(2. 
 
 : 
 
 UNIVERSITY OF CALIFORNIA 
 CALIFORNIA COLLEGE OF MEDICINE 
 
 IIROAPY 
 
 MAY 2 8 1971 
 
 IRVINE. CALIFORNIA

 
 SYPHILITIC LESIONS 
 
 OF THE 
 
 OSSEOUS SYSTEM 
 
 IN 
 
 INFANTS AND TOTING CHILDREN. 
 
 E. W. TAYLOR, M.D., 
 
 SURGEON TO THE NEW YORK DISPENSARY, DEPARTMENT OP VENEREAL AND SKIN DISEASES. 
 PHYSICIAN TO CHA1UTY HOSPITAL, NEW YORK. 
 
 NEW YORK: 
 WILLIAM WOOD & COMPANY, 
 
 527 GKBAT JONES STREET. 
 1875. 
 
 74-09
 
 IZ Vfc 
 
 T2.4 r 
 
 I 875 
 
 Entered according to Act of Congress, in the year 1874, 
 
 by R. W. TAYLOR, M.D., 
 In the Office of the Librarian of Congress at Washington. 
 
 JOHN- F. TROW & SON. 
 
 PRINTERS AND BOOKBINDERS, 
 
 206-213 Enut IZtft St., 
 
 NEW YORK.
 
 TO 
 
 WILLIAM H. DRAPER, M.A., M.D., 
 
 CLINICAL PBOFES8OB OF DISEASES OF THE SKIN IN THE COLLEGE OF PHYSICIANS AND 
 SURGEONS, NEW YOHK ; PHYSICIAN TO THE ROOSEVELT HOSPITAL, ETC., ETC., 
 
 IN ACKNOWLEDGMENT BOTH OF HIS STERLING PERSONAL 
 
 QUALITIES AND OF HIS HIGH PROFESSIONAL 
 
 ATTAINMENTS. 
 
 THIS VOLUME IS RESPECTFULLY DEDICTAED 
 
 T H is
 
 PREFACE. 
 
 WHEN my attention was primarily drawn to lesions of a 
 syphilitic nature occurring in the- osseous system of infants, 
 so little was known upon the subject that I was soon compelled 
 to turn my inquiries from the few works in which, indeed, it 
 was but casually mentioned, to the disease itself, as presented 
 in the sick, to a number exceeding a dozen, the details of 
 which I have been careful to give at length. In a word, 
 the volume of Nature was before me, and in that I studied. 
 As a consequence of which I trust it will be found that, if my 
 descriptions are sometimes minute, it is because the appear- 
 ances were attentively examined ; and that not only are those 
 lesions which constitute the principal topic described with 
 complete accuracy, but certain others which had been pre- 
 viously confounded with them demonstrated to be essentially 
 different. 
 
 In this way, it is true, has occurred that the treatise has been 
 somewhat extended ; for, especially, in order to show in what 
 respects scrofulous and rickety affections are distinct from 
 those exclusively specific, I was obliged to go into a close 
 analysis of them, and to make them fully understood ; a mat- 
 ter the more necessary, as, up to the time I undertook the in- 
 quiry, Science had given it but a very insufficient share of her 
 attention. But not this alone, since, as will be seen, I had to 
 dwell also on that separation of the epiphysis which depends on
 
 vi Preface. 
 
 syphilitic as coii-tradistinguished from that which arises from 
 simple causes; and thereby establish a distinction previously 
 unknown to diagnosis, though one clearly essential to prevent 
 serious mistakes in practice. 
 
 In fact, the field I entered upon was almost untrod, while 
 in one division of it more especially so, or that wherein I was 
 led to investigate those lesions in infants which originate in 
 acquired syphilis, and show that this class of affections do not 
 proceed from congenital causes only ; for of these it is but 
 truth to say that, as the last were but imperfectly understood, 
 so were the former entirely undescribed. 
 
 On the whole, I trust the student will herein find a treatise 
 at once original and complete, or, at least, one that, based on 
 immediate researches in Mature, is, if on that account only, 
 not uneutitled to notice. Such as it is, however, though I 
 thought it due to myself to speak of as the product of pro- 
 tracted study, I deem it also proper to apologize for, as, doubt- 
 less, but too likely to disclose certain of those inaccuracies in- 
 cidental to every undertaking of the sort. 
 
 I have but to add that the drawing to depict the morbid 
 osseous changes is after a photograph taken for me by my 
 friend, Dr. J. W. S. Arnold, whose known skill in this de- 
 partment of art I was very glad to avail myself of. 
 
 125 East 12th Street, N. Y., January, 1875.
 
 CONTENTS. 
 
 Page 
 I. Introductory 9 
 
 II. The Histories of Personal Cases 13 
 
 III. Resume of Cases of the Various Observers 42 
 
 IV. General Considerations and Division of the Subject 55 
 
 V. Description of the Osseous Lesions of the Upper Extremities. . 58 
 
 VI. Enlargements upon the Clavicle, Sternum and Ribs 65 
 
 VII. The Swellings at the Extremities of Tibia and Fibula 68 
 
 VIII. The Swellings upon the Femur. 72 
 
 IX. The Enlargement of the Carpal, Tarsal, Metacarpal and Meta- 
 
 tarsal Bones, and of the Phalanges 75 
 
 X. The Swellings upon the Cranial Bones and upon the Bones of 
 
 the Face 91 
 
 XI. The Swellings on the various Irregular Bones 94 
 
 XII. The Development, Course, and Distribution of the Osseous 
 
 Swellings 95 
 
 XIII. The Effect of the Osseous Enlargements upon the Integuments 
 
 and upon the Joints 99 
 
 XTV. The Degenerative Changes which may occur in the Osseous 
 
 Swellings. The Superficial Form 102 
 
 XV. The Separation of the Epiphyses from the Diaphyses 104 
 
 XVI. The Symptoms induced by the Osseous Swellings Ill 
 
 XVII. The Periostitis of the Hereditary Syphilis of Infants -.J4J. 
 
 XVIII. The Effects of the Osseous Lesions upon the Ultimate Struc- 
 ture and Shape of the Bones 116 
 
 XIX. The Period of Invasion of the Osseous Lesions 120 
 
 XX. Can similar Osseous Lesions be developed in Acquired In- 
 fantile Syphilis ? 121 
 
 XXI. The Intensity of Syphilis in those Cases in which Osseous Le- 
 sions are observed 124 
 
 XXII. The Condition of the Syphilis of the Mothers in whose Infants 
 
 Osseous Lesions are observed. . , .125
 
 CONTENTS. 
 
 Page 
 XXin. Pathological Anatomy 130 
 
 XXIV. The Question of the Relation between Rachitis and Syphilis.. 138 
 
 XXV. The Differential Diagnosis 141 
 
 XXVI. The Treatment 154 
 
 XXVII. The Swellings which occur later in the Life of those Heredi- 
 tarily Syphilitic, at the Junction of the Diaphyses with the 
 
 Epiphyses 160 
 
 XXVIII. The Course of the Gummous Osseous Lesions of Older Chil- 
 dren contrasted with the Lesions of Infancy 164 
 
 XXIX. Miscellaneous Clinical Notes 169 
 
 XXX. Certain Non-specific Affections of the Bones sometimes re- 
 
 gariad as Syphilitic 171 
 
 Appendix 175 
 
 Index.. . 177
 
 SYPHILITIC LESIONS 
 
 OF THE OSSEOUS SYSTEM IN INFANTS 
 AND YOUNG CHILDREN. 
 
 I. INTRODUCTORY. 
 
 THERE is, perhaps, no portion of the field of syphilography 
 in the study of which less progress has been made, than in that 
 of the lesions of the osseous system in infants and children. 
 Prior to the last few years the statement made by early 
 observers, that such lesions were very rare, held full sway, 
 and the baneful influence of the impression thus produced can 
 now be clearly appreciated in the facts that observers attributed 
 to other diseases lesions of this system which were due un- 
 doubtedly to syphilis, and that they did not follow up the study 
 of these cases, because under the weight of the prevailing 
 almost unequivocal statement, it was thought that such syphilitic 
 lesions rarely if ever occurred. In fact, I. think that in the 
 whole range of medical literature, there is not a stronger illus- 
 tration of the blind manner in which acquiescence is given to a 
 dogmatic statement, than that which has been accorded to this. 
 Emanating from early writers upon the venereal diseases of 
 children, whose observations were purely clinical, and which 
 were not matured and confirmed by pathological research, this 
 view has been transmitted from one to another over a long 
 period of years, and it finally came to be accepted as an un- 
 doubted clinical truth. Within the past twenty years, the work 
 of Diday, l which reiterated this statement, has, perhaps, exer- 
 cised a most signal influence in tending to spread it. Following 
 him, in didactic treatise, 'came Vidal," who in his work acqui- 
 esced in the opinion, and after them writers upon diseases of 
 children range themselves in an unqualified manner. There 
 
 1 Traite de la syphilis des enfants nouveau n6s ct des enfants a la mamello. 
 Paris, 1854. 
 8 De la syphilis congenitale. Th&se pour 1'agrdgation. Paris, 1860.
 
 10 Syphilitic Lesions of the Osseous 
 
 are certain reasons, however, beyond this of mere popular be- 
 lief, which tended to strengthen this view, and these are that 
 the syphilitic lesions of the osseous system in infants presented 
 several strong points of resemblance to the bone-lesions of 
 rickets, and that as they did not in every instance present clear 
 syphilitic features they were attributed to scrofula. As these 
 two diseases were brought out in a salient manner, the idea 
 gained ground, that when osseous lesions occurred in children, 
 they were due to either one of them, and some writers put 
 forward the views that syphilis could cause rickets, and that the 
 two diseases were frequently found in the same patient. Thus it 
 can now be readily seen how imprecise were the diagnostic points 
 thus drawn, and what a great barrier existed in the way to true 
 progress in clinical investigation. I have no doubt but that 
 this confusion has tended to produce some of the discrepancies 
 in opinion which now exist among some observers as to the pe- 
 culiarities of the osseous lesions of rickets. Thus it happened 
 that rickets and struma were in the majority of cases considered 
 as the diseases causing many lesions of the bones in children, 
 while their syphilitic origin, in many instances, escaped entirely 
 from consideration. In spite, however, of this well-grounded 
 belief and of the reigning confusion, cases of bone-lesion were 
 from time to time reported as being due to syphilis, and the 
 opinion lurked in the mind that such lesions might occur. If 
 this had not been so, it is very probable that the standstill would 
 have been greater than it really was. These reported cases, how- 
 ever, were not numerous, nor, in the majority of instances, were 
 they carefully and elaborately reported, so that they did not 
 afford the material necessary for clinical study and deduction. 
 This was the state of affairs when, in 1870, an important article 
 M;IS published by Dr. Gr. Wegner, the assistant to Professor 
 Virchow, in Berlin. In it he gave a minute microscopic de- 
 scription of the lesions of the bones in twelve syphilitic 
 children, and he showed quite clearly that the pathological pro- 
 cesses are sui generis. Besides this, he ventured the statement 
 that such lesions were not rare, but were even quite constant. 
 These observations, though not quite exhaustive, have since 
 been fully confirmed, and, in some particulars, added to, by 
 Profs. Waldeyer and Kobner, who also agree with Wegner as 
 to the frequency of occurrence of the lesions. In two years,
 
 System in Infants and Young Children. 1 1 
 
 subsequently, they were again confirmed by Parrot, in Paris, 
 who gives a point of some value in their clinical history. The 
 grand result of these observations has been to place the matter 
 in a more precise light, to give science a standard to work 
 upon, and to produce an impetus for observation which will 
 finally lead to the dissemination of accurate clinical and patho- 
 logical knowledge of these lesions. About a year prior to the 
 publication of Wegner's article, a case came under my obser- 
 vation, which, at the time, greatly interested and puzzled me. 
 It led me to search literature thoroughly, and I finally found a 
 few cases, which convinced me that my own was one of syph- 
 ilitic origin. One of these cases, that of Eanvier, was accom- 
 panied by some interesting pathological details. Early in 1870 
 I read Wegner's article, and it fully confirmed my view, and it 
 has since greatly assisted me in clearly interpreting various 
 features of other cases, which have, fortunately for me, fallen 
 under my notice in the various public charities with which I 
 am connected, through the kindness of friends and in private 
 practice. 
 
 Though Wegner's article lends much assistance in the study 
 of these lesions, the aid is wholly in the matter of pathology, as 
 no clinical facts are given. Then again, on this division of the 
 subject, it is not exhaustive, as it treats mainly of a certain 
 form of lesion found at the junction of the diaphyseswith the 
 epiphyses of long bones, and it does not consider, at equal 
 length, the syphilitic lesions of the short and flat bones; there- 
 fore it is a contribution but to a portion of the subject. Parrot's 
 articles combine clinical and pathological facts, but in the 
 former field he confines himself mainly to the appearances 
 induced by separation of the epiphyses from the diaphyses, 
 describing the resulting condition, a loss of motion, as a pseudo- 
 paralysis. Antecedent and advanced stages are not touched 
 upon, nor does he enter upon the study of diagnosis. In fact, 
 it must be confessed that his papers are narrow in scope and 
 desultory in conclusions. 
 
 Wegner's article is certainly one of the most important recent 
 additions to our knowledge of syphilis, and one which, by posi- 
 tively stating the fact that these lesions are not uncommon, 
 will tend in future to call attention to their study. It must, 
 however, be said in justice to Ranvier, that he sketched the
 
 12 Syphilitic Lesions of the Osseous 
 
 same pathological processes some years before, and showed 
 how syphilis might affect the bones. The great point in "Weg- 
 ner's performance is the fact, that he cited a greater number 
 of cases, and that he based his observations upon a large field 
 of research. These observations and the occurrence under my 
 care of twelve cases, and the opportunities of observing several 
 others, have led me to study the clinical history of these lesions 
 with great care and attention for the past four years. I have 
 also been fortunate in meeting with cases, which, though not of 
 syphilitic origin, have suggested points of resemblance, and have 
 materially assisted me in my studies of their diagnosis. 1 have, 
 therefore, endeavored with this material, which will be seen to be 
 quite ample, to trace the development, course, and decline of these 
 lesions, and the various concomitant circumstances which attend 
 them, and to give, if possible, a complete picture. The lesions due 
 to hereditary syphilis in infants are quite fully described, as the 
 cases are quite numerous, and the question as to whether similar 
 lesions could be developed in the acquired syphilis of infants and 
 young children is, I think, quite fully settled in the affirmative, 
 as two illustrative cases are given. This is a subject of consider- 
 able importance, and until now not treated of, though the opinion 
 was entertained on very insufficient ground that such could not 
 occur. The impression will be conveyed, I think, by our study, 
 that the lesions as observed in the infant are such as may be 
 engrafted on the bones in a greater or less degree during the 
 whole period of their development ; and this is another point of 
 very great pathological import. Then again, in the study of 
 these various cases, it will be found that two show quite clearly 
 a complication of great interest, namely, separation of the epi- 
 physes from the diaphyses. This is a condition attended with 
 much important consideration, and one which has yet not been 
 clearly brought out. In fact, the two cases hereafter detailed, 
 are the only ones on record which show the course of the lesion 
 and its ultimate results in a subject which survived the disease. 
 In a surgical point of view, these cases are of considerable im- 
 portance. I give the history of my cases as well as those of 
 every reported case in as succinct a manner as possible. Many, 
 if not all, of the cases reported by others lack very essential 
 particulars in their history, and they are chiefly valuable from 
 the fact that they call attention to bone-swellings. I have en-
 
 System in Infants and Young Children. 13 
 
 deavored to bring out every point mentioned by the various 
 authors, and to show their importance by a comparative ex- 
 amination of them. The" result will be found to be, if not an 
 exhaustive treatise, certainly a suggestive one, and one in which 
 the essential points of these lesions are set forth. It occurred 
 to me that perhaps I occupied too much space with the cases ; 
 but as they are the store-house from which the deductions are 
 made, and as they may serve in future a useful purpose as pro- 
 totypes, I have given them all without unnecessary words. 
 Another reason which led me to do this was, that these cases have 
 never been before united in a collection, and as 1 have been 
 careful to draw them from the original sources, I have thought 
 that they might be of use for future reference. Though the 
 commentary and cases hinge the one on the other, they of course 
 may be read separately, the descriptions being given in a didac- 
 tic manner in the commentary, while the clinical features may be 
 grasped from a perusal of the cases. In this clinical department, 
 as I have said, the contributions have been scanty, and the de- 
 ductions have heretofore been wholly wanting. 
 
 I have taken pains to review the field of pathology carefully, 
 and I give original illustrations, which I think will fully explain 
 in a simple manner the various changes. Though I give the 
 views and observations of other observers, I have also given my 
 own, which in one or two particulars have cleared obscure 
 points. The sections upon diagnosis and treatment are as com- 
 plete as I could make them. I shall give my cases first, and 
 after them place those of the various other observers. 
 
 II. THE HISTORIES OF PERSONAL OASES. 
 
 CASE I. James B. came under my observation at the College 
 of Physicians and Surgeons in May, 1872. The patient was 
 then a little more than three months old, and though not very 
 fat, still was not thin, and was quite compactly built. Its 
 mother informed me that it had always nursed well, and that 
 its general health was quite good. In answer to inquiries, I 
 learned that it had not had any night sweats of a local charac- 
 ter, and that it had not suffered from fever at night, during 
 which period it usually slept quite well. The mother's history 
 was as follows : She was thirty-five years of age, and had been
 
 14 Syphilitic Lesions of tlie Osseous 
 
 married twelve years. Daring the first nine years of her mar- 
 ried life she had given birth to three healthy children, who are 
 now living. In the tenth year after her marriage she had 
 " sores " upon the genitals, which were followed by a general 
 condition of ill-health ; and she also noticed a roseola of a per- 
 sistent character, and mucous patches, and condylomata. In 
 the two years succeeding this syphilitic infection she had two 
 miscarriages at five months without any known cause. "Within 
 a year after that her health improved markedly, and she then 
 became pregnant with the present child. The father was a 
 very uncommunicative man, and I failed to get his history. 
 
 The child had the snuffles very severely when about a month 
 old, but no rash was observed. When it was six weeks old, the 
 mother noticed that the bones of the forearms were enlarged 
 just above the wrists. These swellings grew gradually larger, 
 and when they had existed six weeks the child came to me. 
 On very careful examination I found a slight papular syphilitic 
 rash, with evidences of a declining roseola. These cutaneous 
 manifestations were quite clear, and were regarded by me and 
 by my friend, Dr. II. B. Walker who was present at the ex- 
 amination as undoubtedly syphilitic. They had evidently es- 
 caped the notice of the mother, but had certainly existed sev- 
 eral weeks. The cranium was normal in every particular, as 
 also were the ribs. As the child was not very fat the swellings 
 on the forearms were quite readily seen. The two bones of 
 each side seemed joined together by a deposit of firm tissue, 
 which was evenly distributed around their lower ends. At this 
 enlargement the interosseous space was not discernible with the 
 tip of the finger, though it was readily found above this point. 
 The surface of the swellings was in their greatest extent smooth 
 and rounded, beginning abruptly from the shafts of the bones, 
 and then forming a decided elevation of fully half an inch, and 
 merging into and being lost in the expanded epiphysis. The 
 swellings on the ulnae were very plainly marked just above the 
 styloid processes, which were lost in them. The integument 
 was slightly stretched, but was normal in appearance, and could 
 be slid easily over the swellings. The parts did not present 
 any perceptible elevation of temperature. Upon manipulation 
 no uneasiness seemed to result, and there were no evidences of 
 the presence of spontaneous pain. -The mother stated that the
 
 System in Infants and Young Children. 15 
 
 Bwellings had attained their present size in a month after she 
 first noticed them, and that for a fortnight she had observed 
 that they did not increase in size. I prescribed for the child 
 the mixed or combination treatment, composed of bichloride of 
 mercury, one grain ; iodide of potassium, four drachms ; syrnp 
 and water, each two ounces: of this mixture it was to take six 
 drops three times a day. In June the cutaneous lesions had dis- 
 appeared, and, as the medicine was well borne on the stomach, 
 I increased the dose to ten drops ; there was no perceptible 
 diminution in the size of the bone-swellings. The dose as thus 
 increased was continued during the month of July with 
 very little irregularity, owing to temporary diarrhoea, and in 
 August the swellings were unmistakably smaller in size. This 
 diminution in size was most marked at the ulnae, as it became 
 possible to define the contour of the styloid processes. Though 
 the osseous lesions had been benefited by the treatment, the 
 general condition of the child was not very good. It had be- 
 come pale, and flabby, and thin. Yet it had never manifested 
 any disturbance of the gastro-intestinal tract, nor had it showed 
 any particular morbid symptom. I also noticed a tendency to 
 lateral expansion of the skull similar to that of chronic hydroce- 
 phalus. This led me to examine the bones very carefully, and 
 I could not find the least abnormality about them. I examined 
 the ribs again also, but they were normal. Under these cir- 
 cumstances I reduced the dose of the mixture to six drops, and 
 ordered that it should take besides one teaspoonf ul of the sweet 
 wine of iron, and a similar quantity of cod-liver oil. In Sep- 
 tember a pustular syphilide and mucous patches were observed. 
 In November I saw the child for the last time. The enlarge- 
 
 O 
 
 ments of the bones had almost wholly disappeared, and their 
 contours could be clearly defined. Upon the radius, at the 
 diaphyso epiphysal junction, there was a slight ridge of a height 
 of about two lines, and a breadth of about a quarter of an 
 inch. Upon the ulnae very slight upliftings of the surface of 
 the bone were felt just above the styloid processes, which seemed 
 normal. At this, the last visit, I saw that the enlargement of 
 the head had got rather more prominent, but there was no 
 alteration of the fontanelle. The general condition of the 
 child was very bad ; its skin was wrinkled and scurfy, and the 
 subcutaneous fat was nearly all absorbed, and the muscles were
 
 16 Syphilitic Lesions of the Osseous 
 
 wasted, in fact, it seemed profoundly cachectic. I am con- 
 vinced that it died soon after, as its mother attended so reg- 
 ularly before. 
 
 CASE II. John B., a male child three months old, was 
 brought to the Woman's Medical College of the New York 
 Infirmary, and was transferred to my clinic on the twenty-fifth 
 of November, 1872. At that time I ascertained that its mother 
 had been syphilitic nearly two years, but I could obtain no 
 history of the father. Upon examination I found a roseola and 
 papular roseola of undoubtedly syphilitic origin, upon the 
 trunks and extremities. The body of the right testicle was en- 
 larged to more than twice its natural size, and there was an 
 hydrocele of the tunica vaginalis. The distal ends of the bones 
 of the forearms were also the seat of morbid changes. Thus 
 just at the junction of the diaphysis with the epiphysis of each 
 bone an enlargement was felt, which began quite abruptly and 
 attained a height of fully half an inch, and merging into was 
 lost in the expanded epiphysis. The surface of the swelling 
 was perfectly smooth, and when carefully examined, both radius 
 and ulna seemed soldered together by a new deposit. The 
 swellings corresponded in size on each arm. If they had not 
 been carefully sought for, these enlargements would have 
 escaped recognition, as the child was quite fat, and at each 
 wrist it was particularly so. The treatment consisted in the 
 administration of one grain of hydrargyrum cum creta and of 
 one grain of iodide of potassium at intervals of half an hour 
 between each dose three times daily. The testicle received 
 proper treatment. The cutaneous lesions disappeared, and in 
 six weeks there was a marked diminution in the size of the en- 
 largements. I have since learned that the treatment was con- 
 tinued for two months longer, and that then no swellings were 
 perceptible upon the bones. There was not at any time any 
 apparent impairment in the use of the limbs, and the joints 
 were not involved. The case also presents an interesting feature, 
 as showing the development of a sarcocele in a hereditarily 
 syphilitic child, a lesion, the existence of which was once denied. 
 The fontanelles were normal, as were also -the ribs and skull- 
 bones. The child had not had local nocturnal sweats, nor had 
 it suffered from gastro-intestinal disturbance.
 
 System in Infants and Youny Children. 17 
 
 CASE III. Mary J. came under my observation on the 
 twentieth of October, 1871. She was then about two months 
 old. Her mother was found to be syphilitic, and had been in- 
 fected about six months ; that is, in the fifth month of preg- 
 nancy. Her lesions were of a severe character, and she seemed 
 very much debilitated. She had been treated for syphilis for 
 about three months, but not very actively. She stated that 
 shortly after the child's birth it had had a dark rash, which had 
 continued to exist, and that its mouth had been very sore, and 
 that it was very restless at night, seeming to be in pain. Upon 
 examination I found that the child was quite well developed, 
 and tolerably fat. The eruption alluded to was a roseola, which 
 had become coppery in tint, and was evidently declining. 
 There were two mucous patches in the mouth, and a condyloma 
 latum upon the margin of the anus. Upon examining closely 
 the various bones of the body, I found that several of them 
 were the seat of enlargement. At each wrist there was a very 
 evident swelling, which began abruptly from the shaft of the 
 bone, and then attaining a height of about three-quarters of an 
 inch, having a smooth surface, merged into the expanded and 
 enlarged epiphyses. The swellings were perfectly symmetrical 
 in size, and an examination of them gave the impression that 
 both bones were welded together with an encircling tissue. At 
 the lower end of the shafts of the tibia and fibula a similar 
 condition was found. Here, however, the swelling was less 
 abrupt from the shaft, and the enlargement of the epiphyses 
 was much more considerable in comparison. Both bones 
 seemed to be joined together inseparably ; in fact, at their two 
 ends they had a somewhat quadrangular shape, and their sur- 
 faces were smooth. Each malleolus could be clearly made out, 
 at its lowermost part, as normal in shape ; consequently the 
 process had 'only involved its upper part. No other bones 
 seemed to be involved. The mother was unable to give a history 
 of these bony tumors. She had not recognized those of the 
 wrists, probably owing to the fatty tissue, but she thought that 
 the condition of the ankles was not natural. The movements 
 of the arms and legs were apparently performed normally. 
 I ordered for this child five drops of the mixed treatment three 
 times a day ; but I only saw it once after, and then, as but three 
 weeks had elapsed, no apparent change had been produced. 
 2
 
 18 Syphilitic Lesions of the Osseous 
 
 I afterwards learned that it had died early in December, of a 
 pulmonary trouble. 
 
 CASE IV. I was asked by its uncle to see P. C.,a male child 
 aged fourteen mouths, on the 10th of July, 1873. I found it 
 to be a quite delicate child, but not remarkably thin. Upon 
 each side of the frontal bone was a very prominent swelling, 
 and this condition was the cause of my visit. Besides these 
 bone-swellings there were enlargements of the bones of the 
 foreanns. An inquiry into the history of the case brought out 
 the following facts : The child had been well at birth, but when 
 a month old it had been covered from head to foot with a rash, 
 had had snuffles very badly and for a long time, and had a very 
 severe inflammation of one eye. When three mouths old the swell- 
 ings on the forearms were noticed, but up to that time the child 
 had nursed and slept well, and in spite of its lesions had grown 
 proportionately. It had never had fever nor sweats at night, 
 but when its nose was stopped up with the coryza its respiration 
 was sometimes a little impeded. At this time it was treated by 
 a village physician, who evidently regarded the case as one of 
 rickets. When the child was six months old, the node on the 
 right frontal eminence had been noticed, and in about three 
 months after, that on the left formed, or rather was noticed. 
 The treatment followed, as nearly as I could ascertain, consisted 
 in the administration of quinine, iron, and cod-liver oil. It was 
 nursed by its mother until three months before the time at 
 which I first saw it, and after that was fed on milk of good 
 quality. In January, 1873, it had suffered severely from sore 
 mouth, and the lesion being persistent, it was touched several 
 times with nitrate of silver stick. An examination of the case 
 resulted in obtaining the following facts: The cranium was 
 normal, except at the points mentioned. There were no evi- 
 dences of thickening of the bones at any of the sutures, no soft 
 spots or depressions upon any of them, and the fontanelle was 
 not abnormally large. The node on the right side of the frontal 
 bone was nearly three-quarters of an inch in all diameters, it 
 being quite round. It was elevated above the plane of the 
 skull nearly one half-inch, and had abrupt but even borders, 
 and its surface was smooth. The node on the left side was 
 about half an inch in diameter, and it corresponded exactly to
 
 System in Infants and Young Children. 19 
 
 its larger fellow. The integument over both swellings was, 
 though slightly stretched, normal, and not in any manner adher- 
 ent. At the line of junction of shafts with the epiphyses of the 
 radius and ulna was a well-marked ring of bone. The upper 
 border of the ring began abruptly at the shaft of the bone, and 
 attaining a height of half an inch, bevelled off again into the 
 epiphysis, having occupied an area of about three-quarters of 
 an inch of the continuity of the bones. When examined from 
 the wrist-joint upwards, the swelling was not as abrupt as it was 
 when felt of from above. This was due to the expansion of 
 the epiphysis. The surface of this ring was smooth, and over it 
 the integument, which was normal, could be readily slid. As 
 the child was not very fat, the swelling could be seen very 
 plainly. The lesion was symmetrical on both bones of both 
 forearms. Upon the ulnae, just above the styloid processes, the 
 swellings were particularly well marked, and their lower bor- 
 ders fused into and enveloped the upper part of the styloid 
 processes. The ribs were normal, and no other enlargement 
 was found upon any of the bones. The wrist-joints were not 
 at all impaired in their motion. Upon the inner side of the 
 left labial commissure, the mucous membrane was very much 
 thickened, of a white color, and cracked in various directions. 
 There was a slight opacity of the left cornea to the right and 
 above its middle part. 
 
 The mother's history was as follows : She had been married 
 three years prior to the birth of the present child, during which 
 time she had twice miscarried. She had become ill soon after 
 marriage, had some eruption of the skin, and suffered severely 
 with sore-throat, or as she called it, diphtheria. She also had 
 had condylomata around the vulva. She had not been treated 
 regularly. The father was said to suffer from rheumatism. 
 
 I prescribed the same mixture, combining the bichloride with 
 the iodide of potassium ; and ordered that the child should take 
 ten drops three times daily, and to increase the dose in a month 
 to fifteen drops. 
 
 As the child lived in the country, I did not see it again for a 
 month, at which time I learned that the medicine had been 
 given quite regularly, except an intermission of a few days, ow- 
 ing to diarrhoea. At this examination I found that the nodes 
 were somewhat less elevated a fact which could be seen by the
 
 20 Syphilitic Lesions of tJie Osseous 
 
 eye as well as appreciated by the touch. As there was no 
 marked change in the swellings on the forearms, I ordered that 
 they should be rubbed every day with ung. hydrarg. The close 
 was then increased to fifteen drops. This line of treatment was 
 followed until November, at which time I saw the child again. 
 The nodes had entirely disappeared, and on the site of their 
 former position a distinct depression of about one-third of aline 
 was found involving their whole area. This fact was well 
 shown on both frontal eminences. As the tip of the finger was 
 passed along the surface of the frontal bone it would slide sud- 
 denly into these depressions. The former rings of bone on the 
 radius and ulna were now almost imperceptible ridges. The 
 general condition of the child was good. 
 
 CASE V. The history of the next child is somewhat incom- 
 plete as to the course of the lesions under the influence of 
 treatment, but still it presents other interesting points. 
 
 T. C., a male child, aged two months, came under my obser- 
 vation in September, 187:2. I had treated its mother for se- 
 condary syphilis about a year previously ; its father was not 
 examined by me, nor could I obtain any history of him. The 
 child when first seen was covered with a very confluent roseola, 
 "had severe eczema of the genital and anal region from the irri- 
 tation of a number of neglected condylomata, and it suffered 
 from aphthae of the mouth. The bones of the forearms were 
 the seat of change at the junction of the shaft with the distal 
 epiphysis. The swelling consisted of what appeared as a ring 
 encircling both bones; it had fully three-quarters of an inch of 
 area, and was raised a little more than half an inch. At the 
 seat of lateral opposition of the two bones the swelling was so 
 much developed that they appeared as if fused together. The 
 surface of the swellings was nearly smooth not at all ridgey. 
 The integument above was uplifted, and the tumors were 
 clearly visible, as the child was quite thin. At the head of the 
 radius and ulna on each arm a similar but smaller ring of bone 
 was found encircling each ; but they would have escaped at- 
 tention if not felt for, as they did not produce any bulging of 
 the integument. The swelling on the ulna was more per- 
 ceptible on the back of the arm, at the base of the olecranon 
 process. There was no impairment in the use of either limb.
 
 System in Infants and Young Children. 21 
 
 At the junction of the shafts of the tibia and fibula of each 
 leg with the lower epiphyses was a ring of bone similar 
 to that observed on the arm ; and there was a similar elevation 
 of the integument, which was very perceptible just above the 
 ankle. The remaining portion of each malleolus appeared as 
 if unaffected. The integument was slightly stretched, but nor- 
 mal. No other bones appeared affected. This child had been 
 vaccinated when a month old, and its mother thought that all 
 its trouble resulted from that. I ordered for it an appropriate 
 treatment ; but I never sa\v it again, as its mother left the city. 
 
 CASE VI. The mother of the next child presented a clear 
 syphilitic history, she having been infected at about the fifth 
 month of pregnancy, her husband having then become syphi- 
 litic. When first seen by me she presented well-marked syphi- 
 litic lesions. She came under my observation on the 1st of 
 June, 1871, having been sent to me by my friend Dr. "YV. H. 
 Draper. Her child's history is as follows : 
 
 Matilda 0. came under my observation June 1st, 1871, she 
 being t.hon six months old. At birth she presented 110 lesions 
 of the skin, and was seemingly a well-developed child ; but when 
 she was afflicted with a roseola^mucous patches, 
 
 k all of which disappeared, and were replaced by a 
 general rjapjilar syjphilide. When the child was six weeks old 
 its mother noticed that its right middle finger was somewhat 
 enlarged, but she could not obtain any evidences of pain. The 
 enlargement slowly increased for two months, when the skin 
 covering the first phalanx became slightly red, thickened, and 
 tender, and very tense from pressure within. This inflamma- 
 tion of the integument and enlargement of the bone progressed 
 very slowly, and at the end of ten weeks which would be the 
 fourth and half month of the existence of the trouble fluctua- 
 tion was discovered, and an incision was made by a surgeon on 
 each side of the finger, thus liberating a quantity of pus. At 
 this time the patient came under my care, and the right hand 
 presented the following appearances: The middle, finger was 
 greatly swollen, being f ally an inch in all diameters, and haying 
 a circumference of two and three-quarters inches. The diameter 
 of its fellow was one-third of an inch, and its circumference 
 slightly less than, an inch. The finger was markedly flexed, and
 
 22 Syphilitic Lesions of the Osseous 
 
 could not even by pressure backwards be fully extended a 
 j condition which was due to the tension produced by the swell- 
 Ling upon the flexor tendon. The fore and ring fingers were 
 very much separated, and were rendered unwieldy by their ab- 
 normal position. This was very noticeable when the child 
 clasped any small article between the thumb and forefinger. 
 The ulcers which resulted from the incisions had a sloughy 
 base similar to that observed in ulcerating gummata, were sur- 
 rounded by a livid, undermined edge, and they secreted con- 
 siderable quantities of a sanious pus. The inflammatory condi- 
 tion of the adjacent integument was quite well marked. There 
 was no evidence, nor had there been, of spontaneous pain ; but 
 the finger was sensitive to handling, as evidenced by the dis- 
 tressed look of the child's face. According to the mother's 
 statement, thechild nursed and slept well, and its strength was 
 not impaired.!^ The mother was placed upon appropriate anti- 
 syphilitic treatment. For the child I ordered a grain of 
 hydrargyrum cum creta three times daily, and treated the ulcers 
 by slightly pencilling them with a solution of nitrate of silver, 
 and the continuous application of an ointment composed of 
 ung. hydrarg., two drachms ; ung. simpl., six drachms. Daring 
 the month of June very little change took place in the finger, 
 but the cutaneous and mucous lesions disappeared. At the end 
 of July it was noticed that the ulcers discharged less, that their 
 edges were less everted and undermined, and that there was 
 a diminution in the circumference of the phalanx of one-quar- 
 ter of an inch. This was probably due both to the lessened 
 size of the bone, and also to the less thickened condition of the 
 integument./] 
 
 During the month of August there was also an improvement, 
 the finger being an eighth of an inch less in circumference. 
 During the early part of this month the child had taken the 
 powders only ten days, in consequence of a gastro-intestinal dis- 
 order, and later in the month they were replaced by the mixed 
 treatment. I had been testing the progress under a strictly 
 mercurial treatment. 
 
 \ The case progressed favorably during the months of Septem- 
 ber, October, and November, for during this period the bone 
 became markedly less swollen. J The ulcers, however, did not 
 wholly heal, and required stimulation once a fortnight as exu-
 
 System in Infants and Young Children. 23 
 
 berant granulations appeared on their floor. It was then evident 
 that the healing process at the base or floor of the ulcers was 
 seated directly upon the bone, and there was a tendency to very 
 slight contraction or bending of their edges towards the bone. 
 Early in January these ulcers were fully healed, and they left 
 behind a thin cicatrix on each side of the finger, which by its 
 central part was adherent to the bone. At this time the finger 
 presented the following appearance: It was three-eighths of 
 an inch longer than its fellow of the other hand, owing to elon- 
 gation of the first phalanx, which was flattened laterally, so that 
 its transverse diameter was a little less than half an inch, while 
 its antero-posterior diameter was about three-quarters of an inch. 
 The mobility of the finger seemed perfect, and the child was 
 able to grasp any article with the hand with normal power. 
 In the management of the case I found it advisable as the pro- 
 gress previously was not satisfactory to me, the treatment how- 
 ever being somewhat experimental to change the simple mer- 
 cury for a combination of iodide of potassium with mercury. 
 The child took for six weeks five drops, and after that to the 
 period of cure ten drops of a mixture composed of bichloride 
 of mercury one grain, iodide of potassium four drachms, mixed 
 with four ounces of syrup. I should add that there were 
 periods varying between a few days and a week, that the 
 mother failed to give the remedy ; but she was upon the whole 
 faithful to her duty, considering the length of time occupied by 
 the treatment. Besides the lesion of the phalanx above de- 
 scribed, there was a similar trouble of one of the metatarsal 
 bones of the left foot, fin July the mother noticed that this 
 foot was wider across the instep than its fellow of the opposite 
 side ; and I found by measurement that such was the case, there 
 being half an inch greater circumference at this point than on 
 a similar point on the other foot. This swelling gradually in- 
 creased, in spite of gentle pressure continuously applied, until 
 the 14th of August^A^hen the tumor was quite large. As far 
 as a careful examination would reveal, I inferred that one 
 of the cuneiform bones, perhaps the middle, was the seat of 
 disease. There was a considerable hydrarthrosis in the articu- 
 lation between the cuneiform and scaphoid bones. There being 
 evidences of fluctuation over the middle cuneiform, I made 
 an incision into the most prominent part of the swelling, and
 
 24 Syphilitic Lesions of the Osseous 
 
 gave vent to about a large teaspogoful of thick healthy pus.l 
 The resulting ulcer was of similar appearance to those oFtha 
 finger, and was a very long time in healing, it being treated in 
 a similar manner. The effusion into the joint was slowly ab- 
 sorbed, the pain ceased, and in December the ulcer had filled up 
 and was covered by a cicatrix, which was slightly adherent to 
 the bone beneath. Upon manipulating the joint I found it was 
 less mobile than natural, but I felt convinced that this condition 
 would gradually cease by exercise of the parts. The abscess 
 of the bone had not resulted in any very perceptible loss of tis- 
 sue, and it was a matter of surnrjse to me that the reparative 
 process had been so perfect. PAt my last observation of the 
 child, January 5th, 1872, its syphilitic lesions had wholly dis- 
 appeared, those of the osseous sjstemjiaving jasted respectively 
 j eleven months in the finger, and six months in the f gotj^ i ^ir**& d-^ , 
 
 The__mother of the two _childreu, the history of whose""' 
 cases now follows, came under my observation in Novem- 
 ber, 1870, she being sent to me by my friend, Dr. W. H. 
 Draper. She was_Jlien in the seventh inonth of her third 
 pregnancy, and was also in the first year oFlsyphilis. She had 
 been infected by her husband when about three months preg- 
 nant, and when first seen by me, having been syphilitic about 
 four mouths, she was suffering very severely with angina and 
 laryngitis. She had become markedly emaciated, and was 
 very weak. About the vulva were large masses of very much 
 hypertrophied condylomata_ lata, which had the bluish con- 
 gested appearance of these lesions when developed during the 
 gravid condition. Her body_was covered with a very copioiis 
 papular syphilide, and there were slightly pigmented spots 
 over the whole surface of a roseola which had been her first 
 rash and had faded. There was a very well-marked cranial 
 alorjecia, and on each angle of the lips was a fissure which 
 commenced in a mucous patch on the inner surface of these 
 parts. Under the circumstances, I placed her upon an active 
 mercurial course combined with tonics ; besides this, the lesions 
 of the mucous membrane were treated locally. Early in Ja- 
 nuary, 1871, she was delivered of a female child, which at 
 birth was well developed, and did not present any evidence of 
 syphilis. The mother had a severe relapse of her syphilis in 
 March.
 
 System in Infants and Young Children. 25 
 
 I examined the father in December, and ascertained that 
 lie had had a chancre and secondary lesions within the year. 
 
 CASE YII. Minnie C., the infant daughter of this woman, 
 was brought to me in March of the same year for treatment. 
 I ascertained that, when a month old, the child had had rose- 
 ola, mucous patches, and coryza, and at this time she had be- 
 come cross and peevish. The urgent symptoms, when seen by 
 me, were the coryza, mucous patches, and emaciation of the 
 child. I ordered it, then, appropriate internal and local treat- 
 ment, and did not see it again until about the middle of June 
 of the same year. At this time I observed serious lesions of 
 the bones and joints, and that the mucous patches in the 
 mouth still persisted. The child's left arm was semiflexed, 
 and it showed a disposition to protect it from handling and 
 from any slight blow. Its mother said that it had held it 
 in this position for nearly two weeks, and that it was evident 
 that it was painful. Upon examination, I found that the 
 elbow-joint was swollen, and that it was very hot to the touch. 
 There was a swelling in the upper part of the olecranon pro- 
 cess, which was uneven, particularly on its superior surface. 
 This swelling, which I could distinctly define as belonging 
 to the bone, was fully as large as a chestnut. There was con- 
 siderable effusion into the elbow-joint, which was most per- 
 ceptible to palpation on its posterior aspect. Though I used 
 some force, I was wholly unable to fully extend the arm. On 
 the other arm I found a swelling, about the size of a pea-nut, 
 just above and almost upon the internal condyle of the hume- 
 rus. The swelling was not very prominent, and to the touch 
 appeared smooth and rounded. There was no impairment of the 
 use of the joint, no perceptible effusion, and no unnatural po- 
 sition of the limb. On the same arm I found a slight enlarge- 
 ment of the radius, just above its styloid process. This swell- 
 ing seemed to be developed around the circumference of the 
 bone. There was no interference by it of the working of the 
 wrist-joint, or of pronation or supination. Upon the right leg, 
 involving the portion of the tibia and fibula which correspond to 
 the point of union of the lower epiphyses with the shafts, was a 
 large swelling just above and merging into each malleolus, which 
 appeared somewhat quadrangular. Though carefully examined
 
 26 Syphilitic Lesions of the Osseous 
 
 by me, 1 could not, by tracing the longitudinal outlines of the 
 bones, and following down with the tip of the finger iu-the space 
 which is normally definable between them at their lower 
 end, make out their outlines at all. The impression conveyed 
 to my mind was, that the swelling had extended around and 
 between the bones, and had here bound them together. The bones 
 of the left leg were not involved. I ordered a local application 
 of a roller bandage, saturated with an evaporating lotion, to 
 the left arm, leaving the other swellings to be influenced by 
 internal treatment. For the latter purpose I prescribed a mix- 
 ture of bichloride of mercury one grain, iodide of potassium four 
 drachms, syrup and water of each two ounces ; of this the 
 child was to take ten drops three times daily. July 15th, 
 child was brought back. Its general health was improved, 
 and its mother thought that it was better, as it was not as 
 fretful as it had been. The elbow -joint was not as perceptibly 
 swollen as when seen last. The bone presented the same en- 
 largement at the olecranon, but there was less effusion into the 
 joint, and mobility was slightly increased. During this inter- 
 val of three weeks, the bandage had been applied by the child's 
 mother every day, and she had ceased applying the lotion ac- 
 cording to my directions, when heat was not perceptible in the 
 joint. The dose of the mixture was now increased to fifteen 
 drops three times a day. 
 
 In two weeks there was perceptible diminution in the size of 
 the various swellings, particularly in the left elbow-joint, which 
 was more mobile, and in the right tibia and fibula. The dose of 
 the mixture was again increased to twenty drops three times a 
 day. Though the weather was quite warm, the child had not 
 discontinued its medicine, as it had not suffered from any gas- 
 trointestinal trouble. 
 
 Late in the month of August, the lesions of the bones having 
 then existed nearly three months, and when the child had been 
 under active treatment fully two months, very marked improve- 
 ment was noticed in these parts. The dose was continued at 
 twenty drops for a month longer. In September the left elbow- 
 joint was, to all appearance, normal, and the swellings on the 
 various bones had entirely disappeared. They had not left 
 any material change in the shafts of the bone, either by increase 
 or loss of tissue, and careful examination failed to reveal any
 
 System in Infants and Young Children. 27 
 
 abnormal condition whatever of the portions previously the 
 seat of disease. The whole treatment had occupied three 
 months, and the lesions of the bones had existed nearly four 
 months. During this time the child had suffered from 
 mucous patches in mouth. The integument over the various 
 bone-swellings was normal. The general health of the child 
 was much improved. 
 
 CASE VIII. Lorette C., the sister of the child whose history 
 is just given, was brought to me on the 7th of June, 1871 ; I 
 then learned that she had been perfectly healthy until a month 
 before, since which time she had suffered from what her parents 
 supposed to be rheumatism. When first seen by me she pre- 
 sented a papular syphilide upon cheeks and forehead, a declin- 
 ing roseola on the body, mucous patches in the mouth, and 
 condylomata lata around the anus. The child suffered most 
 severely at night, when she slept very little. The painful 
 points were the lower end of the left radius, the upper part of 
 left ulna, and the metacarpal bone of the right index finger. 
 At this time the parents suspected that syphilis was the cause of 
 the child's suffering, as the father had been similarly afflicted, 
 and this caused them to bring it to my office. As I knew that this 
 child had not been syphilitic very long, and that it must have 
 acquired its disease, I carefully examined for the initial lesion, 
 and I found that there was an ulcer, sluggish in character and 
 slightly indurated, on the inner aspect of the lower lip, which 
 was accompanied by an enlargement of the submaxillary gland 
 of the same 'side. I learned that its father had noticed it a 
 month before, and had touched it occasionally with a solution of 
 nitrate of silver, which he used for the mucous patches of the 
 other child, whose history precedes this. The mucous patches 
 of the baby sister were undoubtedly the source of the conta- 
 gion of the present child. 
 
 Upon examination I found that the metacarpal bone just 
 mentioned was greatly enlarged, and presented a perfectly oval 
 shape. At its middle it was about an inch and a quarter in 
 diameter, from which point it gradually shaded off on each 
 end, and at its articulation on each end there was scarcely any 
 enlargement perceptible. This bone, thus enlarged, completely 
 filled the triangular space which exists normally between it
 
 28 Syphilitic Lesions of the Osseous 
 
 and the metacarpal bone of the thumb. Upon the palmar sur- 
 face, the swelling was also quite perceptible, while upon the 
 dorsum of the hand the swelling stood saliently out. To the 
 most casual observation it was perfectly evident that the swelling 
 was accurately limited to the region of the second metacarpal 
 bone, for just beyond this region, on the portion of the back of the 
 hand where the third metacarpal bone was situated, a distinct 
 depression was seen in consequence of the abrupt shading off of 
 the tumor. On the palmar surface it was evident that the 
 swelling was distinctly localized in the second bone, and if the 
 child was told to flex the thumb towards the base of the little 
 finger, or if this was done for her, it was seen that in conse- 
 quence of the swelling she could not quite place the tip of her 
 thumb on that site, but that a space of half an inch intervened 
 between the two, whereas, on the left hand this movement was 
 very readily accomplished. To the touch it was quite evident 
 that the enlargement was confined exclusively to the bone, as 
 this structure could be defined in all its relations to the surround- 
 ing parts. The swelling was perfectly even on its surface and 
 the integument, which, though slightly stretched, was normal, 
 and could be slid very readily over any part of the swelling. 
 Upon manipulation pain was produced in this swelling, but the 
 child said she was very much troubled with pain at night, but 
 not during the day. 
 
