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Preliminary report on the treatment of syphilis complicating pregnancy
448
THE AMERICAJ\'" JOUHNAL OF OBSTETRICS AND GYNECOLOGY
C. BECK read a Preliminary Report on the Treatment of Syphilis Complicating Pregnancy. (For original article see page
DR. ALFRED
416.) DISCUSSION DR. .JAMES B. GIVIN.-I h~1n followed up some of these eases, and have been struck by the absence of luetic stigmata. as compared with another set of children of syphilitic mothers who came to the pediatric. clinic and who showed four-plus \Vassermanu reactions. featuTe in this series of cases is the ease with which these babies An inunctions of mercury and responded to antisypl1ilitie treatment. They were not snlvarsan. These observations have shown the importance of continuing anti· syphilitic treatment of the mother after the baby is born. The ha.bies cannot be kept on the breast when the mothers a1·e resistant to treatment. \Ve hope to be able to follow this series of children for a number of years ancl it may be that later these children will show evidences of retarded syphilis. If any of the late 8igns of syphilis appear it will emphasize the importance of following up these cases, keeping them under treatment, and repeating the Wassermann tests at stated in· tervals. Dr. Boeck's statistics arc interesting in comparison with those published by Dr. Jeans, of St. LouiB, who has done a great deal of work in congenital syphilis. Dr. Jeans shows from his personal work and a review of the literature that 30 per cent of all pregnancies in syphilitic families terminate in death at or before term. Dr. Beck's cases show quite different statistics. Dr. Kolmer in the American Journal of DiS('ases of Children, Ma.y, 1920, shows that about 5 per cent of all children coming into R clinic in a large city are syphilitic and that about 5 per cent of tho elinic are syphilitic. The children of these mothers, cases coming to a certainly will not show evidences of lues. if properly DR. GEORGE W. KOSMAK.-1 a.m interested in Dr. Beck's paper, pnrticul::uly I was afraid he was going to say that he ha.d :32 cases of undoubted syphilis but I notice that he modified that assertion somewhat, It is scarcely fair always to assume a positive diagnosis of syphilis simply boeauso thPro is a four-plus Wassermaun reaction. Hospital we find the usual proportion of positive WasserAt the manns and a large number of Wassermann tests a.re made, but all cases are not tested owing to the faet that many aro emergency cases. The babies, however, are tested not later than two to four aays after delivery. :Many positive Wassermalm babies ure strong auc1 vigorous and show no evidence of lues. Therefore it makes us rather doubtful whethel' we ought to make a diagnosis of syphilis where tl11:ire is a positive ·wassllrmann but no other evidence of syphilis. In women it is very difficult to get a history of a primary lesion and the secondary symptoms are so obscure that it is difficult to get any definite information. Of course we must have something dcfmite to go by if we are to establish a standard method of treatment for ~yphilitic patim1ts, but it is a question whether we should depend npon the S]Jecificity of the ·wassermann test since it. has heen found that many other conditions give a positive Wassermann reaction,-conc1itions having no relatio11 to syphilis. Dr. Beck truly asks "Is it fair to subject one of these women to rigid anti· syphilitic treatment who shows no evidence of syphilis but a positive Wassermmln reaction~'' Of eourse it ie trne that we may not be able to find such evidence until the child is older, nevertheless, I think we shoulcl exercise great raution in sub,jecting wome'l to the prolonged treatment that this disease requires.
in the statistics he presents, and more so in his conclusion.
