Williams of Johns Hopkins University, in the 1903 edition of his Obstetrics, tells of a woman who died of tuberculous peritonitis a short time after parturition. The uterus was studded with tubercles and its interior was covered with tuberculous ulcers. The tubercle bacillus had been found in cultures taken from the interior of the uterus during life. Her child was born perfectly healthy and remained so. Williams says in the same place that the induction of premature labor because of tuberculosis is justifiable only in the interests of the child, and this only in those rare cases in which the woman is so ill that she probably will die before term. Norris[151] of Philadelphia agrees with Williams that induction of premature labor is useless, and he says all authorities unite in this opinion.
A tubercular woman should not nurse her infant because she will infect it and exhaust herself. Infants are very susceptible to tuberculosis. Birch-Hirschfeld, in 1891, first demonstrated tuberculosis in the fetus, and Schmorl found it in the placenta in 50 per cent. of a series of cases that he examined. Infection of the child in utero, however, is extremely rare even by the placental way. There is a high death-rate from tuberculosis among infants, but the infection is postnatal. Dietrich of Berlin found that the death-rate from tuberculosis among children in Prussia is higher during the first year of life than in any other year.
The moral conclusion is that artificial abortion in pregnancy complicated with tuberculosis is never indicated except when the good of the child is at stake in the last stage of gestation.
[CHAPTER XIX]
Syphilis in Pregnancy and Marriage
Syphilis in pregnancy at times assumes peculiar malignancy. The virulence depends on the patient's power of resistance, and whether or not there are septic microörganisms mixed with the syphilitic spirochetes. There are, moreover, varying strains of spirochetes which differ in virulence, or there are familial idiosyncrasies. Tropical syphilis is worse than northern infections, and syphilis of the nervous system is often incurable. Fournier was of the opinion that a syphilitic woman who becomes pregnant is more likely to abort than a pregnant woman who becomes syphilitic. The percentage of fetal deaths is also greater in the first class than in the second. The longer a woman has been syphilitic, provided she has not been treated for the disease, the worse the prognosis for the duration of the pregnancy and the life of the fetus. The earlier in pregnancy the syphilis appears, the worse the prognosis for gestation. General fetal mortality in syphilis under the best circumstances is 75 per cent. Syphilis should be looked for in every case where the cause of an abortion is not evident. Ruge holds that in 83 per cent. of repeated abortions syphilis is at fault; late abortions are characteristic of this disease.
Inoculation with syphilis before conception almost always results in abortion. In 130 women studied by Le Pileur there were 3.8 per cent. still-births before infection by syphilis, but 78 per cent. after infection. In premature labor the child is, as a rule, born dead; less frequently it is born syphilitic; still less frequently it is born apparently sound, but the syphilis appears later; in a few cases, when the maternal syphilis is old, the child may be born normal. Interruption of gestation is the commonest symptom in syphilis complicating pregnancy. The labor itself is affected: the pains are weak and tardy. Abnormal presentations occur frequently when the fetus is dead. Chancres on the cervix may cause obstruction, and there may be indurations so dense as to necessitate cesarean delivery. The perineum may become so friable as to tear, as De Lee says, "like wet paper."
When the mother is infected at the time of conception the child is always syphilitic. If the mother is infected early in pregnancy the child is almost always infected. If she is infected late in pregnancy the child may escape infection. Men with tertiary syphilis have begotten children without, to all clinical appearance, inoculating the wife. In such a case the mother may nurse the child with safety to herself, but the child will infect a wet nurse other than its own mother, and in very rare instances mothers in this condition have been floridly infected. The condition here described is called Colles's Law.[152] The doctrine of Colles's Law has fallen into disuse because we can now demonstrate by the Wassermann reaction that almost all apparently healthy mothers of this class are in reality infected. The term now used is "Syphilis by Conception."[153] The virus passes through the fetal placenta to the mother, although immunizing substances are held back by the placenta. A fetus cannot make immunizing bodies before its eighth month, and on that account the earlier the fetus is infected, the more likely it is to die. Recently, however, some scanty testimony has been collected which sustains Colles's Law in a few cases. Ledermann reported three cases, and Nonne others, in which the wives of men with tabes or paralysis bore syphilitic children and yet never responded positively themselves to the Wassermann test, or showed any symptoms suggesting syphilis. To this list Kroon[154] adds a case corresponding fully to the requirements of Colles's Law. A woman of twenty-eight years who had had eight abortions was delivered of a child with undoubted congenital syphilis. The child's father had been infected with syphilis twelve years before. The woman showed no signs of syphilis, two Wassermann tests were negative, and she nursed the child without injury to herself.