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ful. The disease is generally observed before the 4th month of life but cases have been reported as occurring later.
The lesion of osteochondritis is valuable in making a pathological diagnosis of congenital syphilis in those fetuses which are so macerated that a careful examination of the viscera is impossible. In examining the epiphyseal junction for this condition it is well to observe different areas as the change may be noted in one area and not in the adjoining. The pathological condition is less marked in the bone the longer the child has lived.
Wegner distinguished three stages of osteochondritis.
1. Instead of the normal, straight, narrow, white line of calcification at the junction of the epiphysis and diaphysis there is a wide, irregular yellow line which extends into the neighboring layer of cartilage. At times this change is not observed on macroscopical examination but microscopically the irregular broadened zone of calcification is readily made out.
2. The calcification zone is broader, more friable and the zone of cartilage may be either enlarged or diminished.
3. The epiphysis as a whole may become thickened and enlarged. There is an area of soft yellow granulation tissue 3-4 mm. broad between the calcification zone and the bone.
In very severe cases when the epiphysis separates spontaneously
from the diaphysis the fracture surface is irregular and rough, whereas in the normal separation of the epiphysis the fracture surface is smooth. Sometimes this condition has to be differentiated from rickets in which there is a very small amount of calcium salts present. Bertarelli in studying the bacteriology of these lesions has observed spirochetae pallida in the epiphysis, periosteum and capsule of the joint.
The chief symptom of the disease is the loss of function of one or more of the extremities. The articulations are swollen, painful and in extreme cases the epiphyses are separated from the diaphyses. When the wrist joint is the site of the disease, deformity is generally present. Symmetrical joints are often involved and the patient assumes a flaccid attitude. This condition is not readily recognized when other manifestations of syphilis are not present and thus it progresses without treatment until further symptoms develop. However when skin lesions, snuffles, enlargement of the liver and spleen and a definite history accompany the paralysis the diagnosis is somewhat simplified. The Wassermann reaction of the mother and baby is very often of valuable assistance in arriving at a diagnosis. At times it is necessary to differentiate pseudoparalysis from lesions of the central nervous system, Erbs paralysis, and diseases of nutrition.
The prognosis of this condition depends on early diagnosis and prompt treatment. If the treatment is delayed until definite symptoms make their appearance death may intervene on account of the extent of the visceral lesions. Under specific treatment repair takes place rapidly and the separated epiphysis unites firmly with the diaphysis, if maintained in good position. Occasionally after recovery there is a slight lengthening of the bone otherwise there is no sign of the former lesion whatever. The following is a report of a case which occurred in the Out-Patient, Department of the hospital service and may be classified as the third stage of the disease. The infant at birth was a full term, well developed male child that did well up to the third day. At this time it was noticed that the patient made no attempt at moving its extremities and continued to lie quietly in the same position. Later a fracture of the upper extremity of the right humerus was observed and the same condition was present at the lower extremity of the right femur. There were
no other symptoms or physical signs of syphilis present and death occurred on the 8th day.
At autopsy the epiphysis of the right humerus was entirely separated from the diaphysis and the fracture surface was irregular and rough. The epiphyseal line of the left humerus was broad and irregular showing an increase in the calcification zone. At the lower extremities of both femora the epiphyses were hypertrophied, the periosteum and capsule of the knee joint were thickened. On section there was a distinct yellow zone of granulation tissue 3 mm. broad between the diaphysis and the epiphysis and the edges of the calcification zone projected irregularly
into the cartilage. The epiphysis of the right femur was separated from the diaphysis and it was held in position by the periosteum. Spirochetae pallida were found in the lesions of the femora and section of all the long bones showed Wegner's sign. The liver, spleen, pancreas and kidneys were increased in size, of firm consistency and microscopically the changes commonly found in congenital syphilis were observed. The mother of the baby was a para V, 35 years old and apparently in good health. Two children are living and well, one died at one and one-half and the other at two years of age. The Wassermann reaction on the father was negative and that on the mother was strongly positive. CONCLUSIONS. 1. Osteochondritis is more often a complication of congenital syphilis than is generally anticipated.
2. That in all cases of paralysis of the new born syphilis should be considered so that the diagnosis may be made early without waiting for visible signs of the disease.
3. With early and suitable treatment a good functional result without deformity is usually obtained.
Pollak. Deutsche medizinische Wochenschrift. 1896, No. 2.
Parrot. Archives de Physiologie Normale et Pathologique. 1871-72, Vol. 4.
Gilbert. Paris Thèses, 1899-1900, No. 100.
Wegner. Virchow's Achiv. 1870, No. 50.
