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MEDICAL JOURNAL

Vol. XXXIX.-No. 15.

A Weekly Journal of Medicine and Surgery.

BALTIMORE, JULY 23, 1898.

Original Articles.

HEREDITARY SYPHILIS.

By Henry Alfred Robbins, M.D., President of the South Washington Free Dispensary, Washington, D. C.

LECTURE No. 15, MAY 28, 1898.

RECENTLY we have shown you twelve little patients, who have in one form or another exhibited many of the manifestations of syphilis. This little patient, aged three years, we have had under observation for several months. It had dactylitis syphilitica, and under specific treatment it has disappeared.

I want to call your attention particularly to the formation of the patient's skull. The forehead is unusually large and protuberant in the region of the frontal eminences, a Websterian sort of a brow. Instead, however, of the orbital prominences being pronounced and well developed, you will notice that there is a well-marked broad depression a little above the eyebrows. This is a white child. If it were colored I would not, perhaps, call your attention to the fact that the bridge of the nose is broader than usual, but you will also observe that it is somewhat sunken. This photograph was taken by an amateur, a friend of Dr. Arwine. I will call your attention now to another photograph. You see that it represents exactly the typical syphilitic skull as in our little patient. It represents also other manifestations of syphilis, which I will explain further on.

I can find but very little on the subject of changes in the formation of the skull caused by syphilis. I have searched in vain through the library of the surgeon

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general. Jonathan Hutchinson, however, has called attention to it, for nothing escapes that keen observer.

Not long ago I was conversing with my friend and fellow-student of many years ago, Dr. A. J. Schafhert, and he called my attention to little Paul Dombey, in that great novel of Charles Dickens, "Dombey and Son." He showed me an edition of that work, published by Harper Brothers, 1872, illustrated by W. L. Sheppard. There were a number of pictures of little Paul, all showing the typical skull of our little patient. Then the pathetic history of the heir to Dombey shows that Dickens was personally intimate with a skilled physician, well versed in syphilology.

Dickens again and again speaks of the "old, old face," reminding you of what Trousseau said that these children presented the "aspect of old age on the threshold of life." Little Paul struggled on in a condition of extreme marasmus until "the old fashion," the fashion that came in with our first garments, and will last, unchanged, until our race has run its course and the wide firmament is rolled up like a scroll. "The old, old fashion death!"

Recently I found in the Jahrbuch für Kinderheilkunde an article by Elener, in which he reported eighteen cases of hydrocephalus. Of these, three, or 16 per cent., had well-marked congenital syphilis. Osteochondritis, affecting chiefly the epiphyses of the long bones, is caused by syphilis exclusively. It is often the only pathognomonic symptom. It affects chiefly the epiphyses of the femur, tibia, humerus, clavicle and ribs. Epiphyseal cartilages swell, and can be felt projecting as would a ring around

the bone. The swelling is usually smooth, with little or no pain or interference of movement. Occasionally it causes ulceration and necrosis, otherwise it may permanently affect the growth of the limb. The period of its occurrence is usually at birth or during the first month.

Syphilis, as you know, is a frequent cause of abortion. Whitehead reported 117 miscarriages in 256 women, victims of syphilis. In the unwholesome fruit of these women syphilitic lesions were

ful picture to be taken by flashlight, but it did not bring out an exquisite circinate eruption. The hands and feet were covered with bullae, the pemphigus syphilitica. The photograph was taken by a son of Dr. F. R. Bishop. This infant died of meningitis, or, in plain words, cerebral syphilis.

Dr. J. Michael Clarke of Bristol, England, has recently reported two cases of congenital syphilitic cirrhosis of the liver. One occurring in a male infant one month old, the other in a female in

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found on the skin, viscera and serous cavities. Very often, unfortunately, it comes into the world stamped with the ravages of syphilis, as you see in photograph No. 2. This infant, aged seven months, had snuffles at birth. Look at the picture; it is so well portrayed that I imagine I can hear it snuffle. Look at the eyes; it is the best exhibition of keratitis that I have ever seen. The infant also had otorrhea, double; see how shrunken it is, and it has the brow of Alexander Hamilton. This is a wonder

fant of ten weeks. The autopsies showed great destruction of the parenchyma of the liver. Small gumma and miliary gummata were discovered, and newlyformed tissue within the lobules, and in the portal veins. The arteries showed endarteritis obliterans, and the epithelial cells in the bile ducts were also proliferated. Often, however, a syphilitic child is born in apparent good health, and days, weeks, months and years may elapse before the disease shows itself. Then appears the characteristic snuffling.

and eruption in the tainted infant. There may be, however, a period of latency, extending to the period of the second dentition, puberty, and even later.

