Norman R. Ingraham

The diagnosis and treatment of syphilis complicating pregnancy

Abstract Syphilis in the latent stage, as it exists in most pregnant women, is difficult to detect. This means that the disease must be suspected in every case, for a successful termination of pregnancy and a healthy child cannot be expected in the presence of an active or even a quiescent infection of this nature. The incidence of syphilis among pregnant women in the clinic class of patient is usually between 5 and 10 per cent. It occurs probably less frequently in the higher classes but, because it is less often looked for, more cases are likely to escape detection. In the presence of a comparatively early untreated syphilitic infection the infant mortality rate is increased to five times the accepted average. Most authorities agree that syphilis runs a milder course in women than it does in men, but it has never been conclusively shown that pregnancy is the biological agency responsible for this change. There is some evidence that the disease may be activated by the added strain upon the maternal organism during parturition. None the less, when the history and physical examination of the expectant mother are completed, one should be able to suspect the presence of the disease, if the woman is infected, in from 25 per cent to 64 per cent of cases, but in no instance should the blood serum Wassermann reaction be omitted. Since patients with infection of long standing, and those inadequately treated may give birth to a syphilitic child in the presence of a negative serologic examination, every child born descrves the benefit of a study to rule out this disease. In addition to the usual procedures, the umbilical cord blood is of value if all findings are properly interpreted and in this connection roentgenologic studies of the long bones are both reliable and valuable. It is wise to follow suspicious cases for some months at least. The results obtained by early treatment of the syphilitic mother to save her child are scarcely paralleled in any other medical condition. An infected offspring is seldom encountered if therapy has been commenced prior to the fourth month of pregnancy. The observation that the Treponema pallidum does not traverse the placental barrier early, and the fact that antisyphilitic drugs, only with great difficulty, penetrate the membranes separating the maternal and fetal circulation, together emphasize the urgency of preventing infection of the child while there is yet time. For, once the microorganism has gained access to the fetal circulation, it is improbable that the fetus will be cured while still in the womb. On the other hand, nonsyphilitic children, especially after adequate prenatal treatment, result with sufficient frequency to make one feel that the offspring should practically never be treated until the disease in him is demonstrated. This view-point is further strengthened when one considers the prolonged course of active therapy with relatively toxic drugs that is necessary to insure a clinical cure of any syphilitic patient. Treating an infected child for a few weeks postnatally cannot be expected to eradicate this disease. In general, the pregnant syphilitic woman can undergo the same type of treatment regime as can the nonpregnant, but the technic of administration of the medication must be above reproach, and the dosage and type of drug gauged according to the condition of the patient. Too often, in the past, when the physician practicing obstetrics or pediatrics has lost a child suffering from syphilis or has permitted the disease to become clinically manifest before treatment was instituted, the responsibility for the unfortunate outcome has been placed upon the patients lack of cooperation. In the present state of our knowledge the most careful diagnostician may fail to detect an occasional case, but these failures should be very rare indeed. It is to be hoped that the future instances in which syphilis is not diagnosed in the pregnant woman or in her off-spring will be those few in which the disease escaped detection although every available method for revealing its presence had been employed.

Penicillin in the treatment of the syphilitic infant: A progress report

Summary Thirty-six infants with congenital syphilis were treated with intramuscularpenicillin in dosages ranging from 11,000 to 75,000 units per pound of body weight over periods of seven to fifteen days. Fifteen received total dosages of less than 20,000 units per pound of body weight, twenty-one received over 20,000 units per pound of body weight. When three older infants were removed from the lower dosage group, and the two groups were statistically comparable, there was no significant difference in results. The only case of clinical relapse, however, and three other cases meriting re-treatment, occurred in the low dosage group. The impression was that clinical improvement occurred more rapidly with the higher dosages. Nineteen have become clinically well and seronegative. Six became clinically, well, but remained seropositive. Three were seropositivewhen lost to follow-up at 74,59, and 81 days after beginning treatment, and two were clinically well but serologically doubtful. Four of these six patients were in the lower dosage group. Seven died, five while hospitalized for penicillin therapy, two much later after initial clinical improvement. Four have been treated too recently to evaluate beyond the prompt clinical improvement. There was no case of serologic relapse in the whole group, and only oneclinical relapse, which was in the group receiving the lower dosage.

PENICILLIN THERAPY ALONE IN NEUROSYPHILIS: AN ANALYSIS OF CLINICAL RESULTS

Excerpt When we began the treatment of neurosyphilis with penicillin in November 1943, we determined to use penicillin alone without fever or arsenic or any other therapy which could influence the ...