Osteochondritis in the Stillborn*

OSTEOCHONDRITIS (Bbm

IN THE

STILLBORN*

JAMES R. MCCORD, M.D., ATLANTA, GA. the Dqartment of Obstetrios and Gynecology, E,mory Unkversity School of Medicine)

ERTAIN skeletal changes in the fetus and newborn as seen by the C roentgenogram are almost pathognomonic of congenital syphilis. When deviations that are not typical are called syphilis, this excellent method of diagnosis is discredited. Briefly, what are these typical changes? McLean, is one of his classical articles, says : “There is a more advanced stage of the previous lesion (rarefaction) in which the roentgenologist can usually make an unequivocal diagnosis of osseous syphilis in the presence of negative serology and a history of a negative physical examination. The so-called zigzag or saw-tooth metaphysie type is not uncommon. Saw-tooth metaphyses are the first evidence of lawlessness of growth so characteristic of the active stage of syphilis, concerning which there has been so much controversy, ‘7 As long as we make the diagnosis of syphilis upon such lesions we are on safe ground. To quote McLean again: “One should be warned against accepting the presence of one or possibly two minute spurs or buds shown on the metaphyses by the x-rays as evidence of syphilis, since they also occur in rickets. !L’vw sygtkiEitb types show’ ar a’&nite sawdooth ec2ge.” (Italics mine.) Failure to heed the above was the cause of most of my failures. Caffey in a recent article says: “In this non-syphilitic group no cases resembling the following r~er [italics mine] types of syphilitic osteochondritis were found: (1) saw-tooth metaphyses; (2) foci of rarefaction in the angles of the cartilage shaft junctions and multiple infarctions through the ends of the shafts.‘? Evans in a recent communication says: ‘ ‘ . . . and there is no doubt that charaeteristic osseous lesions are found in a very high percentage of cases of fully developed syphilis. The diagnosis in the less obvious cases is more difficult and both positive and negative errors may be made.”

In attempting to prove my point, I desire to present an analysis of roentgen ray studies on 129 negro fetuses at all stages of gestation, the great majority of them stillborn. The work has been done without an experienced and advanced radiologic or histologic background. It is an effort to show that the average doctor can confidently make the diagnosis of advanced congenital syphilis provided he does not split hairs in evaluating the lesions observed. The method of study follows: The diagnosis was made from the film without any lmowledge of the case. If the films showed a positive or doubtful diagnosis, the babies were autopsied. The following tissues were stained by the Levaditi method: kidney, liver, spleen, lung, heart and thymus. The bone lesions were reported as syphilitic only when the organisms of syphilis were found in the stained tissues. The original Levaditi stain was used. It is essential that the method be meticulously followed. As an example, we failed to demonstate the organisms when neutral formalin was used in the place of acid formalin. *Read Colorado

at the Sixty-Sixth Annual Meeting of the Springs, Colo.. May 26 to 28, 1941. 667

American

Gynecological

Society,

668

AMERICAN

.JOLlRS>\I,

OE’

OIHTISTRICS

ASD

(:TKECOLOGT

In t.he entire series, 6he diagnosis OS syphilis as made from the roentgenogram was confirmed by the finding of the organisms of syphilis in 91.5 per cent. There should have been but 1.6 per cent of incorrect

Fig. l.-Abortion (1.070 Gm.), macerated treatment ; diagnosis, doubtful ; organisms doctor to make diagnosis of so early a IeSiOn.

; Wassermann Probably i’ound.

Fig. Z.-Abortion (610 Gm.), macerated ; Wassermann found. Probably ment : diagnosis, syphilis ; organisms average doctor to make positive diagnosis.

as

and not

Kahn, safe

and Kahn, (-plus; early a lesion

I-plus; no for average

as

no treatsafe for

diagnoses. A review of the 11 films incorrectly diagnosed showed that 9 did not have the serrations or saw-tooth metaphyses upon which premise the study originated (Table I). One erroneous diagnosis was hazardous

OS!l’EOCHONDRIT&

MC CORD :

Fig.

3.-Innumerable

F ‘ig. 4.-Term men t ; diagnosis.

safe

diagnosis

organisms

for

found

in baby

IN

of comparatively

(2.820 Gm.1, macerated : Wassermann syphilis, organisms found. Comparatively average doctor. TABLE

I.