 At the lower end of the left radius, just above the stylokl 
 process, was a swelling which encircled the bone, but which I 
 could define clearly as not involving the ulna. This swelling 
 was rounded and smooth on its surface, and was comparable to 
 a round ring having a width of about three quarters of an inch 
 and being about half an inch high. The swelling on the ulna 
 was npon the sides and posterior aspect of the olecranon pro- 
 cess ; it was a"bout the size of that on the radius, but it was ir- 
 regular on its surface. Both of these tumors were painful on 
 manipulation, and they rendered the child alert as to where she 
 placed her arms, and to avoid having them struck. 
 
 I ordered this child to take fifteen drops of a similar mixture 
 to that ordered for her sister, and at the end of a week her 
 pains had ceased and the parts could be manipulated more 
 freely, as they were less sensitive. On the 8th of July, having 
 taken the medicine regularly for a month, the size of the af-
 
 System in Infants and Young Children. 29 
 
 f ected metacarpal bone had diminished to nearly three-quarters 
 of an inch ; there was a corresponding diminution in the size 
 of the other. The dose of the mixture was then increased to 
 twenty drops three times a day, and I may here say that during 
 the whole period it was faithfully administered. In the early 
 part of September these bone-lesions had entirely disappeared. 
 I was not able to determine any difference in the size or shape 
 of either of the second metacarpal bones, and the radius and 
 ulna, which had been affected, were not perceptibly abnormal. 
 At the time this case and that of the sister whose history imme- 
 diately precedes it, were under my observation, I w r as struck with 
 the peculiarity of the almost simultaneous coincidence of the 
 development of osseous lesions in sisters, the one a victim of 
 hereditary, the other of acquired, syphilis. 
 
 CASE IX. James McE. came under my observation in Sep- 
 tember, 1870. His father had been under my care for about 
 fifteen months at the New York Dispensary, he having suffered 
 severely from syphilis during that time. The history of the 
 syphilis in the mother was quite clear, she having been infected 
 about a year previously. The child, which w r as the first, was 
 born early in July, appearing well at birth, but breaking out, 
 with a general rash when about two months old. On this point 
 I could not get positive information, but the mother thought 
 that the child did not have a rash until then. It had at that 
 time also snuffles, and was treated by my friend Dr. Grunhut, 
 one of the physicians for children's diseases at the New York 
 Dispensary. When first seen by me in September, the child 
 seemed quite well developed, having considerable fatty tissue 
 upon the body. It nursed from its mother's breast wholly, she 
 having an abundance of milk. There was no history of any 
 gastro-intestinal disorders, nor of any morbid symptom except 
 the snuffles, with which the child had suffered severely. It 
 had grown in weight during its life, and certainly looked well 
 nourished. The anterior fontanelle was not abnormally large, 
 and the others were closed. There were no soft spots or thinned 
 places on any of the cranial bones. My questions also elicited 
 the facts which follow. "When about two months old, the 
 mother observed that the bones of both forearms became swol- 
 len just above the wrists. Very shortlv afterwards the bones
 
 30 Syphilitic Lesions of the Osseous 
 
 of the legs swelled near the ankles, and a swelling was found 
 under the left knee. The swellings increased in size quite 
 rapidly for a mouth, at which time Dr. Grnnhut mentioned 
 the case to me, and transferred it to me for observation and 
 treatment. The child was three months old when first seen 
 by me. I found the distal ends of the radius and ulna much 
 enlarged, the swelling upon the bones reaching fully a half- 
 inch, and being about three-quarters of an inch long, and in- 
 volving all the sides of the bones. They appeared as if fused 
 together. The swellings on the ankles were as follows: the 
 right fibula was enlarged at its diaphyso-epiphysal junction, in 
 the form of a quite prominent swelling, which began abruptly 
 at the shaft, and ended, after attaining a height of over a 
 half-inch, by fusing into the epiphyses. The ends of the mal- 
 leoli were not enlarged. On the inner side the swelling seemed 
 to coapt closely with the tibia, which, however, was not at all 
 swollen. On the left tibia a precisely similarj but proportion- 
 ately larger swelling was found, while the fibula was normal. 
 Upon the upper part of the right tibia a quite large swelling 
 was seated. It began about at the apex of the tuberosity, and 
 could be traced around the bone from the fibula to its posterior 
 portion, where it was not perceptible to the touch. Its surface 
 was quite uneven, and its lower edge began abruptly, and it 
 ended by its upper part at the joint. It was much more clearly 
 defined if viewed when the leg was considerably flexed than 
 if it was extended. The ribs were normal, as also was every 
 other bone. I prescribed for it six drops thrice daily of the 
 mixture already spoken of, making no local application. The 
 child came regularly to me for a month, at which time I in- 
 creased its dose to ten drops. At this time, Oct. 15, there 
 was a decided diminution in the size of the swellings. I then 
 lost sight of the child until early in January, 1873, when I 
 sought it at its home. I found that the progress had been 
 very unfavorable in the ten weeks which had elapsed. Over 
 the swelling of the left radius I found an ulcer of a diame- 
 ter of half an inch and a depth of a quarter of an inch, with 
 very red undermined edges, a grayish sloughy base, and se- 
 creting a copious amount of unhealthy pus. If the edges 
 of the ulcer were moved with the tip of the finger, it could 
 be seen that they would slide over the bone to a slight ex-
 
 System in Infants and Young Children. 31 
 
 tent, and that the base was evidently seated upon the bone. 
 The skin for full}' three-quarters of an inch around was thick- 
 ened and of a dusky red color. I inferred from these facts 
 that the ulceration had been induced by degenerative changes 
 in the bone-swelling. I should add that this ulcer was seated 
 on the back of the wrist, and that it encroached slightly towards 
 the styloid process of the bone. On the right wrist, over the 
 radius, the integument was very much elevated, and from its 
 redness it appeared as if the seat of an abscess, and at its cen- 
 tre fluctuation was distinctly felt. On the outer side of right 
 ankle was an ulcer of the same general appearance as that on 
 the left arm, but it was somewhat larger in size. On inner 
 side of the right ankle a very minute ulcerated opening in the 
 integument was seen, from which a thin, gummy fluid could 
 be made to escape. As far as I could learn, the swellings had 
 increased in size about a month or six weeks previously, and 
 that they had formed the ulcers seen at this time. The treat- 
 ment had not been followed for two months. This was owing 
 to the intemperate habits of the mother. I opened the abscesses 
 on the radius and upon the tibia, and a quantity of thin pus 
 escaped. The general condition of the child was good. I 
 touched all of the ulcers with a very strong solution of carbolic 
 acid, and filled them with charpie saturated with the same. 
 Under this treatment the ulcers became much improved in a 
 week, as their sloughy appearance had passed away. I then 
 ordered that they should be thoroughly covered with iodoform 
 once a day, and then well protected with lint. The medicine 
 was resumed in ten-drop doses. Early in February the ulcers 
 were very superficial in character and of healthy appearance. 
 The bone-enlargements were somewhat smaller. The dose of 
 the mixture was increased to fifteen drops. The incisions 
 made in January enlarged and formed ulcers, which, owing to 
 treatment, did not assume the sloughy condition of the first 
 two. During February I found it necessary to touch the ulcers 
 lightly with stick nitrate of silver, as they became covered 
 with granulations when they approached the level of the in- 
 tegument. In March they were all thoroughly healed, leaving 
 slightly depressed red cicatrices, which at their centre were 
 adherent to the deep parts. At this time there was a decided 
 diminution in the size of the enlargement at the head of the
 
 32 Syphilitic Lesions of tlie Osseous 
 
 left tibia, and the other swellings were slightly less in size. 
 The medicine was given with tolerable regularity, averaging 
 perhaps two doses daily. It was well borne by the stomach. 
 At the end of April the swellings had all disappeared, and when 
 the diaphyso-epiphysal junctions were examined, the only 
 trace of them was a slight ridge of bone about one-quarter of 
 an inch in breadth. This was well marked on the upper part of 
 the tibia. During the month of March the child had several 
 condylomata lata on the margin of the anus. 
 
 CASE X. Emma N., aged seven weeks, was brought to me 
 by her mother, July 8, 1869, who stated that at birth the child 
 had no appearance of any skin disease upon its body, but that 
 when it was two weeks old it became hoarse, and was so much 
 troubled with the snuffles that its breathing was rendered diffi- 
 cult. She had also noticed that about the same time an erup- 
 tion began to appear on its body, and that very soon after that, 
 perhaps a week, she had observed that some of its bones began 
 to swell. At this time she called her husband's attention to 
 these troubles of the child, and he being mider my care for 
 syphilis at the New York Dispensary, mentioned them to me, and 
 I expressed a desire to see the child. 
 
 Upon examination I found that a very sanious and fetid dis- 
 charge issued from the nostrils, and that it had excoriated the- 
 upper lip. Upon the arms, trunk, and legs Ihere was a very 
 copious, small, flat, papular syphilide, the eruption being great- 
 est on the trunk and forearms. On the latter site it showed a 
 decided tendency to form circles and segments of circles, a fea- 
 ture which I had never until then observed in the papular 
 eruptions of hereditary syphilis. There were well-marked con- 
 dylomata lata around arms and vulva, but the mouth was free 
 from lesions. The child was not very much darker than a white 
 child, and its mother, a mulatto, was quite white. It was well 
 nourished, and its muscles, which were quite well developed, 
 "were covered with considerable adipose tissue. Upon the shafts 
 < d: the bones I found some very peculiar lesions. The sternal end 
 'f the right clavicle was very much enlarged, beginning at the 
 point which corresponds with the junction of the diaphysis 
 \vith the epiphysis. The swelling began here quite abruptly, 
 avid attaining a height of rather more than half an inch, it ended
 
 System in Infants and Young Children. 33 
 
 quite abruptly at the joint which examination showed to be 
 unaffected. The swelling was perceptible to eye and touch, 
 jutting out slightly beyond the chest-walls and upwards towards 
 the neck. It was very clearly defined when the mother held 
 the child on her lap horizontally, and then let the head fall back 
 without any support. This stretched the sterno-cleido mastoid 
 muscle backwards, and the integument quite firmly over the 
 tumor. The latter structure was normal. At the junction of 
 the second and fourth ribs of the right side with the cartilages, 
 were two quite similar enlargements, though somewhat smaller, 
 being rather less than half an inch in height. The surfaces of 
 these swellings were smooth and did not adhere to the integu- 
 ment. Two precisely similar swellings were found on the left side, 
 involving the second and third ribs. At the lower end of the 
 left humerus was a large irregular swelling which expanded 
 the bone laterally to a transverse diameter of full two inches, 
 and which bulged out posteriorly in a markedly perceptible man- 
 ner. Just over each condyle the swelling spread out, forming 
 quite a distortion of the bone, and involving it along the condy- 
 loid ridge for a space of three-quarters of an inch. The swell- 
 ing was also developed on each side of the olecranon process, 
 and complete extension of the arm could not be produced, and 
 it remained continually in a semi-flexed position. There was 
 evidently a small quantity of serum in the joint, as two puffy 
 swellings were found just above the olecranon. The integu- 
 ment, which was not at all adherent, was slightly reddened, and 
 was perceptibly elevated in temperature. The joint was evi- 
 dently painful, as the child shrank from its manipulation. At 
 the distal end of the right radius and ulna, a perfectly smooth 
 enlargement of the bones was noticed, which extended up their 
 shaft fully two inches. The ends of the bones seemed as if 
 welded together. The same condition was observed in the 
 other arm also. At the lower end of the left tibia and fibula 
 was a similar smooth enlargement, but in this instance the 
 swelling was very much greater and the deformity was very 
 apparent, resembling somewhat a dislocation of the two bones 
 forwards on the tarsal bones. Upon careful palpation, I dis- 
 covered a soft fluctuating spot in the centre of this swelling on 
 each side, which corresponded to a point an inch and a half above 
 the ends of each malleolus. The soft fluctuating sensation 
 3
 
 34 Syphilitic Lesions of the Osseous 
 
 was found quite generally over the surface of the tumor, though 
 less so than at the centre. It seemed to follow a line all around 
 the two bones corresponding to a point just an inch and a half 
 above the malleoli, which was the most prominent part of the 
 swelling. Upon further manipulation I discovered that these 
 lower segments of the two bones were detached from the shaft. 
 They could be moved quite considerably in each lateral direc- 
 tion, but I could not assure myself that an autero-posterior 
 motion was produced, owing to the movements of the joint. 
 The lateral motions were attended with soft but distinct cre- 
 pitation. I used traction on the parts, but I did not satisfy 
 myself that any separation was produced between the upper and 
 lower segments of the lx>nes ; the joint-structures seemed to 
 yield, and thus I was unable to localize the point of separation. 
 The upper part of this swelling did not begin abruptly, but it 
 arose gradually from the shaft fully two inches and a half above 
 the malleoli, and became prominently swollen at two inches, as 
 just now stated. In the upper portion the periosteum was evi- 
 dently thickened. There was considerable tenderness of the 
 parts, as the child cried if they were manipulated. The integu- 
 ment, though stretched, was not involved, nor was it the seat 
 of perceptible preternatural heat. 
 
 Upon the right leg a very similar but much larger swelling 
 was found, but in its centre the fluctuation was more distinct, 
 the artificial movements in the various directions were more 
 freely accomplished, and the crepitation was equally as distinct. 
 On the inner ankle it was evident that the integument was in- 
 volved, for it presented for a space of the size of a silver half- 
 dollar a brawny sensation, was there quite hot to the touch, and 
 was not freely movable over the bony tumor beneath. As this 
 thickened and inflamed part gradually shaded off into normal 
 integument all around it, it was plain that suppuration had com- 
 menced in the deep connective tissue. The mother informed 
 me that the swellings had come on during the previous month, 
 but that she had noticed that those of the leg had increased in 
 
 o 
 
 a very marked manner during the preceding fortnight. Her 
 attention had also been attracted towards a seeming inability 
 of the child to move its feet and legs, and that it did not show a 
 die-position to draw them up. When seen by me the legs 
 lay stretched out as if paralyzed, and the two feet turned in
 
 System in Infants and Young Children. 35 
 
 towards one another, and if they were everted they immediately 
 fell inwards as soon as they were released from the grasp. 
 This position of the feet is noticed in the normal condition to a 
 certain extent, but in this instance it was observed in an extreme 
 degree. If the soles of the feet were tickled, or if the integu- 
 ment of them was pinched with a pair of forceps, a very slight 
 jerking motion was produced, which, however, was localized in 
 the thighs, and was not communicated to the muscles passing 
 from the leg to the feet. As far as I could ascertain by very 
 careful examination and observation, the inability to move the 
 limbs and their apparent obtnsenessto peripheral irritation, were 
 equal on both. With the exceptions of the bones spoken of, all 
 the others were to all appearances normal. The cranium was 
 normal in every particular. When first seen at this time, I 
 was rather puzzled with the appearance of the osseous lesions, 
 as I knew nothing then about these swellings at the epiphyses 
 as being of syphilitic origin. I ran over in my mind the osseous 
 lesions of rickets, but could not satisfy myself that the case was 
 one of that disease. On consulting authorities I could only 
 find the reports of the cases of Roger and Fournier, which were 
 in a slight degree similar, and upon conversing with friends 
 who had large experience I could gain no information. How- 
 ever, knowing the undoubted syphilitic history of the child and 
 of its parents, I concluded that all of the lesions resulted from 
 syphilis, and placed it upon an appropriate treatment. In 
 the course of subsequent reading I found Valleix's case, record- 
 ed in Bouchut's treatise on diseases of children, which presented 
 almost similar features, and then I felt certain of my ground. 
 The somewhat unusual character of the case led me to follow 
 it with much attention and care. The mother was directed to 
 give the child a powder containing one grain of hydrargyrum 
 cum creta three times a day. The nose was to be treated 
 locally. In a week the child was again brought to me, and 1 
 found that the cutaneous lesions were somewhat less distinct, 
 and that the coryza was benefited. The osseous lesions on the 
 legs were not at all improved, the swellings were even greater, 
 I thought. That of the left leg was larger in size, it having 
 grown more perceptibly, but the integument was not involved, 
 whereas the integument over the other tumor on the right 
 leg at the spot indicated was evidently undermined with
 
 86 Syphilitic Lesions of tlie Osseous 
 
 pus. I therefore made an incision into the thinnest part of the 
 skin, and a quantity of thick pus escaped, which, after the parts 
 were moved slightly, was followed by a tenacious secretion, 
 viscid in character, yellow or brownish in color, and of the con- 
 sistence of mucilage of gum arabic diluted with an equal 
 quantity of water. This fluid was examined with the micro- 
 scope, and found to consist of granular matter and a few my- 
 eloplaxes. After the evacuation of the contents of the abscess I 
 again examined the parts carefully. The separation of the 
 epiphyses from the shafts of the two bones could be very 
 distinctly made out, and movements could be produced in both 
 lateral and antero-posterior directions. The crepitation was 
 very distinct, but of a soft character. 
 
 In order to preserve the parts, as far as possible, from fur- 
 ther inflammation and destruction, I rendered the joint im- 
 movable by strapping it well with strips of adhesive plaster, 
 leaving an opening corresponding with the orifice of the ab- 
 scess, into which 1 placed a tampon of lint, saturated with bal- 
 sam of Peru. I then bandaged in like manner the other leg, 
 with a view of preventing disorganization, and perhaps of re- 
 solution and absorption by pressure and rest. The elbow-joint 
 was covered with lint saturated in a cooling lotion. At this time 
 I ordered that the child should take three grains of iodide of po- 
 tassium three times daily, an hour after each powder. This treat- 
 ment was followed without any alteration for a fortnight, at the 
 end of which time the lesions of the skin had almost disappeared, 
 and the coryza was less troublesome. The bandages on the 
 legs having become loosened, I applied others. The discharge 
 from the right ankle had been quite profuse for some days 
 after the operation, but had then become less, and was serous 
 in character. The sinus was dressed as before, and directions 
 were given to change the lint twice daily. There was a quite 
 noticeable feature observed in this sinus ; it had not grown 
 much larger, and showed no tendency whatever to ulcerate ; 
 around its orifice it had become slightly thickened, resembling 
 somewhat the sinuses following suppuration of cervical glands. 
 At this time, the child, being ten weeks old, and having been 
 under treatment three weeks, was placed upon increased doses, 
 the iodide in four-grain doses, and the hydrargyrum cum creta 
 two grains three times daily. Nothing unusual was noticed
 
 System in Infants and Young Children. 37 
 
 for four weeks longer, at which time, it being the seventh week 
 of treatment, a very marked diminution was found in the size 
 of the swellings on the clavicle, on the ribs, and on the humerus, 
 and the effusion into the joint had been absorbed. This latter 
 effect had been accomplished simply by rest and the applica- 
 tion of a cooling lotion. There was also a marked diminution 
 in the size of the swelling of the left ankle, and the epiphysib 
 seemed firmly adherent and continuous with the shaft, and it 
 could be distinctly felt that the consolidation was complete, as 
 no unnatural movements could be produced. The treatment 
 was followed up with tolerable regularity until November, 
 when the following condition was found : The bones of the 
 forearms, arm, and the ribs were apparently of their natural 
 size, but just at the junction of each shaft with the epiphysis 
 and of the ribs with their cartilages a slight unevenness of the 
 surfaces was felt. They had been in this condition fully two 
 weeks. The left ankle was also nearly normal, there only be- 
 ing a slight ridge of bone felt, running transversely around the 
 bones. This ridge, which was about a line in area, and of the 
 same height, was somewhat larger in this situation than those 
 were on the other bones. There was no evidence of periosteal 
 swelling upon the shaft, as had been noticed in July. Upon 
 the right ankle, on the spot corresponding to the sinus, which 
 had closed in the latter part of September, was a small, some- 
 what star-shaped, irregular fibrous cicatrix, of a rosy-red color, 
 and adherent, but not very firmly, to the bone beneath. During 
 the past month spontaneous movements had been noticed to 
 take place in the legs, and I found that there was scarcely any 
 abnormal turning in of the toes, and that, if the feet were tickled 
 or pinched, they were quite spasmodically pulled up, and with 
 considerable force. During the summer the child had lived in 
 the country, and had grown stouter. At this time the only 
 progressing lesion of syphilis was a mucous patch in the mouth. 
 Early in 1870 I saw this child again, and then I found that the 
 ridges of bone already described had become almost effaced, 
 wholly so on the arms, forearms, and ribs, and that they were ex- 
 tremely slight on the legs. There was only a slight undulation 
 of the surface, just at the junction of the epiphyses with the di- 
 aphyses. 
 
 The history of the father was, that he became syphilitic about
 
 38 Syphilitic Lesions of the Osseous 
 
 two months before his marriage, having a chancre and rheu- 
 matoid pains. He also had lesions of the mucous membranes 
 and a papular syphilide, having a decided tendency to epider- 
 mal proliferation. 
 
 The mother was married three months before she noticed 
 any rash on her body, and then she suffered severely from con- 
 dylomata, and alopecia was observed on the scalp and in the 
 eyebrows. The child was born a year after marriage, conse- 
 quently she became pregnant and syphilitic about the same 
 time. She expressed her opinion that the child had been born 
 two weeks prematurely. She had not been actively treated, 
 having taken medicine only during the sixth and seventh months 
 of pregnancy. 
 
 CASE XL The mother of the child whose history follows 
 presented well-marked syphilitic symptoms. Her name is Kate 
 HcM., and she was a person who. though not robust, enjoyed 
 good health, and was moderately stout. She was married on 
 the 25th of August, 1872, being then in her seventeenth year. 
 Two months afterwards she had ulcers upon the genitals, and 
 in November she applied for treatment at the Woman's Medi- 
 cal College of the New York Infirmary. At this time she pre- 
 sented a general roseolous syphilide, mucous patches, and she 
 complained of rheumatoid pains. Her condition was the subject 
 of a clinical lecture by me upon two occasions. She was placed 
 upon a proper mercurial treatment, which she was urged to 
 follow carefully and faithfully. Her attendance, however, was 
 very irregular, and she probably did not undergo the influence 
 of mercury for more than a month ; consequently her syphilis, 
 it is fair to assume, was not properly modified, and she might 
 almost be considered as a patient who had not been treated. 
 
 In April, 1873, she became pregnant, and early in January, 
 1874, she gave birth to a male child. Prior to and during her 
 pregnancy she had enjoyed fair health, and had not presented 
 any severe lesion of syphilis. 
 
 On the 17th of February she brought her baby to the college, 
 and stated that it was then six weeks old ; that when it was two 
 weeks old she had noticed a swelling of the right ankle, which 
 increased, became red, and that an opening appeared in it which 
 discharged some pus. Upon examination, I found the following
 
 System in Infants and Young Children. 39 
 
 appearances : The affected ankle, just over the ends of the 
 inalleoli, measured four and a half inches, which was an increase 
 of three-quarters of an inch over that of its fellow of the left 
 side. On the inner aspect, an inch above the end of the malleo- 
 lus, there was a small opening, from which a small quantity of 
 thin pus flowed. The integument, in the shape of a band encir- 
 cling and including the ankle from the end of the rnalleoli to a 
 distance of two inches above, was slightly hypersemic, this con- 
 dition not being great anywhere, but being comparatively great- 
 est just around the opening. The enlargement was quite per- 
 ceptible, and it was also noticed that the leg was abnormally bent, 
 though in a slight degree inwards, so that the bones of the 
 leg were bow-shaped, the convexity looking outwards. This 
 appearance may be noticed to a slight degree in nearly every 
 young child, consequently it must be carefully examined in every 
 case before being pronounced to be abnormal. In this instance, 
 the comparison between it and the other unaffected leg was 
 well marked. This feature was also clearly made out by my 
 clinical assistant as well as several students. It was also observa- 
 ble that the child had very little if any power of using the limb, 
 and its motionless condition contrasted markedly with the ac- 
 tive alternate flexion and extension of its fellow. When ex- 
 amined, it was found that the epiphyses of the tibia and fibula 
 were slightly enlarged, that the integument over them was not 
 at all adherent even at the orifice of the sinus, and that there 
 was no perceptible preternatural heat. Manipulation gave the 
 child pain, as it cried piteously, though it had very little power 
 to pull away the leg. The flexed appearance struck me as be- 
 ing peculiar, and a suspicion occurred to me that a false point of 
 motion existed between the epiphyses and the shafts. Holding 
 the epiphysal extremity firmly with one hand, and grasping the 
 leg in a like manner with the other, I was able with very little 
 force to move the two separated segments, the one upon the other, 
 in a lateral direction. We carefully listened for crepitation, but 
 it was not heard, nor was a grating sensation communicated 
 to my hands ; indeed, it seemed to me as if two soft substances 
 were rubbed very slightly the one over the other. It is Avell to 
 remark that the movement by lateral displacement of these seg- 
 ments was very much limited indeed, and I should think that I 
 moved the outer edge of the epiphysis perhaps one-quarter or one-
 
 40 Syphilitic Lesions of the Osseous 
 
 sixth of an inch beyond the corresponding edge of the shaft. 
 At the same time, it was clearly perceptible to me that very con- 
 siderable bending conld be produced here, and that snch a 
 motion was very readily induced ; but owing to the extreme 
 suffering of the child I did not push the examination further. 
 My reflection, after examining this case, was to the effect that 
 in it the lateral forced displacement was quite limited, much 
 less so than that which I observed some years previously in the 
 preceding case ; and that flexion was the principal motion ob- 
 tainable, and that perhaps cases may be observed in which the 
 former motion may not be obtained, while the latter can be 
 clearly performed. My explanation was that the intervening 
 cartilage between the epiphyses and the diaphyses had not been 
 to a very great extent destroyed, and that as a result the motion 
 was limited. When the epiphysal region w r as carefully drawn 
 outwards, the leg being held in a normal position, it was readily 
 seen that the normal axes of the bones were restored. Upon 
 examination of the other portions of the osseous system, every 
 bone was thought to be normal except the distal end of the 
 left radius and nlna, the epiphyses of which, just as they 
 merged from the diaphyses, were found to be very slightly 
 enlarged, the difference in circumference between the corre- 
 sponding parts left and right being about one-third of an inch. 
 Besides these osseous lesions, the whole integumentary surface 
 was the seat of a roseolous and papular syphilide. The internal 
 treatment consisted in five-drop doses of the mixture already 
 spoken of. The leg was placed in its normal condition, and its 
 malleolar extremity was carefully but firmly bandaged with 
 strips of adhesive plaster, an opening being left over the sinus. 
 The child remained under treatment for a month, in which 
 time much improvement was produced in the osseous affection, 
 so that there was very little, if any, tendency to abnormal 
 flexion ; and there was an evident soldering together of the 
 detached segments. The cutaneous syphilides were improved. 
 The child was not brought again to the college, as its mother 
 regarded it as cured. I have just learned that it was suddenly 
 attacked with an affection of the brain, of which it very soon 
 died, and which was called by the family attendant acute 
 hydrocephalns. It is very probable that if the mother had 
 continued her visits to the clinic regularly, and had faithfully
 
 System in Infants and Young Children. 41 
 
 followed our treatment, which would have been gradually 
 increased in strength, that her child would not have succumbed 
 to the pachy-meningitis, of which undoubtedly it died, and 
 which, to my mind, was of syphilitic origin. I was informed 
 by the mother that the family physician did not regard the 
 osseous lesions as being induced by syphilis. An interesting 
 point in this case is the comparative immunity from inflam- 
 mation which the integument presented, even though the seat 
 of a copious syphilitic eruption. Without any treatment except 
 pressure the sinus closed, and a very minute cicatrix was left. 
 It is a noticeable fact, and one of diagnostic import, that such 
 grave changes should take place in a limb, and that so little, if 
 any, constitutional reaction should be induced. This point will 
 be brought out again further on. 
 
 CASE XII. Through the kindness of Dr. H. T. Hanks, I had 
 the opportunity in May, 1871, of observing a very interesting 
 case of enlargement of several of the phalanges of the fingers. 
 The patient was a child ten weeks old, born of a mother, who, 
 upon examination, I found to have been infected with syphi- 
 lis within a year. This child had enlargements of the first 
 phalanges of the index and ring fingers of the right hand, and 
 of the same phalanx index finger of the left hand. The lesions 
 of these bones had been noticed when the child was a little 
 more than a month old. The swellings consisted in a general 
 enlargement to about three times the normal diameter of the 
 phalanges ; and they caused considerable tension of the inte- 
 gument, and in one finger much hypersemia was observed. The 
 swelled ring-finger displaced the fingers on each side very 
 much, while the two enlarged indices were turned inwards, but 
 did not push very much out of its line of direction the middle 
 finger on either side. The affected fingers were very much 
 flexed, and at their base being thick and bulbous, they gradu- 
 ally tapered off towards the ungual extremity in such a man- 
 ner as to lead to the impression that the second phalanges were 
 also enlarged. Careful manipulation and deep pressure showed 
 very conclusively that these bones were unaffected. The swell- 
 ings were alike observable on the palmar and dorsal surfaces ; 
 and though they rendered the fingers unwieldy, they could be 
 flexed and extended very considerably by a second person. It
 
 42 Syphilitic Lesions of the Osseous 
 
 seemed evident to my mind at the time, that, unless treatment 
 was early instituted, ulceration of the integument was inevitable 
 in one finger. The lesion was due to stasis from pressure 
 within, and not to gummy deposit. This case was sent to the 
 College of Physicians and Surgeons, and, at Dr. Draper's 
 request (he being unavoidably absent), I made it the subject of 
 a clinical lecture. I saw the child but once. 
 
 m. RESUME OF CASES OF THE VARIOUS OBSERVERS. 
 
 M. Roger ' observed a case of acquired infantile syphilis, in a 
 child two years old, who besides having syphilitic lesions of the 
 skin and mucous membranes, presented enlargements of the in- 
 ferior extremity and internal borders of both humeri, enlarge- 
 ment of the anterior surface of the head of the tibia, and nodes 
 on the frontal bone. This is one of the very few recorded cases 
 of the development of osseous lesion in the early stage of ac- 
 quired syphilis of a young child. It may be classed with my 
 case No. 8. It is to be regretted that the date of contagion is 
 not given, as from it we could have ascertained the date of ap- 
 parition of the bone trouble. The case also is wanting in the 
 detail of treatment, course and result. 
 
 Dr. T. Curtis Smith* reports the case of a child, born of syphi- 
 litic parents, upon whom when three weeks old various syphilitic 
 lesions appeared. When first seen by Dr. Smith it was six 
 weeks old, and he found that the first phalanx of the index, 
 middle, and ring fingers of one hand were much enlarged. 
 The swelling of the bones was greatest at the joints, which, 
 however, were not involved, and from there it tapered off ra- 
 pidly towards the next joint, which was also normal. The integu- 
 ment was livid. The joints were not freely movable. The fingers 
 were evidently the seat of mild spontaneous pain, but gentle 
 manipulation could be practised. Under a mercurial treat- 
 ment the enlarged bones were reduced to their normal size in 
 three and a half mouths. Both parents were syphilitic, the hus- 
 band having contracted the disease two years before and having 
 been improperly treated, the mother being contaminated shortly 
 after and not being treated until after the birth of the child. 
 
 1 L 1 Union Medicate, page 249. Paris, 18(55. 
 
 * A Case of Congenital iTactylitis Syphilitica. American Journal of Syphi- 
 lography and Dermatology, Jan., 1872, page 33.
 
 System in Infants and Young Children. 43 
 
 Fournier s * cases are as follows : 
 
 An infant, three months old, having papular syphilides, mu- 
 cous patches, and coryza, had a swelling of the lower end of the 
 right humerus, which was greatest at its internal border. 
 
 Case second : a child, three months old, having a pustular and 
 papular syphilide and coryza, had an enlargement of the upper 
 portions of the radius and ulna. The ulna was double its size 
 at its upper fourth, and the head of the radius was as large as a 
 nut. 
 
 Bertiu,' in his treatise, says that he has seen cases of perios- 
 titis and exostoses in syphilitic children, and then reports the 
 following: 
 
 Pierre S., thirty-six days old, was brought to the Maternity 
 Hospital, on the first of January, 1809, having blennorrhagic 
 ophthalmia and pustules and tubercles of the whole body, and a 
 tumor of the size of a pigeon's egg over the left great trochan- 
 ter, and a periostitis of considerable extent upon the upper and 
 posterior portion of the ulna. The movements of the arm 
 were impaired, and there was redness of the skin over the 
 tumor, and pain existed. The bone lesions and cutaneous 
 rashes disappeared under a mercurial course alone, in five 
 months. 
 
 Archambault," of Paris, reported a case of an infant, whose 
 mother had tertiary syphilis, and who had mucous patches and 
 an enlargement of the last phalanges of the fingers. Being at 
 first regarded as false spina ventoza, it was unsuccessfully 
 treated with anti-strumons remedies ; but when mercury was 
 given the mucous patches soon disappeared, and the bones were 
 reduced to their normal size. 
 
 Barensprung's 4 case was that of a child, born of a syphilitic 
 mother, who, having had tubercles which underwent ulceration 
 on various parts of the body, especially on the head, died of ex- 
 haustion when four months old. At the autopsy the left 
 parietal bone was found to be the seat of considerable necrosis, 
 the morbid processes having involved the periosteum and the 
 
 v I? Union Medicals, page 540. Paris, 1865. 
 
 8 Traite de la Maladie Venerienne chez les enfants nouveau lie's, les f emmes 
 enceintes et les nourrices. Paris, 181 0. Page 361 . 
 
 * I! Union M'dicale, No. 140, 1869, and American Journal of SyphUogra- 
 vhy and Dermatology, Jan., 1871, page 14. 
 
 4 Die hereditare SypMis, pages 126-7, 8. Berlin, 1864.
 
 44 Syphilitic Lesions of the Osseous 
 
 outer lamella of bone. The' case is very badly reported, but well 
 illustrated by chroi no-lithography. 
 
 The same observer speaks of a case in which changes in the 
 bones were observed at the junction of the shaft with the epi- 
 physis at the lower end of the right and at the upper end of the 
 left femora. 
 
 In a third ' case mentioned, a swelling was found upon the 
 sternal end of the clavicle in a child three weeks old. 
 
 Putegnat 4 reports a case of a child, the subject of hereditary 
 syphilis from a half month old, who had a swelling of the 
 upper part of the right thigh, which was followed by an abscess 
 and dislocation of the femur. The bone-lesion was considered 
 by the observer as an instance of the development of rickets in 
 a syphilitic subject. This author also says he has seen a cranial 
 exostosis on a syphilitic infant. 
 
 Bulkley's * cases are two in number, and through his kindness 
 I have had ample opportunities for observation of them, and I 
 quote them nearly in full : 
 
 CASE I. A rather delicate girl ; was first seen when two 
 years and nine months old. Though the early history of 
 syphilis is not clearly made out, the existence of traces of an 
 early interstitial keratitis and the peculiar bone-lesions point 
 to that disease as being undoubtedly their true origin. When 
 fifteen months old, a swelling began on the top of the left ankle, 
 which softened and opened in two months. A similar swelling 
 appeared, two months later, on the outer side of right foot, and 
 it softened and opened in two months. About the same time 
 that is, when the child was fifteen months old the first 
 phalanges of the thumb and index finger of the left hand 
 swelled, and shortly after softened and opened. When the 
 child was a year and nine months old, the right metacarpal 
 bone of the index finger swelled and opened. The pain was so 
 severe in the affected parts that the child's rest was disturbed. 
 When first seen by Bulkley, the child was two years and nine 
 months old ; consequently some of the bone-lesions had existed 
 
 1 Ibid., page 192. 
 
 * Histoire et therapeutique de la syphilis des nouveau nes et des enfants a 
 la mamelle. Paris. 1854. 
 
 1 Rare Cases of Congenital Syphilis. New York MedicalJoumal, May, 1874.
 
 System in Infants and Young Children. 45 
 
 eighteen months the others a year. The affected phalanx of 
 the left forefinger measured two and five-eighth inches its 
 fellow of the right hand measuring one and a half inches. 
 The circumference of the first phalanx of the left thumb mea- 
 sured two and three-eighth inches its analogue measuring 
 about one and five-eighth inches. The swellings were greatest 
 at the affected phalanges, and tapered off to the ends of the 
 fingers. The joints were unaffected. There was an ulcer over 
 each phalanx which extended down to the bone, and a discharge 
 came from each. Upon the right hand there was an ulcer over 
 the middle of the second metacarpal bone, which was swollen 
 in its whole length. The whole of the left foot was moderately 
 swollen, but it was evident that the fourth and fifth metatarsal 
 bones were enlarged. Over these bones was an excavated 
 ulcer, and around it an infiltration and redness of the inte- 
 gument. Upon the outer malleolus there was an excavated ulcer, 
 and upon the middle of the leg a scar of a former ulceration. 
 The following mixture was ordered: $ hyd. bichlor. gr. ss., 
 pot. iod. 3 i, ferri ammon. cit. 3 ss, syr. pruni iv; dose, one 
 teaspoonful three times a day. Simple cerate was ordered for 
 the ulcers. Under this treatment much improvement was 
 observed in a month, as the ulcers on the feet were healed. There 
 was also no discharge from the finger or thumb. The swellings 
 remained the same. In a fortnight after, although a marked 
 improvement of the general health had taken place, it was 
 noticed that the swellings on the thumb and forefinger were 
 slightly increased in size. From the 28th of April, 1873, the 
 treatment was very irregularly followed, and during the greater 
 part of the time neglected; but in January, 1874, a slight 
 diminution in the size of the affected bones was found. There 
 was a marked distortion observed in the thumb ; it was, though 
 thickened, shorter than normal, and bent inwards towards the 
 forefinger, which was slightly flexed. The metacarpal bones 
 were enlarged. All of the bone-swellings seemed indolent. 
 
 The second case was that of a child of a mother in the second 
 year of her syphilis. Shortly after birth it developed well- 
 marked syphilitic lesions, and at the same time a swelling was 
 noticed in the first phalanx of the thumb ; the bone was en- 
 larged to fully twice its natural size. The case was seen by 
 Bulkley when a month old, and was placed ut)on treatment.
 
 46 Syphilitic Lesions of the Osseous 
 
 The swelling gradually subsided, and in seven months was no 
 longer noticeable, but it was observed that the affected phalanx 
 was about one-twelfth of an inch shorter than its fellow, conse- 
 quently the thumb was shortened. As there was nothing ab- 
 normal in its shape, it is probable that the shortening is due to 
 an arrest in development during the existence of the lesion. 
 
 Mr. John Morgan : mentions the case of a child three years 
 old, whose history of hereditary syphilis was clear, who had a 
 very large swelling of the metacarpal bone of the thumb, which 
 was perfectly globular in shape, and presented the appearance 
 as if the thumb had been thrust through a ball of tightly 
 stretched skin. Suppuration occurred, leaving a thickened 
 condition of the parts. The case is rendered almost valueless 
 by the fact that the date of invasion and history of the course 
 of the lesion are not given. The case is similar to my eighth 
 case. The same observer" presented casts of several specimens 
 of what he regarded as dactylitis syphilitica to the Dublin 
 Obstetrical Society, but the descriptions given are so vague and 
 meagre that the cases are worthless for scientific purposes. In 
 the discussion upon them the author's diagnosis was called 
 into question. 
 
 RanvierV case was related before the Society of Biology in 
 June, 1864. 
 
 D. Z., a seamstress, eighteen years of age, of lymphatic tem- 
 perament and delicate constitution, was admitted to Lourcine 
 Hospital, service of M. Simonet, January 19, 1864. She is 
 pregnant six months. Has mucous patches on vulva and anus, 
 adenopathies, roseola and angina. She was not treated other 
 than by local applications. On the 16th of March she was de- 
 livered of a child in her eighth month of pregnancy. The 
 child was thin, but did not present any signs of syphilis. The 
 mother nursed it, and neither received treatment. On the 10th 
 of April an ulcer was found upon the left olecranon, which was 
 two-fifths of an inch in diameter, having a sloughy gray base, 
 and edges thick, sharply cut and undermined. The Sisters of 
 Charity stated that a week after its birth they noticed a tumor, 
 which was regarded as a furuncle, and which opened and 
 
 1 Practical Lessons in the Contagious Diseases, page 235. London, 1872. 
 
 a Dublin Medical Journal, April, 1873, page 35-1 et seq. 
 
 3 Gazette Medicale de Paris, vol. xix. , third series, page 596. 1 864.
 
 System in Infants and Young Children, 47 
 
 formed this ulcer, which was considered by MM. Verueuil and 
 Simonet as a degenerated gamma. There was a slight papular 
 syphili'de of the body. It became emaciated and died on the 
 13th of April. 
 
 Autopsy. Liver tolerably yellow, augmented in volume, two 
 small pale tumors on under surface, one on the upper. The 
 substance of the liver was hardened, and minute points were 
 seen, which consisted of connective tissue and young cells. 
 This same condition was observed around the various vessels 
 and ducts. Other organs not markedly altered. 
 
 o v 
 
 Condition of the JBones. All the epiphyses are separated 
 from the diaphyses, or so slightly adherent that the mildest 
 traction separates them. On a longitudinal section correspond- 
 ing to the long axis of the bone, the following points are ob- 
 served : The proliferation of cartilage is perfectly normal in 
 the portion called by M. Broca couche clwndroide. The car- 
 tilage-cells are spread out as usual in the osseous areolas or 
 spaces. But ossification is tardy, and it is only one-fifth of an 
 inch beyond the limit of apparent ossification that we find osse- 
 ous cells, whilst normally they are found at the most one mil- 
 limetre from this line. The author alludes to the fact that if 
 treatment is adopted the child is either cured or ameliorated, 
 while if not treated, syphilis runs its course. He thinks that 
 this observation supports the view that pregnancy retards the 
 evolution of syphilis in the mother, and that after that process 
 it breaks out again. 
 
 Bargioni's ' case occurred in the service of Professor E. 
 Pellizzari, in the hospital of Santa Maria Nuova, in Florence. 
 At the time it was under observation it attracted considerable 
 attention and discussion, from the fact that it was said to be an 
 instance in which syphilis was communicated together with 
 small-pox in the process of gestation. The reasons for the sus- 
 picions of the latter disease were, that it was raging in the part 
 of the country in which its mother lived, and that four papules 
 on its buttocks resembled those of variola. Its mother had 
 variola some years before. The truth seems to be clear to me, 
 from a perusal of the case, that it was simply one of hereditary 
 
 1 Ascesso articolare e gomme delle ossa e dei polmoni in neonato affetto da 
 eyphilide con eruzioni vajalosa congenita. Lo Sperimentale, page 65, torn, 
 xiv. July, 1864.
 
 48 Syphilitic Lesions of the Osseous 
 
 syphilis, and that some of its pustules resembled those of 
 variola, a feature sometimes observed even in acquired 
 syphilis. The mother was not discovered to be syphilitic, but 
 she stated that the child's father had syphilis before their mar- 
 riage. The lesions on the integument of the child were unmis- 
 takably syphilitic. They consisted of pustules and bullae, well 
 marked on palms, and soles, and onychia ; the mucous mem- 
 branes were also affected, there being a mucous patch in the 
 mouth, and the child suffered severely from snuffles. Its facies 
 was of the peculiar senile expression of syphilitic children. 
 The child gradually became weak, refused food, became ema- 
 ciated, and died when twenty-two days old. 
 
 The autopsy was made thirty-two hours after death. In the 
 head a yellowish mass was found between the dura mater and 
 frontal bone. Under the microscope, it was found to consist of 
 degenerated fat, pus-cells, and of connective tissue. In the 
 lower portion of each lung little masses of induration were 
 present. 
 
 Osseous System. In the right elbow-joint was a quantity of 
 thick yellow pus ; the cartilages were eroded and articular 
 surfaces partly denuded. In the long bones, at the junction of 
 the epiphysis and diaphysis, a mass of yellow, grumous matter 
 is seen, and the parts are very easily separated. This material 
 was infiltrated into the substance of the shaft of the bone, and 
 it contained small portions of necrosed bone. The microscope 
 showed this matter to consist of pus-cells and fatty detritus, 
 whilst in other parts nucleated fusiform cells were found in the 
 granular matrix. 
 
 VALEIX'S CASE. * A female foundling, born September 5th, 
 1834, was found to have, on the 14th of the same month, 
 a few small pustules, containing a drop of white pus, and sur- 
 rounded by tolerably red areola. On the 15th, when the child 
 was ten days old, it was observed that it could not move its right 
 arm that it cried if it was moved, and presented an anxious 
 appearance of countenance. On the 26th, the child being three 
 weeks old, a tumor in which fluctuation was distinctly felt, 
 which occupied and entirely surrounded the right radius, was 
 
 1 Bulletin de la Societe (TAnatomie, tome ix., page 169. Paris, 1834.
 
 System in Infants and Young Children. 49 
 
 discovered. Examination was painful, and the child kept the 
 hands and fingers semi-flexed. The next day a similar pain- 
 ful and fluctuating tumor appeared upon the upper third of the 
 left humerus, which apparently involved the joint, and in 
 elevating the deltoid caused a considerable projection of the 
 shoulder. Pain was present and an inability to move the 
 limbs. The child cried if they were moved. When twenty- 
 three days old, it died of diarrhoea and exhaustion. 
 
 Autopsy. The tumor at the shoulder, which had displaced 
 vessels, nerves, the deltoid, and other muscles, contained about 
 an ounce of thin, inodorous pus, which was contained in a 
 cavity formed on each end by the detached surfaces of the 
 epiphysis, and of the diaphysis of the humerus, while the la- 
 teral walls were composed of the periosteum, which was trans- 
 parent and adherent to the surrounding connective tissue. The 
 ends of the epiphysis and diaphysis presented a red and rough- 
 ened appearance, and were bathed with the pus of the cavity. 
 At the end of the shaft spongy bone-tissue was seen. The 
 periosteum was normal in its relations elsewhere on the shaft, 
 and just above the deltoid it was in contact with a slightly 
 elevated portion of bone of irregular, spongy appearance. 
 
 At the wrist there was also a tumor, which contained pus. 
 The epiphysal portion of the radius was separated from the shaft 
 and also from the interosseous ligament, and its periosteum 
 was detached. At the point on the shaft where the periosteum 
 became detached a new formation of bone was found, which 
 encircled the radius like a sheath, and was adherent to the 
 periosteum, and reached to the head of the bone. At this por- 
 tion the periosteum was thickened and shining, but readily de- 
 tached from the bone with slight force. When the membrane 
 was removed the new bony tissue was found to consist of lon- 
 gitudinal fibres, and was, when pressed, hard, heavy and friable,' 
 and its interstices contained a yellow fluid. It rested upon 
 healthy bone. The inferior portion of the ulna was normal, 
 as was the wrist-joint. 
 
 The right tibia was also involved, its two epiphyses being 
 separated, an abscess being present at each end of the bone. 
 There was also a similar sheath of bone, as in the radius, ex- 
 tending between both ends, where it terminated by a consider- 
 able increased thickening. In the left leg a precisely similar 
 4
 
 50 Syphilitic Lesions of the Osseous 
 
 condition was discovered at the upper end. At the lower end 
 there was no abscess, the periosteum was firmly adherent and 
 normal. The epiphysis was not separated, but it was readily 
 disunited by slight traction, and the two surfaces were rough, 
 dry, and of a deep-red color. The pus escaping from the ab- 
 cesses of the leg was thick and of the color of wine-dregs. 
 Similar lesions were found in the right knee, in the sacrum and 
 ossa ischii. Depaul's induration of the lungs was also found. 
 
