Book - Contributions to Embryology Carnegie Institution No.56-17

From Embryology

Chapter 17. Changes Suggestive of Lues

Embryology - 21 Oct 2019    Facebook link Pinterest link Twitter link  Expand to Translate  
Google Translate - select your language from the list shown below (this will open a new external page)

العربية | català | 中文 | 中國傳統的 | français | Deutsche | עִברִית | हिंदी | bahasa Indonesia | italiano | 日本語 | 한국어 | မြန်မာ | Pilipino | Polskie | português | ਪੰਜਾਬੀ ਦੇ | Română | русский | Español | Swahili | Svensk | ไทย | Türkçe | اردو | ייִדיש | Tiếng Việt    These external translations are automated and may not be accurate. (More? About Translations)

Mall FP. and Meyer AW. Studies on abortuses: a survey of pathologic ova in the Carnegie Embryological Collection. (1921) Contrib. Embryol., Carnegie Inst. Wash. Publ. 275, 12: 1-364.

In this historic 1921 pathology paper, figures and plates of abnormal embryos are not suitable for young students.

1921 Carnegie Collection - Abnormal: Preface | 1 Collection origin | 2 Care and utilization | 3 Classification | 4 Pathologic analysis | 5 Size | 6 Sex incidence | 7 Localized anomalies | 8 Hydatiform uterine | 9 Hydatiform tubal | Chapter 10 Alleged superfetation | 11 Ovarian Pregnancy | 12 Lysis and resorption | 13 Postmortem intrauterine | 14 Hofbauer cells | 15 Villi | 16 Villous nodules | 17 Syphilitic changes | 18 Aspects | Bibliography | Figures | Contribution No.56 | Contributions Series | Embryology History

Historic Disclaimer - information about historic embryology pages 
Mark Hill.jpg
Pages where the terms "Historic Textbook" and "Historic Embryology" appear on this site, and sections within pages where this disclaimer appears, indicate that the content and scientific understanding are specific to the time of publication. This means that while some scientific descriptions are still accurate, the terminology and interpretation of the developmental mechanisms reflect the understanding at the time of original publication and those of the preceding periods, these terms and interpretations may not reflect our current scientific understanding.     (More? Embryology History | Historic Embryology Papers)

Since Schaudin's discovery, attention naturally has been directed very largely from placental lesions of syphilis to the presence of spirochsetse. But unfortunately the hope that the presence of this organism would form not only a crucial but also an infallible criterion for the determination of fetal lues does not seem to have been realized. The search for spirochsetee seems to have been attended by such uncertain results that a routine examination of the placenta has not even been recommended by prominent obstetricians. Slemons (1917 b ), for example, stated that the presence of spirochseta? in the placenta can be demonstrated in only about one-third of the cases of lues, and Mracek (1903) found no histologic evidence of lues in 82 out of 160 placentae from syphilitic women. Slemons found the examination of stained sections more satisfactory than a gross examination of the villi, and stated that a proliferative inflammation of the vessels in the terminal villi constitutes the beginning change in lues. The lumina are said to become obliterated, the connective tissue of the villi increased, and the villous epithelium not only proliferates, but also invades the stroma.


Some uncertainty still seems to attach to the use of the Wassermann test, for Williams (1917) emphasized that lues may develop in an infant even when this test applied to the mother was found negative at the time of its birth. As stated by Williams, others also have observed the contrary condition of a positive Wassermann in the newborn, later becoming negative spontaneously. Slemons, however, found the Wassermann reaction and the placental histology to coincide in 95 per cent of 345 cases, and in 99 per cent even, if misleading cases of toxemia of pregnancy were first excluded. Lues was present in 10 of the 345 cases examined by Slemons, who emphasized the fact that areas in which the structure of the placenta is normal may be present. From these things it seems that, regarding the existence of lues in early specimens, one is thrown back again upon the old question whether fetal lues in its early stages is characterized by any lesion or by any group of lesions which can be regarded as pathognomonic. Since it is recognized that the existence of maternal lues does not necessarily imply its existence in the fetus, the importance of independent criteria regarding its existence in the fetus becomes much greater. This is true in spite of the fact that belief in the transmission of paternal lues direct to the offspring without infection of the mother now seems to be quite generally abandoned. This was inevitable as soon as the cause of lues became known.


Even in this day there seems to be no agreement upon what constitutes valid histologic evidence of the existence of fetal lues, but the opinion that recurring abortion of a macerated fetus, in the absence of other causes, is strongly indicative of lues seems to be held quite generally. It was the belief of obstetricians and gynecologists that abortion or premature labor occurred in a large percentage of cases in which maternal lues antedated conception by several years. Seitz (1904 a ) credited Lutowski as finding that such a result inevitably followed, and himself found gestation interrupted in 91.6 per cent of such cases. Seitz classified 50 per cent of these interruptions of gestation as premature, 16.6 per cent as immature, and 21 per cent as abortions. Fuoss (1888) also quoted Ruge as saying that the fetus is still-born in 80 per cent of the cases of lues. The number of cases in which children which were born prematurely, but living, died soon after birth, is also surprisingly large in the series of Thomsen (1905), in spite of recourse to anti-luetic treatment, and Siemens (1916) reported that all luetic children among 17 which were prematurely born died.


