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attempted in full-term, still-born infants. The arm was grasped firmly in one hand, the forearm in the other, and forcible hyperextension at the elbow made until some structure was felt to give way. It was found upon dissection of these arms that either a rupture of the anterior ligaments at the elbow joint with posterior dislocation of the forearm had occurred, or a posterior dislocation of the lower humeral epiphysis with stripping up of the periosteum behind had been produced. The lesions produced in these experimental dislocations were found to be such as would result

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Fig. 16.-Case III.

Radiograph showing lateral aspect of uninjured arm. The humeral bone is not so dense as that of the other side, the medullary canal being more clearly indicated. The bone nucleus is present in the lower epiphysis. It will be noted that the nucleus in this epiphysis and that in the dislocated epiphysis of the opposite side correspond closely in size and position.

in just such changes as have been observed in the radiographs where it is presumed that a dislocation backward of the lower humeral epiphysis has occurred.

From the study of these cases the following conclusions would seem justified. Forcible manipulation of the arms, necessary for delivery in many cases of breech extraction with the arms extended above the head, may result in either a fracture of the shaft of the humerus, or a dislocation

of the lower humeral epiphysis; in either injury the arm will be found to hang limp at the side at birth, fracture of the humerus is indicated by false point of motion at the center of the shaft of the bone, below the insertion of the deltoid muscle, which, so far as has been observed, is the invariable site of fracture of the humeral shaft in the new-born. Dislocation of the lower epiphysis of the humerus is indicated in those cases where the arm dangles at the side at birth, where fracture of the shaft of the humerus is eliminated by the absence of false point of motion at the center of the shaft, but where abnormal mobility in a backward and forward direction can be produced at the elbow, the forearm held at a right angle to the arm. Distinct crepitus may be present with either

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Fig. 17.-Humeri removed by dissection from still-born infant delivered with great difficulty by version and breech extraction because of its size. The arms had become extended above the head. Upon cutting down upon the shoulder joints the capsular ligaments were found ruptured, there was considerable extravasated blood and both upper epiphysis were found to have been dislocated. While this birth injury is probably unusual there are conditions under which it might reasonably be expected to occur, as in difficult breech extractions after version, with extended arms and particularly in those cases where because of the size of the infant or the relative size of infant to pelvis great violence is done to the former in delivery. As this injury is rare and is usually associated with the death of the child because of other injuries little opportunity is afforded to study the condition. The autopsy in this case would serve to prove that such a birth-injury does occur.

condition, and as this crepitus is often the first thing discovered the diagnosis of fracture may be too hastily made.

Replacement of the dislocated epiphysis, so far as this is possible, should be attempted at once. Traction upon the arm with the forearm extended should be applied, and while this is maintained pressure from behind forward is made over the dislocated epiphysis. The forearm is then flexed to an acute angle and a Velpeau bandage applied for three weeks. Evidently the functions of the displaced epiphysis are not impaired by this injury, and it is probable that the final outcome in these cases is good with or without a complete reduction of the dislocation.



J. R. LOSEE, M. D.

Pathologist to the Hospital.

THE theories of the transmission of syphilis from the parents to the offspring have all had their individual supporters and until experimental evidence can clearly demonstrate each step in the mechanism of the infection, we must reason from history and clinical findings. That many men who have had syphilis and who were very thoroughly or only partially treated, marry and have healthy children, is an accepted fact. On the other hand it is also well known that the wives of men under the same conditions of treatment and in apparent good health, give birth to macerated fetuses and syphilitic children. There is no definite means by which we can assure a parent, who is subject of latent syphilis, that all his children will be born free from any manifestations of the disease.

The paternal theory, that the spermatic fluid infects the ovum and that it goes on to the development of a fetus which in turn infects the mother, seems hardly possible, for one would think such an ovum could not survive. It has also been said that spirochetae cannot survive on egg albumin alone but need differentiated cells which are not present in the ovum. This latter objection has not been absolutely proven however.

It has been possible to produce syphilis experimentally by the injection of spermatic fluid of active syphilitic individuals into animals in only a few instances. Yet continual marital relations are quite a different thing from a single injection into an animal and no doubt several cases of pure spermatic infection have occurred. We all know that many women have been infected directly after marriage regardless of the stage of the husband's infection and that many of these women presented few or no symptoms, but gave birth either to macerated fetuses in which spirochetae were observed or to living children who presented signs of the disease in the first six months of life. I have in my series 33 primiparae, some with, others without symptoms, all of whom gave positive Wassermann reactions, and 16 of whom were delivered of macerated fetuses. In as much as these women all had syphilis and that the time of the infection was in such close relation to their marriage, it would appear that they were infected directly by the spermatic fluid.

The maternal theory, on the other hand, in which the mother is infected primarily and the fetus secondarily is more probable and much simpler to explain.