 PARROT'S CASES. 1 Case first had been observed by M. 
 Gueniot, who had published its history. A child, of very deli- 
 cate build, had a gangrenous ulceration of the right groin and 
 an ulceration of the umbilicus. It seemed to be paralyzed in 
 all of its limbs, and if they were elevated they fell heavily down. 
 The forearms were pronated. Below each knee it was noticed 
 that there was a separation of the shafts of both tibia and fibula 
 from the superior epiphysis, and that a lateral motion could be 
 made The cutaneous sensibility was lessened. It died when 
 twenty-five days old. At the autopsy all the bones of the body, 
 excepting the upper end of both radii and ulnaB, were the seat of 
 inflammation. The lesion consisted of a well-pronounced injec- 
 tion and ecchymosisof the bone-tissue, near the epiphysis, and 
 between the two tissues was a layer of thick greenish pus. The 
 bone lesion was confined to the portion nearest the epiphysis, 
 and was not deeply involved. Periosteum was thickened, red, 
 and adherent, but readily separated. When the pus was re- 
 moved crepitation could be produced. The joints were not in- 
 volved. Pus was found under the capsule of the liver and under 
 the pleura. At the time of observation, Gueniot did not attri- 
 bute the lesions to syphilis, but later Parrot suggested that dis- 
 ease as their cause. It is to be regretted that the history of the 
 parents was not obtained, but the case is accepted by Parrot as 
 one of syphilis. 
 
 The second case was that of a child, twelve days old. The 
 history of its parents was not obtained. It was quite weak. 
 It was noticed that its forearms were markedly pronated, and 
 that when any of the limbs were elevated they would, if al- 
 
 1 Sur tine Pseudo-paralysis cause'e par une alteration du Systeme osseux 
 chez les nouveau nes atteints de Syphilis hercditaire, par M. J. Parrot. Ar- 
 chives de Phyid->gie Normale et Pattologique. Quatrieme Annee. No. 3, 4 et 
 5. Paris, 1872.
 
 System in Infants and Yvuny Children. 51 
 
 lowed, fall heavily down. There was very little movement in 
 the limbs, but some slight motion of the fingers. It died when 
 a month old. At the autopsy an induration of lungs was found, 
 as well as an increase of the connective tissue of the liver. 
 The whole osseous system was said to be involved, the lesion 
 being at the junction of the epiphyses and diaphyses. The first 
 phalanx of the right middle finger, as well as the inferior ex- 
 tremity of the fourth metacarpal bone, were found to be in- 
 volved, as were also the pelvic bones, the scapula, the axis, and 
 the ribs at their junction with the cartilage of the sternum. 
 This case is also accepted by Parrot as syphilitic. 
 
 CASE III. A child, about two months old when first seen, 
 had a syphilitic eruption on its body. The right arm seemed 
 normal, but the left hung by the side of the body. Upon 
 pinching the skin very limited motion was produced. The 
 legs were very thin, and, if pinched, their segments moved 
 after the manner of a wooden toy-man. There was scarcely 
 any spontaneous motion. There was an abnormal cardiac bruit 
 heard. The child died when a little more than a month old. 
 Pulmonary hepatization and vegetations on the valves of the 
 heart were found. Nearly every bone was altered. The cra- 
 nial bones were much altered. The coronoid process ol 
 the right inferior maxillary was thickened, and at its symphysis 
 there was a thickening and softening. The ribs were in- 
 volved. The point of ossification of the head of the right 
 humerus was yellow, and at its internal and inferior ex- 
 tremity was an exostosis, the tissue of which was more com- 
 pact at its periphery than near the primitive bone. The 
 shoulder-joint contained a greenish-yellow liquid, which resem- 
 bled pus, and its capsular ligament was loosened, and permitted 
 excessive motion. The upper part of the ulna was thickened 
 by a superimposed bony layer, thick superiorly and becoming 
 thin and emerging into the shaft inferiorly, and again becom- 
 ing progressively thick towards the inferior epiphysis, being de- 
 veloped upon the external part of the bone. A similar condi- 
 tion was found upon the right iliac. The two epiphyses of 
 the little trochanters were movable, and the spongy tissue w r as 
 altered. The upper epiphysis of the right tibia was mobile 
 upon the diaphysis. At the lower epiphysis the lesion was less
 
 52 Syphilitic Lesions of the Osseous 
 
 pronounced. The lesion was found to vary in intensity in the 
 various bones ; it was well marked upon the metacarpal and 
 metatarsal bones and the phalanges. The calcaneum, astraga- 
 lus and the vertebrae appeared normal. The left scapula was 
 involved at the neck. 
 
 CASE 1Y. Child, syphilitic mother, having ulcers on thighs 
 and buccal muguet / died when a month old. When periosteum 
 was detached from long bones, new bony tissue was found near 
 epiphyses. Changes were noticed at the ossifying portions of 
 diaphyses. Ribs were affected. 
 
 CASE Y. A child, having ulceration of both corneoe and 
 ulcers about the head and in the mouth ; lived to be a month 
 old. At the autopsy the shaft of the femur was found to be 
 altered at both ends. The superior extremity of the hume- 
 rus was markedly involved, and so was the superior extremity 
 of the tibia. The upper end of the ulna was involved, but the 
 lower end was normal. The radius was slightly altered, as 
 were also the sternum astragalus and calcaneum. The clavi- 
 cles were affected at their internal ends, and so were the ribs 
 near the cartilages. 
 
 CASEYI. A child, having extensive cutaneous lesions ; died, 
 when about ten weeks old, from diarrhoea and exhaustion. 
 The right femur was found to be altered. At the upper epi- 
 physis was an increase of the chondroid layers. At the lower 
 end of the bone the epiphysis was separated from the shaft by a 
 gelatinous substance, upon the removal of which a space was left 
 between the two segments of the bone. The tibia was involved 
 at its upper portion more markedly internally than externally, 
 and at its lower internal portion an exostosis existed. 
 
 CASE YII. A still-born child. The spongy tissue of the 
 long bones was red at the middle of the shafts and violaceous 
 near the epiphyses. There was an alteration of the distal ossi- 
 fying layer of the left femur, and the epiphysis was readily 
 broken from the diaphysis. The same condition was found at 
 the upper end of this bone, and also in the tibia and humerus, 
 radius, metacarpal bones and ribs. 
 
 CASE YIII. A still-born child. Tibia and fibula, humerus 
 and ulna, were involved.
 
 System in Infants and Young Children. 53 
 
 Wegner's cases, 1 twelve in number, were those of children 
 either still-born or who died a few days after birth ; one only 
 lived a month. Their chief interest is in the pathological con- 
 ditions observed in them, though they also furnish statistics for 
 clinical deductions. 
 
 1. Syphilitic child, with extensive visceral and cutaneous 
 lesions. The diaphyses of the long bones, including ribs, were 
 the seat of periostitis, and at their junction with the epiphyses 
 there was softening of the tissue and separation of the parts. 
 
 2. Still-born child at seven months, having visceral lesions ; 
 on the line of ossification brittle chalky swellings. 
 
 3. Child having severe visceral lesions ; gummy periostitis 
 on frontal bone ; softening and separation ; at the junction of 
 diaphyses with epiphyses, crepitation observed ; ribs much af- 
 fected. 
 
 4. Child, which lived three hours, having pemphigus and vis- 
 ceral lesions; periostitis of long bones, irregular chalky zones 
 at the line of ossification. 
 
 5. Child, which lived four weeks ; lesions of ocular tissues ; 
 small fluctuating abscess on right parietal bone ; irregular line 
 of ossification infiltrated with chalky masses ; developing fatty 
 degeneration of marrow of bones. 
 
 6. Child of mother having severe secondary lesions : periosti- 
 tis of long bones ; at epiphyses irregularity of ossifying process, 
 same on ribs ; visceral lesions. 
 
 7. Child of mother in second year of syphilis; cutaneous 
 and visceral lesions ; at all of the epiphyses of long bones and 
 on ribs diffuse irregularity of spongy layers. 
 
 8. Child of mother two years syphilitic ; lived six days ; on 
 epiphyses of long bones and ribs extensive alterations. 
 
 9. Child which died soon after birth ; cutaneous and visceral 
 lesions ; at the epiphyses of long bones and on the end of ribs 
 diffused chalky infiltration. 
 
 10. Child of mother early in syphilis ; visceral lesions ; 
 partial separation of epiphyses of some long bones, and changes 
 in same situation in others. 
 
 11. Child of mother a year syphilitic; visceral lesions ; bone 
 
 1 Ueber hereditare Knockensyphilis bei jungen Kindern. Archiv fur pa- 
 thologische Anatomie und Physiologic und fiir klinische Medicin. Band 50, 
 Heft 3, pages 305 et. seq. Berlin, 1870.
 
 54 Syphilitic Lesions of the Osseous 
 
 lesions in first degree on long bones and ribs ; fatty degenera- 
 tion of marrow. 
 
 12. Child, which died shortly after birth ; visceral lesions ; 
 on long bones which are in first and second degree ; partial fatty 
 degeneration of medulla. 
 
 Waldeyer and Kobner's ' cases are also twelve in number. 
 In each case the child succumbed from the severity of its 
 syphilitic lesions, consequently the deductions which can be 
 drawn from their study are chiefly in relation to their patholo- 
 gy. Certain points of clinical interest can also be deduced. 
 
 1. Child, born of a woman affected for two years with 
 syphilis; had cutaneous and visceral lesions, and syphilitic 
 changes at the epiphyses of both tibiae and at the end of ribs. 
 
 2. Child, having extensive visceral lesions ; had syphilitic 
 affection of ribs, tibiae, and bones of feet. Mother was regarded 
 as syphilitic. 
 
 3. Child of a mother in the early stage of syphilis, having 
 three pustules on the sole of one foot and one on the other ; was 
 born probably one week prematurely, and died when nearly a 
 month old. During life an extraordinary flexibility of both 
 hands was noticed. At the autopsy extensive visceral lesions 
 were found, and that the epiphyses of both humeri and of the 
 two bones of the forearm were separated from their diaphyses. 
 Between the two separated portions a reddish matter was 
 observed. 
 
 4. Case in which epiphyses were separated from the diaphy- 
 ses. 
 
 5. Case showing changes in the second stage. 
 
 6. Case of child five weeks old, mother having a papular 
 syphilide; visceral lesions, alterations at the epiphyses of 
 tibiae ; other bones not examined. 
 
 7. Case in which changes of second degree were found at 
 the epiphyses of the long bones. 
 
 8. Case in which the epiphyses were affected in the second 
 degree. 
 
 9. Bone changes at the epiphyses. 
 
 10. Case of a boy who died when three months old, who had 
 papular and pustular syphilides. At the autopsy macroscopic 
 
 1 Beitrage znrr Kenntniss der hereditaren Knockensyphilis. Virchow's Ar- 
 chiv, Band 55, Heft 3 und 4. pages 307 et seq. Berlin, 1872.
 
 System in Infants and Young Children. 55 
 
 changes were noted at the borders of the epiphyses, which 
 were verified by microscopic examination. 
 
 11. Child of syphilitic parents ; contagion probably five or six 
 years previous to birth of child. Diffuse syphilitic changes 
 were noted at the epiphyses. 
 
 12. Child, whose mother did not present any lesions of 
 syphilis, but whose father had been syphilitic three years. 
 Changes at the ends of ribs, also at the epiphyses of the radius, 
 ulna, and humerus. 
 
 IV. GENERAL CONSIDERATIONS AND DIVISION OF THE SUBJECT. 
 
 "We are warranted now in assuming that these series of cases 
 and the details thus given include the bulk, if not all, of our 
 present knowledge of the clinical features of bone-syphilis in 
 infants and children. It becomes necessary, then, to study care- 
 fully the points and facts offered by this array of cases, and to 
 deduce from them, if possible, true conclusions as to the clinical 
 history, diagnosis, prognosis, and treatment of these lesions. 
 In the resume of cases I omitted the pathological details given 
 by the various observers, but I shall fully include them in a 
 subsequent portion of the work. 
 
 It will have been seen already that certain striking and fre- 
 quently-occurring changes are observed to be seated at the 
 junction of the epiphyses with the diaphyses of long bones, and 
 that in addition, though somewhat less frequent, noticeable 
 changes are found upon the flat, irregular, and small bones. 
 We shall then study these changes in the order in which they 
 are most frequent, as that method will tend towards a more 
 correct presentation of the whole subject, and as it is, in fact, 
 rendered necessary by the varying features presented by the 
 lesions in these different classes of bones. In this connection 
 it is essential to recall to mind, in a general way, the condition 
 of the bones at the early periods of life, and also to indicate 
 in a concise manner the pathological changes which they may 
 undergo, reserving a minute description of their pathology to a 
 subsequent portion of the paper. It will be remembered that in 
 the young subject the bones are constantly undergoing active 
 developmental changes, and that the majority of them, in the 
 early years of life, are in an unfinished state, and are then, in
 
 56 Syphilitic Lesions of the Osseous 
 
 the case of the long bones, formed of a shaft or diaphysis, com- 
 posed of bone tissue, constantly augmenting by increase, and of 
 certain smaller portions, situated at each end, and continuous 
 by an intermediate layer of cartilage, which are called epiphyses. 
 Later on these pai ts fuse into one, then constituting a perfect 
 bone. In the irregular bones the process is similar, except that 
 a body or main portion exists instead of a shaft, but the relation 
 between it and the epiphysis is precisely the same. In the long 
 bones the increase in diameter is effected mainly by a laminar 
 deposit from the periosteum, their medullary canal being 
 formed in exact proportion to the growth of the shafts ; while 
 the increase in length is due to a development of the ends of 
 the diaphyses towards the epiphyses. The latter segments at 
 this time are separated from the former by a layer of cartilage, 
 of which tissue they themselves are composed. Then as the 
 requirements of the skeleton demand, varying in point of time 
 in the different bones, ossification begins in the epiphysis, ex- 
 tending toward the diaphyses, and there being met with a 
 similar process which has been taking place in that portion of 
 the bone during its whole existence. Thus it will be seen that 
 at this situation very active changes are constantly going on. In 
 the flat bones we find two modes of increase : first, the develop- 
 ment of the bone proper from its primary membranous condition, 
 and second, by the deposit of layers of bone from the investing 
 periosteum. In the small bones, also, we find the processes of 
 development are quite active, and that at varying times ossifi- 
 cation begins in their substance, which is primarily wholly car- 
 tilaginous, and that they gradually alter in structure while they 
 increase in size. Considering, then, the activity and extent of 
 these morphological changes, it is not surprising that under the 
 influence of syphilis, which so powerfully complicates and 
 modifies normal processes, the nutrition and increase of bones 
 should be materially influenced. Thus pathological studies are 
 simplified by our knowledge of physiology and normal anatomy. 
 So that, applying the united knowledge in this case, we can 
 readily understand that in a given syphilitic child, upon whose 
 bones at the diaphyso-epiphysal junction we find noticeable 
 enlargements, there is there a perversion or interference 
 with the normal course of the development of the bone ; and 
 also, that when we find a small bone enlarged, or even the sub-
 
 System in Infants and Young Children. 57 
 
 ject of more active and degenerative changes, or that a flat 
 bone is studded with perceptible elevations, we can, in the light 
 of our knowledge, suppose that certain pathological changes, 
 perhaps induced by syphilis, have been engrafted upon the 
 physiological. Then, again, when we pursue the subject further, 
 and endeavor to ascertain by microscopic and macroscopic ex- 
 amination what these changes really are, our suspicions are 
 fully confirmed by the appearances which are observed. In 
 speaking of the swellings I shall, throughout the descriptive 
 part of the work, merely allude to them as being due to 
 increased cell proliferation in varying proportions, as this 
 method will be simple in not presenting pathological details in 
 advance, and in avoiding troublesome repetitions. 
 
 Commencing, then, according to the plan already laid out, 
 with the study of the lesions upon the long bones, it must be 
 remembered in advance that similar or somewhat dissimilar 
 changes in the other kinds of bones may or may not be co-ex- 
 istent with them. There are cases in which the long bones 
 alone are involved ; others again in which they and the other 
 varieties of bones are affected together; and others still in 
 which the lesions are developed on the small or on the irregu- 
 lar bones while the long ones escape. 
 
 A careful perusal of those of my cases in which these long 
 bones are altered, shows clearly that they may be divided into 
 two stages, or even classes : a first, in which the morbid pro- 
 cesses, as evidenced by swellings, undergo resolution without 
 perceptible impairment of the structure of the bones, of the 
 parts around and above them, or of the function of the mem- 
 ber of which they form a part ; and a second, in which resolu- 
 tion does not take place, but in which degenerative changes are 
 observed. These degenerative changes may be limited simply 
 to a destruction of the superficial portions of the swellings in 
 greater or less extent, or they may be so severe as to involve 
 the whole diameter of -the swelling in destruction or liquefac- 
 tion, in which event the epiphyses become separated from the 
 diaphyses. A casual knowledge of this subject might lead to 
 the impression that these cases are essentially different in 
 kind, but, as I shall show further on, such an opinioa is errone- 
 ous, as they are really representations of well-defined stages of 
 development of one and the same morbid process. The swell-
 
 58 Syphilitic Lesions of the Osseous 
 
 i 
 
 ings on the other bones may also be divided into similar vari- 
 eties. Pathological facts, as brought out by the observations of 
 "VVegner, Waldeyer, Kobner, and Parrot, show that this clini- 
 cal division is the true one. The seat of the enlargements or 
 swellings on the long bones is, for anatomical reasons, always 
 at the junction of a diaphysis with its epiphysis, and, as my 
 cases show, they are, as thus far met with in clinical practice, 
 developed rather more frequently at the distal end of the 
 bone than at the proximal end, though the reverse may be and 
 has, as we shall see, been quite frequently found. When ex- 
 amined, the swellings are found to present quite well-marked 
 characteristics. We shall study them in their order as just laid 
 out, taking into consideration the degenerative conditions, after 
 we have fully studied the first or resolutive variety. 
 
 V. DESCRIPTION OF THE OSSEOUS LESIONS UPON THE UPPEK EX- 
 TREMITIES. 
 
 In our study of the lesions of the long bones we naturally 
 begin with those which are observed upon the upper extremi- 
 ties. In the main the swellings at the junction of the diaphy- 
 ses of the long bones with their epiphyses present many 
 points of resemblance ; therefore, though the description which 
 immediately follows applies to the enlargements at the distal 
 ends of the radius and ulna, the general features indicated are 
 such as will apply with slight modifications to similar swellings 
 elsewhere located, though of course we shall study them all 
 separately. If now we trace, with the tips of the fingers, the 
 continuities of the bones downward along their shafts, we 
 encounter just at or before the commencement of the epiphy- 
 ses a quite abrupt elevation, which is found to encircle the bone 
 or perhaps bones. Usually this swelling can be felt on all of 
 the surfaces except that which is in coaptation with its 
 companion bone. The surface of this swelling is generally 
 smooth, but it may be slightly undulating, not, however, ridgy. 
 It is gently rounded off at its peripheral portion, where it 
 may end by simply enlarging that part of the bone which cor- 
 responds to the ossifying layer between the shaft and the epi- 
 physis, or it may extend further down and merge gradually into 
 an expanded epiphysis. In the latter case the surface of the 
 tumor is rounded at its proximal and flattened towards its
 
 System in Infants and Young Children. 59 
 
 distal end. In the first case, in which only a limited portion 
 of the shaft and of the epiphysis is involved, the swelling, 
 which is usually from three-quarters to perhaps an inch and a 
 quarter, can be traced as a ring encircling the whole bone, 
 and then the epiphysis beyond it is felt to be normal. In the 
 other case a general enlargement is observed, though the fact 
 may be noted that, though the epiphysis is enlarged, the 
 bulk of the swelling is at its upper and middle parts, 
 and the epiphysis does not seem out of proportion when 
 it is examined just at and from the wrist-joint, with the func- 
 tion of which it produces usually no impairment. The conclu- 
 sion, then, is obvious that in the cases thus far observed, the 
 enlargement of the bone has been confined to the end of the 
 shaft, and perhaps the proximal half or two-thirds of the epi- 
 physis, and does not militate at all against the supposition that 
 in some cases the whole epiphysis may undergo great enlarge- 
 ment. The existence of this condition can be determined by 
 future observation. 
 
 Such, then, is a comprehensive description of the shape and 
 features of the individual swellings of the bones themselves, 
 and of course applies to those of this situation. When the 
 swellings on the two bones are examined together it will be 
 found that there appears to be a direct fusion of the two epi- 
 physes. This can be readily appreciated on a very thin child, 
 but can also be determined, even if the arm is fat, by tracing 
 with the tip of the finger, along the back part of the limb, the 
 course of the interosseous space, which can be clearly made out 
 until we reach the epiphysal region, where the finger meets 
 with a seemingly continuous tissue, so that the usually well-de- 
 fined furrow between the two epiphyses can no longer be dis- 
 tinguished. This condition is undoubtedly due to the great 
 cell proliferation, which appears to have gone on here to such 
 an extent that the bones feel as if soldered together. There is 
 not, however, or rather the symptom has not as yet been ob- 
 served, any impairment in pronation or supination of the limbs. 
 Such are the points elicited by manipulative examination of 
 the swellings. If now the limb is examined by the eye, the 
 swellings of the bones may or may not be visible. Thus, in a 
 child who has considerable development of adipose tissues, the 
 enlargements of the bones of the forearms may wholly escape
 
 60 Syphilitic Lesions of the Osseous 
 
 the observation of its attendant, and, in fact, the child may come 
 to the surgeon for treatment of other symptoms or lesions, and 
 the swellings may even pass unnoticed by him unless search is 
 made for them. Thus in my second case the child was brought 
 for other syphilitic lesions, and when examined carefully the 
 swellings were found, and were clearly demonstrated to the 
 class. In my third case the child's mother thought that per- 
 haps its bones were swollen, but she was not certain. In fact, 
 I suspect strongly that, particularly among the lower classes, 
 such swellings might even be recognized and then not be re- 
 garded as abnormal, and also that they often wholly escape 
 notice. In those children whose fatty tissue is abundant there 
 is no evident stretching of the integument by the pressure 
 within. When, however, we examine a more or less thin child, 
 upon whose forearms these swellings are seated, we can dis- 
 tinctly observe quite large rounded elevations of the integu- 
 ment, which can be clearly made out either by a lateral or ver- 
 tical view of the limb, and they are of such a character as to 
 attract the attention. This fact was well observed in my first 
 case. The swelling is seated just above, or may appear even as 
 if reaching very near to, the wrist-joint, and it involves the 
 whole breadth of the limb. It begins by a gradual iiplifting 
 of the integument, attains a height of perhaps three-quarters of 
 an inch in some cases more, in others less then having a longi- 
 tudinal area of an inch, more or less, subsides by gradually 
 rounding off at or above the joint. The integument in cases 
 which undergo resolution is of course stretched to a greater or 
 less degree. It can be moved over the bony tumor with ease, 
 and according to my observation has never been altered in 
 color. The appearance is somewhat like that of a dislocation, 
 and is identical with the double joint of rickets. 
 
 The description which has been given is applicable to those 
 cases in which both bones of the forearm are enlarged in the 
 region of the carpal epiphyses. This brings us to a considera- 
 tion of the point as to whether the swellings always involve 
 both bones, and if so, whether the swellings are always symme- 
 trically developed on both forearms. In the post-mortem 
 cases, examined by Wegner and Waldeyer and Kobner, it was 
 found by these observers that the lesion was always symmetrical 
 in both bones and on both arms, but the results of clinical obser-
 
 System in Infants and Young Children. 61 
 
 ration, as drawn from twelve of my cases, show that in practice 
 this fact is not borne out. 1 Thus, in these twelve cases, both 
 bones were symmetrically involved in both forearms in seven ; in 
 two the right radius only was affected, in one the radius and 
 ulna of one side only were swollen, and in two the bones of 
 the forearm and in fact all of the long bones of the body 
 escaped. The symmetrical development of the swelling on both 
 bones of both forearms is the rule, and the unsymmetrical de- 
 velopment is the exception, according to our present statistics, 
 but further observation may modify this statement. The de- 
 scription of the swellings, as given when two bones are affected, 
 fully applies to those involving only one bone, except, of course, 
 that the latter are limited to one or other side of the limb 
 instead of involving its whole breadth. The appearances to 
 the eye are varied in the same manner. 
 
 Such, then, being the clinical features of the swellings on the 
 distal ends of the radius and ulna, we come next to a considera- 
 tion of those which are found on the upper end's of these bones. 
 In this situation, owing to the conformation of the limb, the 
 tumors are not as well marked in appearance as are those 
 occurring below. In fact, when the limb is examined in an 
 extended condition on its internal aspect, the swelling is not 
 perceptible. If, however, the swelling should attain large propor- 
 tions a feature which has not as yet been observed in clinical 
 practice it is obvious that it would be perceived even here. 
 
 1 This discrepancy is not as great as might be inferred from the text, and can 
 be quite clearly explained. In many instances, upon post-mortem examina- 
 tion in which the lesions have been observed to be symmetrical, the develop- 
 ment was found to be very unequal, and in some instances the process had 
 gone on to such a slight extent on one side, that no enlargement had been in- 
 duced, and had not the tissue been examined with the microscope there would 
 have been no suspicion of its being the seat of pathological change. It can 
 be plainly seen that in every instance the swelling must have attained some 
 considerable development, otherwise it would not be appreciable to our touch. 
 Thus we must take this fact into consideration in determining the symmetrical 
 and unsymmetrical character of these swellings, and we must bear in mind 
 that more bones may be involved than we think, as we are powerless to deter- 
 mine in cases where the lesion has only gone on to a slight degree. In my 
 eleventh case the enlargement at the junction of the epiphysis with the dia- 
 physis of the right radius was very slight indeed, so much so that it was with 
 difficulty made out, but still it was detected, and the feature was observed by 
 several physicians and students besides myself. An instance like that deve- 
 lops a suspicion that in syphilitic children these lesions may be much more 
 common and extensive than we even now think them to be.
 
 62 Syphilitic Lesions of the Osseous 
 
 But when examined closely on the posterior aspect of the limb, 
 a swelling may be observed upon the olecranon if it has 
 attained an appreciable size. The examination here is best 
 made by semi-flexing the arm, as this movement stretches the 
 integument over the bone and renders the outlines of the ole- 
 cranon more perceptible than in an extended condition of the 
 limb. The main feature observed is an enlargement outwardly 
 and laterally of the olecranon process. When ,now we come to 
 examine these bones by the touch, the swellings become very 
 palpable. Those on the radius consist in a general round en- 
 largement of the upper end of the bone, which, however, is 
 difficult to trace in its upper part if the child is fat and its 
 muscles are well developed, but can be readily traced to the 
 joint and felt to move under the tip of the finger, if pronation 
 is employed in cases of very thin children. It seems very 
 probable that if the swellings on the radius became very large 
 the movements of the limb would be impaired. Examination 
 by the touch of the swellings on the ulna present nothing 
 peculiar when practised upon the internal aspect of the limb, 
 but when the bone is felt posteriorly the olecranon process 
 is found to be enlarged, and to bulge out considerably beyond 
 the plane of the bone as traced upwards along its posterior ridge 
 with the tip of the finger. Besides this enlargement outwardly 
 a lateral expansion is felt distinctly, and when the process is 
 examined near its apex or end it is here found to have a very 
 uneven, if not knotty surface. According to present observa- 
 tion the upper parts of the shafts of the radius and ulna at their 
 junction with their epiphyses are not as frequently the seat of 
 these syphilitic swellings as the lower parts are. Thus in ten 
 of my cases in which the lower epiphyses were affected, the 
 upper ones were only found to be swollen in three. Then, 
 again, in only one of these cases were both bones of both arms 
 symmetrically involved, whereas in two cases the olecranon 
 process only was involved. In this connection Fournier's obser- 
 vation is important, as in one of his cases both radius and ulna 
 of one arm. only were involved, while in the case related by 
 Ranvier, the ulna of one arm only had been affected and the 
 swelling was felt at the base of the olecranon process. In 
 Bertin's case also, the ulna was the only bone of the upper ex- 
 tremity involved. The conclusion, then, is warranted, based on
 
 System in Infants and Young Children. 63 
 
 these combined cases, that in clinical practice the upper epi- 
 physes of the bones of the forearms are not as frequently the 
 seat of syphilitic lesions as the lower ones are, and that the 
 swellings may be symmetrically developed on both bones of 
 both arms, or that both bones of one arm alone may be involved, 
 or even one bone of one arm, or again one bone of both arms 
 may be thus affected. The swellings of the upper epiphyses 
 may or may not coexist with similar swellings on the lower ones. 
 Turning our attention now to the condition of the humerus in 
 syphilitic children, we find in clinical practice that it is even 
 less frequently involved than the upper ends of the radius and 
 ulna are. Thus, in only two of my cases was it noted as being 
 enlarged, and the same condition existed in Roger's, in Four- 
 nier's, and in Parrot's third case. As thus far observed, the 
 swellings at the lower end of the bone have not attained suffi- 
 cient size to present such noticeable elevations of the super- 
 imposed parts as are observed in the wrist, and they would 
 have, in all probability, escaped observation but for the fact 
 that they were perceptible to the touch. A point of some im- 
 portance has been here observed, which is, that the swellings are 
 more often developed at the internal condyle than elsewhere. 
 This fact was well brought out by my case, and is substantiated 
 by those of the three observers already mentioned. In Fournier's 
 case, as well as in my tenth case, an enlargement was noted of 
 the whole breadth of the diaphyso-epiphysal junction, but by 
 the former it was stated to be greatest at the internal border. 
 This point possesses interest both clinically and pathologically, 
 as it proves that while the morbid process may involve the 
 whole ossifying end of a shaft of a bone, it may attain greater 
 proportions in one particular part than in another, and also that 
 it may involve a more or less limited extent of surface of the 
 diaphyso-epiphysal junction. In my case, No. VI., the enlarge- 
 ment was seated just above and upon the internal condyle, oc- 
 cupying a space of perhaps three-quarters of an inch of the in- 
 ternal ridge, and was about the size of a peanut. To casual 
 observation this tumor would probably not have been noticed, 
 but when attention was called to it, and the arm was with care 
 slightly flexed and extended, it could be seen as an elevation of 
 the bone playing under the integument. I can readily see that 
 in a very fat child it would have escaped observation entirely.
 
 64 Syphilitic Lesions of the Osseous 
 
 As regards the distribution of these swellings of the lower end 
 of the humerus, it would seem that they may be either sym- 
 metrically or unsymmetrically developed on the two arms. 
 Thus, in Roger's case, both internal condyles were affected, 
 while in my two cases, in Founder's and in Parrot's case, only 
 one shaft was enlarged. In this connection it is well to bear in 
 mind that at its distal end the humerus has four centres of 
 ossification, and that we may find swellings localized at any 
 one, or at all of them, either at the external condyle, at the con- 
 dyle proper, at the trochlea, or at the internal condyle. .Four of 
 these cases, however, point strongly to the fact, which is impor- 
 tant as regards etiology and diagnosis, that at the internal con- 
 dyle these peculiar syphilitic swellings are very liable to occur. 
 In my tenth case, the swelling involved the whole ossifying re- 
 gion, being quite extensive and presenting an uneven surface to 
 the touch. If the swelling was limited to the trochlea, particu- 
 larly if it was small, it might escape observation entirely. Ac- 
 cording to Wegner's observations, this portion of the humerus 
 is not as frequently affected as the upper, and the syphilitic le- 
 sions were absent here more frequently than in any other of the 
 long bones, except the upper ends of the radius and ulna, which 
 site he found to be less often the seat of swellings than any 
 other. Parrot found in his fifth case that the upper end of the 
 ulna was involved, and that the lower one was unaffected. Fu- 
 ture observations on a greater scale, clinically and pathologi- 
 cally, may perhaps explain this discrepancy. In studying now 
 the changes in the upper end of the humerus, we are forcibly struck 
 with the fact that we have not a case in clinical practice in 
 which these syphilitic swellings were noted here. But in the rec- 
 ords of the post-mortem cases of Parrot, Yalleix, "Wegner, and 
 Waldeyer and Ko'bner, we find instances in which this portion 
 of the bone has been affected, and, as said before, Wegner 
 thinks the upper end is more often involved than the lower. In 
 all of these cases, however, it so happened that the lesions were 
 of a severe form, and went on to their last and destructive 
 stages, so that we have not the history of a tumor in this site in 
 which resolution afterwards took place. To suppose that such 
 tumors might occur, we certainly have abundant evidence in 
 the records of the autopsies, and in the fact that here there is 
 a natural predisposition of the parts to the development of them ;
 
 System in Infants and Young Children. 65 
 
 namely, an ossifying shaft and an epiphysis of considerable 
 size. Supposing then an instance of the occurrence of these 
 tumors here, it is well to bear in mind that there are at the head 
 of the humerns two centres of ossification, and that the swelling 
 might be general and evenly developed, or general and more 
 prominent, at a given spot ; or it might be localized, and then 
 would be situated at either the greater or lesser tuberosity. 
 This point is deduced by analogy from the case of swelling of 
 the internal condyle of this bone, and will also be exemplified 
 hereafter in the case of the femur. As regards the recognition 
 of such tumors by the eye, much would depend upon the quan- 
 tity of the muscular and adipose development of the child ; for in 
 a chubby infant they might escape observation, while in a very 
 thin one they might be very apparent. In Yalleix's case, and 
 in Parrot's third case, the deformity was very perceptible. It 
 is very probable that if the tumor attained a considerable size, 
 it would interfere with the function of the shoulder : joint, in 
 which event attention would surely be called to its existence. 
 Like such lesions developed elsewhere, of course, they may or 
 may not be symmetrically developed. The details of such cases 
 will be looked for and read with interest. 
 
 VI. THE ENLARGEMENTS TTPON THE CLAVICLES, STERNUM AND RIBS. 
 
 Passing now from the shoulder we naturally come to the 
 clavicle, on which bone we find that these tumors sometimes 
 form. In my tenth case, which is the only recorded one of a 
 living child presenting the lesion, the sternal end of the right 
 clavicle was enlarged. The swelling began about an inch from 
 the end of the bone, and becoming somewhat rounded, having 
 a smooth surface, ended at the sternal joint. In this case the 
 tumor was very evident to observation, and I should think that 
 if these swellings attained even a moderate size, they would 
 here be quite readily seen, even in fat children. . They can be 
 more clearly defined by allowing the child's head to hang 
 down without support, while the body is held horizontally, as 
 by this manoeuvre the integument is stretched and the sterno- 
 cleido-mastoid muscle pulled downwards out of the way. This 
 position will be found useful in deciding whether a given 
 tumor is seated in the insertion of this muscle or on the sternal 
 end of the bone, or even in regions not connected with these 
 5
 
 66 Syphilitic Lesions of the Osseous 
 
 structures. My case, though unique in clinical practice, has its 
 analogue in Barensprung's case, which died, in which the tumor 
 was likewise situated at the sternal end. At the autopsy of 
 Parrot's fifth case, both clavicles were found to be swollen at 
 their sternal end. The fact that in the three cases this end of 
 the bone was the only one involved, might leave the impression 
 that this was perhaps the result of chance ; but when we con- 
 sider that at birth all of the clavicle except its sternal epiphy- 
 sas is formed of true osseous tissue, it occurs to the mind that it 
 is at this end that we should naturally look for these swellings, 
 and not at the acromial end, where no epiphysis exists. Con- 
 sequently, this form of tumor will not be met with there, though 
 of course we may find periosteal tumors. The cases, as thus far 
 observed, show that, like other long bones, the clavicles may or 
 may not be symmetrically involved in the syphilitic process, 
 for in one case both bones were affected, and in two cases only 
 one bone was. In the child, then, a swelling at the sternal end 
 of the clavicle would naturally excite a suspicion of its being 
 of syphilitic origin. We shall see further on, that these swell- 
 ings are interesting in the matter of differential diagnosis. As 
 a result of acquired syphilis I have several times seen this part 
 of the bone to be enlarged in patients in whom, from their youth, 
 bony union of the two segments had not yet occurred. From 
 the clavicles we arrive naturally at the sternum, upon which 
 bone the syphilitic tumors under consideration have not been 
 found in clinical practice. From the fact that in the early 
 years of life this bone consists largely of cartilage undergoing 
 ossification, it would be very reasonable to suppose that it 
 would be the seat of the syphilitic change, particularly when 
 we consider how frequently it is involved in the acquired 
 syphilis of adults, but still clinical cases are wanting. Yet the 
 records of autopsies shew that it has been affected by syphilis, 
 consequently cases may hereafter occur. Being situated under 
 an integument which is never as thickly lined with adipose 
 tissue as som.e other parts are, this bone is usually readily seen, 
 and of course any tumors upon it would be proportionately 
 prominent. 
 
 Thus far in our study of these swellings we have found them 
 developed at the junction of a shaft with an epiphysis, a point 
 where the process of ossification is going on actively. We now
 
 System in Infants and Young Children. 67 
 
 come to the study of them when developed at the sternal ends 
 of the ribs. Ilere the ossifying end of the bone is not conti- 
 nuous with an epiphysis which later on undergoes ossification it- 
 self, but rather with a shaft of cartilage, whicli as a rule always 
 retains its primitive structure. The difference, then, is simply 
 in the ossification going on at the expense of, in one instance, 
 temporary and, in the other, of permanent cartilage ; the physio- 
 logical processes being the same in each case. The swellings at 
 the ends of the ribs have only occurred in one out of the four- 
 teen cases seen by me, and in that instance only two ribs were 
 affected on each side, namely, the second and fourth of the 
 right, and the second and third of the left side. Parrot men- 
 tions the fact that he found at the autopsy enlargements of the 
 ribs in his fourth and seventh cases, and Wegner and Wal- 
 deyer and Kobner mention these swellings as being found in the 
 greater number of their cases. The lesion was observed by 
 them here in all stages of its development. We are warranted, 
 then, I think, in assuming that in clinical practice syphilitic 
 swellings at the ends of the ribs are not frequent, at least not 
 as frequent as similar swellings on other long bones ; that they 
 may involve all of the ribs, or that only a limited number of ribs 
 may be involved, and that, judging from the distribution of 
 these swellings elsewhere, they may be either symmetrically or 
 unsymmetrically distributed. To the touch these tumors give 
 the impression of a simple bulbous expansion of the shaft, their 
 surfaces being smooth. Of course they may be more or less 
 prominent in proportion as they are small or large, and as the 
 child is fat or thin. They possess great interest clinically, as 
 they are so liable to be attributed to rickets. In arriving at 
 the diagnosis, it is well to bear in mind the fact of the limited 
 number of syphilitic swellings, and also their possible unsym- 
 metrical occurrence. Yet we shall find that in rickets, though 
 the symmetrical development of the bulbous ends of ribs is the 
 rule, it also has its exceptions. As the ribs possess in early life 
 two regular epiphyses, one for the head, the other for the tu- 
 bercle, it is very probable that these swellings may be developed 
 upon them, but as they would be inaccessible to exploration 
 they would be void of clinical interest, except, perhaps, in the 
 event of their unusually large development, in which case they 
 might perhaps produce pressure on a spinal nerve.
 
 68 Syphilitic Lesions of the Osseous 
 
 VII. THE SWELLINGS AT THE EXTREMITIES OF TIBIA AND FLBCLA. 
 
 Pursuing now the same course in our study of the bone-le- 
 sions of the leg as followed in that of the arm, we commence 
 with the ankle. As developed upon the lower end of the tibia 
 and fibula, the swellings have the same general characters as 
 those found on the corresponding part of the radius and ulna. 
 In tracing the continuity of the bones downward with the fin- 
 ger, a perceptible swell-ing is discovered about two inches 
 above the extremity of either malleolus. The swelling usually 
 begins quite abruptly, and attaining a height of half or three- 
 quarters of an inch, it either merges into the expanded epiphy- 
 ses, or is distinctly limited to a space cf about an inch or an 
 inch and a half in length, in which case it is recognizable as a 
 ring surrounding the bones at their diaphyso-epiphysal junc- 
 tion. In those of my cases in which the epiphyses \vere gener- 
 ally expanded, the swelling was found not to involve the ex- 
 treme portion of either malleolus, and it was evident that the 
 morbid process stopped short of this point. In the ringed 
 form the swelling was distinctly traceable all around the bones, 
 and it seemed to the touch as if perfectly continuous, their line 
 of apposition being apparently lost. This line, though some- 
 times quite difficult to determine, can generally be distinctly 
 made out, by tracing downwards between the two bones with 
 the tip of the fingers, and in the examination of a healthy sub- 
 ject it is readily found. When, however, these bones undergo 
 this local enlargement there seems to be a general fusing or 
 soldering together of them. The surface of the swellings was 
 quite smooth, and in no instance have I found it nodulated. The 
 integument, which in this part of the leg is less provided witfi 
 adipose tissue than any other part except the region of the 
 knee,is usually stretched, but not in such a manner as to induce 
 structural change. It can usually be slid over the swelling be- 
 neath. The resulting deformity of such bone-enlargements is 
 generally quite well marked, rather more so than at the wrist, 
 Of course, it will vary with the greater or less development of 
 the swelling, and with the amount of adipose tissue deposited 
 here. It is well to remember that the child's leg, owing to the 
 delay in muscular development, does not expand from ankle to 
 calf, as it does later on ; that the adipose tissue is more evenly 
 distributed, particularly so at the ankles ; and that the limb in
 
 System in Infants and Young Children. 69 
 
 its continuity preserves a somewhat uniform shape ; conse- 
 quently, that these swellings, if not large, might not be regarded 
 by the child's attendants as abnormal, and might even escape 
 their observation, and could of course under the circumstances 
 escape that of the surgeon, unless he examined with reference 
 to them. There is another point which is of especial interest to 
 the surgeon in determining whether or not swellings exist 
 
 <J O O 
 
 upon these bones in infants, and that is that there is very often 
 a seeming disproportion between the size of the shafts of the 
 tibia and fibula and their epiphyses, the former appearing quite 
 thin, while the latter feel as if unusually large. This condi- 
 tion, which is normal and quite frequently found both in these 
 bones and iu the radius and ulna, might, if not borne in mind, 
 lead to the wrong impression, that an enlargement of the bones 
 existed. 1 In those cases in which the swelling is well marked 
 the deformity is readily seen and is of peculiar appearance. It 
 is most marked on the anterior aspect of the ankle just above 
 the tarsal bones, and it looks as if the bones of the leg had been 
 dislocated forwards. The swelling is also in such cases well 
 seen on the outer and inner sides of the ankle. In two of my 
 cases the parts above the ankle presented a somewhat quadran- 
 gular shape, which was well marked. In exceptional cases the 
 swelling may be more developed at one part than at another, and 
 in some it may be very si ight ; the rule being that it should be 
 generally distributed. The local development of the swelling 
 was observed in one of my cases, in Bulkley's case, and in 
 Parrot's sixth case. 
 
 The statistics of the swellings at this portion of the tibia and 
 fibula show that they occur here quite frequently; indeed "Weg- 
 
 1 Melchior Robert (Nouveau Traite cles Maladies Venvriennes, Paris, 1861, 
 page 692) states that he has seen cases in which, as he expresses it, the syphi- 
 litic virus was too feeble to cause special manifestations, and in which a 
 species of atrophy of the diaphyses and thickening of the epiphyses was no- 
 ticed, a condition which he attributed to syphilis. From our knowledge of 
 the influence of this disease upon the growth and development of bone, it 
 is reasonable to suppose that it has no direct or specific action in causing this 
 condition, particularly as it is said to arise de nopo, and not to result, according 
 to the author, as a sequela of typical syphilitic lesions. It would seem that these 
 cases were similar to those above alluded to, in which the imperfect develop- 
 ment was perhaps even more marked. If we concede to syphilis any influ- 
 ence in producing this condition, it must be in the power which it, like any 
 other debilitating disease, has in impairing the growth and nutrition of 
 tissues generally.
 
 70 Syphilitic Lesions of the Osseous 
 
 ner ranks their frequency in this situation next in order to the 
 lower end of the femur, which site he thinks the most frequently 
 affected of any portion of the long bones, and "Waldeyer and 
 Kobuer found them here also quite often. In the fourteen cases 
 seen by me, swellings at the lower end of the tibia and fibula 
 occurred five times ; in Parrot's eight cases three times, and 
 they were found in Valleix's case, making a total of nine cases. 
 As regards the mode of their distribution, they were found on 
 both legs in three of my cases and in Yalleix's case ; in Par- 
 rot's cases the bones of the right leg were involved in case three, 
 and those of the left in case six, the tibia of one leg and fibula 
 of the other in case eight ; in my ninth case the left tibia and 
 right fibula were the bones involved, the left fibula being only 
 slightly affected, and in Bulkley's case only one bone, the fibula, 
 was involved. The conclusions are, then, that the swellings may 
 be symmetrically distributed on both bones of both legs, that 
 they may occur on both bones of one leg, on either one or other 
 of the bones of each leg, or that a swelling may occur on ono 
 bone of one leg. They have always been found to exist coinci- 
 dently with similar spellings on other bones ; thus, in my four 
 cases, there were in two instances similarly situated swellings 
 on the radius and ulna; in the two others, besides this coinci- 
 dence, there were swellings on other bones; in Bulkley's first 
 case the swelling on the fibula was coincident with syphilitic 
 lesions of the phalanges, metacarpal and metatarsal bones ; and 
 in Parrot's, Wegner's, Waldeyer's and Kobner's cases, various 
 and numerous other bones were found to be coincidently the 
 seat of similar changes. There is no reason why this site might 
 not be the only one involved in a given case of syphilis, but as 
 yet we have not the records of a case showing the fact. In my 
 eleventh case the distal end of the tibia and fibula were en- 
 larged, the lesion having gone on to a degenerative stage, 
 and the only other appreciable bone lesion was a very slight 
 swelling of the distal end of one of the radii. The tibia and 
 fibula are very often affected at their lower ends by rachitic 
 swellings, but the distribution is generally symmetrical, and 
 other long bones, such as the radius and ulna, ribs and femora 
 or the cranium, may or may not be coincidently involved, they 
 being as a rule thus affected. This point will be touched upon 
 when we come to treat of the diagnosis of these swellings. 
 
 o o
 
 System in Infants and Young Children. 71 
 
 The distribution of the soft parts at the knee is such as to 
 render the examination of the bones which compose the joint 
 quite easy, particularly in the case of the tibia and fibula. The 
 contour of these bones, even in the infant, is generally very 
 readily discernible to the naked eye, and their exploration by 
 the touch is proportionately easy ; consequently any swellings 
 which may occur here are generally very likely to be noticed, 
 and of course they can be examined readily. The peculiar 
 swellings, such as we have found on the lower ends of these 
 bones, are also found here. In the fourteen cases which I have 
 seen, a swelling upon the tibia was found in but one. In that 
 case the right tibia was involved and the swelling was distinctly 
 visible on the anterior and lateral or internal portions of the 
 bone, where the elevation of the integument was very well 
 marked. The swelling, commencing externally just at the head 
 of the fibula, was situated just above, and involved the tube- 
 rosity of the tibia, running around the bone and being dis- 
 tinctly traceable until it reached the posterior surface, where it 
 could not be made out. The elevation of the tumor was fully 
 three-quarters of an inch, and its area at its base was certainly 
 an inch and a half. Superiorly it merged into the head of the 
 bone, just near the joint. Its surface was somewhat nodulated 
 anteriorly, but it was quite smooth laterally. In Roger's case 
 a similar enlargement was found anteriorly. A similar swell- 
 ing was also found in Yalleix's case, and Parrot, at the autopsy 
 of five of his cases, found the head of the tibia to be the seat of 
 morbid change. Of these cases there was one in which both 
 tibizfi were enlarged, another in which the tibia and fibula of 
 one leg were swollen, and three in w T hich only one tibia was 
 involved. Parrot states that in his sixth case the swelling was 
 more perceptible internally than anteriorly. Waldeyer and 
 Kobner found this portion of these bones affected, and Wegner 
 did also. The latter thinks that the swellings upon this site 
 occur the fifth in the point of frequency of any of the long boneSj 
 while Parrot places their frequency in the third rank, and those 
 of the fibula in the sixth. It will be seen that in clinical prac- 
 tice only two cases have occurred in which these swellings 
 were found, and in each the tibia was the bone involved ; one 
 of these cases is my ninth, the other is Roger's case, while they 
 have been observed at least seven times at the autopsy. It ia
 
 72 Syphilitic lesions of the Osseous 
 
 well to bear in mind, in explanation of this seeming discre- 
 pancy, that the cases of Parrot and Wegner were those of the 
 severest form of syphilis, in which many bones were affected 
 and in which the other lesions were so severe as to cause death. 
 In the clinical cases the syphilis was comparatively mild in form, 
 and did not destroy life. We can scarcely admit these cases 
 unreservedly for purposes of comparison ; but if we should do 
 so, we should find that they warrant the following conclusions : 
 That the upper part of the tibia is more frequently swollen 
 than the same part of the fibula ; that the swelling may be sym- 
 metrical on the tibiae of the two legs, or may occur on only one 
 bone. We have no recorded instance in clinical practice of a 
 swelling upon the fibula alone, nor upon it and the tibia, nor, 
 again, of swellings on both bones of both legs ; such cases, how- 
 ever, may occur. In this situation we find that though the 
 swelling may involve the whole ossifying upper end of the 
 shaft, it may be greater or rather more perceptible at one 
 portion of it than at another. This, of course, is either due to 
 the fact that the morbid process is greater at a given spot, or 
 that it is distinctly localized there. We have already pointed 
 out the same feature at the lower end of the humerus, where its 
 existence was explained by the fact of the multiplicity of ossi- 
 fying centres; but this explanation fails in this case, as there is 
 but one ossifying region, which, however, is very extensive. 
 
