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Syphilis and pregnancy
Society Transactions THE NEW MEEl’ING
DR. F. W.
SOVAK
trachelitis.
YORK
OBSTETRICAL OP
NOVEMZBER
SOCIETY 8,
1967
(by invitation) presented a paper on Chronic Endo(For original article see page 686, May issue.)
8. A. GAMMELTO~T of Copenhagen, Denmark (by invitation) presented a paper entitled Syphilis and Pregnancy. (For original article see page 747.)
PROFESSOR
DISCUSSION DR. A. C. BECK said that Prof. Gsmmeltoft had taken up many of the points that are in controversy in this country. Contrary to the doctor’s statement, in the Long Island Hospital clinic they are in accord with every idea that was presented and they do not treat the newborn babies of well-treated mothers. Dr. Beck then said that the one point in which he was particularly interested is the question of the Wassermann reaction. In his preliminary report on the treatment of syphilis he laid great stress upon the strongly positive Wassermann, although he npted at that time that the so-called false positive does occur and had been reported by others. In spite of that, his clinic recommended that the patients be well treated with salvarsan, even though these cases showed no other evidence of syphilis. Because of the controversy that arose from that statement, he was particular in following these cases and undoubtedly the strongly positive reaction, in pregnant women means syphilis, even though no other evidence either in the physical examination or in the history is found to substantiate that diagnosis. When Dr. Beck checked the serology of the rest of the family and the husbands, he found just as did Doctor Gammeltoft, that they could substantiate the diagnosis of syphilis by findings other than the positive Wassermann, in all but one case. The eases that were well treated with salvarsan during pregnancy gave birth to splendid babies. When the mothers were well treated during pregnancy the infants were not treated for syphilis in the clinic; they went to the syphilitic clinic and were under the observation of a special pediatrician. In two instances, however, the patients showed signs of syphilis for the first time several years after birth, one at the age of three and the other at the age of four. DR. G. L. MOENCH asked whether it is Prof. Gammeltoft’s impression that the legal measures Denmark has adopted have been successful in, really reducing the incidence of syphilis, for an incidence of between 5 and 6 per cent in his cases seems still rather high. DR. R. T. FRANK asked Prof. Gammeltoft to explain that paradoxical case in which normal children and syphilitic children alternated. Does he think there was an old in,fection of syphilis which became latent at times, in which case the spirochetes could not reach the placenta, and that later they became reactivated?
573
874
THE
AMERICAN
JOIJRNAL
OF
ORSTETRICS
AND
GYNECOLOGY
PROF. GAMMELTOFT (closing) said in answer to Dr. Beck’s question relative to treatment that they had been using old-salvarsan, that subsequently they had changed to neosnlvarsan and silver salvnrsan, arid that they had not noticed 311\ difference between them. He added that ihc bismuth treatment is not as got111 as the sslvarsan treatment. The speaker said that they had investigated the deaths after the use of snlvar8311. In one of the largest hospitals in Denmark for the treatment of venereal disease there had been four cases rlf salvnrsnn poisoning within ten years Three of thcsc deaths were in pregnant terminating in the death of the patients. women. Prof. Gammeltoft stated that 11~ believed with Dr. Beck that if the urine were examined carefully, there is no doubt that pregnant women may be safely treated with salvnrsan. The speaker then discussed the question of the Wassermann reaction and referred to the variability in the reports, stnt,ing that in some places, if one sends specimens of blood to three or four different stations, the reports are not always the same. He said that in Denmark a very important progress was made wlmn of the W:~sscrmnnn reaction by having the government of that country took clmrgc Th. Madsen) carry out practically all the Wasserthe State Serum Institute (Dr. In Denmark this arrangement has greatly mann reactions done in Denmark. lessened that uncertainty about the Wassernmno rcaa&ion which still prevails in some places. In discussing the sensitiveness of the reaction the speaker pointed out that the reaction can be made more or less sensitive. 