analysis enables us to prove the presence of a large quantity of fibroplastic elements, nuclei, and cells, more or less elongated and slender. It is essential, however, that these elements should be present in great

numbers, and should have been taken from a portion of the liver altered in character, yellow and hard, in order that their presence may have any real weight. Unless such be the case, as the liver of newly-born children in the normal state contains always a certain quantity of fibro-plastic tissue, we may be deceived, and assert on seeing a small number of these elements that the liver is diseased, when it is perfectly healthy-a little experience will enable us to avoid this error.

[Dr. Böhmer, having met with an instance of this kind which was declared by Dittrich himself to be an instance of the congenital syphilitic affection of the liver, in order to investigate this subject, examined the bodies of all the syphilitic children who died at the Viennese Foundling Hospital; he, however, was unable to find this hepatic affection in any other instance. In the case referred to, there was exudation on the surface of the liver, uniting it to the diaphragm, and forming a pseudo-membrane of areolar tissue, which passed also into the liver, but did not especially inplicate the portal canals.-P.H.B.]

In the periosteum, and in the bones, we sometimes, but very rarely, meet with these changes which we so frequently see in the adult when suffering from constitutional syphilis. Amongst infants attacked with hereditary syphilis, Bertin only met with a single instance of periostitis; M. Laborie has recorded another, accompanied with well Child Eu marked caries. The lesion which I have frequently observed, partakes

neither of the nature of caries nor of degeneration of the periosteum, it is characterized by premature induration of the long bones. In children born before the full term, or born dead, instead of soft, spongy, vascular bones, not yet perfectly formed, and easily cut with ea a scalpel, I have seen the middle of the tibia and femora, solid, compact, eburnated, and impossible to break or divide them with a cutting instrument. This is a change to which I do not attach much importance, but which is, nevertheless, of sufficient interest to be L mentioned here. It seems to denote an abnormal and precocious activity in the development of the bony tissue, which corresponds with the plastic secretions observed in many other organs.

Lastly, with all these local specific manifestations within and without, and I may say in addition to these symptoms, sometimes a certain number of the general signs of reaction are visible, and which give us the amount of syphilitic poison, and the power of resistance of the newly-born infant. The children are pale and weak, their skin is often rough, especially the face; their debility increases, the appetite is small or completely gone; they rapidly emaciate, diarrhoea supervenes, which further exhausts them, and if they are not rapidly cured they sink into a state of venereal marasmus and cachexia, from the li effects of which they fail not to perish.

The diagnosis of hereditary syphilis may present great difficulties.

Much depends upon the investigator, and on his tact, some surgeons, unfortunately influenced by reminiscences of the doctrines of Broussais, are still in the present day inclined to consider as of a simple inflammatory nature the bulla which appear on the skin, the fissures of the mucous membranes, the affections of the liver, the abscesses in the thymus gland, and the plastic and purulent infiltrations of the lungs, which I consider as syphilitic. They demand that the specific nature of these affections should be proved, by pointing out the anatomical characters in which they differ one from the other, thus affording a melancholy example of absolute reliance on the crude results of pathological anatomy, as if ever as many anatomical variations had been discovered, as there are general and individual specialities. From this grave error, into which an entire school plunged, coincidences are not taken into account, the antecedents of the patients, their age, the districts they inhabit, all are of secondary consequence to the lesion itself, 544 whilst, on the contrary, we ought to view these different circumstances as revealing the decided character and true nature of the anatomical changes. It may be easily understood the amount of difficulty such a manner of viewing facts has caused in the diagnosis of hereditary syphilis, and why certain surgeons have candidly declared this diagnosis impossible.

We shall proceed differently. Persuaded as we are that it is impossible to ascend from lesions to their causes, whilst it is easier for experience to assign causes to the lesions, we shall bear in mind the circumstances abnormal to the child, which may enlighten us as to the nature of its disease. The fact of syphilis having occurred either in the father or mother, invariably pointing out a latent constitutional taint in the newly-born child, must not be kept in the back ground or in the shade. The child who inherits the external traits of its progenitors, and the morbid disposition of all their organs, cannot come forth pure from a germ developed or impregnated under the influence of syphilis. And when a like fact is established, it is impossible to consider it otherwise than a ruling principle controlling all secondary facts, as absolutely as the powerful and vivifying properties of the sun regulate the development of the plant whose seed has been exposed to it. Syphilis being then admitted as interwoven with the impulse communicated to the germ, at least a coincidence, if not a modified impulse results, the effects of which we shall ultimately witness.