REVIEW

STILLBORN

OF MISSED

No serrations; plainly neg. No serrations; plainly neg. No serrations; plainly neg. No serrations; plainly neg. No serrations; plainly neg. No serrations; plainly neg. No serrations: ulainlv nea. No serrations j plainly nei. Confusing; again positive Confusing; not typical serx .ations Hazardous diagnosis : small fetus

and

early

lesion

of Rig.

2.

Kahn, I-plus ; no treatearly lesion, probably un-

DIAGNOSES

380 400 200 1,400 1,800 2,030 1,050 240 600 560 320

Gm. Gm. Gm. GIL Gm. Gm. Gm. Gm. Gm. Gm. Gm.

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JOURNAL

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AND

QYNECOLOCY

Fig. 5.- -Premature (2,120 Gin.), macerated ; Wassermann, 4-plus ; no syphilis, organisms found ; pathognomonlc saw-tooth serratiox dia Lg710SiSl was done. UPI on whit !h this work

(400 Gm.) ; Wassermann developmental: organisms not found; for a fetus of this size.

Fig. .6.,-Abortion

dia die kg%

TABLE

II.

DIAQNOSES

Wassermann-Kahn positive Wassermann-Kahn negative Tests agree Wassermann positive Kahn negative Treated Average weight (Gm.) Serology positive

and Kahn, negative; minute spurs and MISSED

no t1 buds nc

(11)

2 6 8 1 t 816

27%!-

.tment remise

:

ttment : a safe

MC CORD :

OSTEOCHONDRITIS

fN

STILLBORN

671

in that the fetus weighed only 320 Gm. In only one was the lesion apparently typical and the organisms not found. Serology was positive in only 27 per cent of the mothers in this group. The average fetal weight was 816 Gm.

Figs. 7 and merit; diagnosis. advanced.

8.-Premature syphilis;

(1,520 organisms

Fig.

7.

Fig.

8.

Gm.). not not found,

macerated ; Kahn+. 4-plus; no even though lesmns apparently

treatfar

The diagnosis of syphilis was made from 88 films and the organisms of the disease were found in the babies. The outstanding fact in this group is that 94 per cent of the mothers had positive serology. The average

672

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fetal weight was 1,704 Qm. treatment during pregnancy was two (Table III).

Fig.

9.- Abortion

(890

OF

OI3STlVI%RICS

ASD

GPNI~COLOGP

Only 16 of the women had received any and I IIC avcragc nulnber of treatments

Gm.), macerated: Wassermann ment : advanced lesion ; organisms

Fig. lo.-Premature (2,290 Gm.), stillborn, macerated: 4-plus ; diagnosis, syphilis ; no treatment ; organism found periosteal elevation.

and Kahn, found.

~-PIUS:

no treat-

Wassermann and ; serration. rarefaction,

Kahn, and

To compare the serology percentage, 321 negative films were reviewed. Maternal serology was negative in 80 per cent. Fourteen: per cent were positive and the mothers received treatment during pregnancy. The average number of treatments was 8.3. Six per cent were positive with

MC

CORD

:

OSTEOCHONDRITIS

IN

673

STILLBORN

no treatment. It seems justifiable to think that caution should be exercised in diagnosing congenital syphilis of the bones when the maternal serology is negative. The serologic tests used were: a 3 tube Kolmer modiflcation with serum dilutions of 0.05 and l//lo, with icebox fixation and the standard Kahn. Both of these tests were done upon ‘76 mothers. There were only 3 discrepancies. It seems probable that this speaks well for the reliability of the tests during pregnancy.

Fig.

Il.-Rickets

with

periosteal

elevation.

Twenty fetuses were so small that a diagnosis was not attempted. Their average weight was 229 Gm. The tissues were stained and the organisms of syphilis were not found in any of them. The maternal serology in this group was positive in 35 per cent,. The average duration of pregnancy was approximately eighteen to twenty weeks. It is probable that an abortion happened in some of these women before intrauterine infection occurred. It is not wise to attempt the diagnosis of skeletal syphilis on fetuses of this size. TABLE

III.

Number studied Wassermann-Kahn positive Wassermann-Kahn negative Tests disagree (Wassermann neg.-Kahn Wassermann positive Wassermann negative Kahn positive Serology positive (To) Treated Average number treatments Average weight --___(Gm.)

ORGANISMS

FOUND

88 47 3 3 pos.) 27 2 6 94 16 2 1,704

----

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Nine diagnoses were doubtful. The typical serrations were not present. In two the organisms of syphilis were found, and the maternal serology was positive in 33.3 per cent. Only two mothers received any antepartum treatment. The average fetal weight was 1,754 Gm.