*Read before the Section on Obstetrics and Gynecology of the New York Academy of Medicine, March 28, 1916. Appears also in the American Journal of Obstetrics.

Gaucher has shown that the number of recently syphilitic women showing a chancre or the remains of it, is only 37 per cent and the occurrence of the primary lesion in syphilitic pregnant women is about 33 per cent. Owing to the difficulty in making a careful inspection of every portion of the genital tract and the atypical appearance of some primary lesions in this region they are not always observed. The presence of secondary skin lesions in these cases depends on the care of the observer for unless such a patient is examined routinely every day, these signs may be easily overlooked. Therefore, the fact that a patient denies having had symptoms of primary or secondary syphilis, when she is questioned after being delivered of a macerated fetus and has a positive Wassermann reaction, does not prove that they were not present sometime before or during pregnacy. Now that most of the stillbirths from syphilis take place in the latter months of pregnancy, it is fair to assume, that the fetus is infected from the mother through the placenta, and that the time and rate of infection is in proportion to the development of the placenta. The presence of the spirochetae pallida in the placenta and cord is also additional evidence of the close relationship of the fetus to the infecting organism, but whether the placenta can transmit spirochetae without showing pathological evidence of it, is an unanswered question. Therefore, if these organisms can not be transmitted without pathological lesions of the placenta, one might draw some relation between the nonsyphilitic children of syphilitic parents and the normal placenta.

Bertha Sabin has recently studied the transmission of syphilis in its relation to conception and concluded that when the mother has syphilis at the time of conception or acquires it in the first five months of fetal life, the child is almost always syphilitic; in the sixth month, it is only probable and after the sixth, it is rare; but she believes there are exceptional cases of infection of the child, when the mother contracts the disease even later.

The law of Colles, "that a mother may give birth to a living or dead syphilitic child, and yet at no time herself show any evidence of syphilis or otherwise be said to be immune from the disease," has been quite disproven by the introduction of the Wassermann reaction. Even before the Wassermann reaction there were instances in which this law was contradicted by clinical evidence.

Ravolgi says that if the mucous patches in the mouth of the babe cannot innoculate the mother, it is certain that she is immune. If these women are observed over a long period of time some eventually show symptoms of the disease which are not due to recent infection. There is no doubt but that these patients are immune to the disease but immunity consists in the fact that they have the disease and, as Fournier has said, that the only way of becoming immune to syphilis, is to have it.

The law of Profeta, that syphilitic parents may give birth to a nonsyphilitic child or that the child develops an immunity in utero, has also

been disproven by long observation of the infant and by the Wassermann reaction.

A consideration of the effect of syphilis on the offspring includes both the transmission of the infection in its active form, in which the fetus either dies in utero or is alive and develops symptoms during the first year; and the transmission of the latent form of the disease in which the child is normal in every respect at birth and during the first year, but develops typical syphilitic lesions later in life. Fournier has said that parental infection results in the transmission of the disease in 92 per cent of the cases and that the mortality of the offspring amounts to 68.5 per cent. Hochsinger found that of 516 births of syphilitic infants, 253 were born dead, or died shortly after birth. Of the 263 which survived, 55 died before the age of 4 years in spite of energetic treatment, and of the 208 remaining, 51 continued to be healthy. Thus it is to be observed that comparatively few infants born of syphilitic parents go through life without at some time presenting symptoms of the disease.

Maternal syphilis has always been understood to play a considerable part in the etiology of abortions, macerated fetuses, stillbirths during labor and the premature births of infants. Presuming that the disease is transmitted through the placenta, it would seem rather unlikely to cause the termination of pregnancy in the second and third months. Leopold Reischig found only 0.78 per cent of abortions in 500 syphilitic pregnant women and Weber found one abortion in 30 pregnant women with syphilis. Boardman has found 2 positive Wassermann reactions in the examination of several aborting women including many with repeated abortions. Even if pregnancy terminated early in these few women with syphilis it is fair to assume that the same etiological factor or factors were present which have been said to cause abortions in nonspecific women.

Intrauterine death of the fetus from the 6th month to term has long been known to be due in most instances to syphilis. Boardman refers to Trinchese and others who say that 35-40 per cent of stillborn children are due to syphilis. Lobenstine says that the intrauterine death rate amounts to between 40-50 per cent of all the pregnancies infected with syphilis. In the past year, of 27 women who were delivered of macerated fetuses at the Lying-In Hospital, 9 or 37 per cent gave a positive Wassermann reaction. Some observers consider, the relative activity of the disease in the parents at the time of conception, the period of time that has elapsed since the origin of the infection and the influence of treatment, in determining the results as to macerated fetuses or living children with or without symptoms. I have seen a mother with a secondary eruption give birth to a full term syphilitic child which died within the first year. I have also observed a mother with a secondary lesion of the vulva and a positive Wassermann reaction give birth to an apparently healthy infant whose Wassermann reaction was negative at birth and remained so up to six months.

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