 VIII. THE SWELLINGS UPON THE FEMUR. 
 
 Coming now to the lower part of the femur, we find that 
 owing to its being deeply seated amidst muscles, fasciae, etc., 
 and also to its being covered with a greater or less amount of 
 adipose tissue, that its examination is not very readily accom- 
 plished. In children, however, there is not the same resistance 
 or firmness of the soft parts as may be observed later in life, 
 consequently in them the conditions are not as much unfa- 
 vorable to physical exploration. The conditions of course 
 vary very much with the amount of muscular and adipose de- 
 velopment of the child. It is a situation, however, in which, 
 when the swellings are developed as low down as the diaphyso- 
 epiphysal junction, they would be very likely, if small, to pass 
 unrecognized, more especially by the eye, and perhaps by the 
 touch. In but one of my cases was this part of the femur
 
 System in Infants and Young Children. 73 
 
 found to be swollen. In this there was no perceptible eleva- 
 tion of the integument, though the child was thin, nor could 
 any swelling be discerned if the limb was viewed while it was' 
 being alternately flexed or extended. AVhen deep pressure 
 was made upon the bone, a swelling could be felt just above 
 each tuberosity, which could be traced to the anterior surface of 
 the bone, and there quite distinctly made out, but could not 
 be felt posteriorly. The swelling arose quite abruptly from 
 the bone, and was fully five-eighths of an inch high, and occu- 
 . pied a longitudinal area of about an inch and a half. Its sur- 
 face was quite smooth and it rounded off, losing its lower edge 
 in the bone. The integument was of course unaltered. Ac- 
 cording to Wegner, the lower end of the femur is more fre- 
 quently found to be the seat of the peculiar syphilitic changes 
 which we are considering than any other bone in the body of 
 any variety. Whether this fact is to be explained by the con- 
 dition of development of the femur, its lower epiphysis being 
 the only one in the body in which ossification begins before 
 birth, consequently the one in which the processes are most 
 active, I am unable to say. In clinical practice, according to 
 our present knowledge, it seems that it is very seldom in- 
 volved ; future observations, however, may establish a greater 
 frequency of occurrence. Barensprung mentions having found 
 the femur enlarged at this site, and Parrot found it in three of 
 his cases. Judging from our present facets, we should say the 
 swelling is not as a rule developed symmetrically on both 
 limbs, but of course such cases may occur. Although our 
 present experience shows us that these swellings are uniformly 
 distributed along the diaphyso-epiphysal junction, we may 
 infer from analogy that they may be developed in one portion 
 in greater size than in another, and, in fact, that the morbid 
 process may be localized to one spot, as we have already found 
 it upon the humerus and tibia. This part of the leg should 
 be carefully examined in cases of hereditary syphilis, particu- 
 larly if other bone lesions are found. 
 
 The deeply seated position of the upper end of the femur 
 renders examinations of any swellings upon it rather more dif- 
 ficult than at its lower end, and here such swellings might readily 
 pass unnoticed. I have never had the opportunity of examin- 
 ing any syphilitic swellings on this portion of the femur, as
 
 74 Syphilitic Lesions of the Osseous 
 
 they did not occur in any of the fourteen cases seen by me. 
 They have, however, been found quite frequently after death, 
 as Wegner places them in the third rank as regards frequency, 
 and they were also found by Waldeyer and Kobuer. Besides 
 these observers, Parrot mentions them as occurring in several 
 of his cases, and Barensprung gives fragmentary details of a 
 case in which he observed a swelling of the upper part of one 
 femur which coexisted with a similar swelling on the lower 
 part of the opposite femur. Our knowledge of these swell- 
 ings, then, is not grounded upon clinical observation, but is 
 derived by induction from our study of the anatomical struc- 
 ture of the bone, and also from analogical facts observed in 
 these tumors when developed upon other bones of the body. 
 We know that the upper end of the femur has three distinct 
 centres of ossification, one for the head, another for the great 
 trochanter, and a third for the lesser trochanter, consequently 
 we can reasonably assume that these swellings might be deve- 
 loped at any one or at all of these sites. In case a swelling was 
 developed at the neck of the bone, it is probable that the cap- 
 sular ligament would prevent its recognition, and that it might 
 render its examination impossible. If, however, a swelling 
 was formed at either of the trochanters its existence could be 
 determined, even if it was only of moderate size, for in Ber- 
 tin's case, a swelling of the size of a pigeon's egg was found 
 upon the left great trochanter, and in Parrot's third case both 
 of the lesser trochanters were found to be affected. In Putes:- 
 
 O 
 
 nat's case, it is probable that the change took place at the 
 neck, and as the swelling underwent degeneration, a dislocation 
 of the bone was produced. This fact shows us the importance 
 of the early recognition of this syphilitic lesion of bone, and 
 the necessity of a prompt and efficient treatment. There is a 
 point of great interest relating to this portion of the femur, 
 which may be of value as regarding syphilitic tumors developed 
 here. It is this : early in extra-uterine life that portion of the 
 femur which includes the neck, as far down as the base of 
 the two trochanters, is composed of cartilage, and continuous 
 with the shaft below, which is already ossified; consequently, at 
 this spot the processes of development are very active, and are 
 very likely to be modified by syphilis. So that there is good 
 reason for supposing that we may find a swelling involving the
 
 System in Infants and Young Children. 75 
 
 whole breadth of the shaft at this position, which would, of 
 course, be proportionately larger. We are warranted, then, in 
 assuming that we may find syphilitic swellings at the junction 
 of the shaft with the upper portion of the bone ; that, like 
 those developed upon the lower end of the hnmerus, they may 
 be either generally distributed over the whole ossifying sur- 
 face, or may be localized at a given spot, in which case they 
 would be either the result of a local exaggeration of the mor- 
 bid process, or of that process being confined to that particu- 
 lar spot. As the surface of the femur is somewhat uneven, it 
 is probable that the surface of the swellings would not be per- 
 fectly smooth. Reasoning again by analogy, we should be 
 prepared to find either a symmetrical or an unsymmetrical dis- 
 tribution of these swellings on the bones of the two legs ; at 
 any rate, it is fair to presume that one localized spot might 
 be the seat of swelling on one femur, and another spot on the 
 other, or again a general swelling. Swellings on other bones 
 will in all probability be formed, and similar changes may 
 be observed at the other end of the femur, as was observed in 
 Parrot's case. 
 
 IX. THE ENLARGEMENTS OF THE CARPAL, TARSAL, METACARPAL 
 
 AND METATARSAL BONES, AND OF THE PHALANGES. 
 
 HAVING now studied the clinical features of the swellings 
 upon the long bones, we come, in anatomical continuity, to 
 the study of the lesions of the bones composing the hands 
 and the feet. Thus far, in our survey, we have been occupied 
 with syphilitic swellings developed at the junction of the dia- 
 physis of a long bone with either of its epiphyses ; now we 
 come to the consideration of the swellings produced by syphilis 
 in the short, irregular, and flat bones. In these latter the mode 
 of enlargement is not the same as upon the long bones ; for of 
 the short and irregular bones the whole structure is more or 
 less enlarged, while upon the flat bones peculiar, prominent, 
 and circumscribed swellings are variously distributed upon 
 their surface. The similarity in the general appearance of 
 the swellings of the short and irregular bones which com- 
 pose the hands and feet, as well as their intimate anato-
 
 76 Syphilitic Lesions of the Osseous 
 
 mical relations, renders their study together peculiarly appro- 
 priate. 
 
 The clinical history and pathology of the syphilitic lesions of 
 these bones in the adult subject ] have already been qnite fully 
 considered by me about three years ago, and last year* I called 
 attention to some of the features observed in the lesions of these 
 bones of the young child when afflicted with syphilis ; but as this 
 latter account was limited to a cursory description of the swell- 
 ings of the phalanges and metacarpal bones, it is necessary, 
 in keeping with other parts of the treatise, to go over the 
 whole subject systematically. Then, as there are certain well- 
 marked differences in the clinical features, and in the pathologi- 
 cal processes between the swellings in infants and in adults, a 
 separate description of them becomes the more necessary. 
 
 The clinical facts 3 which have thus far been elicited show 
 that any of the bones of the hands or feet are liable to syphilitic 
 lesions, and statistics show that certain of them seem to be more 
 prone than others. Commencing with the phalanges, we find that 
 they are very frequently involved. In Archambault's ca?e all of 
 the distal phalanges were found to be swollen ; in my two cases, 
 in Bulkley's two cases, and in Smith's case, the proximal 
 phalanges were swollen, and I have very recently seen two 
 other cases in which these same phalanges were enlarged. 
 When the swelling invades the third or distal phalanges, the 
 deformity is very striking, and the fingers have a bulbous 
 or clubbed shape, similar, in a measure, to the deformity 
 observed in syphilitic onychia. We have no recorded in- 
 stance of the second or middle phalanx being the seat of 
 
 1 On Dactylitis Syphilitica, Am. Journal of Syphilography and Dermatology, 
 Jan., 1871. 
 
 * Clinical Observations on the Syphilitic Lesions of the Bones of the Hands 
 of Young Children. Brown-Sequard's Archives of Scientific and Practical 
 Medicine, No. 4, 1873. 
 
 s Though attention is called in this work to swellings being more liable to 
 occur upon certain bones and upon certain sites rather than upon others, it is 
 not intended at all to convey the impression that there is any specific selection 
 of site or of a particular bone, as such a view would be unphilosophical and 
 untenable, as there is really no bone of the body which possesses an immunity 
 to the syphilitic action ; on the contrary, it is only intended to draw general 
 conclusions from what appears to be the most frequently occurring conditions 
 or coincidences in clinical practice, as from experience we know that such are 
 tolerably good guides for the deduction of general facts.
 
 System in Infants and Young Children.' 77 
 
 syphilitic lesion in very young children; bnt, judging from 
 the appearances observed in a case of simple enlargement of 
 the second phalanx in a very young child, I should say that 
 such a swelling would present very well-marked features. As 
 this case has considerable interest as regards diagnosis, I have 
 
 O O 7 
 
 thought it advisable to append it in a foot-note. 1 A finger thus 
 enlarged would of course be quite clunisy in its movements. 
 As all of the phalanges seem to be prone to syphilitic inflam- 
 mation, it is very probable that cases of enlargement of the 
 second phalanx will be observed hereafter. I have seen three 
 cases of syphilis in which this phalanx was swollen. One of 
 them was the patient whose history, in all its details, has 
 
 1 Sophie S. , a thin child and of slight build, aged five weeks, was sent to ine, 
 in August, 1871, by Dr. J. Aub, then of New York, now of Cincinnati, with a 
 view of determining whether or not it was the subject of hereditary syphilis, 
 and whether its lesion was dactylitis syphilitica. The child did not present any 
 syphilitic lesion or symptom, and a very careful examination of its parents 
 convinced me that they were not syphilitic. The index finger of the left hand 
 was very much enlarged, the swelling being greatest at the middle phalanx, and 
 from that region it gradually tapered off on each end. Examination showed 
 that this phalanx was enlarged uniformly, having a perfectly smooth surface. 
 The integument immediately over the swelling was very much stretched and 
 of a pinkish hue, elsewhere it was normal. Under the integument which 
 covered the enlarged phalanx a number of large vessels were readily seen. As 
 I was examining the finger, in the midst of an almost dazzling sunlight, I was 
 struck with the translucent appearance of it at this part, and when I shaded 
 its borders and held it up between my eye and the sunlight, the translucency 
 of the swollen phalanx was well marked ; so much so that any small object, 
 like the end of a lead-pencil, was dimly visible on its opposite side. The 
 smaller vessels were also rendered apparent in this examination. The finger 
 at the middle of this phalanx measured two inches and one-eighth, while its 
 fellow of the right hand measured fifteen-sixteenths of an inch at this part. 
 The swollen phalanx was very nearly as thick at each end as it was at its cen- 
 tral part. The mother informed me that the swelling had been observed at 
 birth, and that it was then fully as large as it was when I saw it, and she thought 
 that it did not give the child any uneasiness or pain. As the parents were 
 healthy, there was no reason for attributing the swelling to any inherited blood 
 disease, particularly as it was an unique lesion, and occurring, as it did, in utero, 
 traumatism was to be wholly eliminated as a cause. My diagnosis, then, was 
 that it was a simple hyperplasia of the cartilage composing the phalanx, and 
 that the proliferation had begun in all probability about the time when ossifica- 
 tion had commenced in the bone, probably about the tenth or twelfth week 
 of intra-uterine life. I am of the opinion, from the history of the case, that 
 the swelling consisted of unossified cartilage, and the translucence of the tis- 
 sue is somewhat in favor of such a view.
 
 78 Syphilitic Lesions of the Osseous 
 
 already been published by me ; ' the second was the case of a 
 man having tertiary syphilis and enlargement, of the first and 
 second phalanges of the right index finger. In both of these 
 cases the dactylitis resulted from acquired syphilis. The third 
 case was one of hereditary syphilis, and occurred in the person 
 of a boy, aged eight years, who, when five years old, among 
 other osseous lesions, had an enlargement of the second phalanx 
 of the left middle finger. I shall describe this case at some 
 length in an 'appended note, at a later portion of this work, for 
 by bringing out its points in a clear manner, and by contrasting 
 its features with similar ones observed in the young child, it will 
 convey a true idea as to the differences in the clinical history of 
 the osseous lesions of the bones of the hands as developed early 
 in hereditary syphilis, from those developed in later years. 
 
 By far the most frequently do we find that the first or proxi- 
 mal phalanges are the seat of syphilitic enlargement. Thus I 
 have observed it in my two cases, as in Bulkley's two case?,* 
 and it also occurred in Smith's case, making a total of five 
 against one in which the distal phalanges were swollen. The 
 deformity is very noticeable. The swelling may be slight, 
 but usually is quite well marked, enlarging the bone to twice or 
 thrice its normal diameter, its length being sometimes slightly 
 increased. The general shape of the bone in its breadth is 
 round, while it appears to have in its longitudinal direction an 
 oval shape. It is somewhat broader at its base than at its distal 
 end, the swelling beginning quite perceptibly at the metacarpo- 
 phalangeal joint, which it enlarges, and ending somewhat ab- 
 ruptly at the next joint. The shape of the bone may be compared 
 with that of an acorn. The rounded appearance of the body or 
 middle part of the bone can be distinctly felt on its dorsal sur- 
 face; but it is perhaps more perceptible to the eye on its 
 palmar surface, where this portion of the finger bulges out in 
 the various directions. The integument is generally very much 
 stretched, and it is probable that, when this condition is ex- 
 cessive, ulceration may be induced in it, as we know that the 
 integument of infants inflames under very slight irritating 
 
 1 Op. cit., page 13. 
 
 a I have also very recently seen, as I have said before, two other cases in 
 which the proximal phalanges were enlarged : in one, two fingers of one hand 
 and one of the other were affected ; in the other, one finger of each hand was 
 enlarged. The little finger was not swollen in either case.
 
 System in Infants and Young Children. 79 
 
 causes. We shall see further on that this ulceration of the in- 
 tegument may also result from localized degeneration of the 
 bony tumor itself. The integument may or may not retain its 
 normal color ; I have seen it of the natural hue, when the phalanx 
 under it was enlarged to fully twice its normal size. "When, 
 however, the bone-swelling is so great as to cause much inter- 
 ference with the circulation, a redness will, of course, appear, 
 which may be simply of a rosy blush, or even of a well-marked 
 venous color. This redness of the skin covering the phalanx 
 might sometimes lead the surgeon to fear that ulceratiou was 
 imminent, when really such a complication was very remote. 
 Thus, in the case of simple phalangeal enlargement just men- 
 tioned, as well as in one of the fingers of the case of Dr. Hanks, 
 the redness might have been, upon casual observation, regarded 
 as indicative of phlegmonous inflammation ; but an examination 
 of the suppleness of the integument, of its mobility though 
 slight over the parts beneath it of the absence of heat and 
 pain, and of the fact that slight pressure emptied the vessels 
 for a comparatively long period, convinced me that the process 
 was a passive rather than an active one. The condition of the 
 integument in these cases may be said to be generally that of 
 passive hypersemia, and that when the pressure from within is 
 excessive, acute inflammation may be induced. The integu- 
 ment being thus stretched, loses its slight furrows and surface- 
 markings, but at either end of the swollen phalanx, just over 
 each joint, a quite deep furrow or wrinkle is usually seen. 
 This hypersemic condition of the integument may or may not 
 present a characteristic syphilitic hue. Thus it may be simply 
 of a rosy red or even slightly purplish color, and it may remain 
 in this condition throughout its duration. Or, again, when it 
 has been fully developed, it may assume the somewhat coppery 
 tint peculiar to syphilitic subjects, in which event the feature 
 would perhaps have some little diagnostic import. I saw 
 this condition quite well marked in a case of this complication 
 in which ulceration supervened. However, I think it may be 
 asserted as a quite constant clinical fact, that very often, in 
 cases of tegumentary inflammation, either ulcerative or non- 
 ulcerative, this peculiar coppery tint is either slightly marked 
 or absent, and that it is not by any means as constant early in 
 hereditary syphilis as in adult acquired syphilis.
 
 80 Syphilitic Lesions of the Osseous 
 
 I am inclined to think that the greater or less degree of dis- 
 
 o o 
 
 tnrbance to the circulation and nutrition of the skin, and con- 
 sequently its more or less hyperaemie appearance, is dependent 
 on the fact as to whether the bony swelling has occurred 
 rapidly or slowly ; in the former condition the disturbance is 
 great, as the parts have not time to adapt themselves to the 
 bony expansion within; when, however, the swelling is slowly 
 produced the parts do adapt themselves to the increasing size, 
 the connective and fatty tissues undergo atrophy, and even the 
 skin itself may likewise be changed, and then there may be no 
 hypersemia at all. I saw this condition well exemplified, last 
 year, in a case of acquired dactylitis syphilitica, in which two 
 phalanges were increased to fully four times their natural size, 
 and in which the skin showed no hypersemic or ulcerated con- 
 dition. It had undergone great atrophy, its connective tissue 
 was perhaps nearly all gone, and it appeared as a very thin 
 tegumentary covering, readily movable over the bones. 
 
 I have several times noticed a very peculiar and deceptive ap- 
 pearance of the second phalanx, which might lead the observer 
 to suppose that it also was the seat of enlargement. As the ex- 
 panded distal extremity of the first phalanx ends at the joint, 
 the bone of the next phalanx rests, of course, by articulation upon 
 it, and the ligaments pass from the expanded part of the joint 
 to the other non-expanded end; consequently the whole struc- 
 ture appears enlarged, and as the skin over the enlarged part 
 is stretched out, and does not fit with perfect coaptation to the 
 bone until about opposite the other end of the second phalanx, 
 an appearance is presented as if the proximal half or third of the 
 second phalanx was also enlarged. A careful examination and 
 manipulation of the parts will show conclusively that the lesion is 
 confined to the first phalanx, and this view will be verified as 
 the case is examined from time to time when resolution is tak- 
 ing place. This same expanded condition of two phalanges, 
 the first and the third, was observed in the case of simple car- 
 tilaginous hyperplasia of the second phalanx, just cited. I have, 
 in one instance, seen this tapering condition of the finger so 
 well marked that my impression that the second phalanx was 
 swollen in a diminishing manner, from its base to its end, was 
 so strong that it was only removed by numerous and careful ex- 
 aminations, extending over some months.
 
 System in Infants and Young Children. 81 
 
 In a case of dactylitis from acquired syphilis, reported by 
 Nelaton, and quoted by me, 1 the statement is made that the 
 three phalanges of the fingers were swollen, the first mark- 
 edly, the second slightly, and the third in a scarcely appre- 
 ciable manner. I am inclined to think that the first pha- 
 lanx was the only one involved in the lesion, and that the ta- 
 pering shape of the finger resulting therefrom led to the 
 opinion that the morbid process involved the other phalanges 
 in a gradually diminishing degree. This view has the support 
 of two well-authenticated facts or observations; the first being 
 that a phalanx has never, as yet, been observed to be swollen 
 in a local manner by syphilis, it always having been found 
 totally and uniformly enlarged ; ' the second being that in every 
 recorded case where two phalanges of the same finger have 
 been swollen, the enlargement in each has been so great that no 
 doubt of its existence could be entertained. This point is of 
 very great interest, in a diagnostic point of view, as regards 
 rheumatoid arthritis. 
 
 It is interesting to know also that this tapering condi- 
 tion of the fingers is rendered more noticeable and charac- 
 teristic, when there is an infiltrated condition of the integu- 
 ments, whether due to inflammatory engorgement or to gummy 
 deposit. In these conditions the examination of the bones is 
 
 1 Op. cit., p. 7, Gazette des H5pitaux, 1860, pp. 105 and 106. 
 
 2 The details of all the cases thus far recorded tend to establish this as a 
 fact, and certainly prove that a tapering condition of the bones has never 
 been found. Yet, when we remember that the phalanges are essentially mini- 
 ature long bones in construction, consisting of a diaphysis and an epiphysis, and 
 also that at the junction of these segments syphilitic changes are prone to de- 
 velop, it seems reasonable to suppose that these local swellings might occur 
 here. Indeed, it is somewhat surprising that they have not been found al- 
 ready. Should such a development be noticed, the diagnosis would rest be- 
 tween syphilis and rheumatoid arthritis. In syphilis the swelling would begin 
 further down on the shaft, and should be more extensive than in the other af- 
 fection, the swelling of which should be localized at the joint structure, involv- 
 ing it in its entirety ; whereas in syphilis the enlargement would stop short at 
 the end of the phalanx. Of course, in arriving at a conclusion, the various 
 other concomitant circumstances should be taken into account. These con- 
 siderations apply more properly to the syphilis of more advanced age ; still, as 
 we meet with rheumatoid arthritis even in very young children, the suggestions 
 are important. This localized form of syphilitic swelling will be spoken of 
 in the section treating of enlargements of the metacarpal bones. Apropos of 
 this subject, it is well to mention that the epiphyses of all the phalanges are 
 situated at the proximal ends of the bones. 
 
 6
 
 82 Syphilitic Lesions of the Osseous 
 
 difficult, and the conclusions as to their size are perhaps render- 
 ed less accurate. But, as in infants we do not often find coex- 
 isting gummy infiltration into the integument of the fingers 
 and toes, this as a complication will perhaps never be met, 
 though of course it may be observed later on in the course of 
 the disease. Yolkmann's case, 1 which was quoted by me, with 
 its illustration, was that of a woman whose fingers of one hand 
 presented this tapering condition in a marked degree; the 
 lesion being both of the osseous and tegumentary structures. 
 
 There is no. mention in any of the recorded cases of heredi- 
 tary dactylitis syphilitica of any concomitant lesion of the nails, 
 and it is very probable that if such an affection should be syn- 
 chronously developed, that it would be an accidental rather 
 than a direct result of the bone enlargement. A furrowed con- 
 dition of the nail, similar to that observed after adynamic dis- 
 eases, was observed by me" in my case of dactylitis of acquired 
 syphilis ; but this condition resulted undoubtedly from the inter- 
 ference with the circulation and nutrition of the parts, caused 
 by a very copious gummous infiltration into the integument of 
 the toe. In the early form of hereditary dactylitis, as there is 
 never, as a rule, such a co-existing infiltration ' into the integu- 
 ment, it is very probable that there will not be any complicating 
 lesion of the nail, at least arising from that cause. As the nails 
 are composed of a modified dermal tissue, and are nourished 
 directly from the derma, any lesion of this tissue acts, of 
 course, upon the nails and impairs their nutrition. 
 
 Lancereaux 4 makes the suggestion that in acquired syphilis 
 the nails ma} 7 be affected by osteitis or periostitis of the last pha- 
 langes. I think that, for the reason above given, they are much 
 more likely to be involved when the derma is the seat of mor- 
 bid change, though they may be secondarily involved if the 
 
 J Op. cit., pp. 11-12. 
 
 * Op. cit., pp. 7 and 8. 
 
 * It will be shown further on that & very copious infiltration of the skin has 
 been met with in some of these cases, but it has always been of an inflamma- 
 tory character, not consisting of gummy granulation tissue, and has resulted 
 as a complication produced by the pressure of the bony tumor, or by being in- 
 volved in its degeneration. Being then a simple inflammation, it does not 
 seem to impair the nutrition of the nail, as a chronic infiltration has been 
 known to do. 
 
 4 Traite historique et pratique de la Syphilis. Deuxieme edition, Paris, 
 1873, page 178.
 
 System in Infants and Young Children. 83 
 
 osteitis or periostitis undergo degenerative changes. We have 
 no recorded instance of such a complication, though all of 
 the last phalanges were enlarged in Archambault's case, and 
 one of them was involved in Yolkmann's case, 1 there being 
 no coexisting lesion of the nail. I think that the possibility of 
 the coexistence of these lesions w r as suggested to Lancereaux's 
 mind in examining cases of syphilitic onychia, in which, as 
 usually occurs, there was a general enlargement of the pha- 
 lanx, due to secondary hyperplasia of the dense fibrous tissues 
 under the nail and around the bone. If such a case is critically 
 examined during its entire course, it will become clearly evident 
 that the lesion is limited to the nail, and that all other infiltra- 
 tions are simply the result of congestion. As onychia is very 
 often observed in hereditary syphilis, it is well to clearly under- 
 stand that it is essentially a lesion of the nail structures, and that 
 it does not in a direct way involve the bone, except, perhaps, 
 as a rare occurrence. 
 
 In this swollen condition of the fingers there is, of course, 
 some degree of distortion of their position. This is particularly 
 noticeable if the first phalanx is the seat of swelling, and is more 
 pronounced in proportion as the bone swelling is great, and when 
 it involves, as it generally does, the palmar surface of the bone, 
 the dorsal surface, of course, being proportionately enlarged. In 
 this event there will be observed a decided flexion of the mem- 
 ber, and it will be found that even firm and continuous pres- 
 sure will fail to straighten it. This condition results from the 
 pressure of the bony tumor upon the flexor tendon, and varies 
 with the course of the swelling ; so that if a case be followed 
 carefully it will be seen that extension returns very gradually 
 with the subsidence of the enlargement of the phalanx. It is 
 most marked in the case of the fingers, and not as much so when 
 the thumb is the seat of swelling. 
 
 Besides this temporary deformity, the swelling of a phalanx 
 affects the position of other fingers, particularly if the swollen 
 one is either the middle or ring finger ; in which case the others 
 are pushed to each side, when, being thrown out of their direc- 
 tion, their usefulness is somewhat lost. This fact can be well 
 brought out by giving the child a small thin article to clasp, in 
 
 1 Op. cit., page 12, and Berliner klinische Wochenschrift, No. 7, 1870.
 
 8-4 Syphilitic Lesions of the Osseous 
 
 which case the movement will be seen to be very awkward, and 
 the grasp to be unsteady. The everted condition of the fingers 
 is not as great when the index or little finger is swollen, and does 
 
 O 7 
 
 not exist when the thumb is involved. Whichever member is af- 
 fected, however, the usefulness of the hand becomes impaired. 
 
 Our study has thus far been, while treating of lesions of the 
 short and irregular bones, confined to the syphilitic swellings 
 of the phalanges of the fingers, it being fair to assume that the 
 bones of the toes are affected in a similar manner; in which event 
 they would present somewhat analogous phenomena. We have 
 not on record a case of hereditary dactylitis in infants affecting 
 the toes ; so it will remain for future observation to determine 
 the relative frequency of the lesion. To the extent of my read- 
 ing, the first direct record of syphilitic swellings of the fingers 
 and toes is in the treatise of Baumes, 1 who speaks of a case of 
 hereditary syphilis in a young child, the phalanges of whose 
 hands and feet were enlarged ; but the author alludes solely to 
 the swellings. But Mahon," in his work on the Syphilitic Dis- 
 eases of the New-Born, says that children afflicted with he- 
 reditary syphilis are subject, among other diseases, to softening 
 and curvature of the bones, particularly of those of the hands 
 and feet. Though we have not the recorded fact of an infant 
 the victim of hereditary syphilis presenting a swelling of the 
 phalanges of the toes, such a lesion was found by Yolkmann 3 in 
 his case of hereditary syphilis, the patient being sixteen years of 
 age. In this case all of the phalanges of one toe were swollen ; 
 but as the lesion was of the same nature as that produced by ac- 
 quired syphilis, the case is not applicable to our present study, 
 nor do the statements of Baumes or Mahon in any degree in- 
 struct us. 
 
 The various complications which may arise during the exist- 
 ence of these phalangeal swellings will be treated of at length 
 a little further on ; but it may not be inappropriate to state 
 here that degenerative changes of the bones are very fre- 
 
 1 Pr6cis thcoriqne et pratique des maladies veneriennes. Partie premiere, 
 page 178. Paris, 1840. 
 
 9 Recherches imporfcantes BUT 1'existence, la nature, et la communication dea 
 maladies syphilitiques dans les femmes enceintes, dans les enfants nouveau- 
 n&s, et dans les nourrices. Page 456. Paris, 1804. 
 
 3 Op. cit.. page 11.
 
 System in Infants and Young Children. 85 
 
 quently met with in the dactylitis syphilitica of infants and 
 young children, and that, resulting from these changes, there is 
 a greater or less implication of the integument. This fact will 
 be brought out as showing one point of difference between the 
 course of early and late dactylitis. There is no mention in the 
 records of any of the cases of any synchronous development of 
 joint-lesion in these phalangeal swellings, while such a compli- 
 cation is not at all exceptional in the later form of the trouble. 
 This point, which is also a distinguishing one, will be fully 
 brought out hereafter. Should, however, a joint complication 
 exist it would in all probability be a synovitis, with perhaps an 
 hydrarthrosis, both being secondary to the bone lesion ; in- 
 flammatory in its course, and attended with pronounced symp- 
 toms. As this is the condition, and as there is usually no gum- 
 my deposit at this age, the ultimate result would be that scarcely 
 any impairment of the part would be induced ; whereas if the 
 lesion was due to gummy infiltration, the course would be very 
 slow, and the result a greater or less destruction, with impair- 
 ment of the joint. 
 
 Taking, now, the various cases into consideration, it is inter- 
 esting to determine how frequently the phalanges are involved 
 in the syphilis of infants, as compared with the affections of other 
 bones. Thus, within this limit, I include eleven of my cases, the 
 two cases of Dr. Bulkley, and that case seen by me but once, 
 making a total of fourteen. Out of this number of cases of bone 
 syphilis the phalanges were found to be involved four times, 
 making a frequency not quite as great as that of enlargements 
 at the distal diaphyso-epiphysal junction, and slightly greater 
 than the swellings at the proximal junction, and also of bone 
 lesions elsewhere upon the body. Of these four cases, the bones 
 of the hands were involved symmetrically ' in but one case, 
 in which two fingers of one hand and two of the other were 
 enlarged; in a second case, two fingers of but one hand were 
 swollen ; and in two, one finger of one hand only was en- 
 larged. In Curtis Smith's case, three fingers of one hand 
 
 1 Of the two cases which I have seen since this work was written, in one 
 the lesion involved both hands, enlarging two fingers of one hand and one of 
 the other ; in the other case one finger only of each hand was involved. In 
 each the bones of the toes escaped, the phalanges being the only bones of the 
 body enlarged.
 
 86 Syphilitic Lesions of the Osseous 
 
 were affected, while in Archambault's case every finger was 
 said to be implicated. In the larger proportion of cases, then, 
 an unsymmetrieal development was observed, as is the rule 
 in the dactylitis of later life. The swelling of two or more 
 fingers seems to have occurred rather oftener than that of 
 one; yet in so limited a number of cases this slight differ- 
 ence cannot be greatly insisted upon. It is very probable that 
 in a large number of cases the unique and multiple develop- 
 ments would be in equal proportions. The case of Archam- 
 bault, in which every finger was involved, is very exceptional. 
 A perusal of the various cases shows clearly that in every in- 
 stance only one phalanx of each finger was enlarged ; never 
 were two thus affected. Besides this feature, which is peculiar, 
 there is no instance in which a local swelling of the bone was 
 observed, there being always an uniform enlargement. Per- 
 haps in these particular cases the localization of the lesion to 
 one phalanx of a finger was a matter of chance development ; 
 yet, as compared with this fact, we know that in four given 
 cases of late dactylitis syphilitica, two phalanges of the same fin- 
 ger would have been found to be synchronously enlarged once, 
 and perhaps more than once ; so that, as a comparative fact, it 
 is important. This synchronous affection of two phalanges will 
 be found hereafter to have considerable bearing upon the de- 
 velopment of joint-lesions, and its absence, perhaps, affords one 
 reason why in the early form of the affection we have not ob- 
 served an implication of these structures. Although we can- 
 not lay down the fact as a rule, that only one phalanx is in- 
 volved in this early form of dactylitis, the absence of a case 
 showing multiple enlargement of the phalanges of one finger 
 gives considerable weight to the fact, and we may thus accept 
 this as a tolerably constant peculiarity of this affection. It is 
 proper to state, however, that in Volkmann's case of hereditary 
 syphilis there was in several fingers enlargement of more 
 than one phalanx ; but this occurred in a person sixteen years 
 of age, and the lesion was of the character generally found in 
 a late acquired dactylitis, which we shall find differs materially 
 from the lesion of the infant life. Parrot found at the autopsy 
 an enlargement of the first phalanx of the right middle finger 
 in his second case. It seems that certain fingers are more liable 
 to this affection than others. Thus in the cases seen by me the
 
 System in Infants and Young Children. 87 
 
 thumb was affected twice, the index finger twice, the middle 
 finger once, and the ring finger once. In Smith's case, the 
 index, middle, and ring fingers were affected. From this it 
 would seem that the little finger is not frequently affected, as 
 there is no mention of the fact except in Archambanlt's case, in 
 which every finger was involved. As has been said before, the 
 first phalanx is the only one usually invaded, while the swell- 
 ings of the others are quite exceptional. These phalangeal en- 
 largements may coexist with other bone-swellings, as well as, of 
 course, with other varieties of syphilitic lesion. In the cases 
 thus far recorded the dactylitis was either coexistent with 
 swellings of the metacarpal, metatarsal and tarsal bones, or 
 existed as the only bone lesion. As we have already noticed a 
 decided predilection for syphilitic hyperplasise to develop 
 just at the junction of a shaft with an epiphysis, it seems singu- 
 lar that this form of swelling has not been found upon the 
 phalanges of the fingers and toes, as they also are composed of a 
 body and a distal epiphysis, which remains separate until about 
 the twentieth year. Not only has this form of swelling not 
 been observed in infants, but it has also never been met with in 
 the syphilitic swellings of adults ; for, as has been said before, 
 the swelling has in each instance been found to involve the 
 whole bone. It is interesting to bear this fact in mind, as the 
 occurrence of such a case is quite probable. 
 
 "We find that, like the phalanges, the metacarpal and meta- 
 tarsal bones are also swollen in cases of hereditary syphilis. 
 As shown by three cases, which illustrate enlargements of the 
 first and second metacarpal bones, these swellings are of greater 
 or less extent, and. are not locally developed, but involve the 
 whole length of the bones. In the hand the swellings of the 
 bones are greatest at their middle portion, and less at each end, 
 the bone, in its long diameter, having, consequently, a somewhat 
 oval outline. Though the bone is greatly increased in diameter 
 its length is not at all altered. In Morgan's case, which was that 
 of a child three years old, the metacarpal bone was enlarged 
 BO much that it measured two inches across, and in my 
 case the same variety of bone, in a child four years and four 
 mouths old, measured one inch and a half in diameter, while 
 the same measurement of its fellow was hardly half an inch. 
 According to present observation, the surface of these swell-
 
 88 Syphilitic Lesions of the Osseous 
 
 ings is smooth. The deformity produced by such prominent 
 swellings is, of course, very striking both on the palmar and 
 on the dorsal surface of the hand, where they present well- 
 defined and clearly limited elevations of the skin over the 
 particular bones involved. This clearly denned and limited 
 condition of the swelling becomes an important point in the 
 matter of diagnosis. The integument is, of course, more or less 
 stretched, and varies in hue according to this condition, as we 
 have found in the phalanges. The function of the finger spring- 
 ing from a bone thus swollen is somewhat impaired, as it is 
 not as steady in its movements as the others are, owing to the 
 fact of the interference with the working of the two tendons, 
 and the power of grasping various articles is somewhat lost. 
 Thus if the thumb of my patient was flexed towards the 
 ulnar side of the hand, it was found that it could not, nor 
 could it be made to touch the bone of the little finger by a dis- 
 tance of half an inch, an action easily accomplished on the 
 other hand. There can be no doubt but that in Morgan's case, 
 also, the usefulness of the hand was diminished, and that 
 the child could not hold anything with the combined action 
 of fingers and thumb. Though we have no instances of the 
 last three metacarpal bones being the seat of this enlargement, 
 we have no reason for supposing that such a condition might 
 not occur, when undoubtedly they would present the same 
 general features that have been observed in enlargement of the 
 other bones. As there is not a great deal of space, however, 
 between these last-mentioned bones, the swelling would not, of 
 course, develop itself as much laterally as it has been seen to 
 do in the cases already cited. The enlargement of the bone 
 would go on until those on each side no longer allowed it ; 
 then probably, if the lesion continued, the swelling would be 
 in the direction of the palm and of the dorsum of the hand. 
 When fully enlarged, under these circumstances, the bone, if 
 examined upon transverse section, would appear as if rounded 
 and laterally flattened. In the case of the first and second 
 bones there is no hindrance to expansion, as the ample triangular 
 space which exists between them allows of great swelling be- 
 fore it is filled up. In the event of the fifth metacarpal bone 
 being enlarged, it is very probable that the swelling would be 
 mostly developed towards the ulnar side of the hand, and there it
 
 System in Infants and Young Children. 89 
 
 might attain large proportions. These bones, according to present 
 observation, have only been found to be involved in two cases. 
 Turning our attention now to the foot, we study the swell- 
 ings of the metatarsal bones. In this instance we have very 
 few clinical data to guide us, as there is only one recorded 
 instance in which these bones have been found enlarged. 
 
 O 
 
 In this case the lesion was developed in the fourth and fifth 
 only. The swellings consisted of an uniform enlargement of 
 the bones, there being no noticeable difference in their diameter 
 at any part. There was, of course, considerable deformity ob- 
 served on the back of the foot, but the elevation of the integu- 
 ment was strictly limited to the region of the two bones. 
 To the touch, the enlargement was more evident on the dorsal 
 aspect of the foot, and the contour of the fifth bone more 
 clearly made out than that of the fourth ; of this, the por- 
 tion which rested against the side of the third bone could not 
 be clearly defined, and the line of separation between it and 
 the fifth not very accurately traced. But the examination 
 on this surface was not wholly unprofitable, as the bone 
 swellings could be satisfactorily localized ; whereas, when they 
 were traced, with every care, by the tip of the finger upon the 
 plantar surface, they could scarcely be distinguished as being 
 swollen. This I attributed to the density and resistance of the 
 plantar fascia, and also to the mass of the soft tissues under 
 and over it. I think that this observation establishes the fact 
 very clearly that swellings of the metatarsal bones cannot be 
 examined well on their plantar surface. Upon the palm, when 
 the first, second, and fifth metacarpal bones are swollen, I 
 think it will be found that their examination is both easy and 
 satisfactory, as at these situations the palmar fascia is not dense; 
 but when any of the intermediate bones are enlarged, I imagine 
 that their exploration upon this surface is as profitless as simi- 
 lar explorations on the plantar surface. 
 
 As the metacarpal and metatarsal bones are composed of a 
 shaft and an epiphysis, it is not improbable that in the heredi- 
 tary syphilis of infants, and even in acquired syphilis, up to the 
 age of twenty, swellings may be developed at their junction. 
 In this event the enlargements would be, for all except the first, 
 at the head of the bones, just near the metacarpo or metatarso- 
 phalangeal articulation, while at the first bone it would be at the
 
 90 Syphilitic Lesions of the Osseous 
 
 base, near its carpal joint. There is no record of such a case in 
 the syphilis of infants, but I have full notes of a case of here- 
 ditary syphilis in a girl twenty years of age, who, among other 
 most extensive and varied osseous lesions, had prominent swell- 
 ings at the heads of the third and fourth metacarpal bones of the 
 left hand, and a swelling at the base of the first metacarpal bone 
 of the right. This suggestion may explain cases in future 
 which might appear exceptional. As the epiphyses fuse 
 with their shafts at about the twentieth year, it is very proba- 
 ble that such swellings will not be met with after that period, 
 unless indeed the morbid process had begun previous to the 
 twentieth year ; though, as I have said before, this peculiar 
 localization of the swelling of the metacarpal and metatarsal 
 bones has not been observed in a living case of a syphilitic infant, 
 such a swelling was found, on post-mortem examination, by Par- 
 rot in his fourth case, in which the distal end of the fourth me- 
 tacarpal bone was found to be enlarged : a fact, I need not say, 
 of very great importance. This observer also found enlarge- 
 ments of the metacarpal and metatarsal bones in his third and 
 seventh cases ; as did Wegner and Waldeyer and Ivobner at 
 the autopsy in some of their cases. 
 
 In clinical practice the carpal and tarsal are even less fre- 
 quently swollen in syphilitic infants than any of the other 
 bones composing the hands and feet. From their size, structure, 
 and mode of growth, being composed of ossifying cartilage, it 
 is probable that when affected by syphilis they will be enlarged 
 in their whole extent. As lateral expansion is limited by their 
 close coaptation, the swelling will, of course, point in the di- 
 rection of the palm or sole, or of the dorsum. As the outlines 
 of these bones cannot be clearly defined in the normal con- 
 dition, so their examination when swollen will not result in 
 perfectly definite conclusions. At the wrist the exploration 
 can be made either on the internal or external aspect, but at the 
 instep it must be conducted at the dorsuin. In cases of enlarge- 
 ment of the astragalus, os calcis, or the other bones of either 
 feet or hands, more externally, or rather, laterally situated, 
 probably their outline could be followed with more pre- 
 cision. In the one case observed by me, in which one of the 
 tarsal bones it being probably the middle cuneiform was swol- 
 len, the instep appeared enlarged laterally and in height, and
 
 System in Infants and Y^ung Children. 91 
 
 measurement showed that its circumference was greater by half 
 an inch than that of the unaffected foot. The contour of the 
 bone could not be defined, but the appearance was one of 
 localized swelling. The condition of the parts in this case was 
 rendered more difficult of examination as there was some syno- 
 vitis of the small joints, and hypersemia of the integument. 
 Thus in this, the only case recorded, there were inflammatory 
 complications. As we know that these syphilitic swellings of 
 bone are mostly indolent in character, it is fair to presume that 
 we shall find this condition to obtain in these situations, and 
 that this was perhaps but an exceptional case. However, when 
 we consider that these bones enter largely into the formation 
 of joints whose use is constant, and that in a considerable part of 
 their surface they are covered with synovial membranes, and are 
 consequently more than ordinarily vascular, the suggestion 
 forces itself upon us that here the conditions are favorable to 
 the development of synovitis and tegumentary inflammation ; 
 for which reason they may often coexist, and form a com- 
 plicating feature in these cases. In this event, if the com- 
 plications are well marked, it can be understood that the 
 original lesion may not be recognized, and even perhaps lost 
 sight of. This would almost undoubtedly occur if the case was 
 seen late in its course. This condition may perhaps explain 
 many of the cases of so-called strumous inflammations of these 
 bones and joints, and should be borne in mind, I think, in 
 diagnosticating swellings and synovitis of these parts. The in- 
 flammation of these bones, then, in syphilitic children, presents 
 points of very great clinical interest. They have been found by 
 Parrot and Wegner to be enlarged at post-mortem examination. 
 
 X. THE SWELLINGS UPON THE CRANIAL BONES AND UPON THE 
 BONES OF THE FACE. 
 
 Before treating of the lesions of the various other irregular 
 bones, we will consider those of the skull. The swellings or 
 nodes on the cranial bones are more or less circumscribed, and 
 are variously scattered over their surfaces. Though a large 
 number of cases have been reported, from time to time, within 
 the past ninety years, these swellings may yet be considered as 
 quite unfrequent. Thus, occurring only once in my experi- 
 ence, they have a proportion of one in fifteen, being one of
 
 02 Syphilitic lesions of the Osseous 
 
 the most infrequent of the lesions of the bones of young 
 children. This is, in iny experience, in marked contrast with 
 their frequency in the hereditary syphilis of later life, among 
 which I have seen three instances of these swellings, and, of 
 course, widely differing from their comparative frequence in the 
 acquired syphilis of adults. From the number of cases on record, 
 and from my own case, I think it may be assumed that certain 
 of the cranial bones are more liable than others to the develop- 
 ment of nodes in infants. Thus the frontal was the seat of 
 them in four instances : in my fourth case; in that of Roger ; 
 in Parrot's third ; and in Wegner's third case. The parietal was 
 involved in three instances, namely, in Bare nsp rung's, Des- 
 marres. 1 and in Wegner's fifth case. The occipital was affected 
 in one instance, namely, Desmarres' case, in which also the pari- 
 etal was involved. The description of the nodes in syphilitic 
 infants, judging from my own case, and that of Roger, is similar 
 to that of the same lesions of adults. They consist in well-de- 
 fined, round, or oval tumoi-s of varying size, from quarter or half 
 an inch to even an inch or more in area, having a height aver- 
 aging within three-quarters of an inch, and a smooth, rounded 
 surface. Wegner speaks of slight elevations of the cranial peri- 
 osteum of the size of flaxseed, as being quite commonly found 
 at the autopsy, so that we may meet cases in which these minute 
 nodes are developed. They are due to cellular hyperplasia. In 
 my case the nodes disappeared gradually under treatment, with- 
 out any inflammatory complications ; but I have been struck 
 with the fact that in the cases of Barensprung," Desmarres, 3 and 
 Parrot, 4 they underwent quite rapid degeneration, and gave rise 
 to extensive ulcers. Doublet,* in his treatise, also speaks of the 
 suppuration of tumors of the cranial bones. These facts would 
 certainly point to a peculiar tendency to degenerative changes 
 in this region, and should, of course, be borne in mind in 
 the diagnosis of suppurative inflammations of the head. It is 
 well to mention, however, that in these cases the syphilis was 
 very severe. When the tumors assume an inflammatory condi- 
 tion, and they have then been known to involve very extensive 
 
 1 Traito theorique et pratique des maladies des yeux. Deuxieme edition, 
 tome i., page 626. Paris, 1854. 
 
 8 Op. cit. ' Op. cit. 4 Op. cit. 
 
 * Memoire sur les symptomes et le traitement de la maladie ven6ricnne 
 dans les enfants nouveau-nos. Paris, 1781.
 