NE\Y YORK ACADEMY OF MEDICINE
4'!9
I should like to ask whether the diagnosis in infants stillborn is based upon autopsy findings or merely upon the faet that they were stillborn. In determining the presence of syphilis we have made usc of a history of miscarriages and sqllbirths. If a woman gives a history of one or two stillborn children, we say that she probably has syphilis, and that the stillbirths are due to this cause. In this we are liable to err. In many of these women the miscarriages are due to external causes; they may be induced and we attribute them to syphilis, so we have to be extremely careful in diagnosing syphilis from this source alone. DR. FREDERICK W. RICE.-At Bellevue ancl Manhattan l\faterni.ty Hospital we have been taking the ·Wassermann reaction on every pregnant woman and we have been giving vigorous treatment. If we :find positive Wassermann reaction in the prenatal clinic we turn them over to the genitourinary department for salvarsan treatment every two weeks with mercury between. The babies we treat for one month and then turn them over to the children's clinic. Just what the results will be I do not know as we have not made any study of our statistics . The Wassermann test has also been of g·reat value in allowing us to give the babies who are in need of more nourishment to mothers to nurse who are free from syphilis. DH. BAILEY.--I should like to ask a little more about the dangers of salvarsan. Cne ease arriving at the hospital three clays after its use presented the symptoms of acute yellow atrophy and this patient died. The meclica.l examiner refused to do an autopsy because he said deaths were from this cause. DR. BECK.-I was able tu follow up in all, 73 cases in whie.h the ·wassermann reaction was four-plus in this series. \Ve reported only 32 cases because of doubt due to the insufficiency of the follow-up records. ::Yfany more cases will be included in the complete reports. However, I believe I have included all the deaths. In the beginning of the study the question came up, ''did all these women have syphilis who gave a positive Wassermann reaction''' Up to eighteen months ago I refused to treat a woman when she had a four-plus Wassermann and no oth~CJr evidence of syphilis. The majority of the women gave negative histories of syphilis, and did not rer.ollect having had a rash or a sore, as Dr. Kosmak has pointed. out is usually the case_ Hence one must rely upon the w·assermann reaction, and because of the severity of the treatment I have insisted upon having each Wassermann checked up by a second test, either in my own or in some other laboratory. Twenty-nine of these 32 women were definitely syphilitic. Three of the cases had single four-plus Wassermann reactions aml showed evidences of syphilis. From wha'~ I caii. gather from the literature and from our own observations, I think it is the consensus of opinion that whether the \Vassermann reaction is four-plus or negative during the first month of life does not much, Infants may show a positive :reaction ancl then a negative one and never show any evidences of syphilis. I think we do not know all that we should about the Wassermann reaction in pregnancy and in the newborn. None of these cases were autopsied. One occurred in Bellevue Hospital, and I could not say that the death was not caused by syphilis as I did not wish to place the benefit of the doubt on the goocl result side. However, I eaunot say that these children died of syphilis. One death occurred in the outpatient series ancl two misca.rriages occurred at home, in which I did not have the opportunity to do an autopsy_ We based our diagnosis of syphms on the positive Wassermann and other evidence of syphilis in the patient.
450
THE A)IIERICAX JOURNAL OF OBSTE'l'RICS AKD GYNECOLOGY
With regard to Dr. Bailey's remarks, we do not hesitate to give .salvarsan, and we give it in a largo number of patients. These 32 eases were merely picked ones. \Ve have a great number of cases in which one, two or three injections of salvarsan have been given, that are not included in this series. Hirst has ~aiel that he is afraid to give salvarsan in the last two months of pregnancy, hut most of the eases in this series have been given salvarsan in the last two months of pregnancy without bad results. They were treated in the genitourinary department and the pediatric clinic. We have used different preparations and have not found any that gave severe reactions. vVe have given it in several cases in which there was nephritis and toxemia and they were not harmed. The blood pressure and temperature were watched. There was no rash antepartum or other bad resulls.
THE AMERICAJ\'" JOUHNAL OF OBSTETRICS AND GYNECOLOGY
C. BECK read a Preliminary Report on the Treatment of Syphilis Complicating Pregnancy. (For original article see page
DR. ALFRED
416.) DISCUSSION DR. .JAMES B. GIVIN.-I h~1n followed up some of these eases, and have been struck by the absence of luetic stigmata. as compared with another set of children of syphilitic mothers who came to the pediatric. clinic and who showed four-plus \Vassermanu reactions. featuTe in this series of cases is the ease with which these babies An inunctions of mercury and responded to antisypl1ilitie treatment. They were not snlvarsan. These observations have shown the importance of continuing anti· syphilitic treatment of the mother after the baby is born. The ha.bies cannot be kept on the breast when the mothers a1·e resistant to treatment. \Ve hope to be able to follow this series of children for a number of years ancl it may be that later these children will show evidences of retarded syphilis. If any of the late 8igns of syphilis appear it will emphasize the importance of following up these cases, keeping them under treatment, and repeating the Wassermann tests at stated in· tervals. Dr. Boeck's statistics arc interesting in comparison with those published by Dr. Jeans, of St. LouiB, who has done a great deal of work in congenital syphilis. Dr. Jeans shows from his personal work and a review of the literature that 30 per cent of all pregnancies in syphilitic families terminate in death at or before term. Dr. Beck's cases show quite different statistics. Dr. Kolmer in the American Journal of DiS('ases of Children, Ma.y, 1920, shows that about 5 per cent of all children coming into R clinic in a large city are syphilitic and that about 5 per cent of tho elinic are syphilitic. The children of these mothers, cases coming to a certainly will not show evidences of lues. if properly DR. GEORGE W. KOSMAK.-1 a.m interested in Dr. Beck's paper, pnrticul::uly I was afraid he was going to say that he ha.d :32 cases of undoubted syphilis but I notice that he modified that assertion somewhat, It is scarcely fair always to assume a positive diagnosis of syphilis simply boeauso thPro is a four-plus Wassermaun reaction. Hospital we find the usual proportion of positive WasserAt the manns and a large number of Wassermann tests a.re made, but all cases are not tested owing to the faet that many aro emergency cases. The babies, however, are tested not later than two to four aays after delivery. :Many positive Wassermalm babies ure strong auc1 vigorous and show no evidence of lues. Therefore it makes us rather doubtful whethel' we ought to make a diagnosis of syphilis where tl11:ire is a positive ·wassllrmann but no other evidence of syphilis. In women it is very difficult to get a history of a primary lesion and the secondary symptoms are so obscure that it is difficult to get any definite information. Of course we must have something dcfmite to go by if we are to establish a standard method of treatment for ~yphilitic patim1ts, but it is a question whether we should depend npon the S]Jecificity of the ·wassermann test since it. has heen found that many other conditions give a positive Wassermann reaction,-conc1itions having no relatio11 to syphilis. Dr. Beck truly asks "Is it fair to subject one of these women to rigid anti· syphilitic treatment who shows no evidence of syphilis but a positive Wassermmln reaction~'' Of eourse it ie trne that we may not be able to find such evidence until the child is older, nevertheless, I think we shoulcl exercise great raution in sub,jecting wome'l to the prolonged treatment that this disease requires.