On February 27, 1895, I read before the Medical Society of the District of Columbia an article on "Cerebral Syphilis," in which I reported the case of a boy in which the symptoms of syphilis did not appear until the age of puberty. He was the offspring of a syphilitic father. The boy was my patient in 1886. He gradually lapsed into imbecility and

who reported the hymen to be intact. Patient enjoyed excellent health until four years previously, when she began to have pain in both mammary glands, more especially the left one, which became hard and nodular, and excessively tender to the touch; the nipples were retracted. After consultation it was decided to operate. The examination showed that the tumors involved so much of the gland itself that it necessitated the removal of the greater portion of it. In three weeks there was no union or signs of union in

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died of cerebral syphilis after four years, during which time he gradually and almost imperceptibly faded away.

In the Medical Record of July 28, 1883, Dr. Charles C. F. Gay of Buffalo, N. Y., reported the case of a young woman, aged nineteen, who came under his professional care the spring of 1883. "There was no question raised whatever against the virtue and morals of the patient." She was well educated, and her friendships were with the best people. She had been examined by a gynecologist,

any part of the wound. "It looked and smelled like a syphilitic ulcer." The chimera of cancer was then dissipated and the diagnosis of hereditary syphilis substituted. Under mixed treatment a rapid cure was effected. The right breast rapidly improved, the gummy tumors rapidly disappearing. Ample proof was found to establish the fact that the disease was inherited, and that the patient was "conceived in sin and endured suffering in consequence thereof."

Here, then, was another case in which.

the disease had lain dormant, doing no harm, until the age of puberty had arrived. Dentition, puberty and the menopause are critical periods for those victims of hereditary syphilis.

The poisonous fruit of bacteria is the toxine of syphilis. It is the result of chemical compounds of the germs of syphilis. Should the germs become imprisoned, encapsulated, it will prevent the formation of the poison. This is the cause of latent syphilis. Bottle the germs up, and it will be as harmless as the Spanish fleet at Santiago de Cuba. Should it escape, then the manifestations are those of tertiary syphilis, and we must bombard the truants with mercury and iodide of potash and destroy the vipers, as we are doing with the enemies of our country.

THE THERAPEUTICS OF
INSOMNIA.

By A. K. Bond, M.D.,

Clinical Professor of Diseases of Children, Baltimore Medical College.

OFFERED IN DISCUSSION BEFORE THE BALTIMORE MEDICAL AND SURGICAL ASSOCIATION, MAY 9, 1898.

INSOMNIA may be defined, medically, as any deficiency of sleep which threatens to interfere with health. An occasional spell of wakefulness for an hour or two, and that brevity of slumber-indulgence which is with certain individuals an idiosyncrasy, and with the aged a part of the senile process, are not here considered. Too shallow sleep, with dreaming, and the sleep that leaves a tire on waking, are forms of insomnia.

Although it may seem a self-contradiction, the first thing in the treatment of insomnia is to find out whether it is really present. The testimony of the sleeper as to how much he sleeps is necessarily questionable, albeit he may desire to be truthful. I had recently a patient with pleuritic effusion who would lie back, half-close his eyelids, roll the pupils beneath the upper lid and remain quiet for fifteen minutes at a time. He declared that he did not sleep for a moment, yet I was certain, from the slowing of the pulse

and respiration during this quiet time, that he was really asleep. Moreover, he showed no ill-effects from many days and nights of this alleged insomnia. It is important that this determination be clearly made out in order that the treatment may be properly applied in either case. In both cases remedies must be given, for no patient likes to be considered either a liar or a fool. In the one case tonics and placebos must be used until the patient gets something else to occupy the attention and forgets his alleged insomnia; in the other case hypnotic agencies must be invoked, for sleep is necessary to convalescence. It is said that death will result from absolute insomnia as quickly (about three weeks) as from starvation. In my own practice I pay great attention to the securing of thorough sleep-rest in all cases. of illness, especially in debilitating fevers.