 System in Infants and Young Children. 1>3 
 
 su rf aces, I can readily see how they might be mistaken for ab- 
 scesses, particularly if late in their course, or if for any reason 
 the surgeon is unable to elicit a clear history of the commence- 
 ment of the process. The diagnosis can, of course, be established 
 by the history and concomitant lesions, and by the fact of the 
 deep-seated sub-integumentary position of the swellings when 
 first discovered. Then, again, when an incision is made, the depth 
 of the ulcer and its appearance, and perhaps the extrusion of 
 portions of dead bone, will settle the question as to the focus of 
 the morbid process. A point which is important, as showing 
 that in their course these nodes in children may resemble those 
 in adults, is brought out by my case, in which, after the resolu- 
 tion of the nodes, a distinct depression in the surface of the fron- 
 tal bone on the site of each swelling was found. This is not un- 
 common in adults, particularly when the cases have been neglect- 
 ed, and the nodes have remained for very long periods. It shows 
 distinctly that in the resolutive process fatty degeneration had 
 involved portions of the bone structure, as well as of the cell pro- 
 liferation and heterologous tissue incident to the inflammation. 
 Though hardly material to our present consideration, I think 
 it is well to mention the fact, that the internal surface of the 
 cranial bones has also been found to be altered in syphilitic 
 infants. Thus a case of abscess of the internal table of the fron- 
 tal bone is mentioned by Howitz, in the Hospitals Tidende, 
 and quoted by Behrend. 1 Cruveilhier * found in a case of 
 a syphilitic child an abscess between the dura mater and 
 the orbital plates of the frontal bones near its vertical por- 
 tion. Charrier " found an abscess of the internal table of 
 the frontal bone, as did Bargioni, 4 in the case already de- 
 tailed. "Wegner found internal cranial periostitis in two in- 
 stances, and Waldeyer and Kobner in one. These facts show 
 that in very severe forms of syphilis in infants these bones 
 are very liable to be affected, either on their external or inter- 
 nal aspect, which nodes may be the only osseous lesions ob- 
 served, as they were in the cases of Desmarres, Charrier, Bar- 
 
 1 Ueber syphilitische Knochenleiden und ein eigenthiimliches noch wenig 1 
 bekanntes syphilitiscb.es Lungenleiden bei kleinen Kindern. Syphilidologie, 
 Neue Reihe Dritter Band, pages 602 and 3. Leipsig, 1862. 
 
 2 Atlas d' Anatomic Pathologique. Obs. 10, livraison 15. page 6. Paris. 
 
 3 Cas de Syphilis infantile. Gazette des Hopitaux, No. 43. 1854. 
 
 4 Op. cit.
 
 94 Syphilitic Lesions of the Osseous 
 
 onsprung, Behrend, and Howitz, or they may be coexistent with 
 lesions upon other bones, as in my case, in Roger's, and in Parrot's. 
 
 Very little can be said of syphilitic lesions of the bones of 
 the face, as they seem to enjoy the same general immunity in 
 syphilitic infants which they do in the acquired syphilis of 
 adults. The only direct mention of any of these bones being 
 affected occurs in the history of Parrot's third case, in which a 
 thickening of the right coronoid process of the inferior maxil- 
 lary bone was found, as well as the same condition at the sym- 
 physis menti. As it is a matter of some considerable doubt 
 whether the coronoid process of this bone is developed from a 
 separate centre, we are unable to say positively whether in this 
 instance the lesion was of the same character as that observed 
 at the junction of the diaphysis with the epiphysis of long 
 bones, or whether it was a periostitis, but it is very probable 
 that at the symphysis the lesion was of the first order. In his 
 treatise upon diseases of children, Rosen de Rosenstein ' says, 
 that in order to determine whether a child has syphilitic osseous 
 lesions, it is necessary to examine the condition of the inferior 
 maxillary, the cranium, and the bones of the arms and legs, for 
 tumors and exostoses. This statement renders it probable that 
 this Swedish observer had also seen this bone affected in the 
 syphilis of infants. 
 
 The necroses of the nasal and palate bones, which occurs 
 during long-continued severe syphilitic ulceration of the mucous 
 membranes covering them, need but a passing mention, as they 
 are quite fully described in the various general and special 
 works on the diseases of children. Rosen speaks of a case of 
 necrosis of the hard palate following syphilitic ulcers of its 
 mucous membrane ; a complication of lesions which I have seen 
 twice in hereditarily syphilitic children aged six and eight years. 
 
 XI. THE SWELLINGS ON THE VARIOUS IRREGULAR BONES. 
 
 In clinical practice tumors upon the ossa innominata, sacrum, 
 coccyx, vertebrae, and scapula have not been found. At the 
 autopsy of several children they have been observed by Valleix, 
 Parrot, "Wegner, Waldeyer, and Kobner to be the seat of syphi- 
 litic change. Most of these bones are so deeply situated that 
 their exploration is difficult, if not impossible ; therefore it is 
 1 Traite des maladies des enfants. Trad, franj. Paris, 1793.
 
 System in Infants and Young Children. 95 
 
 very probable tbat very little will ever be learned of these swell- 
 ings in clinical practice. The cardinal point to remember in the 
 examination of these cases, when swellings are discovered upon 
 them, is, that syphilitic changes are peculiarly liable to develop 
 wherever the body of a bone is continuous with an epiphysis ; 
 but of course we may find periosteal swellings on the surfaces 
 of the bones. The diagnosis then may be arrived at by elicit- 
 ing the history of the case, and by remembering the various 
 anatomical points regarding the mode of ossification of the bone 
 in question. Should the patella become the seat of syphilitic 
 inflammation it would be enlarged after the manner of the tar- 
 sal bones. 
 
 Xn. THE DEVELOPMENT, COURSE, AND DISTRIBUTION OF THE 
 OSSEOUS SWELLINGS. 
 
 Such, then, being the situation, distribution, and general cha- 
 racter of these swellings, it remains for us, in our study of their 
 clinical history, to trace their development, course, and decline, 
 and also to consider the various concomitant symptoms and 
 lesions incident to their existence. From a careful study of all 
 of the cases, we observe that there are two principal forms or 
 modes of development of these osseous enlargements ; the first, 
 in which the swelling is developed with comparative slowness, 
 and the second, in which it is rather rapidly formed. Although 
 no division can be so sharply drawn as to apply perfectly to 
 every case, the present one will answer quite well the purpose 
 of simplicity of description, by laying down general facts, and 
 by forming a standard with which exceptional features and cases 
 may- be compared. In determining the rapidity with which 
 these swellings form, it will be seen that there are certain draw- 
 backs to be encountered. Thus, the child is always a passive 
 agent, and cannot contribute any information, and as the swell- 
 ings are not usually markedly salient, it is difficult to trace their 
 progress in an accurate manner, particularly as the amount of 
 increase is very slight. Then again, owing to various causes, 
 they may escape observation until late in their course, so that 
 under these circumstances we are frequently forced to resort to 
 inductive reasoning; as, for instance, having ascertained the 
 child's age, and, if possible, the date of commencement of the
 
 96 Syphilitic Lesions of the Osseous 
 
 swelling, we take into consideration its size, and from these 
 points form an approximative idea of Ihe rapidity with which 
 it has been formed. In the main, however, our inquiries are 
 attended with conclusions sufficiently satisfactory. 
 
 The swellings on the various bones are developed within a 
 period averaging between two and six weeks, generally in th? 
 neighborhood of a month. This average was found quite con 
 stantly in the cases of swellings of the long bones near the epi- 
 physes, and in others generally of coiisiderable extent. It is 
 very probable that they are never formed in less time than two 
 weeks, except in very severe cases, and that they always attain 
 their maximum size within two months. In some instances of 
 circumscribed swellings of local distribution, as at either of the 
 condyles of the humerus, and at the base of the olccranon, or in 
 limited portions of a diaphysal ossifying surface, in which the 
 enlargements are not usually great, it is probable that about two 
 weeks are occupied in their production. 
 
 Little need be said, more than has been already, as to the size of 
 the various swellings. Those of thediaphyso-epiphysal junctions 
 are never, as a rule, extremely large. The histories of the various 
 cases show that on the radius and ulna the swellings, on an aver- 
 age, reach an elevation of from one-half to three-quarters of an 
 inch above the normal plane of the bone, and that upon the 
 tibia and fibula they attain a somewhat greater height ; it being 
 very probable that these measurements are about the maximum 
 which will be observed, for the reason that in cases in which 
 a greater enlargement has occurred, degenerative changes have 
 been engrafted upon the swellings when they have surpassed 
 this limit. According to my observations the difference between 
 the normal and abnormal circumference of the wrists averages 
 between three-quarters and one inch, while at the ankles the 
 difference is from one and a half to two inches. 
 
 Having reached the various limits of enlargement, these swell- 
 ings evince a tendency to run an indolent course without any 
 apparent change, in which condition structural changes of the 
 bones may be induced, such as sclerosis and hypertrophy. But 
 if appropriate and efficient treatment is instituted early, and 
 followed sedulously, the swellings subside, and the bones are left 
 nearly in a normal condition. This fact points strongly and 
 significantly to the absolute necessity of treatment, and also
 
 System in Infants and Young Children. 97 
 
 shows the necessity of accurate diagnosis in determining the 
 nature of the tumors. The study of the various groups of cases 
 warrants us in speaking with considerable precision as to the 
 duration of these swellings, and of asserting that it depends on 
 the following points : the extent and density of the swelling ; 
 the earlier or later period at which treatment is instituted ; and 
 the care with which it is ordered, modified, and followed up. 
 Thus, if the swelling is not very large, and has been two months 
 in forming, it is very probable that two months, at the most, of 
 active and regular treatment will cause its subsidence. If, on 
 the contrary, it has occupied a longer time in forming, and is of 
 considerable size, a proportionately longer time, say about four 
 mouths, will be wanted. The rule is simply this, and it applies 
 with equal force to very many other syphilitic lesions of neo- 
 plastic character, that if the cell-proliferation which constitutes 
 the swelling is young and recent, and has not remained in the 
 tissue framework of the part long enough to become, if we 
 may say so, assimilated, or thoroughly incorporated, it may be 
 quite rapidly removed without having produced structural 
 change. If, however, the cell-proliferation has become old 
 and thoroughly mingled with the tissue framework of the parts, 
 its removal is slow, and certain structural changes are almost 
 inevitably induced ; the final result is better, however, if treat- 
 ment is instituted, even late. In illustration of the first pro- 
 position I cannot offer a better example than that of my eighth 
 case, in which the swelling of a metacarpal bone was- quite large, 
 and in which treatment was instituted immediately upon its 
 development, when, being followed up regularly, full resolution 
 was brought about in two months, leaving the bone, to all ap- 
 pearance, in a normal condition. Whereas the chronicity of 
 these swellings, and their production of structural change when 
 treatment is commenced at a late period, is well illustrated by 
 my sixth case, in which it was instituted at the fourth and a half 
 month of the existence of a bone-swelling of considerable size, 
 and in which seven months elapsed before its subsidence was 
 induced. Then, again, Bulkley's second case is an instance 
 showing that a very long continuance of the bony enlargement, 
 without the intervention of treatment, may result in a perma- 
 nent alteration and hypertrophy of the bone, over which treat- 
 ment has scarcely if any influence whatever. In this case one 
 7
 
 98 Syphilitic Lesions of the Osseous 
 
 bone had been affected eighteen months, and the other one year. 
 So we may conclude that if treatment is not adopted within six 
 months of the development of these tumors, the ultimate results 
 are not favorable, but that more or less profound structural 
 change will remain. It will also be seen that early treat- 
 ment exercises a most powerful and salutary influence over 
 these swellings. The natural tendency to resolution without 
 therapeutical intervention is very slight, but still it has been 
 observed, in a very limited degree, in some of the cases. The 
 average duration of these swellings, then, when uncomplicated 
 by degenerative changes or by lesions of neighboring tissues, 
 may be stated to be about three mouths. . 
 
 In these uncomplicated cases, as well as in those in which 
 proper treatment is followed, the bones, as far as can be ascer- 
 tained by examination, are found to be, after the subsidence of 
 the swellings, in a normal condition ; or, if they are at all altered, 
 the changes are so slight that they would have escaped recogni- 
 tion unless the previous history of the case was known, so that, 
 in general, we may take it as a rule that no serious results will 
 follow. 
 
 In regard to the distribution of these osseous swellings, it 
 seems that the rule is, as shown by the greater proportion of 
 cases, that a number of bones should be affected at the same 
 time, and that the swellings should be quite generally and sym- 
 metrically distributed. These facts are well shown by the cases 
 in which both ankles and wrists, as well as other portions of the 
 skeleton, are involved. Then again there are instances of more 
 than one bone being affected, but not in a symmetrical manner ; 
 and it will even be found that in some cases a single portion of 
 a bone is attacked. As these latter cases are not as numerous 
 as the former, we may conclude that in the point of distribution 
 of osseous lesions in young children, a symmetrical and quite 
 general development is the rule ; to which, however, there are 
 certain exceptions. It would seem that in clinical practice the 
 exceptions consisted mostly in those cases in which such bones 
 as the phalanges, metacarpal, metatarsal, and tarsal bones were 
 those affected. When we contrast the development and distri- 
 bution of the osseous lesions in these cases, we observe that, in 
 these particulars, they resemble very closely those of the vari- 
 ous cutaneous lesions.
 
 System in Infants and Young Children. 90 
 
 There is still another point of considerable interest relating to 
 the development of these swellings ; it is, that they usually 
 all appear synchronously, and then run the same course. In 
 certain very unusual instances this character is wanting, 
 and we meet two, and even three series of osseous swellings. 
 In these cases the first is usually a general and symmetrical de- 
 velopment, and the second and third consist of one or more en- 
 largements, usually, however, unsymmetrically placed. In these 
 cases, however, the first series even may have consisted of a 
 local and nn symmetrical distribution. According to the facts 
 to be gathered from the records of our cases, these relapsing 
 series have all appeared within a year after the invasion of 
 syphilitic lesions, and at the longest time four and a half 
 months after the development of the preceding series ; gener- 
 ally an interval of three months elapses between each crop. A 
 very significant fact, however, is to be noted, in this connection, 
 namely, that in every instance in which more than one crop 
 of osseous swellings has been observed, no treatment had been 
 instituted. This fact points strongly to the suspicion that 
 in many of the cases more bones than those which are detected 
 as being involved in the morbid process are thus affected, but 
 that treatment had removed the nascent pathological changes. 
 In this connection it is interesting to mention again the fact that 
 in the post-mortem observations of Wegner, Waldeyer, Kobner, 
 and Parrot, they very frequently found gradations of pathologi- 
 cal change, and that in the same subject the most pronounced 
 lesions of one bone coexisted with incipient lesions in another. 
 This fact also proves the truth of Bertin's * surmise, made so 
 many years ago, that it was probable that syphilitic lesions 
 would be more common than they were if treatment was not 
 regularly followed. I have noticed, in those cases in which the 
 osseous lesions appeared in crops, that when under treatment they 
 disappeared, their resolution was very nearly synchronously ac- 
 complished, and that a proportionate length of time did not inter- 
 vene in this process as did between their periods of development. 
 
 Xin. THE EFFECT OF THE OSSEOUS ENLARGEMENTS UPON THE IN- 
 TEGUMENT AND UPON THE JOINTS 
 
 THE integument is usually not at all involved coincidently 
 1 Op. cit. page 362.
 
 100 Syphilitic Lesions of the Osseous 
 
 with the bone-lesions, but in some exceptional cases has been 
 found to be secondarily inflamed. Tbe inflammatory process 
 in it varies in intensity from slight hypersemia to deep ulcera- 
 tion. The causes of this hypersemia and ulceration are of two 
 kinds, the one resulting from simple pressure of the bony 
 swelling underneath, the other from the activity of the lesion 
 of the bone. The results vary with the cause ; for whereas, in 
 the former instance, in which pressure is the excitant, a greater 
 or less hypersemia results, and in certain somewhat rare in- 
 stances even ulceration, in the case of the severity of the in- 
 flammatory processes in the bones a lesion of continuity of 
 greater or less intensity and of varied form is induced. The 
 hypersemia from pressure has been well shown in one case of 
 extensive enlargement of a phalanx, and it is in the region of 
 the fingers the tendency is most marked. This, of course, 
 is due to the tightness of the investing integument, and per- 
 haps to the excessive mobility of the parts. As the records 
 of the various cases clearly show, swellings even of quite con- 
 siderable size at the epiphyses are not complicated with dermal 
 change, for the reason, undoubtedly, of the looseness of the 
 covering integuments. It will be seen hereafter that, in cases 
 of synovitis, the integument may become red ' and inflamed. 
 As has been remarked already, the swelling of the bone may 
 take place so slowly that no change is induced, as the integu- 
 ment accommodates itself to the gradually increasing pressure. 
 It might seem at first sight somewhat singular that even in 
 cases of well-marked bony enlargement near joints, the lat- 
 ter structures should escape, even though the lesions are of 
 so chronic a character; yet such is the clinical fact. A study 
 of the anatomical peculiarities in the instances where ar- 
 ticular complications have been observe'd, will, I think, afford 
 good and convincing reasons for this. Out of all of the various 
 clinical cases, only three joints have been inflamed, yet in 
 certain of the cases of Parrot, in Yalleix's, and Bargioni's, a 
 total destruction of joints was found; but this will be shown, 
 further on, to be essentially a different and more exaggerated 
 process. The three instances are as follows : first, the elbow-joint, 
 in which the lesion involved the whole distal ossifying surface 
 of the humerus ; second, the same joint, the lesion being an 
 enlargement of the ossifying base of the olecranou ; the third,
 
 System in Infants and Young Children. 101 
 
 an enlarged tarsal bone with synovitis of the joint. When we 
 examine the structure of the humerus at its lower end, we find 
 that the shaft joins its epiphyses quite low down, even within 
 the joint proper, and that the synovial membrane is reflected 
 upon the point of junction of the shaft with the epiphyses. In 
 the case of the olecranoii process, the ossifying portions are also 
 inclosed within the joint, at the junction of the base of the 
 process with the shaft ; the tarsal bones also are surrounded 
 nearly to their full extent with joint structures ; so that we see 
 distinctly that the liypeneinia and cell proliferation in these in- 
 stances goes on in positions where quite extensive synovial mem- 
 branes exist ; on which account it is fair to suppose that a sympa- 
 thetic or synchronous hypersemia is set up in this so vascular 
 membrane, resulting from which and from movement of the parts 
 we have eifusion and its concomitant symptoms of swelling, red- 
 ness, pain, and impairment of function. As these anatomical 
 reasons are so clear, and as articular complications have not been 
 observed when the swellings have been developed, owing to the 
 normal relation of the parts at considerable distance from joints, 
 as at the junction of the shafts of the radius and ulna, and tibia 
 and fibula, we are certainly warranted in accepting them as the 
 true explanation, and of drawing the evident conclusion that in 
 the mild form of these osseous swellings articular complica- 
 tions are only liable to arise when the shaft and epiphysis unite 
 at or within a joint. 1 As was remarked in a previous part of 
 this essay, the joints of the metacarpal bones and phalanges 
 have not been found to be implicated, yet the conclusion now 
 deduced renders it very probable that these structures might 
 undergo change in this position. The lesion, as judged of 
 from clinical data, is 'a simple hypersemia of the synovial mem- 
 brane, and consequent effusion, which, as thus far observed, 
 has not been very copious. There is no reason for supposing 
 that there is any infiltration into the joint structures, such as 
 we find in late acquired syphilis, as well as in the late form of 
 
 1 This fact is also all the more clearly brought out in the history of personal 
 cases Nos. 10 and 11; for in them the morbid processes at the junction of the 
 epiphyses and diaphyses of the lower end of the tibia and fibula went on to 
 8\ich an extent that separation of these segments resulted, yet left the joints 
 wholly intact. It must be remembered, however, that the junction of these 
 segments is usually rather more than an inch from the joint, and that thero 
 are no synovial prolongations from it.
 
 102 Sypldlitic Lesions of the Osseous 
 
 bone syphilis in children of various ages. The tendency of the 
 condition is to ameliorate with the subsidence of the osseous le- 
 sion, and may be regarded as of a simple and ephemeral char- 
 acter. 
 
 XTV. THE DEGENERATIVE CHANGES WHICH MAY OCCUR IN THE 
 
 OSSEOUS SWELLINGS. THE SUPERFICIAL FORM. 
 
 THOUGH, as we have seen, these bony swellings usually run 
 an indolent course, and, as a rule, subside without undergoing 
 degeneration, there are certain somewhat rare cases in which 
 destructive changes become engrafted upon them. As has been 
 hinted before, these degenerative changes may be divided 
 into two varieties, each of which has clearly denned features. 
 In the first variety the destruction is limited to the more superfi- 
 cial parts of the swelling, whereas, in the second, the degenera- 
 tion involves its whole breadth, usually corresponding to the 
 whole extent of the ossifying surface, in which case a separa- 
 tion of the epiphysis from the diaphysis occurs. 
 
 The superficial form of degeneration was observed in two 
 of my cases and in one of Bulkley's, while the second form was 
 observed in my tenth and eleventh cases. The bones thus 
 affected were the tibia and fibula, radius and ulna, phalanges, 
 metacarpal, metatarsal, and tarsal bones. As thus far observed 
 the swellings have first reached their maximum of enlargement, 
 and then the degenerative changes have become engrafted 
 upon them ; but, of course, cases may occur in which this com- 
 plication will follow closely, or be coincident with the full 
 formation of the swelling. The earlier features of this process 
 are very liable, for obvious reasons, to escape observation ; still, 
 attention may be drawn to them quite early. A localized in- 
 crease of the swelling is first found on the most prominent 
 part, when very soon the integument participates in the inflam- 
 mation, and fluctuation is soon felt. An opening then forms, 
 or an incision is made which ulcerates, the ulceration usually 
 going on until it occupies a space corresponding to the size of 
 the necrotic spot on the bony tumor. There is no tendency, 
 or such has not been observed, of this ulceration to increase 
 beyond these limits. When fully developed, the parts present 
 the following appearances : an elevation of the integument, of
 
 System in Infants and Young Children. 103 
 
 greater or less height, upon which is an ulceration of varying 
 size, from half an inch or less to even an inch and a half, and 
 of a round or oval figure. The edges of this ulcer are un- 
 dermined, slightly everted, red, and thick, while the base is of a 
 brownish green color, formed of necrotic tissues, from which a 
 fetid, sanious pus in small quantity escapes. The tegumentary 
 tissues for a slight distance around are red and inflamed. The 
 ulcer resembles very much an ulcerating gumma, and cer- 
 tainly might be mistaken for such. Critically examined, this 
 ulcer presents the following points : it is of considerable depth, 
 seemingly, at its middle, about half an inch in some cases ; if its 
 edges are moved or slid towards the bone with the tip of the 
 finger, it will be quite distinctly seen that the latter is immov- 
 able, and this point can be observed if any portion of the edge 
 be thus manipulated. Then if the base be carefully examined 
 with the end of a probe, it will be found to be somewhat hard 
 and resisting after the instrument has got through the thin film 
 of necrotic tissue. These points distinctly prove that the ulcer 
 has bony tissue as its base, and if we know the history of the 
 case we may be certain that the tegumentary changes are second- 
 ary to the necrosis of the osseous tumor. It is very probable 
 that a simple sinus may form instead of an ulcer, owing to a 
 greater limitation of the necrosis in the bone and derma ; a point 
 which it is well to bear in mind, that we may not expect in every 
 instance to find such ulcers as those just described. The reasons 
 for this suggestion will appear further on. 
 
 The length of time required for the cure of the cases with 
 these complications was about four months. Though, as I have 
 said before, the general appearances of this ulceration, which is 
 secondary to the osseous necrobiosis, resemble that of an ulcerat- 
 ing gumma, it may assume, during its course, features which 
 might perhaps render it liable to be mistaken for a scrofulous 
 ulcer ; thus the base may become covered with more or less pro- 
 fuse, tough granulations, and the edges may assume the callous 
 purple appearance of scrofulous ulcers, and become markedly 
 everted. In this event I can readily suppose that it would be 
 classed as scrofulous. Yet if the history be carefully looked 
 into, these adventitious appearances will be explained. This 
 further complication is only liable in case of neglect and 
 delay of treatment. The resulting cicatrix may be of variable
 
 104 Syphilitic Lesions of the Osseous 
 
 appearance, either thin and depressed, rendered uneven by 
 fibrous bands, or adherent to the bone. 
 
 XV. THE SEPARATION OF THE EPIPHYSES FROM THE DIAPIIYSE8. 
 
 THE most extensive form of degeneration of these osseous 
 swellings, in which there is a separation of the epiphysis from 
 the diaphysis, appears also to be the rarest in clinical practice. 
 This feature has only been observed in two of my cases, and 
 they are, at present, unique in literature, there being no other 
 recorded cases. But in many of the cases of Wegner, Parrot, 
 "Waldeyer, and Kobiier, as in those of Yalleix and Bar- 
 gioni, a distinct separation of the epiphyses from the diapliy- 
 ses was found. In each of these cases, however, the child 
 died at or soon after birth; consequently, with the above excep- 
 tions, we have not a case which has been followed up until 
 a cure was effected ; and, of course, these are the only ones from 
 which the peculiar and very interesting clinical features can 
 be studied. Many interesting points in clinical practice 
 have been simplified, or have been thoroughly explained, 
 by the details derived from the post-mortem examination 
 of the various cases just alluded to, of which the import- 
 ance can scarcely be over-estimated. There is no peculiar 
 or distinguishing feature to be observed in the early part 
 of the course of this variety of swelling, except, perhaps, that 
 it attains its maximum size in less time than is required by 
 the first variety. A phlegmonous inflammation of the integu- 
 ment rapidly follows, and if the parts are examined at this time, 
 or shortly after, the following features will be observed : the 
 swelling is not as distinctly limited to, nor does it begin as 
 abruptly just above the commencement of, the epiphysis as it does 
 in the simple or resolutive variety. On the contrary, it com- 
 mences on the shaft, just at or above- its middle portion, in an 
 almost imperceptible elevation, which gradually expands until it 
 reaches the epiphysal region, where it becomes a distinct, large 
 swelling. It is very probable that the swelling is at first localized 
 in a similar manner to that in the first variety, and that the en- 
 largement of the shaft further up occurs later. The reason of 
 this will be clearly brought out \>y post-mortem facts. I give 
 the appearances as they were observed in my cases, and they are 
 those which I think will be most generally found at the early and
 
 Systejn in Infants and Young Children. 105 
 
 late periods of the development of these swellings. Very soon 
 it is found, as I have said, that the integument has become in- 
 volved ; that it is less supple, and cannot be moved over the bony 
 tumor beneath ; if carefully manipulated it will be discovered 
 that the focus of the tegumentary inflammation is at or about 
 the point of junction of the shaft with the epiphysis; softening 
 may perhaps be traced nearly round it, if a part such as the 
 arm or leg be involved. In my case the fluctuating spot was 
 found just over the malleolus, but it was evident that a nearly- 
 similar condition existed all around the limb ; consequently 
 the spot where the abscess points may be seated anywhere 
 around the limb. As the changes in the overlying tissues are 
 the direct result of a deep-seated destructive process, an appro- 
 priate examination will at this time reveal the character of the 
 latter. Deep pressure shows that the bone swelling has become 
 more prominent at the junction of the shaft with the epiphysis ; 
 and a softening, or perhaps a feeling of fluctuation, is at this time 
 or soon after felt. The examination being carried further, sup- 
 posing that the morbid processes have reached their height, 
 abnormal movements may be produced in the parts. Thus hold- 
 ing the foot and the epiphyses (we will suppose the lesion to be 
 developed, as it was in my case, at the lower end of the shafts of 
 the tibia and fibula) firmly in one hand, and with the other grasp- 
 ing the shafts of the bones, it becomes very evident that a slight 
 bending movement is permitted between the two segments of the 
 bones just mentioned. If a lateral motion is made by attempt- 
 ing to slide the surfaces over one another, the lower segment 
 moves slightly in either of the directions, and when the same is 
 attempted in an antero-posterior direction, it is found to be very 
 slightly accomplished. The sliding movements are generally 
 attended with a crepitation of a soft kind, and not at all dry or 
 harsh. This sound, however, may not be elicited, or it may be 
 very faint indeed. In one instance the sensation appeared to 
 me as if two soft bodies were gently rubbed, the one over the 
 other. Its absence or masked condition may be accounted for 
 by the intervention of the products of degeneration between the 
 two ends of the bony segments. This was well shown by my 
 first case ; for before the contents of the abscess, if we may so 
 term it, were evacuated, crepitation was very slight, but imme- 
 d iately after the operation it was very distinctly heard : so I
 
 106 Syphilitic Lesions of the Osseous 
 
 think that the explanation given is the true one. As the parts 
 are naturally soft and succulent, it is very probable that this 
 sound will always be of the soft variety just mentioned. The 
 movements will, of course, be of greater or less extent, but it is 
 very probable that they will always be more free in a lateral 
 than in an antero-posterior direction. They will, of course, de- 
 pend upon various causes ; thus the greater the amount of tissue 
 degeneration which exists between the two segments, in that pro- 
 portion will the movements be greater; then again, the greater 
 or less thickening of the periosteum which we shall find to be 
 thus affected in this lesion, will act in varying degrees as an im- 
 pediment to motion. Finally, the infiltration of the surrounding 
 integument will also tend in a measure to prevent it. In the 
 case which serves me as the text of this description, the integu-: 
 ment over the swelling did not fall into extensive ulceration, 
 but only enough of it was destroyed to allow the exit of the 
 products of degeneration, and a sinus was formed. This sinus 
 presented no very peculiar features ; its orifice became thickened 
 by fibrous tissue somewhat after the form of similar openings 
 leading to inflamed ganglia in strumous subjects, but there was 
 less tendency to the invasion of the surrounding tissues, and there 
 was not any puckering of the integument. One case, however ? 
 will not constitute a rule, particularly as the tendency to neo- 
 plastic fibrous growths of the skin varies so largely in different 
 persons, even in those free from any blood disease. So we may 
 find in these cases the typical sinus observed after scrofulous 
 abscesses. In my first case the little patient was a mulatto, 
 and I should not have been surprised at such a development 
 in her, as her race is so liable to such growths. We find both 
 in hereditary and acquired syphilis this tendency to the deve- 
 lopment of fibrous tissue in sinuses or scars. The fact that 
 severe ulceration was not induced, and that a sinus was formed, 
 is of considerable clinical interest, as it shows that we need not 
 of necessity have ulceration of the integument of such extent 
 as has been described as accompanying the first form of 
 degeneration of these bony tumors. So we must accept these 
 clinical facts as being liable to be observed in these instances : 
 first, a circumscribed ulceration ; second, a sinus of the skin. In 
 my second case of this lesion a sinus was formed, but owing to 
 treatment it rapidly closed before sufficient time had elapsed for
 
 System in Infants and Young Children. 107 
 
 fibroid proliferation to occur. It is interesting to note that a 
 sinus rather than an ulcer was produced. Passing now to the 
 course followed by these severe bony swellings, we find that, 
 under appropriate treatment, the enlargement gradually sub- 
 sides, that, after a time, the viscid secretion, which, however, 
 towards the end becomes of a purulent character, ceases to 
 escape, that the sinus closes, and, finally, that scarcely any evi- 
 dence is left of pre-existing bone lesion. 
 
 The secretion which escapes is, as said before, quite thick 
 in consistence, of a light brown color, of neutral reaction, and 
 found, by microscopic examination, to contain leucocytes in 
 considerable quantity, a few myeloplaxes, and granular matter. 
 Like all productions of degenerated bone from syphilis, in an 
 uncomplicated case, it is free from pus when first evacuated, 
 though this may appear later on. "We have seen, that, in this 
 form of extensive bony degeneration, lesions of continuity have 
 been produced in the periosteum and in the integument; 
 but the details of my tenth case prove distinctly that the bone 
 changes may be almost of the same severity, and yet that these 
 superficial tissues will not undergo any ulcerative action what- 
 ever beyond those absolutely necessary to give vent to pent-up 
 secretions. In my tenth case, upon one leg the epiphyses of the 
 tibia and fibula were found to be completely separated from 
 the shafts, yet there was no extrusion of the products of de- 
 generation, nor did an opening upon the surface occur. This 
 fact is of great clinical interest, and its knowledge is very im- 
 portant in the matter of prognosis. It proves distinctly that 
 the degenerated debris of bony and cartilaginous tissues may 
 be absorbed, probably by undergoing at first fatty transforma- 
 tion, and that, coincidently, or in a short time afterward, the 
 normal nutrition and growth of the bone are restored. I ex- 
 amined my case in especial reference to this point, and I con- 
 vinced myself thoroughly that this absorption had taken place 
 without any lesion of the periosteum. One of the most inter- 
 esting features of this form of lesion is the part which is 
 played during its course by the periosteum a part which, be- 
 sides being interesting, is of vital importance, as influencing 
 the final result. As I observed in my case, and as the facts 
 observed at the autopsy of Valleix's and Bargioni's cases 
 further support, this membrane undergoes very considerable
 
 108 Syphilitic Lesions of the Osseous 
 
 thickening coiucidently with the active and severe degenerative 
 changes which are developed between epiphyses and diaphyses. 
 This thickening is, as we have seen, not localized exactly to the 
 seat of bone inflammation, but it extends quite a considerable 
 distance up the shaft. . The result is that a very thick tube of 
 bone is formed under the periosteum, and that it serves to give 
 stability to parts which have been so materially weakened; 
 when, acting as a splint, it tends to prevent motion, and in a 
 measure keeps the parts from further disorganization. Of 
 course, if this siib-periosteal tube was only formed just over the 
 morbid focus, it could not give the power of support which it 
 does, as it extends quite far up. In fact, during the height of 
 activity of the destructive processes this wise provision of 
 nature is the chief, if not the only, means of averting total dis- 
 organization of the limb, and jt exerts an equally important 
 influence upon the final result. Then, coincidently with the 
 absorption or extrusion of the softened tissue, bony formations 
 jut inwards between the two detached -ends of the segments of 
 the bones, upon which an healthy nutrition soon becomes en- 
 grafted ; till, in the course of time, the two become gradually 
 welded together, and, on the morbid processes ceasing, scarce- 
 ly anything abnormal can be detected in the parts. In my 
 ease a mere ridge of about the breadth of one line was 
 noticed, and the thickening of the periosteum gradually sub- 
 sided as the parts assumed a normal condition. The length of 
 time required for the cure of this severe form was, in my first 
 case, six months, being about one-third longer in course than that 
 of the simple uncomplicated swellings. In the second case which 
 I observed of this lesion, the reparative process was established 
 within two weeks, or rather disorganization was averted in that 
 time, and from the appearances presented by the case at my 
 last examination, I think that a perfect cure would have been 
 brought about in three months ; so that I think we may con- 
 clude that, in such cases, from three to six months of treatment 
 are required to restore the parts to as near a normal condition 
 as we by our art can hope to attain. Now, though these cases 
 show us that disorganization of these bones and joints may not 
 occur, a perusal of the cases of Valleix and Bargioni also show 
 that certain rapidly destructive changes may supervene, and 
 that these tissues and organs may undergo disorganization.
 
 System in Infants and Young Children. 109 
 
 In these cases the epiphyses are extruded, the joints are wholly 
 destroyed, and the limb, left in a state of permanent defor- 
 mity, is more QT less useless in its function. As thus fur 
 observed, these complications have only occurred in cases 
 attended with a fatal result, and we have no record of a 
 recovery under the circumstances. In these instances it is 
 probable that death was induced principally by the visceral 
 lesions with which the child was afflicted, and was perhaps 
 accelerated by the systemic reaction incident to such pro- 
 found reflex disturbance as must exist in such a case, and 
 by the exhaustion consequent upon so great a drain upon the 
 system as such extensive tissue destruction would entail. But 
 as we know that in children not suffering from syphilis this con- 
 dition may exist in its severest form, and yet not compromise 
 life, we may assume that in cases of syphilis in which visceral 
 lesions do not exist, or are mild in character, that even this se- 
 vere form of destruction may occur, and yet the child live. 
 
 The separation ' of the epiphyses from the diaphyses may oc- 
 cur in any of the long bones of syphilitic children, but the facts 
 observed by the German observers, and by Parrot at post-mortem 
 examinations, seem to show that those of the arms and legs are 
 most liable to be thus affected, and that the proximal and distal 
 ends are thus liable in about the same proportions. 
 
 This accident or complication is accompanied by certain 
 well-marked subjective symptoms, which may be summed up 
 concisely in the words, inability to move the affected members. 
 These symptoms were very much dwelt upon by Parrot, and 
 also by Gueniot; 2 but I think that the former attaches more 
 importance to them than they really deserve. Thus he entitles 
 
 1 1 find it stated by Parrot (op. cit.) that Underwood says " that a loose- 
 ness of one or other of the articulations may be accepted as very probable 
 indication of syphilis," and he makes the suggestion that perhaps the English 
 observer had met with cases of separation of the epiphyses from the dia- 
 physes in syphilitic children. Parrot quotes from the translation of Under- 
 wood's work, ' ' Traite des Maladies des Enfauts, traduction Francaise. Paris, 
 1786, page 361." I have been unable to find this edition of the work ; hut-in 
 the ninth edition of it, edited by Marshall Hall, and published in London in 
 1835, I cannot find this sentence. 
 
 a Gazette des Hopitaux, Fev. 9, 1869. This observer reports a case which 
 Parrot uses, and I transcribe it as No. 1. Gueniot did not report it at the 
 time as being syphilitic, but afterwards, at the suggestion of Parrot, arrived at 
 the conclusion that it arose from that disease.
 
 110 Syphilitic Lesions of the Osseous 
 
 his three articles after them, calling them a pseudo-paralysis, 
 caused by an alteration of the osseous system in newly-born 
 children affected with hereditary syphilis. This false paralysis ia 
 simply an indisposition or want of power to move the limbs, 
 owing to a false point of motion existing in their continuity. 
 The same features are observed, and the same conditions ob- 
 tained in cases of fracture of bones, and as they are explained 
 in so simple a manner I hardly think it necessary to so mag- 
 nify their importance as to burden literature with another name 
 for them. The appearances presented by children whose bones 
 are thus affected, vary, of course, with the particular one involv- 
 ed, as with the end which is involved, and are in the main those 
 which would be observed if any of them were fractured, ex- 
 cept, perhaps, that there is much less sensitiveness and swelling 
 of the surrounding parts generally. In one of Parrot's cases, 
 and I must acknowledge that he has observed and recorded his 
 cases faithfully, and that his contribution is one of consider- 
 able value, the arms hung heavily down as if paralyzed, the 
 hands being turned towards the trunk. In my tenth case the 
 legs hung down in a powerless manner, and the feet turned in 
 to such a degree that they rested fully on their inner sides. 
 Owing to the existence of a false joint, or rather false point of 
 motion, there is a total relaxation of the muscles, and no move- 
 ments are made in the limb; certainly, there are none in that 
 part in which the bony levers are divided into two, whereas in 
 the upper division of the limb, as the thigh or arm, slight 
 movements will be observed. When the parts are handled 
 (to speak from a clear recollection of my cases), they, if 
 moved to their normal position, quickly return to the position 
 they abnormally assume ; thus, when I everted the foot, it re- 
 mained so while held, but, immediately that I loosened it, it 
 tumbled over heavily upon its inner side. I think that this 
 same motion would be observed in the hand. When the hands 
 or feet are tickled or pricked, a slight convulsive motion is in- 
 duced in the muscles, but mostly so in those of the upper and 
 unaffected region. Parrot says, very happily, that in one of his 
 cases a jerking motion was produced similar to that seen when a 
 jointed toy is pulled by a string. This fact goes to show that the 
 muscular power is temporarily in abeyance, and that if stimulus 
 be applied to the members a disordered and jerking movement
 
 System in Infants and Young Children. Ill 
 
 results. "When improvement begins in the osseous lesions, par- 
 ticularly if the parts are subjected to judicious use, this condi- 
 tion gradually disappears, and when the continuity of the bones 
 is complete again, the muscles move these levers in perfect 
 harmony of action and co-ordination. This general suggestive 
 description will answer for almost any case which may arise, 
 the features of course differing according to the conformation 
 and function of the bone affected. 
 
 It is well, however, to describe the features observed in my 
 eleventh case, the second one in which I found separation of 
 the epiphysis from the diaphysis. In this an unusual bending 
 of the lower part of the leg inwards was found, the part which 
 allowed and induced this abnormal position being at the junction 
 of the lower third of the tibia and fibula with their epiphyses, 
 the convexity of the resulting bow looking outwardly. This con- 
 dition was due to the preponderance of action of the flexor mus- 
 cles over the extensors, which, drawing upon the lower segments 
 of the bones of the leg in which a false point of motion existed, 
 produced the deformity noticed. In the present instance 
 this deformity was slight, but of course it may be very exten- 
 sive. As a slight bending is noticed as the normal condition of 
 the legs of children, so it is well to look into the condition 
 carefully if it exists, and to make comparisons with the healthy 
 leg, or with that of another infant, as by this means false conclu- 
 sions will be avoided. 
 
 XVI. THE SYMPTOMS INDUCED BY THE OSSEOUS SWELLINGS. 
 
 When we consider the severity of the pain which so fre- 
 quently accompanies the development of osseous and periosteal 
 lesions in the adult, we naturally conclude by analogy that the 
 various osseous swellings in infants have been attended with 
 pain in their development and course. The comparison, how- 
 ever, is not a perfect one between the two cases, for in the first 
 instance the lesion is an inflammation in a fully formed, dense, 
 unyielding structure, whereas in the latter the lesion is mainly 
 an abnormal nutrition attended with inflammation, but in a 
 nascent structure, as yet soft, unfinished and yielding; so 
 that in infants there is a probability that as the conditions are 
 altered the amount of pain may be less. This opinion or sup- 
 position is based on the fact which I was careful to elicit from.
 
 112 Syphilitic Lesions of the Osseous 
 
 the mothers of the various children, that they did not notice 
 any very unusual suffering of the children. Some were quite 
 restless at night, and appeared as if in pain ; but it is well 
 known what diverse and erroneous conclusions may be and are 
 formed under these circumstances, which often leave us at a 
 loss to say whether or not in these very young children these 
 lesions are attended with pain. I endeavored to ascertain the 
 fact, from several of the mothers, whether manipulation of the 
 swollen parts gave uneasiness at night when the child seemed 
 restless, but I could not obtain satisfactory information. When 
 examined in an uncomplicated state I have not found these 
 swellings to be the seat of pain, particularly those of the dia- 
 physo-epiphysal junction of the long bones; indeed, I have 
 been surprised at the unconcerned manner of the infants when 
 I have been very carefully manipulating them. Still I saw a 
 marked exception to this in the case of a child under the care 
 of Dr. Dessau, the history of which I shall give further on. In 
 this instance the restlessness and evident pain of the child 
 caused its mother to bring it to the Dispensary. Here the 
 typical lesions of syphilis were found. Manipulation of the 
 swollen fingers and of the expanded distal ends of the forearms 
 was evidently attended with acute pain, as the child shrank 
 from the examination. The mother thought that the pains were 
 more severe at night. In the instance of the child with nodes 
 on the frontal bone, I thought that there was considerable sensi- 
 tiveness, as it shrank from my grasp. This fact I have also ob- 
 served in cases of enlarged phalanges; so that I have derived 
 the impression that when the swellings are found upon the 
 bones of the head and upon the phalanges and their neighbor- 
 ing bones, considerable pain and tenderness exist, but that 
 on the long bones very little, if any, is, as a rule observed. So 
 that, though it is very probable that pain is a concomitant symp- 
 tom of these swellings, the demeanor of the children does not 
 manifest it in the majority of cases. Moreover, in this connec- 
 tion, we have an important witness in my eighth case ; in which 
 there were lesions of the metacarpal bones and of the long bones 
 at their diaphyso-epiphysal junction, for in it we have unmis- 
 takable evidences of very severe pain. This case is one of 
 acquired syphilis in a child four and a half years old, in whom 
 osseous lesions precisely similar to those of infants were ob-
 
 System in Infants and Young Children. 113 
 
 served. Now this child complained bitterly of her pains, and 
 was old enough to describe them, and to distinctly localize 
 them at the points where osseous enlargements were found. 
 Moreover, they observed a nocturnal recurrence, not being 
 felt during the day ; and so much did they resemble those of the 
 child's father, that he himself suspected their syphilitic origin. 
 This being indubitable evidence, the question arises, how 
 does this affect the negative evidence which I have already 
 brought out? Bearing it in mind, from the fact tbat many of 
 the infants seemed fretful at night, I am inclined to think that 
 these osseous and periosteal swellings in them are attended 
 with pain. When the various osseous swellings undergo the 
 superficial form of degeneration, it is probable, as the de- 
 struction of the superimposed epidermis is very slow, and is not 
 of a phlegmonous nature, that the pain is very insignificant ; 
 but if, owing to the rapidity of the osseous degeneration, it does 
 assume a phlegmonous nature, it is probable pain will be pres- 
 ent. 
 
 I have already shown that the subacute mode of develop- 
 ment is the one usually observed when the epiphyses become 
 separated from the diaphyses, so that I think it may be assumed 
 that this whole process might be accomplished with very little 
 pain and a surprisingly slight amount of systemic reaction. 
 Yet I can readily see that if the process should assume the 
 rapid form which has been observed, that it would be attended 
 with pain ; indeed the details of the various cases of other ob- 
 servers render this supposition very probable. In this form the 
 inflammation of the integument is of a rather more phlegmonous 
 character than the more superficial variety, and of course 
 attended with more or less pain. When a separation of the 
 segments has occurred the pain will be due to the abnormal 
 condition of the parts, and although, perhaps, it is not sponta- 
 neously present, any movements, voluntary or involuntary, will, 
 as a matter of course, give rise to it. 
 
 When the bony tumors have reached such a size that in- 
 jurious pressure is exerted upon the integument, then pain 
 becomes a complicating feature, and exists in proportion as 
 the pressure induces disorganization of the integument. In 
 several instances in which the phalanges have been very much 
 swollen, and in which much cutaneous hypersemia existed, I
 
 114 Syphilitic Lesions of the Osseous 
 
 found by examination very considerable pain and tenderness. 
 In the event of synovial complications, it is very probable that 
 pain of an acute character will be present, and in three 
 instances I have seen this condition very well marked. These 
 latter conditions which induce pain are, however, merely 
 secondary in their nature, yet, in order to make our study com- 
 plete, it has been necessary to consider them at some length. 
 
 XVII. THE PERIOSTITIS OF THE HEREDITARY SYPHILIS OF INFANTS. 
 
 In our previous study we have found that periostitis, as a 
 complicating lesion in hereditary syphilitic children, occurs quite 
 frequently. Thus, in the complex lesion of the fingers, it plays 
 an active part ; it is also the essential lesion in the nodes of 
 the cranium; it is -developed, as a concomitant lesion, to a 
 greater or less extent, in the diaphyso-epiphysal swelling, and in 
 the separation of the segments attains considerable extent. 
 Yet we have not met with any ease of its development in the 
 form of distinct circumscribed swellings along the shafts of 
 the long bones, after the manner observed in acquired syphilis, 
 and also as observed in late hereditary syphilis. This form of 
 swelling is admitted by many authors; but, as I have shown by 
 giving all the cases, not one of which contained an instance 
 of such, it is fair to presume that it is rare. Mayr ' distinctly 
 says that he has seen such swellings, and many other authors speak 
 to the same effect. Yet, as cases are not brought forward, I am 
 disposed to think that allusion has been made to swellings of 
 the diaphyso-epiphysal junction, or perhaps to nodes. As I have 
 already stated, Bertm" says he has seen cases of periostitis and 
 of exostosis, and, as an example, details a case of osseous 
 swelling at the great trochanter of the femur. Indeed, I am in 
 accord in my views with those of Mr. Jonathan Hutchinson,* 
 who has studied infantile syphilis with an unusual care and zeal. 
 He thinks that periostitis, rare in infancy, is quite common 
 in childhood. The very severe and extensive osseous lesions 
 found after death by Wegner and others were chiefly those of 
 
 1 Ueber Syphilis hereditaria, Separat-abdruck aus dem Jahrbuche fur 
 Kinderheilkunde. Wien, 1862, page 7. 
 
 * Op. cit. p. 360. 
 
 3 New Facts and Opinions as to Hereditary Syphilis. London Hospital 
 Reports, vol. ii., pages 175 and 176. London, 1865.
 
 System in Infants and Young Children. 115 
 
 the points just alluded to; but the former says that he found 
 localized periostitis, and, as we have already seen, he observed 
 this lesion in a very peculiar and diffuse form upon the cranial 
 bones. Although in some of his cases this inflammation is de- 
 scribed as involving the greater parts of some of the shafts, it 
 was in reality only a complication and perhaps an extension 
 from continuity of surface of the epiphysal lesion, and did 
 not exist unconnected with it. In a recent work on infantile 
 syphilis, M. Violet * gives the statistics of the service of M. 
 Gailleton in the Antiquaille Hospital of Lyons for a period of 
 one year, in which he made autopsies upon thirteen syphilitic 
 children, besides which he gives five made by his friend .M. 
 Poncet, making a total of eighteen cases. Ont of this number 
 he found the diaphyso-epiphysal lesion six times ; but makes 
 no mention of having observed any periosteal swellings. Clini- 
 c-ally, the lesion in the form spoken of is rare, though of course 
 it may occur. I hope to be able to show, in a future work, that 
 periostitis of hereditarily syphilitic children, as of adults, is not at 
 all uncommon, and that it may then reach an excessive develop- 
 ment. We shall see further on, as indeed we have already known 
 in a negative way, that in infants the lesion is of a proliferat- 
 ing variety, or rather that it is a simple hyperplasia of perios- 
 teal tissue, but that the lesion of older subjects may be accom- 
 panied by gummy infiltration, though it is very often wholly 
 of the hyperplasic form. It is evident that Lancereaux 8 has not 
 observed periostitis in hereditary syphilis, as he makes no men- 
 tion of it, but he speaks in the first edition of his work of having 
 once observed the peculiar separation of the epiphysis, such as 
 we have studied. Considering the attention which this observer 
 pays to the study of morbid anatomy, his silence on this parti- 
 cular point is significant. Yery recently Poncet * has published 
 the result of his investigations into the bone-lesions of heredi- 
 tary syphilis. Out of twelve cases he found the diaphyso-epi- 
 physal lesion nine times, and he confirms the observations pre- 
 viously made. He does not speak of periostitis in an uncompli- 
 cated form. 
 
