From a clinical standpoint, in this early period, only those bone changes are recognizable in which the periosteum is also involved. The finer changes at the cartilaginous borders of the bones cannot be made out by palpation, but can be demonstrated radioscopically.
Very frequently a radioscopic examination in syphilitic infants will show that the whole osseous system has been changed in toto while only a few bones will show any pathological changes clinically. (See Figs. 127, 12S and 12Sa.) The most prominent manifestations arc swelling in the region of the epiphyses of the long hollow bones, and motor disturbances.
These swellings that form a spindle-shaped extension from the diaphysis to the epiphysis affect especially the periosteum and the surrounding soft parts. The periosteum appears thickened, with a jelly like infiltration and is permeated in different layers by ossifying or chondrifying proliferations. Quite frequently all of the tendon inser tions and all of the muscle bellies surrounding the diaphyses are fused together into one uniform jelly-like mass.
Such swellings may be found in the region of one or more joints. The elbow-joint is most frequently involved. The swollen portion is nearly always decidedly tender.
Two kinds of motor disturbances must be distinguished, the para lytic and the spastic. The latter can be grouped together as the syphi litic znyotonia of infancy. Myotonia may cause inability to move an extremity, hut is nevertheless always a spastic condition as opposed to the so-called Parrot's pseudoparalysis, which represents a flaccid para lysis of the arm with more or less pain, and resulting from syphilitic inflammatory involvement of the bone and muscles. It is an important fact that in syphilitic hone disease of the lower extremities contractures result, while in the upper extremities we have instead a flaccid paralysis, a phenomenon that is dependent upon the different relations of the musculature to the large joints in the upper and lower extremities. The occurrence of muscle involvement in the extremities in early hereditary syphilis is of great importance (Fig. 130).
One always finds specific vascular changes in the affected muscles in which interstitial as well as parenchymatous and degenerative changes are demonstrable. The nerve-fibres, on the other hand, have always remained unaffected in those cases that I have examined. It is evident that such myopathies can lead to paralytic manifestations. As a rule
myostitis starts from an inflamed periosteum, but is may arise inde pendently. A warning must be given however against the too rapid diagnosis of gumma in the case of a nodule in the sternocleidoinastoid muscle of the newborn child. Even in syphilitic children this is always a traumatic hxmatoma.
The clinical manifestations in the bone system in early heredi tary syphilis consist of swelling of the bones and restricted motion, which are often associated with swelling of the soft parts, separation of the epiphyses, and crepitation.
The possibility of the occurrence of paralysis of central origin in early hereditary syphilis cannot be positively denied. It must be said, however, that the findings that we have up to the present time (Sch lichter, Zappert, von Peters, Scherer) do not suffice for the establishment of a spinal basis for these congenitally syphilitic motor anomalies in infancy. In most cases of supposed spinal etiology we have either a simple birth palsy, with or without syphilis, or a continuous spasm of toxic origin, which may occur as well in syphilitic as in other children. The clinical picture of this form of paralysis may be a very variable one. Almost without exception flaccid paralyses are located in the upper extremities and resemble those resulting from peripheral plexus lesions in which there is not necessarily always much pain in the extremity. There are paralytic manifestations in hereditary syphilis in which the whole upper extremity appears paralyzed, even dangling; then again others in which the type of an upper arm paralysis is most prominent, and finally those in which there is rather a forearm type of paralysis.
According to my investigations these paralytic manifestations are always the result of muscle involvement alone, which probably in most cases takes its origin in inflammatory periosteal affections. Since the muscle disease, in the absence of severe periosteal involvement., is not by any means always painful, it is easily seen why severe pain is as frequently absent in pseudoparalysis. The Klumpke—D6jerine type of paralysis with involvement of the oculopupilla•y fibres is not a form of specific motor disturbance in infancy but is rather to be attributed to obstetrical plexus paralysis, if found in hereditary syphilitic newborn and older infants.