REPORT OF THE WORK DONE IN THE BABIES' CLASS FROM OCTOBER 1, 1913 to SEPTEMBER 30, 1914.
By EMELYN L. COOLIDGE, M.D., Attending Pediatrician.
DURING the year 5,019 visits were made to the Class, 1,854 new patients being treated. These figures are considerably in advance of those given in any previous year, in spite of the fact that so many more milk stations and similar places have been opened where feeding cases may be treated free of charge. This seems very encouraging to us because it shows the majority of the mothers appreciate the special care we give and return year after year with each new baby as it arrives, rather than go to other places for treatment.
We have treated cases of pneumonia in the Class and by visits of the nurse at home very successfully during the past winter. Usually we do not feel it best to undertake the full care of such cases because the exposure to the baby in coming out to the Class is too great but in
several instances the mother could not be prevailed upon to place the child in a hospital and rather than to subject her to the kind of medical treatment she could afford at home, we have continued with the case and in all instances with the best of results. As the fresh air treatment has proved so beneficial to cases of pneumonia, we have reasoned that it could hardly harm the baby to be brought to the Class in a baby carriage or even in the arms of the mother, if kept in a comfortable and recumbent position so that no unusual strain was put on the heart action. Daily visits to the patients made by our nurse and a call at the Class once or twice weekly were required; in this way the pulse could be carefully watched and stimulants given at just the right time. Object lessons as to the proper method of making and applying a mustard paste, giving an alcohol sponge bath, a high enema etc. which were given these mothers by our nurse were invaluable aids in saving the pneumonia cases. We found that it was perfectly practical to teach the mothers how to give an inhalation of steam by using a cheap tea kettle from the five and ten cent store and often elongating the spout by means of heavy paper or bent cardboard. These steam inhalations are more beneficial to many of the patients with an irritating, dry cough than any medication we can prescribe. The cough mixtures used so often cause vomiting or anorexia that we have made it a practice to avoid them whenever it was possible and rely on the inhalations of steam and application of mustard paste instead.
We have placed all the specific cases in a class by themselves and they have been treated by one assistant who has had the nurse make frequent follow up calls in order not to lose sight of them. We have gotten better results in this way than in previous years when no special physician has taken charge of them. We have found it advisable to use mercurial ointment inunctions as well as injections of neosalvarsan. The disease seeming to yield much more readily under this combined treatment. We have given intramuscular injections of the neosalvarsan exclusively and obtained good results without painful reactions to the little patients. In a few instances there would be a slight inflammation at the site of the injection for a day or two but nothing of serious import took place in any of the cases. From watching our own cases and comparing these with some others that have had intravenous injections, we cannot but feel that it is wiser not to subject these young infants to the strain of a surgical operation such as the intravenous administration necessitates. Here, as in everything relating to babies, the milder method of treatment seems the best. Frequent blood examinations have been made in the Laboratory in order to determine how each case was progressing. In several of the cases where there has been marked separation of the epiphyses very interesting X-ray plates have been kindly made by Dr. Truesdell, thus adding interest in working up the
The Special Class of twenty mothers with their first babies has been continued as usual this last year. This class is chiefly an educational one to teach these mothers what can be accomplished in the tenements by really intelligent care and feeding of their babies. Each week the nurse makes a visit to the homes and teaches the mother by object lessons and once in two weeks the babies are brought to the Class to be weighed and examined by a doctor in charge of this set of patients. The pride and interest taken by the mothers in following out the instructions given to them are very gratifying.
Of all our patients we feel that we have done the best work this last year with our premature babies. This class of babies is so difficult to save even under the best conditions, that it seemed at first almost a hopeless proposition to do very much for them in a tenement house. We have spared no effort to save these babies and have treated eighteen in their own homes since last January. Of these we have not lost a single case. They have been discharged from the wards as soon as the mothers were fit to go home and the Babies Class nurse has then been sent at once to instruct the mothers in the special care required by this delicate class of babies. We have been aided in saving these babies by a special fund appropriated by The Ladies' Auxiliary. By means of this fund we have been able to buy special milk, special cotton suits and other necessities which the parents could not afford to supply but which meant everything in our struggle to save these tiny patients. Some seven months premature twins whose condition was so poor that it seemed practically hopeless at first, have developed into fine babies under this method of home treatment and we feel more than ever justified in saying that as a rule, these babies do better at home than in a hospital ward, if correct instructions can be given the mothers. During the coming year we intend to place all these premature infants in a separate class and make a very careful study of their needs. The little cotton suit we now employ was first made by a Babies Hospital nurse for a private patient and found so useful in keeping these babies warm that we expect to use them exclusively.