The presence of spirochetae in the viscera, placenta and cord, and in the long bones, which are often the site of an osteochondritis in these macerated fetuses, assists in confirming the diagnosis. The fact that spirochetae are not found in the viscera of these macerated fetuses, does not by any means exclude syphilis as its cause, for it is often necessary to make a diligent search of many sections of the tissue to find these organisms and even then the infected area may have been overlooked. The interval between the death of the child and its delivery, and between the delivery and the autopsy, are practical factors in finding these organisms. I have observed sections of macerated liver tissue in which a miscroscopic field would be filled with spirochetae and others in which only an occasional organism would be seen. Lobenstine mentions, in an article on syphilis and parturition, that 39 out of 50 macerated fetuses at the Frauen-Klinik at Kiel showed the presence of spirochetae.

Syphilis has also been held responsible many times for the intrapartum

Fig. 1.-Pancreas from a case of congenital syphilis in an infant showing marked enlargement of head of gland.

death of the infant, but in this stage such complications as long labor, pressure on the cord, premature separation of the placenta, operative procedure and many other mechanical conditions, which sometimes occur during delivery and which cause asphyxia, will have to be excluded before syphilis is considered as the sole etiological factor present. Of 17 nonmacerated stillbirths from 8 months to term, I have observed but 2 positive Wasserman reactions on the mothers, and one of these was a central placenta praevia with considerable antepartum hemorrhage. Of the 15 cases with a negative reaction, 12 had some complication during delivery. I recall a case which occurred recently whose Wassermann reaction was positive and who gave a history of several macerated fetuses; but on this occasion the fetus was living during labor and she was delivered of an enormous stillborn infant which did not present any macroscopic lesions of syphilis at autopsy. There is equally sufficient

reason to believe that the death of this child was due to asphyxia as well as syphilis, yet syphilis will, no doubt, be credited with the accident.

Boardman says that syphilis is very often the cause of premature births and that two thirds of all syphilitic children are born about the 8th month. In my series of 106 mothers with positive Wassermann reactions there were 31 living babies, delivered at term and 3 of these died in the first few days of life. This appears to be rather a large proportion of syphilitic children to reach term but, seven of these mothers had received treatment during the last three months of gestation.

In a consideration of the effect of lues on the child if born alive, Engel and Reimer state, that children showing symptoms in the first 4 weeks of life, nearly all die; of those showing them in the second month,

Only about With regard

two thirds die and in the 3rd month about one-half die. 28 per cent of children born syphilitic survive the first year. to the Wassermann reaction in the newborn Muller gives a large series, showing that in those infants with active symptoms nearly all are positive, and those children born apparently healthy but of syphilitic mothers with active signs or positive Wassermann reactions, show a reaction in 40 per cent of the cases and that many more develop a positive reaction in a few weeks or months often accompanied by symptoms."

The Wassermann reaction is as valuable in making a diagnosis in these doubtful cases of syphilis of the infant as it is in determining the etiology of many obscure medical and surgical conditions secondary to this disease. Inasmuch as this test is not a true antigen antibody reaction and that in the hands of many workers, diseases other than

syphilis have given a positive reaction, it as fallen somewhat into disrepute among many clinicians. In this work which I have carried on with the mother and infant and have made use of the Wassermann reaction very largely in confirming a diagnosis, I feel that a 4 plus Wassermann in this zone almost invariably means but one thing. Of those very

Fig. 3-Spirochetae at the site of an osteochondritis. exceptional occasions in which the reaction is positive in nonspecific cases, the clinical factors are vastly different from those of lues. Cases with positive Wassermann reactions on whom I could find no history or signs of syphilis whatever, have always had the test repeated once or twice at intervals of 2 to 3 months with the same result. Reuben in the Archives of Pediatrics, 1911, quotes statistics in which he says that of

125 mothers, who at no time had any syphilitic symptoms and who at no time had received any antispecific treatment, 82 or 71 per cent gave a positive reaction.

Infants with active luetic symptoms have almost as high a proportion of positive reactions as patients with secondary symptoms in the acquired

Fig. 4. Spirochetae at the site of an osteochondritis.

form of the disease. Veeder and Jeans have found 76 positive, one doubtful and five negative reactions in the examination of the blood of 82 cases of clinical syphilis in infants. Holt reports out of 31 cases of hereditary syphilis 30 gave a positive reaction. In my series of 38 infants exhibiting clinical syphilis at birth or within the first 3 months, 36 or

95 per cent gave a positive reaction. Of 20 infants of mothers with or without symptoms and with a positive reaction eleven were positive. Of the 9 negative reactions of infants 5 mothers had received considerable antepartum treatment. The cases without symptoms have not been followed, and, as to the length of time the infants remained without symptoms and without a change in the reaction I cannot say. These reactions were often controlled by serum from infants with no symptoms or history of syphilis and in them a negative reaction was always obtained. A few of these infants with positive reactions returned at intervals up to a year and as long as symptoms were present the reaction remained positive. McCarthy says that an infant reacting negatively at first, may later give a positive reaction with the advent of symptoms. Concerning the Wassermann reaction later in life in these syphilitic children. Churchill, Kellner, and others have noted that it begins to disappear after 4 or 5 years, in spite of definite stigmata and it nearly always reappears with the recurrence of active symptoms.

A comparison of the reaction in mother and infant is interesting and the ratios vary in the hands of different investigators. Boas and Thompson reported 35 mothers of syphilitic infants, 26 of whom gave a positive reaction and 9 a negative reaction. Sabin reports 23 cases in which the reaction was positive in all the mothers and at the end of the first week it was positive in 16 infants.

Of the seven with negative reactions, 4 were positive within the first two months and three remained negative up to six months. I have observed 38 positive Wassermann reactions on 42 mothers who were either delivered of living infants which developed symptoms during the first six months or of macerated fetuses in which the spirochetae were found. The four negative reactions will have to be attributed to the insensitiveness of the antigen to combine with the few antibodies present in the serum of these specific mothers. Not until serologists employ an antigen sufficiently sensitive to unite with these sera of small antibody content will positive results be obtained in all these cases. It appears rather difficult to understand that spirochetae may be sufficient in number and virulence to produce symptoms in the infant and at the same time not produce enough antibodies in the blood serum of the mothers to give a positive Wassermann reaction.

Fildes reports that of 1015 different sera collected at birth from the placental end of the umbilical cord, 14 or 1.3 per cent gave a positive Wassermann reaction. These infants were especially examined and with the exception of one, were declared healthy. This exception exhibited evident symptoms of congenital lues. Of the thirteen healthy infants with positive placental reactions, seven returned later at two and onehalf to four months for reexamination, all seven still remained healthy and gave a negative Wassermann reaction. I have examined the cord blood of only four mothers, all of whom had a positive Wasserman re