Fig. 1X-Aged 16, premature (1,500 Gm.), no treatment ; diagnosis, syphilis ; organisms pathognomonic.

Fig.

13.-Other

bones

alive; Wassermann Rather found.

of same baby

as in Fig.

rare

and

Kahn, 4-p&3; lesion probably

12.

CONCLUSIONS

1. Typical saw-tooth serrations are pathognomonic of congenital syphilis. 2. Properly done Wassermann and Kahn tests should be positive in probably 90 per cent of the mothers of syphilitic babies.

MC CORD :

OSTEOCHONDRITIS

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3. It can be said, rather arbitrarily, that it is unwise to diagnose congenital syphilis by the roentgen ray in fetuses weighing less than 500 Gm. REFERENCES

(1) Pendergrms, E. P., and Bromr, R. S. : Am. J. Roentgenol. 22: 1, 1929. Congenital Syphilis, Philadelphia, 1940, Lea & Febiger. and Pakula:

(2)

Dennie

50 ARMSTRONG

STREET DISCUSSTON

DR. GRANDISON D. ROYSTON, ST. LOUIS, Mo.-It is generally recognized that syphilis and nephritis must be excluded or recognized as a cause in every stillbirth. It is further recognized that routine serologic tests are indicated as early as possible in every pregnant woman, while autopsies on all stillbirths are highly desirable. Yet often the autopsy reports of ‘( autolysis of tissues, ” negative serologic reactions, etc., are discouraging. Dr. MeCord’s report denotes that the roentgenograms are the simplest means of diagnosing syphilis as the cause of fetal death. Serologic reactions of cord blood are of doubtful value since the latter may carry complement fixation antibodies from the mother. These so-called “reagens” may disappear in from one to twelve weeks after birth, when the child’s true status may be determined. Roberts believes if the infant reaches the age of four months without positive blood tests or physical evidence of the disease, it probably is not syphilitic. Jeans and Cooke have never found syphilis in an infant with no physical evidence of syphilis, whose Wassermann was negative at two months of age. The qualitative Wassermann reaction on cord blood is of only minimal importance, but the quantitative determination of titer and comparison with subsequent blood tests seems of greater value. Placental study is of no importance if the mother has received treatment, for even inadequate treatment usually renders the placenta free from evidence of syphilis. I agree with the essayist in preferring the standard Kahn to the Wassermann test. More than twenty-seven years ago, Ludwig Pick taught that osteochondritis of the long bones was pathognomonic of syphilis, yet it has been too frequently overlooked. Stokes reported that among more than 209 patients with syphilitic bone lesions, only 24 per cent had had serologic tests, while 82 per cent were found to be positive on examination. He emphasizes the necessity of skillful interpretation of the roentgenograms. Syphilis is a preponderantly constructive osteoplastic process, followed later by destructive changes. Osteochondritis or periostitis in the syphilitic infant is limited to the first five months of the baby’s life. It is usually observed at birth or during the first two or three months of life. It is important to remember that syphilitic bone lesions According to Shands, the order of are always bilateral in the first months of life. frequency of these lesions is : (1) the lower ends of the femur; (2) lower ends of the tibia and fibula; and (3) lower ends of the radius and ulna. The cases of congenital bone syphilis in the St. Louis Children’s Hospital from 1920 to 1938 were reviewed by Jostes and Roche of the Orthopedic Department. It is interesting to see that in their series of 34 cases, they found the tibia and fibula involved more than twice as often as the femur. In the Washington University Clinic, among the last 8,571 obstetric admissions, 6,227 white and 2,344 negroes, 2.8 per cent of the white patients and 14.5 per cent of the negroes were syphilitic. The general incidence of pregnancy and syphilis was 6 per cent. Only 5.8 per cent of these women gave any history of a primary or a secondary lesion. Among more than 500 infants born of syphilitic mothers, Soule found only two infants with undoubted syphilis, after they had had a negative cord blood recaction at birth. This result is due to the fact that practically all of our syphilitic patients are closely supervised for the greater part of pregnancy and receive some treatment. DR. dently syphilis

KARL M. WILSON, ROCHESTER, N. Y.-My from that of Dr. McCord and Dr. Royston, in my clinic. As a matter of fact, in the

material is quite different since we see very little fourteen years since the

eviacute clinic