 1 Etude pratique de la syphilis infantile, page 44. Paris, 1874. 
 
 1 Traite historique et pratique de la syphilis, page 550. Paris, 1866. 
 
 ' Progres Me'dicale, page 237. Paris, 1874.
 
 116 Syphilitic Lesions of the Osseous 
 
 XVIII. THE EFFKCTS OF THE OSSEOUS LESIONS UPON THE ULTI- 
 MATE STKUCTUBE AND SHAPE OF THE BONES. 
 
 As can be readily seen there are certain difficulties, and I 
 might almost say impossibilities, in tracing the results in later 
 years of the lesions of the bones with which the infant was af- 
 flicted. Yet a determination of their condition after the sub- 
 sidence of the lesions is a study at once interesting and import- 
 ant, as from it we may deduce facts or indications both as to 
 treatment and prognosis. 
 
 The recent very able and exhaustive clinical and experi- 
 mental researches of Oilier, 1 and the clinical studies of Fon- 
 cet, 3 have done very much to increase our knowledge of the 
 effects of inflammation, in its various stages, upon the growth 
 and development of bones. These studies may be practically 
 applied to the cases under our consideration. One of the main 
 points which these authors have proved is, that inflammation 
 without destructive change taking place at the junction of a 
 shaft with its epiphysis, results in augmented growth and length 
 of the bone. Several of the foregoing cases are peculiarly 
 appropriate examples for the determination, clinically, of the 
 truth of this view or hypothesis. My observations of the cases, 
 with a few exceptions, have been confined to the period of ex- 
 istence and decline of the osseous lesions, a period at which 
 conclusions cannot be drawn. 
 
 I am inclined to think, however, that it will be difficult to set- 
 tle this point satisfactorily in the long bones, as the lesion is so 
 often developed symmetrically ; whence it results that we have 
 no proper standard of comparison, and also because the amount 
 of increased growth must, under any circumstances, be scarcely 
 appreciable. I examined my second case a year after the ces- 
 sation of the morbid processes, but could not discover any in- 
 crease of length. It is very probable that if the lesion is treated 
 early and efficiently, no appreciable change will be induced, 
 but that, if allowed to run its course, it will exert an influence 
 over the future size of the bone. 
 
 Inflammation with destructive change at the diaphyso-epiphy- 
 
 1 Traite experimental et clinique de la regeneration des os. Paris, 1867. 
 
 2 De 1'ostcite envisages au point de vue de 1'accroissement des os. Gazette 
 HSbdoraadaire, fros. 42, 46, and 49. Paris, 1872.
 
 System in Infants and Young Child ten. 117 
 
 sal junction is known (having been proved by these observers) 
 to produce arrest of development longitudinally. Therefore, in 
 the case of separation of these segments, we should expect that, 
 as the inflammatory processes are severe and destructive, the 
 influence upon future growth would be proportionately mani- 
 fest. This point is of especial interest in the question of 
 prognosis. It prompted rne to follow up the little patient in 
 whom this lesion was so well marked, and two years and a 
 half after her cure I examined the bones of the legs carefully ; 
 but could not perceive that an arrest of development, how- 
 ever trifling, had been induced. As compared with the length 
 of the other long bones, these seemed normal, the child being 
 fully as tall as it should have been at the age of three. I am 
 inclined to think that the prompt and efficient treatment insti- 
 tuted averted such structural changes as \vould have interfered 
 with the future growth of the bones. As we know that bone 
 is constantly formed, during its periods of development, by the 
 ossification of a layer of cartilage of greater or less breadth 
 which exists between the shaft and the epiphysis, and which is 
 probably replaced as fast as used up by cell-growth from the 
 proximal end of the epiphysis, it perhaps happened that; in this 
 instance this layer was not wholly destroyed, or that it was re- 
 placed in the natural condition, and that the process of ossifica- 
 tion began again in a normal manner from the shaft. Had 
 it happened, however, that a bony cicatrix had been formed at 
 this point, it can be readily seen that all future ossification and 
 longitudinal growth would either have ended, or that it would 
 have been very slight. This explanation is, I think, the most 
 rational of any which can be given, and is in perfect accord 
 with our physiological and pathological knowledge. It is now 
 a definitely settled fact, that chronic inflammation alone of the 
 shaft of a bone may cause its elongation. As we have found such 
 inflammation affecting the metacarpal and metatarsal bones 
 and phalanges, we should naturally look for such a sequela. As 
 these bones also have an epiphysis, and as their whole length is 
 usually involved in the inflammatory process, it is probable that 
 the increase of their length is due to two causes ; first, the in- 
 flammation of the diaphysis; second, that of the epiphysis. 
 In my case, number six, the lengthening of a phalanx was 
 fully one-eighth of an inch more than normal, the result of
 
 118 Syphilitic Lesions of the Osseous 
 
 an inflammation of six months' standing. For so short a 
 bone this increase is certainly very considerable. I have seen 
 an instance of a phalanx being enlarged longitudinally fully 
 half an inch in a patient fourteen years old, the victim of heredi- 
 tary syphilis. The ease was shown at the February meeting, 
 1874, of the New York Dermatological Society, by my friend 
 Dr. E. L. Keyes. It also presented other very interesting osse- 
 ous lesions. The inflammation of the shaft, however, may be 
 attended with considerable destructive change, and still increas- 
 ed length may result. I have learned from observation of my 
 cases that, in every instance in which chronic inflammation has 
 involved a shaft, increased length of the bone does not neces- 
 sarily result. Thus, I have seen two instances in which, after 
 the cessation of the chronic inflammation of a short bone, its 
 length was materially shortened, and this without any destruc- 
 tive change. Perhaps this feature is to be explained by the 
 fact that the cartilage at the end of the shaft was very early and 
 rapidly ossified, and thus that thereafter the ossific matrix was 
 not in the condition for copious bone-proliferation. 
 
 Increase of diameter will also be observed in some cases, the 
 amount of which will vary \vith the duration, and perhaps in- 
 tensity, of the inflammation. In the cases of the phalanges, 
 metacarpal, and metatarsal bones this feature can be very well 
 observed. When the irregular bones have been enlarged, their 
 ultimate condition may be that of greater or less enlargement, 
 seldom that of very marked diminution. 
 
 These, then, are the main sequelse of these bone-lesions of 
 children. But what has thus far been said, refers in the main 
 to instances of inflammation uncomplicated with destructive 
 change. Wlien necrosis or caries complicates the inflammation, 
 the ultimate result varies with the extent and situation of the 
 process, of which it may be said succinctly that deformity and 
 diminution of size are the result. Thus I have seen a metacar- 
 pal bone very much attenuated at its centre, a phalanx flattened 
 laterally, and a tarsal bone rendered smaller and irregular in 
 shape. In the one instance of nodes upon the cranium, there 
 was a decided loss of tissue. Now it is necessary to state here, 
 in anticipation, that these sequelae result from an inflammation 
 which is more closely allied to the simple form than to syphilitic 
 inflammation. In the early stages of hereditary syphilis, the
 
 System in Infants and Young Children. 119 
 
 osseous lesions are usually unattended with the proliferation of 
 gummy or granulation-tissue, and, as has been said, partake 
 in their nature of the character of simple osteitis, consequently 
 having their sequelae similar to those of this latter affection. 
 Later on in hereditary syphilis, however, the proliferation of 
 granulation-tissue becomes a complicating part of the process, 
 when, of course, the sequelae are different. Thus, whenever this 
 tissue is proliferated, there is a liability to its degeneration, as 
 also to its final absorption ; in which events destruction of the 
 bones, of greater or less extent, result, when the sequelae may be 
 summed up as a loss of tissue. In these cases the inflammation 
 is generally of a mild character, and the sequelae of the more 
 simple form of the process, such as lengthening of the bone, 
 are not generally induced, though of course, in exceptional cases, 
 they may be. In some instances, somewhat rare however, of 
 infantile bone-syphilis, gummy tissue is proliferated, in which 
 cases the final condition of the bones would be such as has just 
 been stated. This fact, as to the difference in the nature of the 
 lesion in early and late hereditary syphilis, is only introduced 
 here incidentally to render intelligible this portion of our study ; 
 a fuller consideration of it being reserved for the section treat- 
 ing of pathology. 
 
 In the consideration of these sequelae, it is interesting to bear 
 in mind that they are, in many instances, to a great extent, if 
 not indeed wholly, preventable by the early adoption of an ap- 
 propriate and active treatment : a fact upon which attention 
 should be especially invited, as pointing to the prevention of 
 degeneration and deformity of the bones. 
 
 Bouchut 1 speaks of an extraordinary hardness of some of the 
 long bones which he has found in syphilitic children either 
 prematurely born or at term, a condition which he attributes to 
 an abnormal activity of development, and which process, he 
 thinks, is of the same category as the plastic infiltrations into the 
 other organs. I have been astonished at tlie harmony of state- 
 ment of a number of observers who deny the syphilitic nature 
 or origin of this condition. Waldeyer and Kobner say positively 
 that they have observed the same state of the bones of children 
 
 1 Traitc pratique des maladies des nonveaux ne'e, des enfants a la mamelle, 
 et de la seconde enfance. Sixieme edition. Page 1061. Paris, 1873.
 
 120 Syphilitic Lesions of the Osseous 
 
 who were not syphilitic. It is probable, then, that this condi- 
 tion is not at all due to syphilis, though it suggests the point, 
 that, in consequence of inflammation of the bones of hereditarily 
 syphilitic children, we may have a sclerosis of the tissue result- 
 ing as a se'quela ; but in that event, it must be subjoined that 
 there would be nothing specific in its nature, as this condensa- 
 tion of tissue is one of the recognized results of every variety 
 of inflammation. I have no doubt that it existed in several of 
 the bones which I have seen after the cessation of the inflam- 
 matory process, but owing to their small size I was unable to 
 determine the fact. We may, therefore, add to the other 
 sequelae of these osseous lesions, a sclerosis of the bones. 
 
 XIX. THE PERIOD OF INVASION OF THE OSSEOUS LESIONS. 
 
 The facts which have been observed by AVegner and Waldeyer 
 and Kobner prove beyond a possibility of doubt that the bones 
 are affected by syphilis in intra-uterine life, it being very prob- 
 able that the syphilitic impress is stamped upon their develop- 
 ment just at the time when it is most active. Since, in clinical 
 practice, we find, as a rule which can be laid down with con- 
 siderable precision, that the swellings of the bones appear 
 shortly after birth, so it may be that the cell changes which con- 
 stitute them begin before birth, though but recognizable, or 
 recognized, some time after. Out of ten of my cases the exist- 
 ence of osseous swellings was noticed in six at. about the sixth 
 week of life; and this was about the period at which similar 
 lesions were observed in the cases of Ranvier, Archambault, 
 Barensprung, Bertin, Foamier, Valleix, Bargioni, and in Bulk- 
 ley's first case. In one of these the period was three weeks, and 
 in another thirty-six days. In two of my cases the swellings 
 were not observed until the child was three months old, while 
 in Bulkley's second case the child was fifteen months. These 
 figures indicate clearly the very early development of this mor- 
 bid process, and suggest what we shall find is borne out by 
 pathological histology, that it is essentially connected with the 
 development of the osseous system, and is consequently most 
 prone to appear early in life, when this system is undergoing 
 the most active morphological changes. 
 
 In the cases of Wegner, Parrot, Waldeyer and Kobner, Val- 
 leix and Bargioni, as has been said before, the swellings were
 
 System in In/ants and Young Children. 121 
 
 found either in still-born children, at birth or shortly . after. 
 They were very extensive, and were complicated in many instan- 
 ces with profound degenerative changes. The children were 
 afflicted with the severest form of syphilis, the visceral lesions be- 
 ing very extensive. Wherefore, we must take these as excep- 
 tional cases ; as examples of the severest form of this syphilitic 
 lesion ; and must attribute the somewhat precocious evolution of 
 the enlargements to the great activity of the disease. The cases, 
 such as we are likely to meet in clinical practice, and which 
 may be considered as typical in their nature and course, are my 
 own and those of Kanvier, Archambault, Bertin, and Fournier. 
 It is a fact of some importance, that in the greater number 
 of cases in which the lesions appeared at about the sixth week, 
 the swellings were more numerous and more symmetrical than 
 those which appeared later. A comparative perusal of the 
 cases will bring this point out clearly. We, therefore, may 
 lay down, as a rule, that these osseous lesions are developed 
 at about the third to the sixth week of life, or that period 
 in the history of hereditary syphilis when, in consequence 
 of some unexplained cause, we notice an explosion or rather 
 general manifestation of syphilitic lesions and symptoms, in 
 a child who previously, perhaps, had shown no evidences of 
 the disease; that, in a smaller number of cases, these osse- 
 ous affections may develop late in the first year, and even 
 during the second or third ; and that, in these later periods, 
 there may be, and usually is, an absence of symmetrical distri- 
 bution, with a number of swellings much less. There may, 
 however, be exceptions to these last qualifications. We are un- 
 able to offer an explanation of the fact of the limited extent of 
 development of the lesions at this age of the child, except it 
 be in the waning power of the virus. 
 
 Passing beyond these years we may find these inflammatory 
 or irritative lesions, but the rule is then that they appear of 
 another order, and, in fact, essentially the same as those of late 
 acquired syphilis. 
 
 XX. CAN SIMILAR OSSEOUS LESIONS BE DEVELOPED IN ACQUIRED 
 
 INFANTILE SYPHILIS? 
 
 We come now to a point in the etiology of these .bony tu 
 mors which is of the utmost doctrinal importance> as well as of
 
 122 Syphilitic Lesions of the Osseous 
 
 practical interest. Thus far, I have always alluded to heredi- 
 tary syphilis as their cause ; now the question arises, can they 
 be developed in the acquired syphilis of infants ? Let us look 
 at this question in a comparative light. An infant who has 
 been born in a healthy condition, and who afterwards becomes 
 infected with syphilis, is certainly not as profoundly syphilitic 
 as one who inherits the disease, and who may be said to have 
 never possessed an healthy organism and nutrition. In the 
 fii-st instance, it is probable that the manifestations of the 
 disease would be mild and superficial, and would only involve 
 a limited number of tissues, while, in the second, the extreme of 
 the manifestation might be looked for. So that we should ex- 
 pect, by analogy, that tissues which usually escape in mild forms 
 of syphilis, might escape in this instance. Other than this, I 
 know of no reason for assuming an immunity to bone-lesion in 
 acquired infantile syphilis ; on the contrary, our knowledge of 
 the malignant type which this disease sometimes assumes in its 
 acquired form in the adult, points out to us clearly that it may 
 likewise invade the more delicate and immature organism of the 
 infant ; so that I think there is no lesion of syphilis which may 
 not be developed in the infant who has by any chance acquired 
 the disease. As these lesions are intimately connected with the 
 natural morphological conditions of the bones, it is necessary for 
 their development that the child should not have reached the 
 age when these changes have ceased, at which time, of course, it 
 would be no longer susceptible of morbid impress. I take the 
 pains to consider this subject at some length for the reason of 
 its intrinsic interest, and also from the fact that such eminent 
 observers as Waldeyer and Kobner assert that this form of 
 lesion is the exclusive appanage of hereditary syphilis. I 
 think that these observers have arrived at this conclusion from 
 the facts, first, that they are disposed to regard such swellings, 
 when they occur later than the early months of life, as due to 
 rickets ; and, secondly, because at the autopsy of a case of syphi- 
 lis acquired by vaccination, Kobner ' found that the osseous 
 system was normal. I think I can show that they are partly 
 mistaken as to their first reason, and I shall certainly show, by 
 
 1 Die tJbertragung der Syphilis durch die Vaccination. Archiv f iir Derma- 
 tologie und Syphilis. Zweites Heft, p. 147. 1871.
 
 System in Infants and Young Children. 123 
 
 the details of two cases, that similar lesions of the bones have 
 been found in acquired infantile syphilis. In the entire range 
 of medical literature I am able to find but one recorded case ; 
 though, of course, others must have occurred that escaped obser- 
 vation ; my eighth case being the second example. These two 
 cases will show beyond a doubt, I think, that these irritative or 
 inflammatory bone-lesions may be caused by acquired syphilis. 
 The first case is that of Roger, the details of which have been 
 given already. The situation and course of the osseous lesions 
 in this case are such as show clearly that they belong to the same 
 category as those of all the other cases. It will be noticed, how- 
 ever, that although symmetry of development is shown, there is 
 not that tendency to a general distribution which some of the 
 cases show so clearly. In my eighth case the lesions were of the 
 inflammatory order peculiar to those of infants, and though iden- 
 tical bones were not symmetrically involved, there is an evident 
 invasion of the bones of both sides of the body, showing a ten- 
 dency to symmetry. Summing up these two cases, then, and 
 comparing them with the typical ones which we have studied, 
 we observe that the lesion is of the same inflammatory nature, 
 and shows the same tendency to involve the diaphyso-epiphysal 
 junction of long bones, and the whole length of short ones, in 
 the same manner that we observe in infants. We may as- 
 sume, then, that the processes are identical ; whence these cases 
 prove conclusively that these peculiar osseous lesions may re- 
 sult from both the hereditary and acquired syphilis of infants. 
 It is almost needless to call attention to the fact that the lesions 
 in these cases did not resemble, either in their evolution, course, 
 or decline, the bone swellings due to gummy infiltration. It 
 may happen that hereafter cases will be found of acquired in- 
 fantile syphilis, in which the distribution of the lesions is 
 as general and symmetrical as those of the hereditary form. 
 This condition would undoubtedly be dependent in a great 
 measure upon the time of development of the lesions. Thus, if 
 the infection occurred soon after birth, the lesions would, per- 
 haps, be similar in their distribution to those of hereditary sy- 
 philitic infants, for at this time of life the osseous growth is 
 most active; should, however, infection occur later, a more 
 sparse and unsymmetrical development would, perhaps, result. 
 This view is drawn by analogy from our knowledge of
 
 124 Syphilitic Lesions of the Osseous 
 
 the course of the lesions in hereditary syphilis, and of the mode 
 of development of the osseous system. We must also take into 
 consideration, as regards the less pronounced character of the 
 lesions, and their comparative infrequency in acquired infantile 
 syphilis, that the infection is very probably much less intense 
 than in the hereditary form. Again, there is another point of 
 much importance in this connection, namely, that of the greater 
 or less tendency, or even immunity, to the action of syphilis pos- 
 sessed by the infant. 
 
 XXI. THE INTENSITY OF SYPHILIS IN THOSE CASES IN WHICH 
 OSSEOUS LESIONS ARE OBSERVED. 
 
 The histories of all of the cases, without any notable excep- 
 tions, show that the concomitant manifestations of syphilis upon 
 the organism generally, and upon other tissues than that of the 
 bones, were well marked ; proving that the disease was in a 
 quite active stage. As the concurrent testimony of all the cases 
 points so clearly to this fact, it is unnecessary to dwell any 
 farther upon it ; and I think we are warranted in drawing the 
 conclusion from it, that, in infantile syphilis, osseous lesions are 
 generally met with in those cases in which the disease, if not 
 severe, is yet active. It is almost unnecessary, however, to state, 
 that even in this severe or active condition of syphilis, osseous 
 lesions may not develop, as it is quite probable that they will 
 not be observed in very mild cases ; yet can we not insist very 
 strongly on this point, as some of the preceding cases were cer- 
 tainly not very severe. The cases of Wegner, Waldeyer and 
 Kobner, and Parrot were of the most malignant form, the super- 
 ficial and visceral lesions extensive, and the osseous lesions of the 
 most marked type ; insomuch that it would seem very probable 
 that the extent of distribution and severity of the latter lesions 
 are materially influenced by the more or less malignant char- 
 acter of the disease which they manifest. The same remarks 
 apply, of course, to every other variety of lesion. Diday, : when 
 he wrote his book, seemed evidently surprised at the immunity 
 of the osseous system in infantile syphilis, and alludes to the 
 vital hyper-activity of this system at the earlier periods of life. 
 We are now in possession of facts which show that this im- 
 
 1 Op. tit.
 
 System in Infants and Young Children. 125 
 
 inanity does not exist, and have cogent reasons for believing 
 that the morphological activity of the osseous system tends 
 seriously to predispose it to syphilitic modification. Behind all 
 these conditions, namely, of intensity of the virus and active 
 morphological change, there is a point of very great interest to 
 be remembered ; it is, that in some individuals there are local 
 tissue tendencies to abnormal cell-proliferation, and such may 
 enter as a very serious modifying influence in the production of 
 the bone-lesions. Such tendencies to hyperplasia are com- 
 monly seen in children, affecting all tissues and organs, a point 
 of no little importance in forming our conclusions, prospective 
 or retrospective, in cases of the sort. The condition just 
 alluded to is generally spoken of as scrofula, but under what- 
 ever name it is considered, certainly must be conceded to 
 exercise a powerful influence on the course of inflammations in 
 children. I am inclined to think that this tendency existed in 
 my eleventh case, in which separation of the epiphysis occurred; 
 for the cutaneous lesions were of a very mild character, and the 
 general condition of the infant did not indicate a profound 
 cachexia. The scope and purpose of this treatise does not 
 permit me to consider this subject more fully ; so that I have to 
 confine myself to a simple mention of it. 
 
 XXII. THE CONDITION OF THE SYPHILIS OP THE MOTHERS IN 
 
 WHOSE INFANTS OSSEOUS LESIONS ABE OBSERVED. 
 
 The question of the intensity of the syphilis in the child 
 brings us to the consideration of one of the final points in the 
 clinical history of these osseous lesions ; what is the condition, 
 as regards syphilis, of the progenitors of these children? 
 Knowing, as we do, that the recent development and the 
 severity of the syphilis of the mother tend to produce severe 
 syphilis in the child, we might summarily pass over the etio- 
 logy of these lesions by briefly saying that they were undoubtedly 
 an expression of a severe form of syphilis in the parents. But 
 I think that, as we have facts from which to draw conclusions, 
 it is well to bring them out, and endeavor to establish their 
 bearing in this matter. I shall not introduce the vexed ques- 
 tion of the influence of the syphilitic father upon disease of 
 the child, as it is still an unsettled point ; one, besides, which, 
 has recently been very ably handled by my friend Dr. F. K.
 
 126 Syphilitic Lesions of the Osseous 
 
 Sturgis, 1 and also been treated of at some length in France by 
 Mireur,* and, quite exhaustive! y, in Christiania, by Oewre.* My 
 remarks and conclusions will be based upon the history, as far 
 as obtainable, of the syphilis of the mothers of the children 
 whose cases I have detailed. 
 
 Of my twelve cases, the mothers of three of the children had 
 been syphilitic fully two years ; one of them was at the end of 
 her first year of syphilis ; three were infected at the fifth 
 month, and two became syphilitic at conception. The case not 
 included in this category is the one of acquired syphilis, and 
 will be treated of separately. 
 
 Comparative analysis of these cases shows us very clearly 
 that a recent infection and severe form of syphilis in the 
 mother were attended by extensive and profound osseous 
 lesions in the child ; but we cannot also deduce the antithesis 
 of this proposition that a quite distant infection and a mild 
 form of the disease were attended with osseous lesions limited 
 in extent and severity. The ninth and tenth cases show clearly 
 the weight of the first assertion. The mothers became syphi- 
 litic at conception, and, although the disease was active, were not 
 treated, while the children had extensive osseous lesions, com- 
 plicated with severe degenerative changes. The three cases in 
 which infection of the mothers occurred in the fifth month of 
 pregnancy, show osseous lesions of a somewhat milder form. 
 In one of these cases degenerative changes occurred, but they 
 were not as severe as they were in those cases, nor were the 
 lesions nearly as extensive. The mothers did not undergo 
 treatment. In another of this second series the mother was 
 negligently treated for about three months, and the lesions, 
 though numerous, were of the resolutive variety. The third of 
 this group is the one most marked. The mother of this child 
 gave evidences, during her pregnancy, of severe syphilitic lesions 
 and profound cachexia, and I felt apprehensive that her child 
 would be still-born. She followed quite regularly, under my 
 instruction, an active treatment, and, though her child showed 
 
 1 On the Etiology of Hereditary Syphilis. New York Medical Journal, July, 
 1871, and July, 1873. 
 
 8 Essai sur 1'heredite de la syphilis. Paris, 1867. 
 
 ' In a series of three articles published in the Nordskt Medicinskt Arkiv, 
 for the years 1871-72 and 73.
 
 System in In/anU and Young Children. 127 
 
 severe syphilitic manifestations, the} 7 were not as bad as I 
 should have expected, and the osseous lesions were not as 
 11 nine rous as in the other cases, exhibiting no degenerative 
 tendency. When all the symptoms of the mother of this 
 child are compared with those of the mothers of the first 
 group, it can be readily seen that we have every reason to 
 think that, unless treatment had been followed, the osseous 
 lesions would have been equally as profound as in the children 
 of the first series. 
 
 The lesions of the children whose mothers had been syphili- 
 tic from one to two years, show no well-marked characteris- 
 tics, except that perhaps they were rather more extensive than 
 might have been expected to occur at the rather late period of 
 the infection. They did not show degenerative tendency, but 
 in some instances were quite as numerous as those resulting 
 from recent infection. An important point here presents it- 
 self, and one which we must not lose sight of, namely, that 
 the mothers were scarcely, if at all, treated, and we have every 
 reason to believe that, if they had been, the children might 
 have escaped with perhaps an almost uncontaminated organism. 
 The eleventh case also belongs to this category, and is interesting 
 in the fact that the child's syphilis was not manifestly very active, 
 though born of a mother within the second year of her disease, 
 which had not been properly treated. In this instance, I 
 thought that there was an inherent tendency in the child to tis- 
 sue degeneration. These cases show clearly that a remote 
 period of infection of the mother does not give to her offspring 
 a total immunity to the development of syphilitic lesions, in- 
 cluding those of the bones. However, some of these cases are 
 what may be called examples of remote contagion. We, to-day, 
 recognize clearly the fact that, within a period of one year and 
 a half or two years and a half after syphilitic contagion, there 
 is engrafted upon the organism a tendency to the development 
 of its peculiar hypersemia and hyperplasia, which we speak of 
 as syphilitic lesions. After this time, this tendency, we know, 
 may gradually cease and even become extinct; yet are we un- 
 able to lay it down as a law, at what period this extinction occurs; 
 consequently, as the tendency to the development of these 
 lesions is transmissible, we cannot, say when this transmissibility 
 also ceases. We know that this peculiar proliferative action
 
 128 Syphilitic Lesions of the Osseous 
 
 is greater and more lasting in some persons than in others, but 
 are unable to assign any reasons more exact of this variation, 
 than those herein already given. Some mothers, whose nutri- 
 tion may not be affected by syphilis, may, and we see such cases 
 very often, transmit children, who have a like immunity. As 
 we have no other reliable records of cases, we must assume, 
 judging from our present knowledge, that the tendency to the 
 transmission of severe forms of syphilis with osseous lesions is 
 confined to the early years of the disease in the mother, and 
 that, as her tendency to hyperplasia and hyperoemia wanes, so 
 will it gradually become less apparent in her offspring. As I 
 have said before, we cannot lay down any rule, except, per- 
 haps, that, after the fifth or sixth year of contagion, hereditary 
 transmission of syphilis in the form of grave lesions ceases, or 
 manifests itself but very feebly. The dates, as far as given 
 by other observers, show that the contagion was quite recent 
 in most of the cases, and in none of them very remote. This 
 point is one of great importance, and one which will well repay 
 accurate clinical observation and study in the future. 
 
 There is, in this matter of the transmission, one point which 
 has been well brought out by one of my cases, and, in a negative 
 manner, by nearly all the rest; I mean, the value of treatment. 
 This cannot be too much insisted on in the cases of pregnant 
 women as tending to insure a healthy organism in the foetus. 
 The development of the osseous lesions in the child four years 
 and four months old, who was the subject of acquired syphilis, 
 is an instance of the disturbance of normal nutrition by the 
 syphilitic virus ; but this lesion was simply a proliferative one, 
 such as we see very frequently in the early stages of acquired 
 syphilis; a mere thickening of the fibrous tissues of the joints 
 and bones, and not proceeding from gummy infiltration, as 
 manifested by external and other symptoms. This case and 
 tliat of Roger, as has been said before, prove clearly that sy- 
 philis may induce the same developmental changes in the bones 
 in its acquired as well as in its hereditary form. This peculiar 
 condition of the system, in which predisposition to active ab- 
 normal cell-proliferation may exist in the mothers, and may 
 then render their disease graver in character. The transmissi- 
 bility of this condition with syphilis to the child, and the effect 
 of the two upon its organism, are points in. pathology of
 
 System in Infants and Young Children. 129 
 
 very great import, worthy of attentive observation and reflec- 
 tion. It might also be desirable in such an investigation to 
 consider the age of the mother, as we know that a very young 
 organism is usually more severely affected by syphilis than a 
 mature one. The fact of the youth of the mother rendering 
 her syphilis more severe, makes it probable that the disease in 
 her offspring would be equally so. This was suggested to me 
 by my eleventh case, in which the mother received the conta- 
 gion in her seventeenth year, in whose child was found a ten- 
 dency to active cell-proliferation. 
 
 In order that a clearer view may be given of the comparative 
 condition of the syphilis in the mothers and children of my 
 cases, I will here, in parallel columns, oppose the main facts of 
 each instance. 
 
 MOTHERS. CHILDREN. 
 
 CASE 1. Mother two years Lesions in infant extensive 
 syphilitic ; rather mild form of and symmetrical, 
 disease. No treatment. 
 
 CASE 2. Mother two years Lesions in infant extensive 
 syphilitic ; apparent waning or and symmetrical, 
 running out of the disease. 
 Treated for short time. 
 
 CASE 3. Mother infected at Lesions in infant extensive 
 fifth month of pregnancy ; and symmetrical, 
 treatment for three months ; 
 syphilis severe and not suffi- 
 ciently modified by the mer- 
 cury. 
 
 CASE 4. Mother within sec- Lesions in infant extensive ; 
 ond year of syphilis ; no regu- showed a tendency to develop 
 lar treatment ; form of disease in crops, 
 not especially severe. 
 
 CASES. Mother nearly a year Lesions in child were not 
 syphilitic ; disease not of grave extensive, but underwent de- 
 form; treatment for three generative changes. Infant's 
 months. health not bad. 
 
 CASE 6. Infection of mother Lesions in child not exten- 
 at sixth month of pregnancy; sive, but underwent degenera- 
 rather severe form of disease ; tive change, 
 no treatment. 
 9
 
 130 Syphilitic Lesions of the Osseous 
 
 CASE 7. Infection of mother Lesions in child not exten 
 at fifth month ; severe form of sive, nor symmetrically dis.- 
 disease; active and regular tributed ; mild in type, 
 treatment. 
 
 CASE 8. Acquired sypliilis. Lesions may be classed as 
 
 being moderately severe. 
 
 CASE 9. Mother infected at Lesions extensive and sym- 
 the beginning of pregnancy ; metrical, followed by degen- 
 disease rather severe ; no effi- eration. 
 cient treatment. 
 
 CASE 10. Mother infected at Lesions in child very exten- 
 the beginning of pregnancy ; sive ; underwent profound de- 
 treatment (not active) for two generation, 
 months. 
 
 CASE 11. Mother syphilitic Syphilis of the child not 
 fifteen months ; no treatment ; very severe ; a limited number 
 disease rather mild of form ; of bones affected ; degeneration 
 probable strumous tendency. of osseous lesions probably in- 
 duced by struma. 
 
 CASE 12. Syphilis of mother Lesions of child mild ; limit- 
 not active ; no treatment. ed number of bones affected. 
 
 XXm. PATHOLOGICAL ANATOMY. 
 
 WE now come to the consideration of the nature and char- 
 acter of these osseous lesions, and, in order to clearly and cor- 
 rectly understand them, it is necessary to recall to mind the 
 minute changes which take place in the development of bone, 
 as these affections are, in the main, deviations of greater or less 
 extent in the course of the normal growth of that tissue. These 
 changes we have found to be seated in two distinct portions of 
 the bones ; at their ossifying ends, and on their surfaces : con- 
 sequently, as the conditions of development are somewhat 
 different, we shall have to study them separately, beginning 
 with the lesions of the diaphyso-epiphysal junction. 
 
 Normally, there exists at the end of the spongy portion of 
 the shaft, and between it and the cartilage, which may be per- 
 manent, as in the ribs, or temporary, as in the other long bones, a 
 narrow line of cartilage, somewhat lighter in color than the rest, 
 which can, only be detected by careful examination. This line
 
 System in Infants and Young Children. 131 
 
 is very narrow, being the layer called by Guerin the couche 
 c/iondro'ide, and in it take place the processes which precede the 
 formation of bone. It extends transversely across the end of 
 the bone, either in a straight line or in a curve. The ossifying 
 process may be briefly described as follows : At the distal end 
 or edge of this layer the cartilage cells are found to be enlarged, 
 flattened, and placed the one on top of the other, in such a 
 manner that they appear as if arranged in so many vertical lines. 
 The tissue on each side of these lines is the cartilage matrix, 
 forming a framework or trabeculse, from which thin processes 
 of this tissue pass between each flattened cell. This prolon- 
 gation inwards, however, is exceedingly thin, and, as we ap- 
 proach the bone, becomes gradually thinner, until finally, from 
 the very close approximation of the cells, it disappears alto- 
 gether. Passing down towards the bone, we find, of course, 
 that the cells are packed more and more closely together, so 
 that at last they touch, and leave no intervening tissue. But 
 between the rows of cells in the longitudinal direction the 
 cartilaginous trabeculre continue to exist : but near the bone, 
 
 O f 
 
 that is, near the proximal edge of the layer of Guerin, it is 
 noticed that these become slightly granular, being here cartilage 
 which has become calcified, from the deposit of lime salts. 
 Following the cells up towards the bone, we observe that near 
 it they lose abruptly their peculiar character, becoming large, 
 granular, and terminating in processes, varying in length, and 
 somewhat caudate. Then, examining the condition of the parts, 
 just as the cartilage and bone meet, we find that the trabeculae 
 have become firm, and here consist of a tissue ready to be con- 
 verted into bone. They are more susceptible of color from 
 carmine here than further on, and this shows that it is a nascent 
 tissue. On examination, these trabeculae are found to form 
 canals which run chiefly in the longitudinal direction, though 
 some transversely. Within these channels, or medullary cavi- 
 ties, we find the peculiar granular cells which are called osteo- 
 blasts, arranged in concentric circles ; and into these also pro- 
 ject the vessels, which are developed from the spongy substance 
 of the diaphysis. So that, to sum up, we have in this region, 
 as factors of the future bone, a calcified matrix perforated by 
 canals or medullary cavities which are filled with osteoblasts or 
 cells, which then undergo change, and, it is probable, form the
 
 132 Syphilitic Lesions of tlie Osseous 
 
 lacunae and also vessels in abundance. Some text-books on 
 histology give very clear illustrations of this process. Though 
 we cannot state precisely the exact changes, yet we know that 
 it is upon the calcified matrix, the cells, and vessels, that the 
 formation of the bone depends. In the healthy state the line 
 of demarcation between the cartilage and the spongy bone is 
 sharply and accurately marked. In syphilitic infants, as we 
 shall find, this condition is very much altered. 
 
 In giving the description of the pathological changes, I have 
 thought it best to follow "Wegner in his division of the subject ; 
 but the appearances I give as observed by myself, as in some 
 minor points we are at issue. He describes three stages of this 
 affection of the ossifying process. In the first stage, if the 
 bone be examined with the naked e}"e, it is seen that the line of 
 Guerin is not as even and regular as normal, but somewhat 
 wavy and irregular ; it is perhaps twice thicker than usual, 
 being, we assume, from a half to a line in width. It has a 
 white shining or whitish-red color, and is compact of structure. 
 Under the microscope, the abnormal width is clearly seen. 
 The cartilage cells are found to be proliferated in an unusually 
 abundant manner. The lesion is then in this stage simply an 
 exuberant cell proliferation, without corresponding ossification. 
 In the second stage, we observe that the line of Guerin is 
 rather more uneven in its relation to the epiphysal cartilage ; 
 that it is nodulated ; and that there are warty or papillae-like 
 processes of calcified cartilage projecting into the distal 
 hyaline matrix. Wegner compares them, from their broad 
 bases and tapering ends, with the papillae of the cutis. Be- 
 tween these papillae, if we may so call them, in the hyaline 
 cartilage, we find spots of lime appearing like isolated clusters 
 of calcified cartilage. On the periphery the infiltration en- 
 croaches further into the cartilage than at its centre. Then, 
 when we examine the relations of this calcified line to the 
 spongy bone, we find corresponding depressions into which the 
 spongy tissue passes. When a section in this stage is examined 
 under a lens of three hundred diameters, we observe that the 
 longitudinal rows of the cartilage cells are more abundant 
 than in the first stage, and that there is very little intercellular 
 substance. The vessels are abundant, and their canals at the 
 ossifying line are surrounded by a considerable quantity of
 
 System in Infants and Young Children. 133 
 
 connective tissue. The walls of the cavities are broader at their 
 bases, and are sclerotic. In many places an osteoid substance 
 is developed from the cartilage, and from the medulla which 
 enters with the vessels. This substance is found to be in some 
 places true bone, which passes into the spongoid layer. Beyond 
 the layer of Guerin, we find irregularly distributed spots of cal- 
 cified cartilage, forming a zone of considerable breadth. 
 
 The principal points in the second stage, then, are greater pro- 
 
 liferation of cartilage cells, premature sclerosis of the inter- 
 cellular substance, formation of bone in the form of processes 
 beyond the normal layer, and delay in bone formation else- 
 where ; in other words, irregular osteogenesis, abnormally pre- 
 mature in some spots, in others retarded. In the third stage, 
 there is a general enlargement of the epiphysis, with a thicken- 
 ing of the perichondrium and periosteum. Under the micro- 
 scope the following appearances are discoverable : The lower- 
 most layer of hyaline cartilage is bluish, transparent, moist, 
 and swelling when cut. Then comes a layer irregular and 
 wavy, with serrated processes, exhibiting a grayish-white and 
 homogeneous mass. This layer, though greatly altered, is 
 brittle, and can readily be removed. Next to this comes a 
 layer of grayish-red or yellow substance, soft, and sometimes 
 viscid, which is gradually lost in the spongy substance of the 
 diaphysis. The medullary tissue of the latter continues for a 
 considerable distance further, and, instead of being of a normal
 
 134 Syphilitic Lesions of the Osseous 
 
 red, is of a gray or grayish-red color. This layer seems to 
 destroy the firm cohesion of the ephiphysis to the shaft. Under 
 the microscope, we find, in this stage, that the proliferation of 
 cartilage cells is greater, as is also the lime infiltration. In the 
 layer nearest the bone we see nucleated cells, a granular detritus, 
 and spindle-shaped cells. In this, the third stage, the layer which 
 is just described after Wegner, in reality consists largely of 
 granulation-tissue. This tissue is formed at the end of the 
 shaft in great abundance, and follows the vessels into the me- 
 dullary spaces. Wegner does not consider it a granulation 
 tissue, or at least does not say so. My sections show clearly 
 that it is such, and Waldeyer and Kobner say that they observed 
 this tissue. The changes may then be summed up as follows : 
 In the first stage we have a simple hyperplasia of cells, with 
 irregular deposition of lime salts ; in the second, an intensifica- 
 tion of this condition ; and in the third, a new element, namely 
 the abnormal proliferation of all the elements of the tissues, 
 with an infiltration of granulation-tissue into the medullary 
 spaces following the vessels. In the first stage we find nothing 
 of this kind. This is the condition simply and succinctly 
 stated. Wegner calls the process osteo-chondritis,aud considers 
 it due to irritation which arises from the condition of the blood. 
 As such, it would not be a specific process ; but when we consider 
 that there is proliferation of granulation-tissue, we must certainly 
 regard this opinion as faulty. Waldeyer and Kobner do not, 
 as I have said, partake of this view, but are disposed to look 
 upon it as a specific process. Parrot rejects Wegner's view of 
 the origin of the disease, not seeming to be aware of the views 
 of Waldeyer and Kobner, and applies to it the name dystrophie 
 sypldlitique des os. As this simply means an abnormal condi- 
 tion of nutrition, it does not in any degree place the matter in 
 a clearer light. He thinks that the process is not at all of an 
 inflammatory nature. When we examine this morbid process, 
 we certainly see an inflammatory condition in it ; wherefore, 
 on this subject there can be no doubt ; so that I am disposed to 
 look upon it as an exaggerated and perverted nutrition of these 
 tissues, in some instances complicated by the proliferation of a 
 granulation-tissue. AVegner thinks that he did not find many 
 vessels in the region of cartilage thus affected, but Waldeyer 
 and Kobner distinctly say they found them in abundance, and
 
 System in Infants and Young Children. 135 
 
 my own preparations lead me to coincide with them. Applying 
 these details to clinical observation, I think we may assume 
 that in the majority of cases of swellings at the diaphyso- 
 epiphysal junction, the morbid alterations do not pass beyond 
 the second stage ; consequently, that they are scarcely ever com- 
 posed of granulation-tissue, hi the cases in which we found 
 superficial destruction of the swelling, it is very probable that 
 the necrosis was due to localized degeneration of the cartilage 
 cell elements, and that the granulation-tissue was not formed. 
 But in the cases in which there was separation of the epi- 
 physes from the diaphyses, granulation-tissue was undoubtedly 
 formed, which softened down, and then destroyed the continui- 
 ty of the bone. Thus we have a convincing reason why the 
 swellings run the course which they are seen to take. The 
 presence of granulation-tissue in this inflammation shows us its 
 specific character, as we know that this is one of the constant 
 products of syphilis. It brings to our mind the fact already 
 elicited, namely, that its development in the bone lesions of in- 
 fants is not as constant as it is in those of older children. Thus, 
 in infancy, the lesion is of the inflammatory nature above de- 
 scribed, superadded to which we have, in very marked and severe 
 cases, granulation-tissue infiltration ; whereas in bone lesions of 
 older children we shall find that granulation-tissue is a very con- 
 stant morbid product of hereditary syphilis. It is almost need- 
 less to say that mature granulation-tissue constitutes the so-called 
 gummy masses. In the light of this knowledge, we must look 
 on the cases in which granulation-tissue is formed as represen- 
 tatives of the most advanced of the morbid changes in children ; 
 the simple form of inflammation is, however, the more common. 
 It seems somewhat anomalous that the bones should not be in- 
 variably the seat of granulation-tissue infiltration, seeing that in 
 the viscera of infants we so constantly find this tissue in great 
 abundance. 
 
 Such, then, are the clinical facts as explained by pathology. 
 The situation of these swellings being similar to those of 
 rickets, it is easily seen how they might be, and have been, 
 mistaken for that disease. We shall speak further on of the 
 diagnostic points as observed at the clinic; here it is only 
 necessary to allude to the fact, that in syphilis there is a super- 
 abundance of a calcareous deposit, besides the other morbid
 
 136 Syphilitic Lesions of the Osseous 
 
 changes, while in rickets everything is normal, except that the 
 cartilage cells are exuberant in quantity, and that tLe cartila- 
 ginous trabeculse are not calcified. Then, in syphilis the essential 
 changes are strictly limited to theepiphysis, certain other changes 
 being adventitious and secondary, while in rickets the whole 
 bone is involved, though the changes are most perceptible in 
 this part. There is a pathological fact of some interest which 
 explains a feature observed in the clinic, which is, that in 
 many of the cases the changes in the bones are found in various 
 stages of development, some just beginning, and others fully 
 formed; this accounts for the variety of size in which we find 
 the bone swellings. 
 
 The lesion upon the flat bones is periostitis, and this may be 
 of the same varieties as are found in the acquired syphilis of 
 adults. In cases such as we shall usually meet in practice, it 
 is probable that the inflammation is of the proliferative or 
 fibrous form, being then a simple periostitis. Though we should 
 expect, from the general character of the osseous lesions in in- 
 fants, to find the periostitis, as a rule, to be of this variety, 
 though really of an inflammatory nature, there is every reason 
 to believe that we may also find the gmnmousform of periostitis. 
 This difference is, however, simply one of degree ; the first is a 
 hyperplasia of the normal tissue of the periosteum, while the 
 second is the same process complicated by the additional pro- 
 liferation of a granulation-tissue. We have found instances of 
 this gummous form of periostitis as detailed in the various 
 cases of Bargioni, Parrot, Barensprung and Desmares; but 
 these cases are examples of the most severe and fully devel- 
 oped type of osseous lesion, similar in character to those in 
 which we find separation of the epiphyses from the diaphyses. 
 In one of my cases large nodes were found, upon the resolution 
 of which a loss of tissue was observed. This condition points 
 to the existence of an infiltration of granulation-tissue, and 
 its subsequent fatty change, with absorption of it and the nor- 
 mal cells of the texture. TVegner found very frequently pro- 
 liferating periostitis of the skull, and in one instance general 
 hyperostosis. Thus, then, we may conclude in the majority 
 of cases, such certainly as are usually met with in clinical 
 practice, that the lesion will be found to be a simple prolifer- 
 ating periostitis, but that in exceptional ones we may find the
 
 System in Infants and Young Children. 137 
 
 gummous form. In the latter there may be great destruction 
 of bone and of the investing integument. 
 
 The morbid anatomy of periostitis has so often been de- 
 scribed that I think it superfluous to go minutely into its con- 
 sideration here ; on which, account I confine myself to a general 
 sketch of the subject. 
 
 We have found in the clinical part of our study that perios- 
 teal swellings of the shafts of long bones are not very common. 
 Still, they may be met with, and will be of either of the two 
 varieties above mentioned. In cases of osteochondritis of the 
 bones we find well-marked thickening of the periosteum and 
 of the perichondrium. This is usually limited to the focus of 
 the lesion, and only exists as a complication; which we have 
 observed to act in a very benefici'al manner in those cases in 
 which the epiphyses became separated. Here the prolifera- 
 ting process becomes very active, assumes an ossifying state, 
 and, by the formation of a bony tube, prevents the total de- 
 struction of a member, acting as a splint. 
 
 The lesion is of a complex character when the phalanges and 
 metacarpal bones become inflamed. We have no microscopic 
 data upon which to speak positively,. so that we are forced to 
 reason by analogy, as well as by the clinical history of the swell- 
 ings. It is probable that the affection begins in the periosteum, 
 and that the cell-genesis is very copious, since the size of the 
 swelling is sometimes considerable. At the same time the can- 
 cellous structure of the bones becomes involved, and we have 
 general enlargement of it. These two morbid changes involve 
 also the nutrition of the cartilage of the epiphysis, and here also 
 we have hyperplasia. Thus the condition is periostitis, osteitis, 
 and perhaps osteochondritis. In such profound bone lesions, it 
 is common to expect a considerable degree of subsequent de- 
 formity, and we have already called attention to instances of 
 permanent enlargement, and also to hypertrophy in the longi- 
 tudinal direction. In the small irregular bones the lesion is a 
 cellular hyperplasia beginning probably at the centre of ossifi- 
 cation, and consisting in a very active and exuberant prolifera- 
 tion of the cartilage cells. There is also a concomitant perios- 
 titis. In this form of inflammation, also, the periosteum plays 
 an important part, as from it new bone is formed, which takes 
 the place of that lost by softening, when such occurs, of the pro-
 
 138 Syphilitic Lesions of the Osseous 
 
 liferated cell elements of the cartilage. The bone may remain 
 smaller and perhaps distorted. 
 