4nd hc rnent.ioned that the obstetric clinic did not want the reaction to be hypersensitivt~ for the reason that with a reliable tt&inic and a nonhyperse~lsitive reaction C’VI’II :I weak positive result is a definite criterion of the presence of syphilis. With the method employed by the Danish State Serum Institute it is conceivable that in extremely rare instances but, on the other hand, even a weak reaction a case of syphilis may be overlooked; is an unquestionable sign of syphilis. The speaker then discussed the question of whether a case of syphilis should He believed that the dermatologist be treated by the obstetrician or a specialist. And IIC added that as far as Denmark was best able to cope with these cases. was concerned there was no difficulty about the transfer of syphilitic patients to the specialist. With regard to the children the professor emphasized the point that the eonstant observation of the child in the “Special Department” for the first six months of life is quite different from seeing the child once evory two or three In some children, he said, the first rash is very slight, and if one sees weeks. such a child eight days later, the rash has disappeared, one finds no visible sign of syphilis, an,d a subsequent positive Wassermann reaction comes as a surprise. relative to the The professor replied to the question asked by Dr. Thalheimer reaction during pregnancy, that pregnancy in itself produces no positive reaction. Babies with a weak positive reaction and no clinical sign of syphilis are not treated. The speaker next discussed the question of the transmission of syphilitic antibodies from mother to child, and stated that he considered such transmission possible without the child being infected. Prof. Gammeltoft said that their incidence Answering Dr. Moench’s question, He referred of G per cent of syphilis was the average percentage in his clinic. to the fact that this clinic dated from the year 1759, a.nd, after speaking of the he went on to say that their patients object for which it was primarily founded, normal cases in very poor women, and married consist of unmarried women, women with some complication of pregnancy, but that they are not allowed to admit any normal cases which are able to pay, and that this limitation of admission is the reason why they have such a high percentage of syphilis in their
cliuic. Ile later years,
bclio\-cd they hai1 I~ecu :rblc to retlucc the prmv~t:rgc~ of syphilis iu but it was wry curious to uoticc ho\v tlrc iuvitleuc*e of syphilis always fIc said that about six mouths ago tile iucitleuce of syphilis goes up and d”\W. \\as very low, aud that in the last thncc or four months before his departure from On the wl~olc, he believed, they Ilnl-c 1)eumnrk the incidence had rise,, once more. of syphilis iii later gears. He xv a right to feel that there has beeu :I decrease ferred to the laws affectiug prostitutiou nut1 said that lie did uot bcliere that the applicntiou of legal measures for the abolition of prostitution 11:~s resulted iu :luy iwwase of the disease, but-on the whole-rather a decrease. liespouding to Dr. Frnuk ‘s question respecting the alteruntiug cases of coingeuitxl syphilis and normal childrcu, tlie Iwofessor said he was uiiahle to offer any explanation of this apparent capriciousuess of nature. Some people, he s:li~l~ believe that white iufarrts II:LVC somethiug to do vitll syphilis, but lie did not tllink that this theory would :It all hold good. Iii this couuectiou he referred lo the work of Olaf Thomsr~~. Ilr s;iitl IIC only meiitioued tllr qucstiou of ttlc wtiitc, iufaret in I~l:lreut:c bec:luse it m:ry l)e possible that the infection sometimes twvs’s though the iuf:lwt, to tllc vhilil.
DR.
JOIIX II. GIRVIN presented terb- Accidental Fixation
a
report
of
Ihree
of Uterus Following
cases of High AnCesarean Section.
C!ASE l.-Mrs. T. D., Italian, aged forty, admitted to Presbyterian Hospital oct”t~tY 4, 1326. Coniplwiued of “tumor” iu the right side of nbdomeu which 11:1tl txen present for fire months; rcwutly slight Ilain over this mass. .4ln:tya enjoyed good hc:~l~ll, has had 12 preguaueies, (3 miscarriages at 3 months, 10 full-term babies, li of wllicll are living). Present illness dates from hst labor, March 5, 1920, at which time a cesarwu section was done. Sfter S 11oiws of actire labor, the fetal head had not cugaged aud the patient’s genelal strength was failing. Cirsarcan section ~-ns doue in the usual mauner and both lubes werr bisected I~C:IT the coruu:~t end and the stumps burietl in the layers of the broad ligameut. Postoperative conv:~Icsccncc uo~n:ll, and for two mouths :I i’tcrwnrd the patieut felt ~vell. Then she began to notice iL tru(lcr swelling iu the right lower quadrant of the nbdomeu with occasional lhn iu this region. Period; hat1 been scant since operation aud she had a modcrate yellow raginnl tlischarge. General physical esaminatiou was essentially negative. Abdomiunl scar 31/z inchrs long, slightly to left of midline, cstending 1,‘~ iuch nbol-e umbilicus nud about 3 inches below. Iu right lower quadrant was a tl:wci, teilder m:~ss ahout 3 inches a(*ross, smooth, firm aud slightly movable in all diwctions. Trnt:ltiw di:lguosis, high fixilion of uterus following cesarenu section. 011 October 5, the patient was operatrd upou by 1)~. 1~~s. WXeu the Iwitoneum was opened the uterus was fouuti to 11e adherent to the xbdomhtl \\;til, ,just below :uid to the right of the iiavel, at tile site of the ccwrean iucisi 111, iu the fundus. The very dcusc nllhesious nwc rut and while this was behg douc the uterus was toru open at the site of the old wound and thick reddish yellow material exuded. A suprawgiuat lrpsterectomy and right sxlpiugectom> were doiic~ :rud the appendix removed. Drainage was cl;usi~lcrwl but not done and the :~hlomeu closed iu the custonmry maunw.