in the statistics he presents, and more so in his conclusion.
NE\Y YORK ACADEMY OF MEDICINE
4'!9
I should like to ask whether the diagnosis in infants stillborn is based upon autopsy findings or merely upon the faet that they were stillborn. In determining the presence of syphilis we have made usc of a history of miscarriages and sqllbirths. If a woman gives a history of one or two stillborn children, we say that she probably has syphilis, and that the stillbirths are due to this cause. In this we are liable to err. In many of these women the miscarriages are due to external causes; they may be induced and we attribute them to syphilis, so we have to be extremely careful in diagnosing syphilis from this source alone. DR. FREDERICK W. RICE.-At Bellevue ancl Manhattan l\faterni.ty Hospital we have been taking the ·Wassermann reaction on every pregnant woman and we have been giving vigorous treatment. If we :find positive Wassermann reaction in the prenatal clinic we turn them over to the genitourinary department for salvarsan treatment every two weeks with mercury between. The babies we treat for one month and then turn them over to the children's clinic. Just what the results will be I do not know as we have not made any study of our statistics . The Wassermann test has also been of g·reat value in allowing us to give the babies who are in need of more nourishment to mothers to nurse who are free from syphilis. DH. BAILEY.--I should like to ask a little more about the dangers of salvarsan. Cne ease arriving at the hospital three clays after its use presented the symptoms of acute yellow atrophy and this patient died. The meclica.l examiner refused to do an autopsy because he said deaths were from this cause. DR. BECK.-I was able tu follow up in all, 73 cases in whie.h the ·wassermann reaction was four-plus in this series. \Ve reported only 32 cases because of doubt due to the insufficiency of the follow-up records. ::Yfany more cases will be included in the complete reports. However, I believe I have included all the deaths. In the beginning of the study the question came up, ''did all these women have syphilis who gave a positive Wassermann reaction''' Up to eighteen months ago I refused to treat a woman when she had a four-plus Wassermann and no oth~CJr evidence of syphilis. The majority of the women gave negative histories of syphilis, and did not rer.ollect having had a rash or a sore, as Dr. Kosmak has pointed. out is usually the case_ Hence one must rely upon the w·assermann reaction, and because of the severity of the treatment I have insisted upon having each Wassermann checked up by a second test, either in my own or in some other laboratory. Twenty-nine of these 32 women were definitely syphilitic. Three of the cases had single four-plus Wassermann reactions aml showed evidences of syphilis. From wha'~ I caii. gather from the literature and from our own observations, I think it is the consensus of opinion that whether the \Vassermann reaction is four-plus or negative during the first month of life does not much, Infants may show a positive :reaction ancl then a negative one and never show any evidences of syphilis. I think we do not know all that we should about the Wassermann reaction in pregnancy and in the newborn. None of these cases were autopsied. One occurred in Bellevue Hospital, and I could not say that the death was not caused by syphilis as I did not wish to place the benefit of the doubt on the goocl result side. However, I eaunot say that these children died of syphilis. One death occurred in the outpatient series ancl two misca.rriages occurred at home, in which I did not have the opportunity to do an autopsy_ We based our diagnosis of syphms on the positive Wassermann and other evidence of syphilis in the patient.
450
THE A)IIERICAX JOURNAL OF OBSTE'l'RICS AKD GYNECOLOGY
With regard to Dr. Bailey's remarks, we do not hesitate to give .salvarsan, and we give it in a largo number of patients. These 32 eases were merely picked ones. \Ve have a great number of cases in which one, two or three injections of salvarsan have been given, that are not included in this series. Hirst has ~aiel that he is afraid to give salvarsan in the last two months of pregnancy, hut most of the eases in this series have been given salvarsan in the last two months of pregnancy without bad results. They were treated in the genitourinary department and the pediatric clinic. We have used different preparations and have not found any that gave severe reactions. vVe have given it in several cases in which there was nephritis and toxemia and they were not harmed. The blood pressure and temperature were watched. There was no rash antepartum or other bad resulls.