 The periostitis, besides being of the simple or proliferate 
 and gnmmous form, may also be of the ossifying variety. In 
 fact, in some of the bones, the history of which we have studied, 
 there has been this complication ; and it is well to remark that 
 we may expect to find it, seeing that ossifying periostitis is a 
 frequent sequela, or, in point of fact, the advanced form of the 
 proliferative variety, when it runs a chronic course, and is not 
 complicated by degenerative changes. Thus, it will be seen 
 that in infants the whole structure of the bone is liable to inflam- 
 mation. It may be limited to a region or a tissue, may involve 
 more than one tissue, and, in point of fact, each and every com- 
 ponent tissue of the bones. The lesion is usually of an inflam- 
 matory type, consisting in a hyperplasia of normal tissues, and 
 in cases somewhat exceptional, a new tissue formation is super- 
 added, namely, the granulation-tissue, and this complicates the 
 other form of trouble. All of which lesions are intimately as- 
 sociated with, if not perhaps excited by, the activity of the nu- 
 trition of these structures, necessitated by the advancing require- 
 ments of the new being. 
 
 XXIV. THE QUESTION OF THE RELATION BETWEEN RACHITIS AND 
 
 SYPHILIS. 
 
 It is necessary, in order to render complete our study of sy- 
 philitic osseous lesions, to consider the relation between rickets 
 and syphilis. This question, though, in strict truth, a side issue, 
 rather than a leading point, is rendered all the more worthy of 
 study by the fact that the views generally held regarding it are 
 not clearly drawn, and are wanting in scientific precision. By 
 most authors the point is summarily passed over with the asser- 
 tion that syphilis may cause rickets, leaving the pathological 
 relation of the two diseases wholly untouched. This is one of 
 the many instances in medical science in which conclusions are 
 drawn from coincidences, rather than from study, and a rigid 
 induction of a number of cases. Now, it certainly does happen 
 that children the subjects of hereditary syphilis become rachitic, 
 but it does not necessarily follow that the latter condition was 
 caused by the syphilis. It is somewhat surprising that so care- 
 ful an observer as Parrot should have fallen into this error. He
 
 System in Infants and Young Children. 139 
 
 reported recently a case 1 of a child born syphilitic, who, when 
 ten months old, became rachitic. The history of the infant in 
 the interval is not given. In his deductions from the case," he, 
 appears to think himself warranted in stating that syphilis may 
 be considered as one of the causes of rickets. The effect of 
 such assertions is to perpetuate error ; indeed, the case of Parrot 
 has already been quoted in an unqualified manner. Waldeyer 
 and Kobner report a case of rickets in a syphilitic child ; 
 while Poncet,* in an analytical table of cases of infantile osse- 
 ous syphilitic lesions, reports one in which rickets supervened. 
 
 Submitted to a rigid scientific examination, this question 
 should be put as follows : Is rachitis one of the usual con- 
 ditions or lesions produced by syphilis ? This brings the ques- 
 tion to a scientific standpoint, while if it is put as follows : Can 
 syphilis cause rickets? it is imprecise and not in accordance 
 with our advanced views. In the light of recent knowledge of 
 the pathological histology of syphilis, we know that there are 
 certain well-marked lesions developed in the various organs and 
 tissues by that disease ; also, that besides producing these lesions, 
 which may be considered specific in character, it may induce a 
 general condition of cachexia. This latter condition may impair 
 the function of organs, and induce disturbances of nutrition, 
 which, though they owe their origin to syphilis, cannot be prop- 
 erly and scientifically called syphilitic. In the previous chap- 
 ter we have found certain well-marked lesions, and both clinical 
 and pathological facts warrant the assertion, that they are spe- 
 cific in character, peculiar to syphilis, and produced only by an 
 active condition of that disease in the organism. When com- 
 pared histologically, the lesions of rachitis and syphilis are 
 found to be very dissimilar ; now, as there are undoubted lesions 
 induced by syphilis, it certain!}' is fair to infer that'lesions en- 
 tirely different in character are not induced by it. Then, again, 
 looking at the origin of rickets, it is found to be a disease of devel- 
 opment due to the absence of some of the component parts of 
 the blood. This condition does not obtain in syphilis. There- 
 fore I think that as syphilis has its own clearly- marked osseous 
 lesions, which differ so strongly from those of rachitis, and as the 
 
 1 Observation de Rachitis d'origine Syphilitique. Gazette Medicale de Paris, 
 No. 14, 1874. 
 
 9 Op. cit. * Op. cit.
 
 140 Syphilitic Lesions of the Osseous 
 
 latter disease is induced by a state of the blood not observed in 
 syphilis, that, in point of fact, there is no connection between the 
 two diseases. We are, then, in the position to state definitely that 
 there is no specific relation whatever between rickets and syphi- 
 lis. But it is not well to dismiss the case by simply considering 
 syphilis in its specific manifestations. We have already alluded 
 to its power of inducing cachexia, of impairing the nutrition of 
 tissues, and the function of organs. Now, it is in this influence 
 in my opinion, that the connection between rickets and syphilis 
 exists, if it exists at all. The condition of cachexia is frequently 
 induced by syphilis in the child, and results very often in low- 
 ering its nutrition, and renders it liable to intercurrent diseases. 
 In this condition we observe glandular engorgements, catarrhs 
 of mucous membranes, tendencies to local congestions, and 
 other affections, which, without being specific in character, re- 
 motely owe their origin to syphilis, and as such cannot, with 
 accuracy, be classed as syphilitic. In this condition it is very 
 probable that rachitis may develop itself, as we know that de- 
 bilitating and adynamic influences are potent in the causation of 
 that disease. Yet under the circumstances the specific action of 
 syphilis does not take place, but it acts remotely as other lower- 
 ing influences do. So that while we are prepared to admit that 
 syphilis may be one of the causes of rickets, it must be under- 
 stood to arise in the qualified manner we have specified. A 
 point of importance as corroborating the view that rickets is 
 not identical with syphilis (to state the question clearly) is that, 
 in any given case of a syphilitic child, who becomes rachitic, 
 the latter disease is not at all under the control of anti-syphilitic 
 remedies ; and we know full well the great, influence they ex- 
 ert over tissue changes due to the specific action of syphilis. 
 Finally, there is a clinical point of some weight, which is in 
 support of the view either that rachitis in syphilis is a result of 
 the cachexia, or that it is a mere coincidence ; which is, that 
 the rachitis, as observed in many of the cases, appears late, 
 after the syphilis is exhausted, so to speak, or has been thought 
 to be cured ; in other words, not in the regular period of evolu- 
 tion of syphilitic lesions, but many months after, at a period 
 when we expect the cachexia as a result of the influence of the 
 syphilis ; indeed, at a period when a child not affected with 
 syphilis would be liable to it.
 
 System in Infants and Young Children. 141 
 
 XXV. THE DIFFERENTIAL DIAGNOSIS. 
 
 In drawing the distinguishing features of these swellings 
 from those produced by other affections which may simulate 
 them, we shall follow the same general division which we have 
 established in the study of their clinical history. Diagnosis is 
 always one of the most essential parts of clinical investigation, 
 and at the present time, in the study of the syphilitic bone-af- 
 fections, it becomes urgently necessary that it should be clearly 
 and accurately elaborated. The swellings at the diaphyso- 
 epiphysal junction are liable to be mistaken for three different 
 affections. In their first, or resolutive form, they may be con- 
 founded with rickets ; in the form in which the swellings are 
 locally developed on either side of the bone, they may be mis- 
 taken for hereditary epiphysal exostoses ; in the third, or de- 
 generative form, in which separation of epiphyses occurs, they 
 may be .falsely diagnosticated as cases of abscess, or synovitis, or 
 of that form of bone inflammation which has been variously 
 called osteite, osteoperiostite juxta epiphysaire, absce sous 
 periostique aigu (Chassaignac), decollement des epiphyses, 
 epiphysentrennung (Klose), medullite aigue des os, osteides 
 epiphysaires des adolescents (Gosselin), necrosis, and separation 
 of the epiphysis. The idea of fracture might possibly occur, 
 but it could be readily dissipated by a study of the case. There 
 are also points of diagnosis in the syphilitic osseous lesions of 
 the clavicle, of the bones of the hands and feet, and of the 
 cranial bones, which require study. That form, also, in which 
 the swellings undergo superficial necrosis is liable to be con- 
 founded with certain other conditions, which we shall take care 
 to consider. 
 
 Diagnosis of the Osseous Swellings of Syphilis from those 
 
 of Rickets. 
 
 There are certain points in the concomitant symptoms and 
 lesions which, if clearly brought out, will generally establish the 
 difference between rachitic swellings and the osteo-chondritis 
 Byphilitica. Thus in rickets we generally have a prodromal 
 stage in which the general health of the child shows signs of 
 impairment by well-marked symptoms ; a condition not observed 
 in syphilis. A point of the greatest importance to remember
 
 142 Syphilitic Lesions of the Osseous 
 
 is, that usually these swellings in syphilis show themselves very 
 Boon after birth, having been developed, in all probability, in 
 utero ; while, in rickets, they usually come on after the sixth 
 month, but though in some rare instances at an earlier date they 
 are hardly ever formed during the foetal period. Then, again, 
 in syphilis there is usually a history of other symptoms or ma- 
 nifestations, such as snuffles, coryza, cutaneous and mucous 
 lesions ; in addition to which, though the condition of the child 
 may give evidence of cachexia, it is not, in the great majority of 
 cases, as well marked as in rickets. In the latter disease the 
 syphilitic symptoms are wanting, and the following is more 
 probably what may be expected. The child is pallid, is noticed 
 to sweat around the neck and head, is restless at night, and 
 troubled with gastro-intestinal disorder, soon followed by a ge- 
 neral hypenesthesia. A little later we find bone lesions, and 
 perhaps laryngismus stridulus, with convulsions. All of which 
 prodromal symptoms are wanting in syphilis, and do not make 
 their appearance at similar periods. Thus, in syphilis, though 
 we find the radius, ulna, tibia, and fibula, enlarged at either 
 end, we very rarely find the skull-bones and ribs to be involved 
 coincidently. In rickets the lesion is generally upon the occiput, 
 and consists of a thinning of the bone in spots, constituting 
 the condition known as soft occiput or cranio-tabes ; while at 
 the same time a thickening is observable at the sutures. These, 
 moreover, are, in almost every instance, present. In syphilis 
 the lesion consists of a circumscribed tumor, or tumors of greater 
 or less extent, seated upon the frontal and parietal bones, and 
 rarely upon the occipital bone. These lesions, moreover, are 
 not very common in syphilis. In rickets the ribs are almost al- 
 ways implicated ; so that Dr. Parry, who has written two of the 
 best and most comprehensive 1 articles, in any language, upon 
 this subject, and those experience is very great, says that he 
 has met with but one case in which the forearms were affected 
 and the ribs not. 
 
 In rickets the extremities of all, or of nearly all, of the ribs 
 are enlarged symmetrically ; while in syphilis the number so 
 
 1 Observations on the Frequency and Symptoms of Rachitis. American 
 Journal of Medical Sciences, Jan., 1872. 
 
 Remarks on the Pathological Anatomy, Causes and Treatment of Rickets. 
 Same Journal, April, 1872.
 
 System in Infants and Young Children. 143 
 
 affected is small, and the swellings unsymmetrical. In syphilis 
 the fontanelles are noticed to close at the usual period, in rick- 
 ets there is delay. The subsequent course of the bone trouble 
 is conspicuously different in the two diseases, being generally 
 followed in syphilis by resolution, without change; in rickets, 
 on the contrary, we may find both bending of the shaft, and 
 distortion of joint. In syphilis also there is a tendency to ne- 
 crotic degenerative change, which never occurs in rickets. The 
 
 O O ' 
 
 main points, therefore, to guide us in this differential diagnosis 
 are found in a comparison of the prodromal and concomitant 
 symptoms, in the difference noticed in the periods of evolution of 
 the bone lesions, and in the changes in the cranial bones, which in 
 rickets are clearly distinct, as well as of invariable occurrence ; 
 bearing in mind, also, that the ribs are so frequently, univer- 
 sally, and in a symmetrical manner, involved in rickets, in direct 
 opposition to what may be observed in syphilis. In cases of 
 syphilitic bone lesion in which, in addition to the changes which 
 resemble those of rickets, we find nodes, enlarged phalanges, 
 and metatarsal bones; but especially when degenerative changes 
 and other concomitant symptoms, such as sinuses, cutaneous 
 ulcers, or synovitis exist ; there can be no doubt entertained as 
 to the syphilitic origin, to the total exclusion of rickets. As 
 there is a probability of the coincidence of rickets with sy- 
 philis, some uncertainty might perhaps exist in any individual 
 case as to the real cause of the bone lesion. In this event at- 
 tention to the points already brought out will lead to correct 
 conclusions, and will enable the surgeon to institute a proper 
 treatment. If, in such a case, the prodromal symptoms of 
 rickets are detected (and they should be carefully inquired 
 after), and if then the lesions had been developed after the 
 manner just stated as being peculiar to rickets, it is fair to 
 assume that the case is one of the latter disease. In such an 
 instance the age of the child would be an important considera- 
 tion; for as rickets usually appears after the sixth month, and 
 very rarely before, and as the number of bones involved is usually 
 large in syphilis at this early age, there would in all probability 
 be a smaller number of bones affected, and the symmetry of 
 evolution would not be as well marked as in rickets. Besides 
 this point, the others already brought out would, if carefully 
 considered, lead to a correct diagnosis.
 
 144 Syphilitic Lesions of the Osseous 
 
 Diagnosis of Swellings at the Sternal end of the Clavicle. 
 
 In the event of the swelling involving the sternal end of the 
 clavicle, it is well to bear in mind that near this situation we 
 may have enlarged lymphatic ganglia, or gum my tumors of the 
 sterno-cleido-mastoid muscle, the latter being developed usually 
 near the tendon. Both of these might perhaps be incorrectly 
 regarded as bone swellings ; bnt if the child's head be allowed 
 to fall backwards, and the parts then examined, all doubts will 
 be quickly removed. Gummatous ulcers occur at this site, and 
 are to be diagnosticated by their implicating only the skin. 
 
 Diagnosis of Swellings complicated with Superficial Necrosis. 
 
 In the cases of superficial ulceration of the integument, and 
 of destruction of the upper part of the bony tumor, the pecu- 
 liar features of which have already been brought out, mistakes 
 might be occasioned by regarding them as gummatous ulcers, 
 or even as inflamed bursse in the situation of the malleoli, but 
 an inquiry into the history and features of the case will enable 
 us to remove the error. The position of the ulcer or ulcers 
 will be a point of some significance, and an examination with a 
 probe would very probably discover that their base is seated 
 upon the bone ; upon which, besides, it may, in many cases, be 
 found that the edges are movable. In adults it is a well- 
 known clinical fact that gummatous ulcers develop in greater 
 frequency at the upper and lower thirds of a limb than at its 
 middle ; bnt in children having hereditary syphilis, this feature, 
 according to my observations, is not so well-marked, and, con- 
 sequently, does not so frequently arise as a source of error in 
 diagnosis. In infantile life, since bursse are as yet so slightly 
 developed, and not at all liable to suppurative inflammation, 
 these ulcers should not be attributed to this cause. 
 
 Diagnosis of Swellings seated on the lateral borders of the 
 
 Shaft. 
 
 In case we find the localized tumors at the diaphyso-epiphysal 
 junction of either side of the bone such as we have already 
 described, we perhaps might mistake them for hereditary 
 epiphysal exostoses ; but the latter swellings are scarcely if 
 ever congenital, rarely appearing before the end of the first 
 year ; attain to variable sizes, many of them being much larger
 
 System in Infants and Young Children. 145 
 
 than we ever discover in syphilitic swellings, some even being 
 as large as an orange ; they may coexist with smaller osseous 
 growths on the shafts ; and, besides, not being attended with 
 any other syphilitic lesions and symptoms, are, of course, unin- 
 fluenced by anti-syphilitic treatment, which causes those of a 
 syphilitic nature to subside rapidly. In this connection, it is 
 well to direct attention to a remarkable case l reported by Dr. 
 Poore, of the Charing Cross Hospital, London, and also to 
 Virchow's admirable lecture upon osseous * tumors. 
 
 Diagnosis of those Swellings in which there is Separation of 
 the Epiphyses from the Diaphyses. 
 
 The clinical facts brought out by the various cases show that 
 this complication may supervene, and proceed either rapidly or 
 with comparative slowness. If sufficient attention is bestowed 
 upon the case, the diagnosis of simple abscess will certainly 
 not be arrived at. Leaving out of consideration the history of 
 the case, and perhaps the existence of syphilitic lesions, or, 
 again, traces of such as have passed away, there are peculiari- 
 ties in these cases which will assist in making the distinction. 
 Thus the fact that the bone is enlarged in its whole diameter, 
 with softening localized at one spot, or perhaps extending more 
 or less around the limb, is distinctive of bone lesion rather than 
 of phlegmonous inflammation. The position of the inflamma- 
 tion would also seem peculiar, and the amount of functional 
 impairment or disturbance would be out of all proportion for 
 an abscess of whatever severity. If seen before necrotic 
 changes supervene, the case will not be liable to be thus regard- 
 ed ; and if, as so often happens, a. similar condition, though 
 in a less advanced stage, exist in other portions of the extremi- 
 ties, a false conclusion will scarcely be arrived at. There 
 is a bare probability that this condition of separation of these 
 segments may be mistaken for synovitis. In the legs, as the 
 epiphyses are of considerable length, the focus of inflamma- 
 tion will occur so far up the shaft that this suspicion can hardly 
 be entertained ; but in the arm and upper part of the fore- 
 aim, or even at the approximating ends of the femur and tibia, 
 
 1 Hereditary Exostoses, Lancet, page 771, November 29, 1873. 
 IJ Pathologic des Tumeurs, Trad. Franc. Dix-septieme legon, Tome Deux- 
 ieme. Paris, 1869. 
 10
 
 1 16 Syphilitic Lesions of the Osseous 
 
 where the epiphyses are shorter, the inflammation being so 
 closely contiguous to the joint, might be regarded as having its 
 focus in it. The distinguishing feature would be the compara- 
 tive absence of pain both in moving the joint proper, the seg- 
 ments being held steadily, and also when the articular surfaces 
 are pushed forcibly together. Besides this, the inflammation 
 of the connective tissue would be much greater at a much ear- 
 lier period than in synovitis. In either event, whether the case 
 be looked upon as abscess or synovitis, an incision being made, 
 the nature of the morbid condition can be clearly understood. 
 In those very severe cases in which there is total destruction 
 and perhaps extrusion of the epiphysis, the gravity of the 
 lesions would indicate the state, and then it would be necessary 
 to determine whether or not it was due to syphilis. 
 
 As before stated, the fact of the separation of the epiphyses 
 from the diaphyses being due to a syphilitic cause, might be 
 overlooked, and the case be regarded as simple in its character, 
 when one of the names already mentioned could be assigned to 
 it. There are certain facts and features connected with the 
 syphilitic process which materially assist in arriving at just 
 conclusions. Let us consider, first, the features of the simple 
 or non-specific form of inflammation, and then contrast them 
 with those presented by the syphilitic. There occurs during 
 the period of development of the bones a violent form of in- 
 flammation, which often results in the separation of the distal 
 segments from the shafts. This accident occurs usually sub- 
 sequent to infancy, or during the period of adolescence ; 
 hence called by Gosselin ' osteide epiphysaires des adolescents, 
 while Frank, 3 who has written a good account of it, (and it is 
 singular that such is totally wanting in the English language,) 
 denominates the condition KrankJieit d#r EntwicJdungsjahre. 
 For my own part, I am inclined to think that it rarely if 
 ever occurs in infancy, and that the view of Gosselin, that 
 it is a trouble coincident in development with the ossifica- 
 tion of the epiphyses, is sustained by clinical observation. I 
 cannot find an instance anywhere mentioned of its occurrence 
 
 1 Momoire sur les Osteides epiphysaires des Adolescents. Archives Gcnjr- 
 rales de Medecine, Nov., 1858. 
 
 2 Ueber entziindliche Epiphysenlosung, eine Krankheit der Entwicklungs- 
 jahre, Giessen, 18J1.
 
 System in Infants and Young Children. 147 
 
 in a child under one year of age, nor have I ever seen such. 
 Frank states that it may occur between the twenty-third day 
 and the twenty-first year ; but the only example of it which he 
 cites in the infant, is the case of Valleix, which, as we have 
 seen, is very probably syphilitic in its nature ; his other cases, 
 as well as those reported by other observers, are those of ado- 
 lescents. Here then we have an important fact which materi- 
 ally assists us in arriving at correct conclusions. All of the 
 recorded cases of this form of lesion, when produced by syphi- 
 lis, have been those of infants under three months, while the 
 simple form is shown to appear much later in life. In syphi- 
 lis the inflammation is coincident with the development of the 
 shaft ; in the simple form it coexists with the ossification of 
 the epiphyses. Bouclmt ' has recently shown that a phleg- 
 monous form of periostitis may occur spontaneously in young 
 infants ; wherefore, it is fair to assume that we may have the 
 same process in the ends of the shafts, and extending into the 
 epiphyses. In the simple form of epiphysal separation there is 
 sometimes a history of traumatism ; it may result from expo- 
 sure to cold, and has been known to occur in much debilitated 
 subjects ; it may be confined to one bone, or, though rarely, 
 involve several. In syphilis, as the lesion is in most cases evi- 
 dence of a severe form, there are usually other lesions or symp- 
 toms which indicate that disease; there ( is no history of trau- 
 matism, or of cold, but in all probability an implication of 
 other bones, which latter may be affected in various degrees. 
 Thus, perhaps, on another shaft the morbid process has simply 
 reached the stage of enlargement ; but, in addition, there may 
 exist such osseous lesions as nodes and phalangeal enlarge- 
 ments which would positively indicate syphilis. Besides all 
 these there is the age of the child, which we have already seen 
 to be an evidence of so much importance. The course of the 
 morbid process, when of a non-specific origin, presents certain 
 characteristic particulars. Thus pain of an acute character 
 referrible to the joint is felt at the outset, redness and swelling 
 soon supervene, and symptoms of severe systemic reaction 
 follow. These symptoms are always much more pronounced 
 in the simple than in the specific form, going on even to the 
 
 1 De la periostite phlegmoneuse aigue chez les enfants. Gazette des Hopi- 
 taux, 20, 21, 1874.
 
 148 Syphilitic Lesions of the Osseous 
 
 development of a typhoidal condition, which sometimes results 
 in death. Then, again, after the redness and swelling have 
 appeared, which are usually not so clearly limited to the epi- 
 physal region as in the syphilitic form, evidence of implication 
 of the lymphatics is soon seeii in red elevated and painful lines 
 extending up the limb. In fact, in this trouble we have an 
 inflammation of the greatest severity, attended with the most 
 formidable symptoms. There are, of course, cases which are of 
 a milder character. Let us contrast this condition with that of 
 syphilis, bearing in mind, as usual, the difference of age. Thus 
 we have seen that even when the process was of the most 
 aggravated type, the systemic reaction was not in proportion to 
 the activity of the lesion ; in fact, this point is not only signifi- 
 cant, but also somewhat surprising. Though redness and swell- 
 ing supervene, these features are somewhat less pronounced 
 than in the other form. There is a greater tendency to a locali- 
 zation of the morbid processes to the original focus ; there is 
 usually no lymphangitis ; and, as far as can be learned by 
 observation, the pain is not as great as might be expected. 
 These, then, are the distinguishing guides in severe instances. 
 Now, then, my cases show that there may be a total separation 
 of the parts, and yet the visible signs and symptoms may be of 
 a mild character. Thus, the swelling occurs slowly ; the sepa- 
 ration coincidently with it; and, though an abscess occurs 
 under the skin, it is not accompanied with very much heat or 
 redness, which, besides, are quite sharply localized ; finally, 
 there is scarcely any evidence of implication of the system, 
 which may not be in any degree affected. If we reflect on the 
 nature of the changes, we may arrive at a reasonable explana- 
 tion. Thus, in syphilis, the separation is due to a softening 
 down of immature cells, and the subsequent symptoms result 
 from the cutting off of the blood supply ; whereas, in the sim- 
 ple form, the process is inflammatory from the commencement. 
 In the milder form also there will be a history of syphilis, in 
 addition to which, other lesions, of an undoubted character, may 
 coexist, leading to a correct diagnosis. "Wherefore, I think 
 that if a given case is carefully studied, both in itself, and in its 
 concomitant lesions and circumstances, mistakes of diagnosis 
 may be avoided. The main points of assistance are : first, the 
 age of the patient; second, the previous history; third, the
 
 System in Infants and Young Children. 149 
 
 coexistent symptoms and lesions ; and, fourth, the dissimilarity 
 in the course of the two affections ; the violent phlegmasic 
 character of the simple form, and the comparatively snbacute 
 character of the syphilitic. Perhaps the fact of the percepti- 
 ble thickening of the periosteum of the shaft above the epiphy- 
 sis may be a point of assistance as settling a syphilitic origin. 
 If a case of this kind was seen after separation had occurred, a 
 diagnosis of fracture might possibly be made; but the absence 
 of injury, and the fact that swelling had existed prior to the 
 separation, the probable existence of other bone lesions, and the 
 history of the case, taken together ought certainly to prevent 
 that error. 
 
 Diagnosis of the Enlargement of the Phalanges and of the 
 other Bones of the Hands and Feet. 
 
 In infants and young children, the phalanges are sometimes 
 observed to be very much enlarged, and inquiry into the his- 
 tory of the case fails to elicit that syphilis is the cause. The 
 clinical features of these swellings are similar to those of the 
 syphilitic enlargements described in chapter nine. Indeed in 
 their development, course and decline, these non-specific en- 
 largements are similar to those of syphilis ; and, after careful 
 comparative- study of these cases, I must confess that there are 
 almost no distinguishing points; so that we are forced to rely 
 upon the previous history and upon coexistent lesions or their 
 sequeke. Some of these cases may present 110 difficulties, 
 owing to the presence of other bone lesions undoubtedly syphi- 
 litic. However, during the years in which I have been studying 
 these syphilitic osseous lesions, 1 have met with a number of 
 cases of enlargement of the phalanges in which no history of 
 syphilis was obtained, and which I am convinced were not 
 syphilitic. In several of these cases I have found an extremely 
 debilitated condition of the system, due sometimes to poverty 
 and want of care ; in others to the depressing influence of a past 
 attack of the exanthemata or of diphtheria. In these cases 
 that concatenation of lesions and symptoms which is called 
 scrofula was present a condition which, when succinctly stated, 
 may be described as a tendency to local congestion and abnor- 
 mal cell proliferation in various organs and tissues. As results 
 of my own study and observations, I am led to the opinion that
 
 150 Syphilitic Lesions of tlie Osseous 
 
 in this condition hyperplastic processes may occur in bone ; 
 for as the natural morphological changes in that structure are 
 usually active, under the influence of this dyscrasia they be- 
 come abnormally so, and induce enlargements of the bones. 
 The lesion in such cases is an osteitis and periostitis, and is much 
 less amenable to treatment than the syphilitic variety. The 
 enlargements we are speaking of may be the result of trauma- 
 tism even in a healthy subject. It is necessary to bring these 
 points prominently forward, as there has been a tendency of 
 late to class all cases of enlargement of the phalanges in chil- 
 dren as syphilitic. If, then, in a given case, upon careful 
 inquiry into the history of the mother and of the child, and 
 after a thorough examination of the latter, no evidence of 
 syphilis is obtained, the suspicion of that disease should at once 
 be rejected. The features which point to syphilis, besides the 
 history and concomitant symptoms, are the somewhat gradual 
 and painless enlarging of the bone, the absence of any joint 
 complication, and the fact that necrotic processes, if they com- 
 plicate the case, are developed after the swelling has attained 
 its maximum size that is, rather late. In cases of trail ma- 
 tism, pain, and consequent uneasiness of the child, may be 
 noticed, while the necrotic change appears earlier. In the 
 variety of swelling due to the depraved condition of the sys- 
 tem above spoken of, I have sometimes noticed that the en- 
 largements occur rather more rapidly than in syphilis ; that 
 they are more liable to undergo a rapidly destructive change ; 
 and that they more frequently involve the joints. But, as I 
 have before stated, these distinctions are far from being abso- 
 lutely reliable, and in any case the diagnosis hinges upon the 
 history and concomitant symptoms and lesions. It will be 
 remembered that in the descriptive part I pointed out that the 
 hyperaemic condition of the integument of the fingers, in cases 
 in which excessive pressure is exerted by the bony swelling, 
 was sometimes accompanied with a coppery appearance of the 
 member, yet as this peculiarity is infrequent, and as it is simu- 
 lated by simple chronic congestion, we cannot attach much im- 
 portance to it. 
 
 As we sometimes see rheumatoid arthritis even in young 
 children, though not in infants, it is well to state the points 
 of distinction between its lesions and those of syphilis. This
 
 System in Infants and Young Children. 151 
 
 disease is usually attended with well-marked fever; the joints, 
 particularly the large ones, are affected, and if the fingers are 
 involved, it will be found that the enlargements of the 
 phalanges are greatest at the joints, which are affected much 
 more profoundly than in syphilis. The main points of dis- 
 tinction are : the antecedent symptoms, the great pain, the 
 localized intensity of the inflammation, with consequent swel- 
 ling, which, as stated, are first limited principally to the joints. 
 These points, as contracted with dactylitis syphilitica, are so 
 well characterized as to prevent any error in the diagnosis. 
 
 Little need be said of the enlargements of the phalanges pro- 
 duced by exostoses and enchondromata, as their size, localiza- 
 tion, and history, are usually such as to clearly suggest their 
 nature. 
 
 A perusal of the case, given in a foot-note to chapter xv., 
 will give a sufficient idea of the appearances presented by the 
 phalanges, when the seat of cartilaginous hyperplasia. This 
 condition begins necessarily in utero, is localized to one, or per- 
 haps two bones, and discoverable at birth. Being unattended 
 with inflammatory symptoms, the phalanx will, upon inspec- 
 tion, appear translucent. The condition is very rare, as the 
 case detailed in the note is the only one which I have seen, or 
 indeed, read of. 
 
 The diagnosis of the swellings of the carpal and metacarpal 
 bones, and the corresponding bones of the feet, depends largely 
 upon the history of the case. In these swellings joint compli- 
 cations are rather more frequently observed ; in which event 
 the general redness and swelling might mislead the surgeon 
 into the belief that those structures were the focus of the in- 
 flammation ; but inquiry into the history of the case, and a care- 
 ful examination of it, would undoubtedly lead to more correct 
 conclusions. It is necessary to bear in mind that these swell- 
 ings may arise from the same condition which produces the 
 phalangeal enlargements, and also that they may be the result 
 of traumatism ; but here also articular complications are rather 
 more liable to occur; indeed, in many instances the morbid pro- 
 cesses begin in the structures which compose the joints. How- 
 ever, to render the matter certain, the history of the case, and 
 its concomitant features, must be thoroughly looked into, by 
 which course only a correct conclusion can be arrived at.
 
 152 Syphilitic Lesions of the Osseous 
 
 Tlie Diagnosis of Nodes on the Cranial Bones. 
 
 The swellings upon the cranial bones, in like manner, present 
 several points of interest in diagnosis. The small variety of 
 node described by Wegner, consisting as it does of minute oval 
 or round elevations, exists thus far only as a pathological rarity, 
 and is not simulated by any other affection. Therefore, if 
 met with, it can be unequivocally ascribed to syphilis. In the 
 larger variety, in which the swellings develop to a considerable 
 extent, they might perhaps be regarded, when in an indolent 
 and uninflamed condition, as sebaceous tumors, which are deeply 
 seated, and have become attached to the pericranium. But, 
 besides that in the young child this peculiar condition of the 
 wen is very rarely if ever met with, there would be the absence 
 of any other 8} T mptom or lesion to cause a suspicion of syphilis, 
 and the sebaceous tumor, if carefully examined, would be 
 found in many, perhaps the majority, of instances, soft upon 
 pressure, rounder, and more abrupt at the edges, than the node. 
 The situation may likewise assist to guide us, as nodes are 
 seated generally toward the lateral parts of the frontal, and upon 
 the parietal bones. We have seen, in the clinical part, that in 
 several cases inflammatory complications rapidly supervened. 
 In these the general appearances and symptoms were those of 
 phlegmonous inflammation of the subcutaneous tissue of the 
 scalp. So that we have reason for suspecting nodes which 
 have undergone degeneration, in the event of meeting with 
 such abscesses on the heads of syphilitic children. But these are 
 the facts which help us. The node is deeply seated, and may 
 be attended in its evolution with pain, and generally enlarges 
 gradually ; points which, once ascertained, there is no longer 
 likelihood of mistake. But in those instances already alluded 
 to, in which a rapidly destructive condition of the bones early 
 complicates the case, the diagnosis will remain doubtful until 
 after an incision is made in the part, when the nature and ex- 
 tent of the condition can be ascertained. The depth and per- 
 haps the occurrence of bony sequestra will then be determining 
 points. A history of syphilis or the existence of its lesions may 
 assist. These cases require care in their diagnosis. When 
 the node runs a chronic course, is fully developed, and then, 
 afterwards, undergoes necrotic change, with its concomitant
 
 System in Infants and Young Children. 153 
 
 symptoms, usually no difficulty will be experienced in ar- 
 riving at a conclusion; but, as I have said before, doubt .will 
 more usually arise in those cases in which the necrotic tendency 
 begins with the development of the tumor. There is a point 
 of considerable importance in diagnosis which deserves men- 
 tion ; it is this, in rare instances wens undergo ulceration of a 
 persistent character, which involves the tissues around in in- 
 flammation, is only cured by its enucleation, and might be 
 mistaken for an ulcerating gumma of bone and integument. 
 Should such a condition obtain in the infant, one, however, that 
 we can hardly expect, it is easy to see how it might, from its 
 being deep-seated and chronic in character, be looked upon as 
 an instance of the inflammatory node. 
 
 I once saw in a typical case of rickets, in which, unquestion- 
 ably, there was 110 syphilitic complication, a state of the skull 
 bones which struck me at the time as being very likely to be re- 
 garded as syphilitic. The patient was a child eighteen months 
 old, who at its sixth month had the usual symptoms of rickets, 
 with swellings at the distal ends of the ribs and of the radii and 
 ulnae. It had continued in a miserable condition of health, and 
 at its ninth month a swelling was found on the left side of the 
 frontal bone, just outside the eminence; this increased, and was 
 followed by a similar swelling on the right side, at its fourteenth 
 month. When first seen by me, the left or first swelling was 
 elevated above the plane of the bone about three- quarters of a 
 line ; it was oval in shape, having a flat, smooth surface, and being 
 an inch and a half long, by three-quarters of an inch wide. On 
 the right side was a swelling precisely similar, except as to size, 
 which was but one-half that of the other. These swellings dif- 
 fer strikingly from the typical nodes, but still they are excep- 
 tional as occurring in rickets ; and indeed I cannot find such an in- 
 stance mentioned. The lesion 1 was simply a thickening of the 
 
 1 This was undoubtedly an instance of that abnormal periosteal osteogenesis 
 which is caused by rickets. It consists in an excessive development of the 
 young connective tissue, and a corresponding increase in the number of the 
 capillaries. Such swellings may be found upon the surfaces of the bones 
 generally, and are to be remembered in questions of diagnosis. When oc- 
 curring on the cranial bones, they are, according to Rindfleisch (A Manual of 
 Pathological Histology, Vol. 2, London, 1873), usually sharply circumscribed 
 as in the case in the text, differing from those upon other bones, where they 
 usually are not thus limited.
 
 154 Syphilitic Lesions of the Osseous 
 
 periosteum, and was caused by the rachitic blood disorder. We 
 not unfrequently find thickening of the periosteum in rickets 
 near the sutural margins, but, as I have said, not usually in the 
 situation here spoken of. It is well, therefore, to bear in mind, 
 in making our diagnosis, the probable existence of this form of 
 flat, broad rachitic 1 swelling of the skull, as a precaution against 
 error. 
 
 XXVI. THE TREATMENT. 
 
 We now come to treatment. Though perhaps foreign to the 
 present investigation, it may be well to briefly mention the 
 beneficial results of a proper and well-regulated mercurial treat- 
 ment of a pregnant woman, in preventing the future develop- 
 ment of syphilitic lesions in her child. My own cases clearly 
 indicate that the neglect of treatment of the malady in the 
 parent has resulted in her bringing forth a tainted offspring, 
 
 1 These rachitic periosteal thickenings of the cranial bones, as well as their 
 resulting enlargement, are particularly to be borne in mind in making a diag- 
 nosis between rickets and syphilis. In the case just mentioned the tissue was 
 undoubtedly still unossified, and it is fair to suppose that on the completion of 
 the ossific process, a deformity, misleading in its appearances, would result. 
 I saw this condition in its developed state in a patient, whose lesions were 
 such, that doubt was entertained by several as to their etiology. Its import - 
 ance therefore warrants its insertion in this connection. The patient was a 
 girl fourteen years old, who, in early life, suffered severely from rickets, and 
 whose frame was thereby much distorted. She was under my treatment for 
 several years, for a very extensive lupus vulgaris of the face. She also had 
 upon the right lateral portion of the frontal bone a swelling having an area of 
 an inch and a quarter, and being about half an inch high. It was perfectly 
 smooth, and its margins sloped imperceptibly into the surrounding bones. 
 The case was seen by many physicians; by some of whom it was thought that 
 the association of the cutaneous and osseous lesions was an evidence of heredi- 
 tary syphilis, though there was no history of that disease ; others argued that, 
 as lupus was an undoubted evidence of scrofula, therefore the osseous lesion 
 was the result of that disease. Should the last hypothesis be accepted, we 
 should come to look upon nodes as lesions of scrofula, an opinion not tenable. 
 Now, inquiry into the chronology of the affections and a knowledge of the le- 
 sions of the cranial bones, which rickets produces, clears up the case conclu- 
 sively. Thus, in her early infancy, the girl had rickets affecting the osseous 
 system generally, at which time the peculiar hyperplasia of the periosteum, 
 which that disease induces, occurred on the frontal bone. The cell prolifera- 
 tion being active, a large swelling resulted, which, later on, became ossified, 
 and proceeding in growth with the cranium remained permanent. The lupus, 
 which developed several years later, was probably the expression of the debili- 
 tated state of health.
 
 System in Infants and Young Children* 155 
 
 one in which, perhaps, are developed severe osseous and other 
 lesions. Wherefore, as a prophylactic consideration, this mat- 
 ter deserves especial attention. 
 
 Let us now consider, with brevity, the indications for the 
 treatment of infants hereditarily syphilitic affected with osse- 
 ous lesions. We have already seen, in studying their patholog- 
 ical anatomy, that they are essentially cellular hyperplasia of 
 the forming bone, and of the periosteum, produced by a recent 
 acute syphilitic action. This state differs, in being more ad- 
 vanced, from that of cases in which such bony lesions are ab- 
 sent ; and thus, while we have to treat a recent syphilitic condi- 
 tion, we have superadded the lesions already alluded to. A su- 
 perficial knowledge of these cases might lead to the opinion that 
 children thus affected had lesions of a tertiary character, as they 
 are of bone, and hence that they required the treatment usually 
 employed in that stage ; but, as I have, I think, clearly shown, 
 these lesions are of a different character from gummy tumor 
 proliferation, being less advanced, and more closely allied to sim- 
 ple cell proliferation. The condition, as warranted by patholo- 
 gy, can be rightly compared with that of the late adult acquired 
 syphilis in which gummy tumor proliferation has not yet ap- 
 peared. Now, in this stage, it is well known that the combined 
 or mixed treatment of mercury and iodide of potassium is much 
 more efficacious than is either of those medicines administered 
 alone. And my experience in the treatment of these osseous 
 lesions is that the infant should be treated by the same reme- 
 dies, and on the same principle. The prescription which I 
 have used, and which I see no reason to modify, is as follows : 
 
 $ Hydrarg. bichlor gr. i. 
 
 Potassii iodidi 3 iv. 
 
 Syrupi aurant., 
 
 Aquae, aa i ij. 
 
 M. 
 
 We may also use the bin-iodide instead of the bichloride. 
 The dose of this mixture, for a young child about two months 
 old, is five drops, which should be gradually increased, in the 
 manner recorded in the cases. I have pushed this remedy as 
 high as twenty drops in some cases of severe hereditary syphi- 
 litic lesions. A matter important to be borne in mind is, that
 
 156 Syphilitic Lesions of the Osseous 
 
 as the taking of medicine has of necessity to extend over a 
 long period of time, we must use such a remedy as is not likely 
 to derange the gastro-intestinal functions, or will induce ca- 
 chexia, but which, yet, will be sufficiently powerful to control 
 the disease. These indications are, I think, fully met by the 
 prescription above given. Fears may perhaps be entertained 
 by the practitioner, that this long-continued treatment might re- 
 sult injuriously to the health of the child; but such are entirely 
 without foundation. It will be found that under the influence of 
 the mixture alone, even without the simultaneous administra- 
 tion of tonics, the health of the infant will be greatly improved, 
 sometimes in a very striking manner. There need be no ap- 
 prehensions of salivation, or of any noxious effect of the mer- 
 cury ; for when this combination is used, the iodide of potassium 
 corrects such a tendency, and this constitutes another advantage 
 in its favor. There is good reason for believing that the power 
 of the mercurial, in such a protracted course of treatment, will, 
 after a time, from the system becoming habituated to its action, 
 fail of the desired specific effect. This also occurs in adult 
 syphilis, and is to be successfully met by discontinuing the treat- 
 ment for a short period, several times during the course. In 
 this interval of rest, the system becomes again subject to the 
 mercurial influence, and its action is again made manifest. I 
 have omitted to mention, in my remarks upon treatment, the 
 propriety of ordering these intermissions, though regarding 
 them as essential ; for the reason that very frequently they occur 
 in the cases of these children by the negligence and sometimes 
 the indifference of the parents. The practitioner will some- 
 times undoubtedly encounter great difficulty in enforcing regu- 
 larity in the treatment, and periods in which the medicine is 
 not given, and perhaps forgotten, will certainly occur, even 
 among intelligent people. 
 
 Cases may be met with in 'which the assimilative processes 
 of the child are imperfectly performed, as well also as instances 
 in which the digestion is slow, and attended with an acid con- 
 
 O 
 
 dition of the stomach, tinder such circumstances a proper 
 preparatory treatment, the nature of which will be indicated 
 by the peculiarities of the case, is necessary, in order that 
 the medicine shall be well borne, and that benefit shall result 
 from it.
 
 System in Infants and Young Children. 157 
 
 It is of importance also to advert to the necessity of a well- 
 regulated and sufficient diet during the period in which spe- 
 cific medication is followed. In order that good should he 
 produced, and to avoid cachexia, plenty of nourishing food 
 should be given, otherwise the action of the medicine is lower- 
 ing to the economy, even to the point of being harmful. This 
 remark applies with equal force to the treatment of all forms 
 of hereditary syphilitic lesions, as it does also to the adult. In 
 the treatment of cases among the poorer classes, a want of food 
 will often be found to be a serious obstacle to success. It is 
 unnecessary to go fully into a consideration of the forms of 
 diet required ; for it is a well-known fact that the mother's 
 milk, if of a good quality, and of sufficient quantity, is the best 
 food obtainable; or, in default of this, that of a wet-nurse ; x or, 
 again, a good quality of cows' milk. In addition, much good 
 may be obtained from the administration of cod-liver oil in full 
 doses ; preparations of iron and quinine will also be found in 
 many cases beneficial, and in some essential. 
 
 I have used the hypodermic injections of corrosive sublimate 
 in hereditary syphilis, and coincidently given the iodide inter- 
 nally, but, from a no inconsiderable experience, would advise 
 that this treatment should not be used. These injections in- 
 duce great subcutaneous infiltration and inflammation, and are 
 very frequently followed by abscesses. I have seen severe sys- 
 temic reaction follow them, even when used with caution, inde- 
 pendent of which objection they are almost inadmissible by 
 reason of the pain they induce, and the repugnance they excite 
 in the minds of the parents. In fact, I think that for infants 
 they are a cruel method of treatment, and that they should 
 scarcely ever be employed. There may be cases in which the 
 
 1 It would be improper to pass over this point without careful consideration. 
 There is, as is well known, a very great liability that a syphilitic child may 
 convey syphilis to any healthy woman who nurses it at the breast ; conse- 
 quently, under no circumstances would it be right to expose such a person 
 to that serious risk. Though the child might not have, when examined, le- 
 gions of the mouth, there is a probability that such might develop ; or, again, 
 as its blood possesses contagious properties, this also might be the means of 
 conveying the disease. As to the propriety of suckling it by a syphilitic 
 woman, whose milk may appear to be of good quality and sufficient in quan- 
 tity, if by such a better nourishment can be given than by its mother, it may 
 have that j but in such cases cows' milk is really the best diet.
 
 158 Syphilitic Lesions of the Osseous 
 
 course of the osseous lesions is so rapid, that we wish to induce 
 the effect of the remedy immediately, in which event we may 
 have, of necessity, to use them ; but I should strongly advise 
 their discontinuance just as soon as the urgent indications have 
 passed away. 
 
 Much has been said of the value of mercurial inunctions as 
 a speedy and certain way of inducing the effects of the min- 
 eral. They are, in many instances, of infinite value in adult 
 acquired syphilis ; but in that of infants are apt to produce se- 
 vere cutaneous inflammation, and sometimes grave systemic dis- 
 turbance, such as great enfeeblement, impoverishment of the 
 blood, with cachexia. For these reasons, and also because in 
 these cases their use is to be extended over such a long period, 
 and that it is almost impossible to get the attendants to use them 
 intelligently and regularly, I am not disposed to advise them, 
 notwithstanding their great potency as used in the adult. 
 
 As to the method of continuing the use of the mixed treatment, 
 I should advise the reader to follow the history of several of the 
 cases, as such a perusal will give a more practical idea than 
 any didactic statement can possibly convey. In summer, gastro- 
 intestinal disorders may supervene, in which case the hydrargy- 
 rum cum creta, with astringents, can be given, and perhaps the 
 iodide continued. During the continuance of warm weather, 
 it is well to anticipate these frequently-occurring troubles, and 
 prudent to send the little patient into the country. Another 
 point is, that if the mother is able, she should continue to give 
 the child the breast, as in that case it is less liable to bowel dif- 
 ficulties. I say nothing of medication of the child through the 
 mother, as it is totally ineffectual. 
 
 Locally, in the case of the ulcerations, I think that nothing is 
 as beneficial as the application of iodoform into their cavities, 
 with a covering to the other parts of balsam of Peru ointment. 
 
 When separation of the epiphyses occurs, the indications are 
 the same as in fracture, namely, immobility of the parts by 
 means of an accurately fitting splint, or a bandage. Adhesive 
 plaster, pi aster-of- Paris, and the starcH bandage, may seve- 
 rally be made use of. The adhesive plaster, if properly applied, 
 is, perhaps, the best, as it is readily removed, easily reapplied, 
 and adjusted as the swelling diminishes. It is very necessary 
 not only to keep the parts in juxtaposition, but also to main-
 
 System in Infants and Young Children. 159 
 
 tain pressure, which is as beneficial in these cases as it is in 
 synovitis. When the latter complication arises, rest should be in- 
 sisted upon, and cooling lotions applied, in addition to such medi- 
 cinal treatment as the disease requires. Surgical interference may 
 be demanded when the epiphysis is wholly separated, which then 
 acts as a foreign body. In such an instance, the removal of the 
 fragment, the application of carbolized lint in the cavity, and the 
 maintenance of a fixed position, are the main indications. 
 
 It may happen, in case of enlargement of the phalanges, that 
 the medicine has no effect, and that the swelling persists. In 
 such an event the surgeon might, perhaps, think of resorting to 
 exsection, a proceeding which, in my opinion, should be delayed 
 as long as possible. Indeed, I think that the mercurial prepa- 
 ration should be persevered with for eight or ten months, while 
 at the same time pressure is made use of. Even in case of 
 failure, there is no good reason for removal of the bone if it 
 be simply in a swollen condition. Should, however, necrotic 
 changes supervene, together with sinuses, and the usual chronic 
 inflammatory condition, perhaps an operation would be impera- 
 tive ; biit I should strongly counsel delay, and a perseverance 
 with treatment. 
 