DR. F. W.
SOVAK
trachelitis.
YORK
OBSTETRICAL OP
NOVEMZBER
SOCIETY 8,
1967
(by invitation) presented a paper on Chronic Endo(For original article see page 686, May issue.)
8. A. GAMMELTO~T of Copenhagen, Denmark (by invitation) presented a paper entitled Syphilis and Pregnancy. (For original article see page 747.)
PROFESSOR
DISCUSSION DR. A. C. BECK said that Prof. Gsmmeltoft had taken up many of the points that are in controversy in this country. Contrary to the doctor’s statement, in the Long Island Hospital clinic they are in accord with every idea that was presented and they do not treat the newborn babies of well-treated mothers. Dr. Beck then said that the one point in which he was particularly interested is the question of the Wassermann reaction. In his preliminary report on the treatment of syphilis he laid great stress upon the strongly positive Wassermann, although he npted at that time that the so-called false positive does occur and had been reported by others. In spite of that, his clinic recommended that the patients be well treated with salvarsan, even though these cases showed no other evidence of syphilis. Because of the controversy that arose from that statement, he was particular in following these cases and undoubtedly the strongly positive reaction, in pregnant women means syphilis, even though no other evidence either in the physical examination or in the history is found to substantiate that diagnosis. When Dr. Beck checked the serology of the rest of the family and the husbands, he found just as did Doctor Gammeltoft, that they could substantiate the diagnosis of syphilis by findings other than the positive Wassermann, in all but one case. The eases that were well treated with salvarsan during pregnancy gave birth to splendid babies. When the mothers were well treated during pregnancy the infants were not treated for syphilis in the clinic; they went to the syphilitic clinic and were under the observation of a special pediatrician. In two instances, however, the patients showed signs of syphilis for the first time several years after birth, one at the age of three and the other at the age of four. DR. G. L. MOENCH asked whether it is Prof. Gammeltoft’s impression that the legal measures Denmark has adopted have been successful in, really reducing the incidence of syphilis, for an incidence of between 5 and 6 per cent in his cases seems still rather high. DR. R. T. FRANK asked Prof. Gammeltoft to explain that paradoxical case in which normal children and syphilitic children alternated. Does he think there was an old in,fection of syphilis which became latent at times, in which case the spirochetes could not reach the placenta, and that later they became reactivated?
573
874
THE
AMERICAN
JOIJRNAL
OF
ORSTETRICS
AND
GYNECOLOGY
PROF. GAMMELTOFT (closing) said in answer to Dr. Beck’s question relative to treatment that they had been using old-salvarsan, that subsequently they had changed to neosnlvarsan and silver salvnrsan, arid that they had not noticed 311\ difference between them. He added that ihc bismuth treatment is not as got111 as the sslvarsan treatment. The speaker said that they had investigated the deaths after the use of snlvar8311. In one of the largest hospitals in Denmark for the treatment of venereal disease there had been four cases rlf salvnrsnn poisoning within ten years Three of thcsc deaths were in pregnant terminating in the death of the patients. women. Prof. Gammeltoft stated that 11~ believed with Dr. Beck that if the urine were examined carefully, there is no doubt that pregnant women may be safely treated with salvnrsan. The speaker then discussed the question of the Wassermann reaction and referred to the variability in the reports, stnt,ing that in some places, if one sends specimens of blood to three or four different stations, the reports are not always the same. He said that in Denmark a very important progress was made wlmn of the W:~sscrmnnn reaction by having the government of that country took clmrgc Th. Madsen) carry out practically all the Wasserthe State Serum Institute (Dr. In Denmark this arrangement has greatly mann reactions done in Denmark. lessened that uncertainty about the Wassernmno rcaa&ion which still prevails in some places. In discussing the sensitiveness of the reaction the speaker pointed out that the reaction can be made more or less sensitive. 