For myself, I believe in a modified impulse, but I rely solely on the fact of the coincidence, which at present is sufficient for my illustration. I presume then that the parents have the syphilitic taint, and the child affected with a lesion of a doubtful nature, inflammatory or specific, according as each may be of opinion. The first case in

which such an appearance presents itself disbelief is allowable, for experience must necessarily be obtained, but in a second and third case the same thing is observed; ten, twenty, or thirty instances or even more follow on each other, and in every case the newly-born child is always the subject of a doubtful disease, and in each case its parents are tainted with syphilis, then the doubt must vanish and give place to certainty.

But hitherto I have only spoken of doubtful lesions. What then is to be concluded, when notwithstanding what can be said on the s subject, these abnormal affections, different in their appearance, present

distinctive characters, and group themselves in pairs or even in threes uit

or fours in the same individual, with an appearance of uniformity? Is there not in this constant assemblage of suspected lesions an over

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ormity powering revelation of their intimate nature differing from a simpleret be inflammatory cause? Is there not evidently beyond these lesions a general specific cause which begets them? But then, if such a cause exist, and if we must leave the domain of ordinary inflammation, what other specific cause can we allow if it be not that of syphilis, whichhuck · is observed in the parents. There is no longer any doubt in this respect; the study of antecedents is of the greatest importance in those affections of newly-born children, which are believed to be the result of syphilis. This is not yet all; in these lesions, obscure as they may be toonbel many surgeons, I discover distinctive characters which separate them from ordinary inflammation; most assuredly syphilitic pemphigus does not resemble simple inflammatory pemphigus; the pulmonary nodules described by M. Depaul no more resemble lobular pneumonia than the plastic infiltration of the liver, or the diffuse suppuration of the thymus gland, approach hepatitis or simple inflammation of the thymus gland. Infants affected with hereditary syphilis may be rapidly cured when they are treated in a proper manner-one even sees cases which have reached the last stage of marasmus, and which terminate in recovery. But in such a case death is much more commonly the consequence of the disease.

The treatment consists in subjecting the mother to a mercurial course, whether she herself manifests evident symptoms of syphilis, or whether she does not.

Might this mercurial treatment be proposed to a healthy nurse who has the care of an infant affected with syphilis? This is a more serious question than would be imagined at first sight, for it is generally asserted, but without too great proof, that the use of mercury may produce very serious inconvenience. I hardly believe it, and for my part, I have never seen mercurial treatment, properly carried out, followed by an unfortunate result. In making such a proposition to

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SPECIAL PATHOLOGY OF INFANCY.

[Part III. a nurse, we must carefully explain to her the consequences that may result from it, that she may herself decide with a full knowledge of all the facts.

As regards the mother we need not hesitate. (In the present state, of our knowledge, the fact of transmission of syphilis by the father

is not very certainly established, and in almost all the cases of well observed hereditary syphilis, the cause has been found to depend on the mother. But whether the mother has or has not apparent symptoms of syphilis, she is not the less under the influence of a syphilitic diathesis, which should be treated by mercury. If she nurse, the mercurial treatment possesses a double advantage, since it acts at the same time both on the mother and child.

The treatment attended with the best results consists in administering to the nurse pills of proto-iodide of mercury in doses of .75 to 1.5 grains daily, without pushing it to salivation:

Proto-iodide of mercury

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To be made into thirty pills (silvered), two or three to be taken daily. Under the influence of this remedy, although minute analyses have not detected any trace of the medicine in the milk, the children are rapidly restored to health, and the syphilitic affections disappear.

If analysis do not detect the mercury in the milk it is no reason why it should not be present, more particularly if we reflect on the very small quantity which must be mixed with it. For instance, nurses who took from .30 to .60 grains of iodide of potassium daily, had sensible traces, but only slight ones it is true, of iodine in the milk. Since an agent so easily detected as iodine is only found in small quantities, how difficult, then, must it be to recognize mercury, which requires very complicated manipulations to detect it, and of which the patients, proportionally to the iodine, can take but very small doses.

[M. Cazeaux (Bulletin de l'Acad., xvi) terminated a prolonged discussion at the Academie with the following conclusions: 1. In the immense majority of cases the symptoms of constitutional syphilis are not manifested until some weeks after birth. 2. Such excessive rarity should give rise to great caution in the nosological classification of the lesions of new-born children. 3. The coincidence of old syphilis in the parents, and of doubtful or ill-characterized symptoms in the infant, is insufficient to establish the relation of cause and effect between the two facts. 4. If pemphigus and abscess of the lungs and thymus may rigorously be referred to a syphilitic origin, there is no proof that they may not be due to other causes. 5. Pemphigus has long been observed, and referred by authors sometimes to syphilitic cachexy and sometimes to other causes. 6. In the actual condition of science it is impossible to distinguish alterations which may be syphilitic from those which result from other morbid conditions of the parents or foetus; and this uncertainty should render a practitioner very circumspect in pronouncing an opinion upon the nature of such