Insomnia may proceed from digestive abnormalities. In childhood this form of sleeplessness is accompanied by horrid nightmares; in adults the nightmare is omitted, the adult being a child less imaginative, less sensitive nervously. The writer was recently called late at night to a patient under very heavy business strain, who had begun to be insomnic. He feared that if this were added to the business burden she would in a few days break down completely. Believing that the business care had probably interfered with the digestive functions, and by diminishing the appetite lowered nutrition, he gave about two grains of calomel and an abundant though simple lunch. The patient had no further insomnia.

Such

In some persons one-tenth grain doses of calomel will almost certainly relieve sleepless tossings, the wakefulness disappearing as soon as the beginning of perceptible peristalsis tells of the re-establishment of digestive processes. patients should avoid heavy articles of food after about 5 o'clock in the afternoon, taking a simple evening and bedtime lunch. The aged often sleep better if a glass of milk is at the bedside, an empty stomach, irritable but not inflamed, being better satisfied if it is kept occupied. A gentleman now paying up in insomnia for overwork of brain and neglect of recreations in earlier life told

me recently that of all the many hypnotics he had tried, the best and most reliable was a glass of hot malted milk at bedtime.

I have at present a patient in whom chronic partial insomnia is associated with and apparently dependent on chronic interstitial nephritis. I suppose the circulatory disturbances and blood pollution of the nephritis will prevent complete sleep. As she seems to have gotten used to the brief sleep, and as hypnotic drugs seem not to have any permanent power, it seems better to treat the nephritis and ignore the insomnia, especially as the patient has a great objection to taking drugs for sleep.

It should not be forgotten that very considerable disturbance of the nervous system may arise (in the absence of nephritis) from a direct irritation of the urinary passages by excessively concentrated urine or urine containing abnormal substances in solution. In such cases diuretics and other agents for rendering the urine normal lessen the insomnia. The intimate relation between kidney irritation and unwholesome processes (by-fermentations and putrefactions) in the small and large intestinal tracts has only recently been brought to light. The fact that unwholesome and abnormal substances passing from the bowel into the blood-stream and out through the kidney will, if eliminated thus in great quantity, produce acute kidney and nervous disturbances, and if eliminated in small quantity for months or years cause chronic nephritis and wreck of health, with, perhaps, general disease of the blood vessels, explains the long known fact that in some insomnias it is very difficult to tell in what degree the sleep disorder often present is traceable to the kidneys, in how much to the digestive tract, in how much to circulation faults. Recently a patient reported that she had become so worn out by the repeated and abundant action of a moderate dose of calomel that she slept for fourteen hours on a stretch. In the causation of this sleep I see not so much of fatigue as of the calomel action in righting the digestive tract, equalizing the blood pressure, purifying the blood and acting gently on

the kidneys. The well-known beneficial influence of vigorous exercise in the open air upon insomnia may be, in part at least, attributed to its stimulation of digestive processes and its breaking down and extrusion through skin and kidneys of many unwholesome tissue wastes which had been tainting the blood supply of the nervous system and irritating the kidneys as they passed sluggishly out. The subject of gouty and lithemic insomnias comes in under this head.

Certain cases of insomnia (and these often of the gravest sort) are directly dependent upon anatomical disease in the nervous tissues of the body. Syphilitic insomnias demand iodide of potassium often in enormous doses. The worst cases of insomnia due to brain disease are, of course, committed to the care of the asylum physician, the quiet of mind obtained in the asylum and the skilled care aiding greatly to the relief of this symptom. But even in the asylum cases physicians are becoming convinced that acute exacerbations of insomnia are precipitated by the extraneous conditions upon which I have dwelt above, which also intensify in many cases the insomnia attendant upon local brain disease.

Apart from cases of actual local disease in their tissues, it is probable that the nervous centers seldom originate insomnia; they cry and fret, not because of any disease of their own, but because they are bathed with impure blood, with blood that is deficient in oxygen, with blood that lacks nutritive elements. is in the intestine that pours foulness instead of nutriment into the blood-stream, in the kidneys and skin that dam back waste materials that the original fault lies.

It

Insomnia is at times apparently due to reflex excitement of the nervous centers by the local irritation of intestinal or nephritic tracts. Yet even this response is not so marked in normal nervous systems. It is only occasionally that a train of intense thought is the simple cause of insomnia. In a healthy brain, strong and well nourished by pure blood, long deep thought will lead to sleep. Viewed from this standpoint, it is easy to see why the hypnotic, administered (as many give it) without any regard to the extra-nerv

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