4nd hc rnent.ioned that the obstetric clinic did not want the reaction to be hypersensitivt~ for the reason that with a reliable tt&inic and a nonhyperse~lsitive reaction C’VI’II :I weak positive result is a definite criterion of the presence of syphilis. With the method employed by the Danish State Serum Institute it is conceivable that in extremely rare instances but, on the other hand, even a weak reaction a case of syphilis may be overlooked; is an unquestionable sign of syphilis. The speaker then discussed the question of whether a case of syphilis should He believed that the dermatologist be treated by the obstetrician or a specialist. And IIC added that as far as Denmark was best able to cope with these cases. was concerned there was no difficulty about the transfer of syphilitic patients to the specialist. With regard to the children the professor emphasized the point that the eonstant observation of the child in the “Special Department” for the first six months of life is quite different from seeing the child once evory two or three In some children, he said, the first rash is very slight, and if one sees weeks. such a child eight days later, the rash has disappeared, one finds no visible sign of syphilis, an,d a subsequent positive Wassermann reaction comes as a surprise. relative to the The professor replied to the question asked by Dr. Thalheimer reaction during pregnancy, that pregnancy in itself produces no positive reaction. Babies with a weak positive reaction and no clinical sign of syphilis are not treated. The speaker next discussed the question of the transmission of syphilitic antibodies from mother to child, and stated that he considered such transmission possible without the child being infected. Prof. Gammeltoft said that their incidence Answering Dr. Moench’s question, He referred of G per cent of syphilis was the average percentage in his clinic. to the fact that this clinic dated from the year 1759, a.nd, after speaking of the he went on to say that their patients object for which it was primarily founded, normal cases in very poor women, and married consist of unmarried women, women with some complication of pregnancy, but that they are not allowed to admit any normal cases which are able to pay, and that this limitation of admission is the reason why they have such a high percentage of syphilis in their
cliuic. Ile later years,
bclio\-cd they hai1 I~ecu :rblc to retlucc the prmv~t:rgc~ of syphilis iu but it was wry curious to uoticc ho\v tlrc iuvitleuc*e of syphilis always fIc said that about six mouths ago tile iucitleuce of syphilis goes up and d”\W. \\as very low, aud that in the last thncc or four months before his departure from On the wl~olc, he believed, they Ilnl-c 1)eumnrk the incidence had rise,, once more. of syphilis iii later gears. He xv a right to feel that there has beeu :I decrease ferred to the laws affectiug prostitutiou nut1 said that lie did uot bcliere that the applicntiou of legal measures for the abolition of prostitution 11:~s resulted iu :luy iwwase of the disease, but-on the whole-rather a decrease. liespouding to Dr. Frnuk ‘s question respecting the alteruntiug cases of coingeuitxl syphilis and normal childrcu, tlie Iwofessor said he was uiiahle to offer any explanation of this apparent capriciousuess of nature. Some people, he s:li~l~ believe that white iufarrts II:LVC somethiug to do vitll syphilis, but lie did not tllink that this theory would :It all hold good. Iii this couuectiou he referred lo the work of Olaf Thomsr~~. Ilr s;iitl IIC only meiitioued tllr qucstiou of ttlc wtiitc, iufaret in I~l:lreut:c bec:luse it m:ry l)e possible that the infection sometimes twvs’s though the iuf:lwt, to tllc vhilil.
DR.
JOIIX II. GIRVIN presented terb- Accidental Fixation
a
report
of
Ihree
of Uterus Following
cases of High AnCesarean Section.
C!ASE l.-Mrs. T. D., Italian, aged forty, admitted to Presbyterian Hospital oct”t~tY 4, 1326. Coniplwiued of “tumor” iu the right side of nbdomeu which 11:1tl txen present for fire months; rcwutly slight Ilain over this mass. .4ln:tya enjoyed good hc:~l~ll, has had 12 preguaueies, (3 miscarriages at 3 months, 10 full-term babies, li of wllicll are living). Present illness dates from hst labor, March 5, 1920, at which time a cesarwu section was done. Sfter S 11oiws of actire labor, the fetal head had not cugaged aud the patient’s genelal strength was failing. Cirsarcan section ~-ns doue in the usual mauner and both lubes werr bisected I~C:IT the coruu:~t end and the stumps burietl in the layers of the broad ligameut. Postoperative conv:~Icsccncc uo~n:ll, and for two mouths :I i’tcrwnrd the patieut felt ~vell. Then she began to notice iL tru(lcr swelling iu the right lower quadrant of the nbdomeu with occasional lhn iu this region. Period; hat1 been scant since operation aud she had a modcrate yellow raginnl tlischarge. General physical esaminatiou was essentially negative. Abdomiunl scar 31/z inchrs long, slightly to left of midline, cstending 1,‘~ iuch nbol-e umbilicus nud about 3 inches below. Iu right lower quadrant was a tl:wci, teilder m:~ss ahout 3 inches a(*ross, smooth, firm aud slightly movable in all diwctions. Trnt:ltiw di:lguosis, high fixilion of uterus following cesarenu section. 011 October 5, the patient was operatrd upou by 1)~. 1~~s. WXeu the Iwitoneum was opened the uterus was fouuti to 11e adherent to the xbdomhtl \\;til, ,just below :uid to the right of the iiavel, at tile site of the ccwrean iucisi 111, iu the fundus. The very dcusc nllhesious nwc rut and while this was behg douc the uterus was toru open at the site of the old wound and thick reddish yellow material exuded. A suprawgiuat lrpsterectomy and right sxlpiugectom> were doiic~ :rud the appendix removed. Drainage was cl;usi~lcrwl but not done and the :~hlomeu closed iu the custonmry maunw.