that they may even be present in intrauterine life. Dr. Taylor has most frequently seen osteochoudritis about six weeks after birth. The changes in the cranial bones seem to be later symptoms, and to occur most com monly after the second year. In some cases reported by Drs. Barlow and Lees the ages of the children were between:two and three years. Bone changes usually occur in the most severe cases, although it is said that they are sometimes the only symptom of the disease. If the patient re covers, all traces of the morbid growth may disappear, but it is not rare to find curvatures or twists left as evidence of the cachexia which has passed away.
Symptoms.—The first manifestation of the constitutional taint may oc cur early or late, according to the degree to which the system is affected by the virus. When the syphilitic poison is very active, the disease may first show itself during intrauterine life. The foetus then dies and is born dead before the proper time Syphilis is thus a common cause of miscarriage ; and in all cases where premature labour is found to have occurred repeat edly, we should not fail to make inquiry as to the previous health of the parents. If examination of the aborted foetus be made, the bones and in ternal organs exhibit signs of being profoundly affected by the syphilitic poison.
In a less active state of the virus the child, although diseased, may be born alive. He is then much emaciated and looks shrivelled. His body is covered with an eruption of pemphigus which extends even to the palms of the hands and soles of the feet. He snuffles and has a hoarse cry. If, as generally happens, the internal organs are extensively diseased, the child dies. If no disease of the internal organs be present, the child may linger for a longer time, but he generally dies in the end. It is only in very rare cases that he struggles on and eventually recovers.
Usually when a syphilitic child is born alive, he has at first a healthy appearance. After a time—often between two and six weeks, rarely after three months—the first signs of the disease appear. Before this, however, the child in many cases has an unhealthy look, although it is difficult to say in what this unhealthiness consists. There is often great restlessness ; and the infant may sleep badly at' night, sometimes breaking out into paroxysms of violent crying, which are a source of great perplexity and dis tress to his attendants. It seems probable that this symptom is due to nocturnal pains in the bones, such as often affect adults before the outbreak of constitutional symptoms. The sleeplessness soon ceases under the in fluence of specific treatment. Sometimes the outbreak of the general symp toms is determined by a febrile disease, such as vaccination or one of the exanthemata. Thus, it is not very rare to see the rash of measles subside leaving the syphilitic eruption in its place.
Snuffling is one of the earliest symptoms. It should always be inquired for, as while the child is breathing through the mouth it is not noticed, and the mother attributing the symptom to a cold may not think it deserving of mention. The snuffling is most evident when the child takes the breast, and his manner of doing so is very characteristic. Each breath is drawn
with difficulty through the nostrils, and if the obstruction is great respira tion has to be suspended while the babe sucks. Consequently, he can only draw the milk by short snatches. After every two or three mouthfuls he is forced to desist, and can be seen lying with the nipple in his half open mouth so as to renew his supply of air before he begins again. A discharge from the nostrils soon appears. This is at first watery, but soon becomes thicker and forms crusts which block up the nasal openings. Little ulcera tions and cracks are generally seen about the nostrils and upper lip, due either to mucous patches or to scalding by the irritating secretion from the nose. Li bad cases ulceration of the Schneiclerian membrane may take place, and the septum is sometimes perforated. Occasionally, necrosis of the nasal bones follows, and fragments of the bones may be found in the dried discharge. The bones may be also loosened so that the bridge of the nose is flattened and sinks clown.
Another early symptom is the rash. This appears, as a rule, shortly after the beginning of the coryza. It is seen as flattened, slightly elevated spots, of a rusty red or coppery colour, scattered over the perimeum, upon the genitals, and around the anus. Sometimes it begins as a uniform, clingy red blush covering the belly, the perineum, and the buttocks. It soon assumes the tint of the lean of ham ; its edge is distinctly circumscribed, and at the circumference isolated spots are seen of the same colour. The eruption is not confined to the lower part of the body. It is often seen in the folds of the joints, particularly of the armpits, along the sides of the neck, and over the chin. Other varieties of eruption are also seen. Ecthy matous and tubercular spots are not uncommon, and mucous patches and ulcerations are constantly present on the skin. The ecthymatous pustules are met with in the more weakly children. They are generally covered with a thick scab, under which the skin may ulcerate into deep, sharply cut sores. Mucous patches lie at the outlets of the various passages opening on to the surface of the body, and in other places where the skin is especially delicate: and moist. Thus they are seen around the anus, and in a girl round the vulva ; also about the commissures of the lips, and between the fingers and toes. They are round or oval patches, slightly elevated. The surface is of a grayish colour and is moistened by constant secretion. On a mucous membrane they quickly become converted into shallow ulcers. Ulcerations and cracks invade the angles of the mouth and alm of the nose. They are linear and leave behind them linear cicatrices when they heal. The skin itself of a syphilitic child presents a very characteristic appearance. In severe cases it is dry, inelastic, and wrinkled in loose folds. The complex ion is yellowish, and has been compared to weak café-au-lait. This tint is unequally distributed, being most marked on the prominent parts, as the nose, cheeks, forehead and chin. The general colour of the skin may be muddy ; but in children who survive it generally becomes singularly blood less, and remains pale long after other symptoms have disappeared.