 In cases of enlargement of the phalanges, or of either of 
 the ends of the shaft, when ulceration does not complicate the 
 case, benefit can be obtained by slight continuous pressure, com- 
 bined with the constant application of a mercurial preparation, 
 either in the shape of the ointment, which should be half of 
 the officinal strength, or of a mercurial plaster, either of the 
 simple variety, or the Emplastrum de Vigo. When such an 
 application is made, care should be exercised that inflammation 
 of the skin is not produced, as nlceration of a chronic charac- 
 ter might result. At any rate, the plaster or ointment, kept in 
 close position by a bandage, should be frequently changed, as 
 it becomes loose in a few days. 
 
 The nodes on the scalp require, in the uncomplicated condi- 
 tion, little or no local treatment, beyond daily frictions with 
 mercurial ointment. When they degenerate into abscess, and 
 consequently induce a phlegmonous state of the scalp, a free 
 crucial incision should be made, the detritus carefully removed, 
 and the whole thoroughly mopped with carbolic acid ren- 
 dered fluid by a few drops of water; the 'cavity then to be
 
 160 Syphilitic Lesions of the Osseous 
 
 stuffed with charpie, and cold-water dressing applied to the 
 Bcalp. The next day this should be removed, and if the parts 
 present a sloughy appearance, the application of the carbolic 
 acid should be repeated, taking care to merely moisten the sur- 
 face, and not to allow any of the acid to flow from the wound. 
 Or, the cavity can be dusted with iodoform, and then stuffed 
 with lint, and a cooling lotion applied to the spot, and to the 
 scalp for some distance beyond it, as long as any inflamma- 
 tory symptoms remain. This latter application is of much im- 
 portance, as such phlegmonous inflammations of the scalp very 
 often give rise to adenitis of the post-cervical ganglia, which 
 in syphilitic subjects are particularly liable to suppuration. 
 These directions as to treatment of bony abscesses about the scalp 
 apply equally to those developed in other parts. 
 
 Such, therefore, are the main outlines of treatment, which 
 will be found to meet the principal indications. Some minor 
 points may arise and demand treatment, for which the practi- 
 tioner will find a sufficient guide in general principles. 
 
 XX VH. THE SWELLINGS WHICH OCCUR LATER IN THE LIFE OF 
 THOSE HEREDITARILY SYPHILITIC, AT THE JUNCTION OF THK 
 DIAPHYSE8 WITH THE EPIPHYSE8. 
 
 In connection with our study of these diaphyso-epiphysal 
 swellings in hereditarily syphilitic infants, it is appropriate to 
 call attention to some observations made by Ftirneanx Jordan 
 upon somewhat similar lesions developed in later periods of 
 life in victims of hereditary syphilis. 1 This surgeon reports a 
 number of cases in which enlargements occurred at the lower 
 ends of the femur, hnmerns, radius, as also at the great tro- 
 chanter, on the ilium, and at the upper end of the humerus. 
 These swellings ran an indolent course, attended with but slight 
 pain, and while in some instances they had led to sclerosis of 
 the bones, in others caries occurred, and dermal sinuses were 
 formed ; in some instances a secondary synovitis was induced. 
 This author thinks that when the humerus, radius, or ulna are 
 affected, the joint complication comes on sooner than when the 
 
 1 On the Hereditarily Syphilitic Character of an Inflammation of the Bones 
 hitherto regarded as Strumous. Medical Times and Gasettt, March 16th 
 and 23d, 1867.
 
 System in Infants and Young Children. 1 61 
 
 larger bones of the leg are the seat of swelling. Sometimes, 
 though rarely, he found synovitis of the knee-joint the first 
 evidence that enlargement had occurred in the femur. In one- 
 third of his cases (he reports fifteen), the upper end of the shaft 
 of the femur was attacked, the lesion being limited to the base 
 of the great trochanter, while the head and neck of the bone 
 remained unaffected. In one instance lie found such a swell- 
 ing at the internal condyle of the humerus, a situation which 
 we, in our studies, have found to be much prone to syphilitic 
 swellings in infants. In the one case, in which the ilium was 
 involved, he satisfied himself that the inflammation was on the 
 dorsum, and that its crest, with its separate centre of ossification, 
 was free. Mr. Jordan ventures the suggestion that caries of 
 the vertebrae coming on late in adult life is mostly, if not always, 
 due to hereditary syphilis. 
 
 As regards the intensity of the morbid process, there is 
 considerable variation ; in some cases the osteitis is very slight, 
 in others it produces sclerosis, while in the worst form caries is 
 induced. Necrosis is not a result of this lesion, according to 
 this author. Its chronicity, however, is worthy of mention; 
 since, in one instance, a sinus remained open for eleven years, 
 in another, as long as twenty. But while in those instances in 
 which degeneration occurs we may observe this extreme chron- 
 icity, there are, Jordan is of opinion, cases so slight as some- 
 times to escape detection, while others are observed, particularly 
 in dispensary practice, in which the patient complains of stiff- 
 ness of the wrist, elbow, or ankle, or of a larger joint, and perhaps 
 impairment of motion, either in extension or flexion, prona- 
 tion or supination. In these instances an enlargement of the 
 distal extremities of the bone or bones is found to be the cause. 
 In the majority of these cases Mr. Jordan thinks that in heredi- 
 tary syphilis is to be found the origin of the trouble. As 
 already said, the greater or less immunity of joint complica- 
 tion depends upon two facts ; first, the chronicity and severity 
 of the inflammation, and secondly, as to the size of the epiphysis ; 
 for, if long, the inflammation naturally is more remote from the 
 joint, but if short, it runs its course near the joint, which is very 
 liable to be implicated with it. It will be seen that, in my own 
 observations upon joint complications secondary to diaphyso- 
 epiphysal swellings, tliis fact was clearly brought out by 
 11
 
 162 Syphilitic Lesions of the Osseous 
 
 several of my cases, and was also explained in my comments 
 thereon. 
 
 The focns of this osteitis, which, from inference, I should con- 
 sider as simply inflammatory, and not attended with gummy 
 tumor or granulation tissue proliferation, is at the end of the 
 shaft in the cancellous tissue. According to Mr. Jordan, the in- 
 flammatory process is greatest in the shaft, and may or may 
 not involve the epiphysis. Being developed at a time when 
 the changes of the cartilage are less active than in the earliest 
 periods of life, it is very probable, as suggested by Jordan, 
 that the epiphyses are scarcely, if at all, affected ; hence, that 
 the lesion is an osteitis rather than an osteo-chondritis. 
 
 The ages at which he has noticed this trouble are between 
 the fifteenth and thirty-fifth years of life, and even as late 
 as the fortieth. The illustrative cases are open to the same 
 objections that many cases of supposed hereditary syphilis are 
 subject to, namely, that the hereditary syphilitic diathesis is 
 assumed from the existence of the remains or sequelae of lesions 
 which are thought to be of syphilitic origin, and are consid- 
 ered as not being produced by any other condition of the sys- 
 tem. This fact is to be sincerely regretted ; since, in drawing 
 such important conclusions as these cases suggest, it is very 
 essential to establish beyond a shadow of a doubt the influence 
 of syphilis as the cause of the lesions. Yet 1 think that many 
 of Mr. Jordan's cases will warrant the suspicion, I may even 
 say the diagnosis, of syphilis, for which reason his conclusions, 
 which he states in a very modest way, are certainly of great 
 value. They are suggestive rather than conclusive ; yet open 
 out to us a field of study which should be carefully exam- 
 ined, for by drawing true conclusions in these cases we are pre- 
 pared to undertake their treatment in a more definite or 
 intelligent way, and rescue such cases from that great gulf 
 of ignorance which we unfortunately call scrofula. Another 
 point of very great importance is adduced by Mr. Jordan in 
 these cases, which ie, that mercury exercises upon them a bene- 
 ficial effect. This fact may be in favor of the syphilitic 
 origin of the lesions, and should, therefore, be borne in 
 mind. 
 
 Since we have found that in the early infancy of syphilitic 
 children this peculiar part of the bones is liable to undergo in-
 
 System in Infants and Young Children. 163 
 
 i 
 
 flammation, when we consider how active the natural changes 
 are at this point, and that the} 7 remain thus for such a num- 
 ber of years, it certainly seems very probable that it should be 
 affected later in the life of the syphilitic individual, as well 
 as in its early life, particularly as- in the majority of cases it is 
 a lesion consisting in perverted nutrition. 
 
 During the past summer I have had under my observation 
 a patient sent to me by my friend, Dr. Gibney, in whom the 
 peculiar osseous lesions described by Jordan are manifested. 
 The case is that of a German girl, eight years of age, who pre- 
 sents a clear history of syphilis, which was acquired at her 
 third year. Shortly after, having a typical rash and condylo- 
 mata, she was attacked with severe pains in the bones, recur- 
 ring especially severe at night. When the child was five years 
 old, having been in the meantime sickly, it was noticed that 
 some of her bones swelled near the joints. The swelling in- 
 creased slowly, until enlargements of considerable size were 
 produced. Though treated by various practitioners for a long 
 time, no diminution was observed. When first seen by me, late 
 in May of 1874, I found that the index and middle fingers of 
 the left hand were slightly enlarged, that the distal diaphyso- 
 epiphysal junction of the radius and ulna in each arm was man- 
 ifestly swollen, and that a similar condition existed at the low- 
 er extremities of the femora. I tried iodide of potassium in 
 increasing doses, combined with iron and quinine, with the re- 
 sult of relieving the nocturnal pain, which was severe and 
 continuous. This failing to reduce the swelling, I used the 
 mixed treatment, according to the formula already given, ad- 
 ministering half-teaspoonf ul doses. As thus far observed, in 
 a trial of two months, the effect is very gratifying, as there is a 
 perceptible decrease in the size of the swellings, and much 
 more suppleness and mobility of the limbs, particularly the 
 lower : moreover, the general health has materially improved. 
 It must be borne in mind that, in cases where the swellings 
 have existed, as here stated, so long, the chances of the ul- 
 timate restoration of the parts are not very great, as the bones 
 have then passed into a sclerotic condition, difficult if not im- 
 possible to be removed. This remark applies with equal force 
 to any form of syphilitic bone lesion. Therefore, we cannot say 
 definitely, in any such chronic case in which anti-syphilitic
 
 164 Syphilitic Lesions of the Osseous 
 
 treatment is not absolutely successful, that this fact militates 
 against the correctness of the diagnosis. 
 
 It may be well to state in reference to this case that, though 
 the child is younger than any of those spoken of by Jordan, 
 nevertheless I am disposed to think that the lesion was an 
 osteitis of the end of the shaft rather than an osteo-chondritis. 
 The peculiar character of the case supports this view. Thus 
 the swellings occurred at the period when osteitis is to be ex- 
 pected ; they grew much more slowly than those of infancy, 
 and did not attain such a relatively large size as when the car- 
 tilaginous segments are mainly implicated. There was, besides, 
 an evidence, in the tapering condition of the bones, that the 
 process had extended a short distance up the shaft, thus seeming 
 to show that it had originated in it. This case would favor the 
 view that this condition can be developed at an earlier period 
 than is stated by Jordan, and there is no anatomical reason why 
 it should not. 
 
 Another important consideration is, the occurrence of this 
 lesion in acquired syphilis. This, together with the fact that 
 the true osteo-chondritis may be the result of this form of dis- 
 ease, as in* my eighth case, in which the existence of that lesion 
 is clearly shown, go to prove that the bones are affected simi- 
 larly in both the hereditary and acquired syphilis of children. 
 Added to this, we know that in both of these varieties of 
 syphilis, gummous proliferation may also be developed in a sim- 
 ilar manner. Thus, there is ample evidence adduced to war- 
 rant the general statement that the osseous lesions in infants 
 and older children are similar in nature and character, whether 
 resulting from hereditary or acquired syphilis. This know- 
 ledge is very important; for while the hereditary osseous 
 lesions have hitherto been slightly and incorrectly understood, 
 there was scarcely anything known of the osseous lesions of ac- 
 quired syphilis in children ; indeed^ the fact of their occurrence 
 has hardly ever been mentioned. 
 
 XXVIII. THE COURSE OF THE GTJMMOUS OSSEOUS LESIONS OF 
 OLDEE CHILDREN, CONTRASTED WITH THE LESIONS OF IN- 
 FANCY. 
 
 It has been shown in the clinical division of this work, and 
 also in the pathological part, that the osseous lesions produced
 
 System in Infants and Young Children. 165 
 
 by hereditary syphilis in the infant differ somewhat in nature, 
 course, and features, from those of later life. Space will not 
 permit me to describe the lesions of more advanced years in 
 an exhaustive manner in this work ; but for the sake of com- 
 pleteness I have thought it best to give a general idea of them, 
 as supplementary to the description already given. To this 
 end I have selected from my notes the following case, as it will 
 show somewhat fully the points of contrast: 
 
 The patient was a German boy, Henry Schwartz, who was 
 first seen by me in 1871, he being then a little over nine years 
 of age. Being accompanied by his mother, he came to the 
 college in February, having been sent by one of my friends, 
 who was his teacher. His mother bore evidences of a severe 
 form of syphilis, in the fall of the nasal arch, in a nasal twang 
 with which she spoke, owing to loss of tissue in the palatal 
 region. She also had deep cicatrices at the side of the nose, 
 running up the left ala. Her husband had suffered from syph- 
 ilis, and had died of a nervous affection which was ushered in 
 by hemiplegia. Prior to the birth of the present child the 
 mother had had two miscarriages, late in pregnancy. Shortly 
 after his birth he had severe syphilitic manifestations. He re- 
 mained sickly, weak, and delicate, until he was five years of 
 age, during which period he was irregularly and, as I learned, 
 not properly treated with mercurials. "When about five and a 
 half years of age he was afflicted with a series of bony swel- 
 lings, which troubled him for two years. 
 
 When first examined by me I found the following abnor- 
 malities of the osseous system : On the right hand, the index 
 finger was a mere stump, just reaching to the first phalangeal 
 joint of the middle finger. "When I had carefully manipulated 
 the parts, I found that the whole of the first phalanx, the proxi- 
 mal third of the second, and the distal third of its metarcarpal 
 bone, had been absorbed. The latter bone tapered off gradu- 
 ally to its end, at which point a band, undoubtedly of fibrous 
 tissue, was attached, which, at its other end, held the remains 
 of the second phalanx. This fibrous band could be distinctly 
 felt, and it was found to allow of slight extension when 
 traction was exerted upon the end of the finger. It answered, 
 in a measure, the purpose of joint structures, and allowed the 
 finger to be bent to an abnormal degree, in all directions. Very
 
 166 Syphilitic Lesions of the Osseous 
 
 slight voluntary motion was present, and the grasp with this 
 finger was not firm. There was not as much redundance of in- 
 tegument as might have been expected, there being, however, 
 a large fold at the base of the finger. The remaining bones of 
 this member were unnaturally small and thin, and the nail was 
 very small and curved. There was no trace of cicatrix about the 
 parts. The little finger of this hand reached to the first pha- 
 langeal joint of the ring-finger, but all of the phalanges were 
 perfect, and the shortening was found to ~be due to the loss of 
 one-half of the corresponding metacarpal bone. A similar 
 fibrous band held the bones together, but there was not such 
 extensive preternatural mobility of this finger as there was of 
 the index. 
 
 Similar changes were also found upon the left hand. The 
 first phalanx of the thumb had disappeared, and the second 
 abutted against the end of the metacarpal bone, which seemed 
 enlarged and bulbous. The same condition of mobility ex- 
 isted as was found in the right index finger. In the middle 
 finger the second phalanx was found to be wanting, and the 
 first and third were joined together with fibrous tissue. An 
 attenuated condition of these bones was also found, but they 
 were slightly enlarged at their approximating ends. There was 
 unnatural mobility of the parts, and the power of the grasp was 
 destroyed. Besides these alterations there was a loss of nearly 
 an inch of the distal end of the left radius, and of fully an 
 inch and a half of the right ulna. These bones ended 
 by conical- shaped extremities. There was surprisingly little 
 disturbance of the motions of the forearms induced by this loss 
 of bone. In the region thus affected the integument appeared 
 normal. These latter affections had appeared six months after 
 the swelling of the phalanges. The boy had also had nodes on 
 the ulna and on both tibiae, while on the latter slight depres- 
 sions in the bones resulting therefrom might be felt. There 
 were, also, large depressed cicatrices upon the anterior surfaces 
 of the legs. 
 
 The swellings on the tibiae and ulna began w'hen the boy 
 was about five years of age. They were preceded by pain, 
 which, though at some periods worse at night, at others was 
 severe during the whole day. They grew slowly and gradually 
 larger, until they were perceptibly prominent; during the whole
 
 System in Infants and Young Children. 1G7 
 
 period being the seat of pain. In a year they reached their 
 maximum size, and during the two following years, under an ir- 
 regular treatment, they more slowly subsided ; until, in the end, 
 those on the tibire were replaced by depressions. 
 
 Six months after the swellings on the extremities had ap- 
 peared, the bones of the hands were observed to enlarge slowly, 
 there being also severe pain, similar in character to that in 
 the nodes. In rather more than a year, the hands were very 
 much disfigured by the enlargement of the bones, their 
 movements being much interfered with. The affected fingers 
 were found to be movable only with difficulty, and, when the 
 others were flexed on the palm,- remained extended. They 
 would yield, however, to artificial motions. The joints were 
 said to be the seat of greater 'swelling than any other part of the 
 fingers, and the mother stated that at one time the tissues over 
 them were red, inflamed, and painful. These members then re- 
 mained more than a year in this indolent swollen state, and 
 then gradually began to grow smaller. The process of atten- 
 uation occupied rather more than a year, and, finally, re- 
 sulted in the conditions described as found by me. After care- 
 ful inquiry I elicited the fact that, though pain of severe form 
 existed during the period of the increase of size of the bones, 
 when they reached the greatest extent of enlargement, and 
 during the period of subsidence, it was of a mild form, and 
 sometimes not at all present. During these years the general 
 health of the child had been quite bad, and he had an affec- 
 tion of the left eye, undoubtedly a keratitis which had left a 
 small opacity over one border of the pupil. He had also suf- 
 fered severely with frequently recurring pulmonary troubles. 
 
 Let us now merely study the bone-lesions. It is an un- 
 doubted fact, proved not only by the history of the case, and 
 by its state of evolution, but also by the co-existence of gum- 
 matous ulcers in the subcutaneous connective tissue, that the na- 
 ture of the osseous lesions was of the gummy tumor variety. 
 Hence the case is interesting, as showing, in a typical manner, 
 the evolution and decline of these .lesions. Occurring at a 
 more advanced age, and at a corresponding stage in hereditary 
 syphilis, they attack both long and short bones. Under the 
 periosteum and in the bone structure, this granulation tissue is 
 slowly proliferated, the process occupying a long time. In the
 
 168 Syphilitic Lesions of the Osseous 
 
 neighborhood of joints, the tissues become thoroughly infiltra- 
 ted with this morbid growth. An ephemeral hydrarthrosis 
 then complicates the case, as recognised by its peculiar 
 symptoms, this being the only evidence of inflammatory 
 action observed, which we, appreciating the nature of the 
 case, know is merely an epiphenomenon. Going on in this 
 indolent manner, the bone becomes very much swollen, remains 
 in that condition some months, and then this enlargement, in a 
 similar slow manner, grows less, until, finally, portions of some 
 bones, the whole of others, with their articular appendages, are 
 totally absorbed. The disappearance of the joint structures 
 shows undoubtedly that their substance was previously infiltra- 
 ted. The integument may be inflamed by pressure, but usu- 
 ally the action is subacute. This gives, in the main, a clear 
 idea of the course of the gummous osseous lesions. It may 
 happen that degeneration complicates the case, when the 
 same subacute indolent condition may also be noticed. This 
 state, contrasted with that of infants, differs in the age at 
 which the osseous lesions are developed, in the slowness 
 of their course; those in infancy being more rapid, and 
 in presenting greater evidence of inflammatory action, and 
 in v living: the tissues and organs around and connected with 
 
 C Jj 
 
 them in a more acute morbid action. Then, in the stage of 
 decline and in the sequelae there are distinctive points ; thus, 
 in infancy if the bone remains permanently enlarged, still its 
 size is less than when it is the seat of gummy degene 
 ration; and, when subsidence does occur, it ceases when the 
 normal size of the bone is reached, not usually going on to 
 absorption in any marked degree. The joints are in some 
 cases involved in active inflammation, but, at the decline of 
 the morbid action, remain in their integrity, not having, 
 as in the later affection, undergone absorption. Thus summed 
 up succinctly, the syphilitic osseous lesions of infancy are at- 
 tended -with signs of a somewhat active inflammation, which re- 
 acts in a similar manner on those tissues which are near the 
 bones ; whereas the lesions of syphilis of more advanced life, run 
 a very chronic course, being, as a rule, attended with symptoms 
 of a snbacnte character; and while the former may result in 
 s >me disngurement or distortion of the bone, the latter are fre- 
 quently followed by a greater or less total destruction of them.
 
 System in Infants and Young Children. 169 
 
 XXIX. MISCELLANEOUS CLINICAL NOTES. 
 
 I was asked bj my friend, Dr. S. H. Dessau, physician to the 
 children's department of the New York Dispensary, on the 5th 
 of June, 1874, to see a child which had been brought to his 
 
 * J O 
 
 service for treatment, the mother alleging at the time that its 
 affection was restlessness at ni^ht. It was first brought to the 
 
 S O 
 
 dispensary on the 22d of May, and was then two months old, 
 consequently, being about ten weeks old when first seen by me. 
 At this time I found the following lesions : There was a very- 
 copious, large papular syphilide over the face, crusts on the 
 scalp, mucous patches in the mouth, and fissures at the labial 
 commissures, while the child suffered much from coryza. 
 There were a few papules around the buttocks which had not 
 gone on. to ulceration. At the distal extremity of each radius 
 and ulna at the diaphyso-epiphisal junction, was a well-marked 
 enlargement of the bones. The swelling began abruptly 
 from the shafts, and, attaining a height of about half an inch, 
 declined by ending in the epiphyses, which it enlarged, except 
 at the carpal joints, where they appeared of the normal propor- 
 tions. The swelling was of an intermediate condition between 
 the ringed form of enlargement and that which involves the whole 
 epiphysis, both of which forms have been already described. 
 The surfaces of these swellings were perfectly smooth and not 
 at all unequal, nor adherent to integument, which, not being 
 stretched, was freely movable over the bones. There were also 
 osseous lesions upon the hands ; the first phalanx of the right 
 index finger was enlarged to about double its size ; the enlarge- 
 ment being quite even, and the bone having the shape of an 
 acorn. The joints at either end of the bone were unaffected. 
 The integument was not very much stretched, and was unalter- 
 ed. The tapering of the finger was well marked. The index 
 finger of the left hand was not as much swollen, and in every 
 particular resembled that of the right hand. The left ring fin- 
 ger was enlarged in a somewhat greater degree than either of 
 the two first described, and in all its characters resembled the 
 other two. It was very evident that mild spontaneous pain 
 existed in the swollen parts, as the child, which was generally 
 good tempered, flinched from gentle manipulation, and cried 
 piteously if the parts were thoroughly examined. My impres-
 
 170 Syphilitic Lesions of the Osseous 
 
 sion was that the bones were slightly painful, and I am of the 
 opinion, as there are no other known reasons for the child's rest- 
 lessness at night, that pain was present in the swellings. This, 
 perhaps, was due to the fact that they were as yet in an advanc- 
 ing stage, and, consequently, still the seat of inflammation. 
 
 The mother stated that she noticed the swellings when the 
 child was a month old, and that they were then as large us 
 when 1 first saw them. The mixed treatment was administered, 
 and local applications were used. On the 17th of July, the 
 cutaneous and mucous lesions had disappeared, and all the 
 swellings were markedly diminished in size. At this date, ow- 
 ing to the advancing cachexia, which was undoubtedly render- 
 ed more severe by the want of care and of proper and sufficient 
 nourishment, cod-liver oil was ordered, m addition to the altera- 
 tive. On the 19th of July, a severe and persistent diarrhoea 
 set in, and the child was not seen again. It is supposed that it 
 died, as the previous attendance of its mother had been, for a 
 dispensary patient, exceptionally regular. 
 
 The chief value of this suggestive case is, I think, in the 
 weight which it carries with it in favor of the view that 
 
 O 
 
 the course of these lesions is attended with more or less pain. 
 Ft is unnecessary to dwell any longer on this point, as it has re- 
 ceived full attention in the chapter devoted to the consideration 
 of that subject. In a diagnostic point of view, it is of interest 
 as showing that the coexistence of diaphyso-epiphysal swellings 
 with enlarged phalanges would clearly establish its syphilitic 
 nature. The existence, moreover, of undoubted syphilitic 
 lesions of the skin and mucous membrane would settle the 
 question. An interesting point in treatment is suggested by 
 the case, namely, the urgent necessity of sufficient and nourish- 
 ing food during the period when mercury is being administered. 
 The weight of this fact has already been considered. 
 
 Since that portion of this work which contains the cases of 
 other -observers was written, three cases of syphilitic osseous 
 lesions in infants have been reported; two by 'Parrot, and one 
 by 'Charrin. As they suggest no new points, being only confirm- 
 atory of such as have already been fully and carefully described 
 by me, it is unnecessary to give even brief descriptions of them. 
 
 1 Gazette Medicale de Paris, No. 44, 1873. 
 
 * Gazette Medicale de Paris, Nos. 31 and 34, 1873.
 
 System in Infants and Young Children. 171 
 
 XXX. CERTAIN NON-SPECIFIC AFFECTIONS OF THE BONES, SOMETIMES 
 
 REGARDED AS SYPHILITIC. 
 
 As supplementary and even essential to the knowledge of 
 the osseous lesions of syphilis in infants, it is necessary to con- 
 sider, somewhat fully, a non-specific condition, already alluded 
 to in a previous part of this treatise, which frequently predis- 
 poses to inflammation of the bones. By examining the dis- 
 tinguishing characters of which I hope to show the real nature 
 of what is ordinarily and vaguely classed as scrofulous. Although 
 it is generally conceded that there is a scrofulous affection of 
 the bones, yet the knowledge of it is so- very limited, that in no 
 text book is it described with any degree of clearness ; affec- 
 tions of the bones when not presenting the features of rachitis 
 are often vaguely classed as syphilitic or as scrofulous, whence 
 it has occurred that the points of distinction between the lesions 
 of these diseases have not been clearly and forcibly elaborated. 
 To add to this want of precise and accurate knowledge, scrofu- 
 la has, by many, been looked upon as in some undefined manner, 
 remotely dependent upon syphilis ; so that there has been no 
 serious painstaking endeavor made to differentiate in a scienti- 
 fic manner the features of the bone affections of the two dis- 
 eases. And further, the view has been entertained by many, 
 that because the lesions of the osseous system are of sucli grave 
 character, they must necessarily be of syphilitic origin ; so 
 that in many instances, although there was not the slightest 
 reason for suspecting syphilis, cases of osseous inflammation 
 and swelling have been unequivocally, and of course, wrongly 
 called syphilitic. In illustration I cannot do better than quote 
 from a clinical 1 lecture by Prof. S. G. Gross of Philadelphia. 
 This gentleman, to whose opinion in matters of general surgery 
 the utmost respect should be accorded, exhibited to his class a 
 colored child, aged two and a half years, as presenting a syphil- 
 itic lesion of the osseous system. A year previous its hand 
 had been trodden upon, and, in consequence, the metacarpal 
 bone of the thumb had become inflamed and swollen, in which 
 state it remained. Although there is absolutely no history of 
 syphilis, past or present in the child or in its parents, the lectur- 
 
 1 Philadelphia Medical Times, October, 1872.
 
 172 Syphilitic Lesions of the Osseous 
 
 er told his class that it was a case of dactylitis ' syphilitica, and 
 that the bone would never have swollen if there was not a 
 syphilitic taint in the child's system ! Under the influence of 
 Buch teaching, what progress can be made in the study of the 
 bone affections in infants? Such a statement is undoubtedly 
 based on the opinion that syphilis is the necessary cause of 
 most of the osseous affections in the young. Such being the 
 condition of opinion, I have thought that my work would be 
 incomplete in an essential particular, if I did not contribute to 
 this subject the result of my observations, made while studying 
 with care cases of syphilitic osseous lesions, as well as those 
 which did not arise from that disease. 
 
 During the past four years my attention has been called par- 
 ticularly to a series of cases of children affected with osseous le- 
 sions. In them there was no history of syphilis, no concomitant 
 lesions or symptoms to point to that disease ; neither were the pa- 
 rents syphilitic. I state these facts, as the cases were examined 
 with more than usual care, and used as a means of contrasting sy- 
 philitic with non-syphilitic lesions. How, then, shall we explain 
 the origin of the bone affections in these cases ? What is their 
 etiology ? Examined carefully, these children were found to 
 be pallid, weak and thin, their assimilative processes were far 
 from perfect. They severally suffered with lesions of a hyper- 
 plastic character, indicating a lowered state of the vital processes. 
 The hyperplastic or proliferative changes, consisted in glan- 
 dular engorgements, in tendencies to active hypersemia of the 
 mucous membranes. In them, inflammations were very readily 
 and quickly set up, very severe in character, and were at- 
 tended with the production of large quantities of pus. The 
 antecedent history of these children varied ; in some there had 
 been exhausting attacks of the exanthemata ; in others poverty 
 and want, of proper food and care had induced a low state of the 
 system ; while in a third class a naturally feeble organism had, 
 
 1 In Dr. Gross's " Surgery," published in 1872, he states that dactylitis syph- 
 ilitica, which, as is well known, is universally regarded as rare, is common in 
 his practice. At that time, this statement seemed somewhat remarkable, as 
 there were then less than six cases of it reported in all literature ; but 
 fince the publication of this case and the comments thereon which shows us 
 clearly in what an unprecise and easy manner the diagnosis of syphilis is arrived 
 at, it is readily understood why the Professor enjoys such an exceptional ex- 
 perience.
 
 System in Infants and Young Children. 173 
 
 by the influence of a succession of mild affections, or perhaps of 
 a persistent dyspepsia, or of a diarrhoea fallen into a state of great 
 anaemia. Their condition may, perhaps, be called scrofula, yet 
 whatever name is applied to it, it consists essentially and patho- 
 logically in a state in which the blood-making function is greatly 
 impaired and the general nutrition of all of the tissues 
 seriously at fault. In the latter there is a tendency to excessive 
 cell-proliferation, while hypersemia of great intensity is very 
 liable to occur. In the osseous system of such subjects there is 
 no immunity to these abnormal changes, but, on the contrary, 
 by reason of its very rapid growth, they are liable to develop. 
 In this connection it is well to remark that owing to this activity 
 of growth, traumatic causes, even slight, are capable of inducing 
 inflammation, which, moreover, may be exceptionally severe if 
 it occurs in a child whose nutrition is lowered in the manner 
 just now described. It is also true that in traumatic osseous in- 
 flammation syphilis may exert a powerful modifying influence. 
 I think that these facts, which are based on careful and extend- 
 ed clinical study, will convince observers that a condition of 
 lowered nutrition of the infant may predispose to the development 
 of osseous lesion, and that such may occur as a result of tran- 
 matism simply and without the existence of a syphilitic taint. 
 
 An important question here arises, namely : Are there any 
 distinguishing characteristic in these osseous lesions which will 
 enable the physician to promptly and correctly diagnosticate them 
 from those of syphilis ? It must be confessed that in the main 
 they resemble in many particulars the lesions of syphilis, still 
 there are certain quite constant features which are important to 
 know. As a rule the osseous lesions, above alluded to, are devel- 
 oped rather rapidly, may be complicated early by degeneration, 
 and, for the most part, do not primarily affect the joints. There 
 are usually a smaller number of bones involved than in syphilis, 
 and there is a greater tendency to unsymmetrical development. 
 Pain is generally a constant symptom, and, in short, there is usually 
 a much more pronounced condition of inflammation than we find 
 in syphilis. "When degeneration occurs there may follow sinuses 
 which have the typical scrofulous appearance, which we have 
 observed to be not constant in syphilis. Finally a point of some 
 importance may be determined by the bone or bones involved; 
 thus, in this condition, it is very probable that the cranial bones
 
 17-1 Syphilitic Lesions of the Osseous 
 
 would be unaffected, and that the lesion would be limited gen- 
 erally to the long bones, or perhaps to the phalanges, whereas 
 in syphilis we have found that a number of different classes of 
 bones were often coincidently involved. Still, as I have said in 
 the chapter on diagnosis, the distinction very often rests upon 
 the history of the case, and upon the co-existence of lesions, which 
 are undoubtedly syphilitic. Treatment will not always afford 
 conclusive evidence, but it may sometimes assist in a measure. 
 There is an interesting clinical fact worthy of remembrance, 
 which is, that when these same osseous lesions occur later in the 
 life of the child, there is a decided tendency to articular com- 
 plication, indeed, in many children under these circumstances, 
 the morbid process begins in the joint. 
 
 Dr. S. 0. Busey, 1 of Washington, has recently reported a case, 
 which is of decided interest in this connection. It was that 
 of a female child, in whose parents there was no history of 
 syphilis and in whom there is no mention of syphilitic affec- 
 tions. Apparently healthy at birth it had, when three months 
 old, an eruption affecting the entire scalp and described as 
 scabby. A bronchial affection supervened when six months 
 old, followed by a severe diarrhoea at its tenth month. These 
 two affections continued until the child was reduced to four- 
 teen pounds in weight. When thirteen months old, being 
 still in miserable health, a swelling of the left middle finger 
 was found, limited to the first phalanx and measuring near 
 its metacarpal articulation two and half inches. Remain big in- 
 dolent for four months fluctuation was discovered, which, on 
 its being incised, gave vent to pus. During the following two 
 months the swelling decreased slightly. 
 
 In the total absence of any evidence of syphilis, I am in- 
 clined to think that this osseous inflammation was induced by 
 the profound state of cachexia. The case illustrates very 
 forcibly the general position which I have taken as regards the 
 development of bone-inflammation. There are points in the 
 case which are interesting, and at the same time suggestive of 
 a non-syphilitic origin. The details of the case and its illus- 
 tration show that the lesion begun and was greatest at the prox- 
 imal end of the bone. Now, we know that in this position the 
 
 1 Case of daotylitis syphilitica in a child eighteen months old. American 
 Journal of MedLal Science, Oct., 1874.
 
 System in Infants and Young Children. 175 
 
 epiphysis is situated, consequently it is fair to assume that the 
 lesion was developed at its junction with the shaft. In our 
 study of syphilis of the phalanges, we found that in every re- 
 corded case of infants, the whole bone was uniformly enlarged, 
 and that the peculiar syphilitic processes which occur at the 
 diaphyso-epiphysal junction had not as yet been met with in 
 these bones. We are warranted then in assuming this to be the 
 rule, nevertheless it may have its exceptions. Thus this point 
 militates somewhat against a syphilitic origin, and in the event 
 that it was syphilitic the instance would be exceptional. At a 
 recent meeting of the Dermatological Society, Dr. E. L. Keyes 
 exhibited a cachectic child, with inflammation attended with 
 degeneration at the junction of the distal epiphvsis with 
 shaft of the radius. Of the cases seen by me, which illustrate 
 this condition, in some the phalanges, in another the rnetacar- 
 pal and metatarsal bones, and in others the long bones, were in- 
 volved. Some of these were my own cases, while others were 
 submitted to me for study and opinion by friends. 
 
 It is to be hoped that, in future, in the study of these cases 
 a hasty diagnosis of syphilis will not be arrived at and that ob- 
 servers will bear in mind in forming their opinion, the condition 
 here described. 
 
 APPENDIX. 
 
 IN the chapter on pathological anatomy the description of the morbid 
 process is given with the idea of conveying a general view of the subject ; it is 
 necessary, however, to present a special description of the features shown by 
 the illustration, which is taken from a micro-photograph of three hundred 
 diameters. . On the left of the figure the trabeoulae are much enlarged, and 
 instead of appearing as if composed of lacunae and canaliculi, are seen to be 
 infiltrated with small, round, nucleated cells. The medullary spaces are 
 obscured and compressed by the cell-growth, and in some specimens the con- 
 tained blood-vessels are also choked. In the median line these small cells 
 constitute a complete layer running through the specimen. There are here 
 some fusiform nucleated cells and granular matter. To the right the inter- 
 ference with the ossifying process is clearly shown. The cartilage cells are 
 there in a condition far from normal, being greatly increased in number, and 
 in size much smaller than they should be. They are also more irregularly placed, 
 not being, as they should be ranged in longitudinal rows. Besides this 
 change, the intercellular substance is seen to be much increased, as shown by 
 the wavy lines in black, and near them are spots of localized calcareous 
 deposit, which, owing to their transparency, are not delineated, but are shown 
 in the drawing by blank white spaces. In this region, also, the peculiar 
 round cells are seen following the blood-vessels, which are numerous. This 
 specimen demonstrates clearly not only the presence of granulation tissue, but 
 also that the process is of an inflammatory nature.
 
 INDEX. 
 
 ACQUIRED Infantile Syphilis ; do osseous le- 
 sions occur in ? 122 ; answered affirmative- 
 ly, 123. 
 
 Archatnbault ; case of syphilitic digital swell- 
 ings in child, 43. 
 
 Arthritis rheumatoid, distinguished from syph- 
 ilitic, 150. 
 
 BAKENSPRUNG ; necrosis from syphilis in child, 
 
 43. 
 B.irgioni ; case of suspected hereditary syphilis ; 
 
 autopsy, 47. 
 Banmes, case of, 84. 
 Bertin. case of, 43. 
 Bones, certain non-specific affections of, 171 ; 
 
 how diagnosed from syphilitic, 173. 
 " intra-uterine syphilis of, 120. 
 " early periods of attack of after birth, 
 
 ibid. 
 
 " hardness of, probably not due to syphi- 
 lis, ibid. 
 " of infants, syphilitic lesions in, case i., 
 
 13. 
 
 ' " " with syphilis in other tis- 
 sues, case ii., 16. 
 " " " with roseola and condylo- 
 
 ma, case iii., 17. 
 " " " showing nodes on cranium, 
 
 case iv., 18. 
 " '' " with roseola, condylomata 
 
 and aphthae, case v., 20. 
 " " " with abscess and distortion 
 
 of fingers, case vi., 21. 
 " " " with coryza and mucous 
 
 patches, case vii., 25. 
 
 " " " accompanied by roseola, 
 mucous patches and con- 
 dylomata, case viii., 27. 
 " ' " progress of, in a patient 
 otherwise healthy, case ix., 
 29. 
 
 ** " " appearing on clavicle, ribs, 
 humerus, and ankle, case 
 x., 32. 
 
 " " " discovering motion between 
 epiphyses and shafts, case 
 xi., 38. 
 
 " " " discoverable in phalanges, 
 case xii., 41. 
 
 Bulkley : osseous lesions of syphilitic origin in 
 
 child, 44. 
 Busey, Dr. S. C., interesting case reported by, 
 
 174. 
 
 CARPAL, Tarsal, Metacarpal, Metatarsal bones, 
 with phalanges, enlargements of, 75. 
 
 " bones, less liable to swellings in in- 
 
 " fants, 90. 
 Cartilage, hyperplasia of, 77. 
 Charrin, caso of osseous lesions by, 170. 
 Clavicle, enlargements on, 65. 
 Cranial internal periostitis, 93. 
 Cranium, minute nodes of, 92 ; diagnosis of,152 ; 
 rachitic swellings on, diagnosis of, 153. 
 
 DEGENERATIVE changes in osseous swellings, 
 102 ; duration of treatment of, 103 ; con- 
 founded with scrofula, ibid. 
 Dessau, Dr. S. H., case, having papular erup- 
 tion on buttocks, etc., with enlargements 
 011 bones, 169. 
 Diagnosis differential, 141. 
 
 " of non-specific affections of bones, 173. 
 
 " of rachitis on cranium, 153. 
 
 " of nodes on " 152. 
 
 " of separation of diaphyses from 
 
 epiphyses, 145. 
 
 " of periostitis in infants, 136. 
 " of syphilis in phalanges, 150. 
 " of swellings on ribs, 67. 
 " " " clavicle, 144. 
 
 Diday, errors of, 9, 124 
 
 EPIPHYSES, extrusion of, 109. 
 
 " subjective symptoms of, 109. 
 " errors of Parrot relating to, ibid. 
 " and diaphyses, separation of, rare, 
 104 ; examined pout- mortem, 
 ibid ; method of exploring, 105 ; 
 facts relating to, 106 ; diagnosis 
 of, 145. 
 Exostoses epiphysal, hereditary, 144. 
 
 FACIAL bones, little liable to syphilitic lesions, 
 
 94. 
 Femur, swellings upon, 72. 
 
 " lower end of particularly liable to 
 certain syphilitic changes, 73.
 
 Index. 
 
 Femur, swellings at upper part of, difficult of 
 
 detection, ibid. 
 Fingers, distortion of, occasioned by swellings, 
 
 S3. 
 Fournier ; cases of osseous syphilitic lesions in 
 
 infants. 43. 
 Frontal and parietal oftener attacked than 
 
 other cranial bones, 92. 
 
 GIBNEY, Dr., case of peculiar swellings near 
 
 joints, 163. 
 
 Gross, Dr., statements of, note, 172. 
 Gucrin, coucke c/wndrolde, 131. 
 Gummous os>eous lesions, 164 : case of, 165 ; 
 
 course of, 168. 
 
 HUMEBCS less frequently affected than radius 
 
 or ulna, 63. 
 
 Hutchinson on periostitis, 114. 
 Hyperplasia, tendency to, 125. 
 
 INTEGUMENT not primarily involved, 100. 
 
 " condition of, in bone-swellings, 
 
 ibid. 
 
 JOINTS, immunity of, ibid. 
 Jordan, Furneaux, on diaphyso-epiphysal syph- 
 ilitic swellings in adults, 160. 
 " doubts as to a syphilitic origin in 
 cases given by, 162. 
 
 KEYES, Dr. E. L., case furnished by, 175. 
 
 MAHON, views of, 84. 
 
 Malformation resulting from osseous lesions, 
 
 116. 
 
 " admitting of arrest by treat- 
 
 ment, 119. 
 
 Mayr on periost tix, 114. 
 Metacarpal bones, swellings of, 87. 
 Metatarsal bones, swellings of, 89. 
 Mild attacks not usually productive of osseous 
 
 lesions in child, 124. 
 
 Morgan ; swelling of metacarpal bone, 48. 
 Mother, value of treatment of, as a prophylac- 
 tic to the child, 154. 
 " and child, equal severity of symptoms 
 
 in, 12<>. 
 " recent severe syphilis in, most likely to 
 
 affect infant, 126. 
 
 Mothers and children, comparative table of 
 syphilis in, 129. 
 
 NODES on the cranial bone?, diagnosis of, 152 ; 
 resemblance to in case of rickets, 153. 
 
 ONYCHIA of hereditary syphilis does not in- 
 volve the bone, 83. 
 Osseous and cartilaginous tissues, absorption 
 
 of, 107. 
 
 enlargements, average period of de- 
 velopment of, 95; average size of, 
 96 ; usual course of, 96 ; termination 
 
 of, 97 ; uniform distribution of, 98 ; 
 synchronous, 9<J ; post mortem ex- , 
 animation of, ibid. 
 Osseous lesions in the upper extremities, 58. 
 
 " " pathological anatomy of, 130. 
 
 Ossifying process, morbid changes in, 131. 
 
 " " dissent from Wegner con- 
 
 cerning, 132. 
 Osteochondritis, characters of, 137. 
 
 PAIN as a diagnostic symptom, 112. 
 
 " comparative absence of in osseous swell- 
 ings of infants, 111. 
 Pathological anatomy, 130. 
 Parrot, views of, 109. 
 
 " case of separation of tibia and fibula 
 from epiphyses in child ; autopsy, 
 
 50. 
 
 " " reported by, of infantile para- 
 lysis ; autopsy, 50. 
 " " cranial and other bones af 
 
 fected, 51. 
 
 " " periosteum detached, 52. 
 " " corneas, head, and mouth ulcer- 
 ated ; humerus, etc., involved ; 
 ibid. 
 
 " " femur and tibia affected, ibid. 
 " autopsy of still-born child, ibid. 
 " ' " " child, ibid. 
 " cases of osseous lesions reported by, 
 
 170. 
 " observations on syphilis in bones of 
 
 children, 10. 
 
 Pelvic bones rarely attacked, 94. 
 Periostitis, varieties and diagnosis of in in- 
 fants, 136 ; parts attacked by, 114 ; infre- 
 quency of, 115 ; diagnosis of, 136 ; acute 
 phlegmonous, 147. 
 
 Periosteal osseous tube serving as splint, 108. 
 Phalanges, enlargement of, from cartilaginous 
 
 hyperplasia, 77. 
 
 " especially liable to osseous enlarge- 
 ments, 76. 
 
 " the proximal most frequently at- 
 tacked, 78. 
 " comparative frequency of syphilitic 
 
 swellings of, 85. 
 
 " enlargement of, 149 ; syphilitic, 
 diagnosis of, 150 ; exseetion of, 
 rarely to be resorted to, 159. 
 Phalanx, second, deceptive uppearances of, SO. 
 
 " rheumatoid arthritis of, note, 81. 
 Plan and scope of the present Work, 12, 13. 
 Poncet, cases of, 115. 
 
 Putegnat ; case of hereditary syphilis in thigh 
 of child ; case of cranial exostosis in syphi- 
 litic child, 44. 
 
 RADIUS and ulna, swellings on the distal ends 
 
 of, 60. 
 " " ' " on upper end of, 
 
 61. 
 
 Ranvier bad shown how syphilis may affect 
 the bones, 11 ; case of, 46.
 
 Index. 
 
 179 
 
 Ribs?, swellings at sternal end of, C7 ; diagnosis, 
 
 ibid. 
 
 Rickets pathologically distinguished from sy- 
 philis, 135. 
 
 " and syphilis, relations between, 138. 
 Roger, infantile syphilitic swellings on hume- 
 
 rus and tibia, with nodes, case of, 42. 
 Smith, Dr. T. C., case of syphilitic swellings in 
 
 fingers of child, reported by, ibid. 
 Skull, syphilitic lesions of, in infant", infre- 
 quent, ill. 
 
 Syphilitic lesions confounded with scrofula, 10. 
 " " erroneous opinions on the fre- 
 
 quency of, 9. 
 
 Swellings at the diaphyso-epiphysal union liable 
 to be confounded with syphilis, 
 141. 
 " at sternal end of clavicle, diagnosis, 
 
 of, 144. 
 
 " complicated with necrosis, ibid. 
 " on the borders of shaft, diagnosis of, 
 
 144. 
 
 " with separation of epiphyses from 
 diaphyses, 145 ; occurs only in the 
 early months of life, 147 ; other 
 distinctions concerning, 148. 
 
 TARSAL bones, little liable to swellings in in- 
 fants, 90. 
 
 Tibia, upper part of, more frequently swollen 
 
 than fibula at same point*, 72. 
 ' and fibula, swellings at extremities of, 
 
 ea 
 
 " apparent disproportion between shafts 
 
 and epiphyses of, ('At. 
 " swellings of, frequent, ibid. 
 Toes, syphilitic swellings of, 84. 
 Treatment in the mother prophylactic to the 
 
 child, 154. 
 
 " of hereditary syphilis in infants, 155. 
 " mixed, no risk in prolonging. 156. 
 " necessity of sustaining the system 
 
 during, 157. 
 " injections hypodermic, hurtful in, 
 
 ibid. 
 
 " mercurial inunctions in, objected 
 to, 158. 
 
 VALEIX, syphilitic tumors on radius and ulna 
 
 of child : autopsy, 50. 
 Vidal, errors of, 9. 
 Violet, cases of. 115. 
 Volkmann's case, 82. 
 
 WALDEYER, Prof., on occurrence of syphilis in 
 
 bones of children, 10 ; cases. 54. 
 Wegner's cases, particulars of, 53. 
 
 THE END.
 
 Date Due 
 
 CAT. NO ?3 233 
 
 PRINTED IN U.S.A.
 
 C les . 
 
 Osse ous s nS f 
 
 WS270 
 
 a. i 
 Taylor. 
 
 Syphilitic lesions of the osseous 
 system in infants and young children 
 
 CALIFORNIA COLLEGE OF MEDICINE LIBRARY 
 
 UNIVERSITY OF CALIFORNIA, IRVINE 
 
 IRVINE, CALIFORNIA 92664