Thomsen found that lues could be excluded with considerable certainty in only 11 out of 27 controlled cases which had given birth to macerated fetuses. But more important still is the fact revealed by examination of Thomson's protocols, that 24 out of 27 still-born fetuses of luetic mothers were macerated. It should be added, however, that no evidence of the existence of lues was present in 8 of these 24 macerated fetuses. Premature labor occurred in only 62 per cent of Thomson's series of luetic mothers, as compared with 91 per cent in that of Seitz, and 100 per cent in the series of Lutowski. However, Urfey (1901) cautioned against the assumption that repeated abortion in the later months of pregnancy always is due to lues, and held that a non-specific chronic endometritis is not infrequently the cause. This indeed seems highly probable when considering the marked changes which may be produced in the decidua by chronic inflammation. Unfortunately, Thomson's protocols do not state whether the evidence of lues was based on gross or upon microscopic examination or upon both. This is especially regrettable, because this series included cases which bore no gross but only microscopic evidence of the existence of lues.


The foregoing statement abundantly emphasizes the lack of correlation existing between the effects of lues upon the life of the conceptuses and the continuation of the gestation and the histologic and bacteriologic evidences contained in the conceptus. If neither spirochaetse nor characteristic histologic changes can be found in many of these prematurely born and macerated, luetic conceptuses, then one would seem to be compelled to assume not only that death of the conceptus is due to the influence of toxins, but that toxins may cause its death without producing any recognizable structural change in either placenta or fetus. The use of antiluetic treatment may be responsible for the differences in the varying frequency with which luetic mothers give birth to luetic babies, and it is possible that the use of antiluetic treatment may affect the time of appearance of fetal lesions. Surely, a chronic systemic disease, which is believed almost invariably to cause the death of the conceptus and premature birth, especially after the sixth month of gestation, can scarcely be presumed to produce no structural fetal changes whatsoever before this time. This would seem to be possible only if the maturing fetus showed a decidedly diminishing resistance, both to the luetic disturbances and to infection.


How early luetic lesions may appear in the fetus has been especially considered by Engman (1912), who thinks that many placental lesions which have been referred to lues probably may not be such. This opinion was expressed also by Williams (1917), and Thomsen called attention to the fact that luetic changes in the fetal organs, so common in the seventh to the tenth month, are exceptional in the first 6 months of gestation. But it is well to remember in this connection the caution of Mracek (1903) that cases of abortion occurring in the third and fourth, and especially in still earlier months, usually do not come to hospitals for treatment, and that observations on the placental lesions in lues hence have been made very largely upon material from the seventh and eighth months. Mracek found luetic placental lesions as early as the fifth month, and Siemens (1916) slightly earlier than this. Since 10 of the placentae in a series of 78 examined by Mracek weighed from 200 to 300 grams, it is evident from this fact alone that he dealt with some rather early cases of gestation. In a routine examination of 400 placentae, Slemons found luetic lesions present in 6 out of 17 premature deliveries in which the fetus had a length of 30 to 40 cm. and a weight of 1,000 to 2,000 grams. Since fetuses in the Carnegie Collection with a length of 30 to 40 cm. have an age of approximately 34 weeks, and those weighing 1,000 to 2,000 grams an age of 28 to 35 Y^ weeks, it is evident that the weight of these luetic fetuses examined by Slemons was relatively low, as might be expected.


The appearance of fetal luetic lesions may depend upon many factors, and Thomsen's observation, that luetic inflammatory changes in the extra-abdominal portions of the umbilical vessels never were present before the fifth and sixth month, can not be regarded as final, in view of the differences of opinion concerning the specific nature of these changes. Thomsen also implied that the vascular were accompanied by other changes in the fetal organs.


That changes which are entirely comparable to what has been called "granulation cell proliferation" by E. Fraenkel (1873), or "granular hyperplasia" by Ercolani (1871, 1873) occur in very young villi, is abundantly evident from an examination of specimens in the Carnegie Collection. However, it does not therefore follow that such specimens are necessarily luetic. Thomsen, too, recognized that these changes in the villi, to which, and edema, he attributed the disproportion in weight between fetus and placenta, possibly occur in other conditions, but it is significant that he never found them present in controls. Thomsen further emphasized that this hyperplasia of the stroma of the villi is never so pronounced in other conditions as in lues, and that the degree of hyperplasia of the stroma and of infiltration of the extra-abdominal portions of the umbilical vessels run parallel with the severity of the infection. Thomsen also concluded that, although other diseases can cause similar changes in the umbilical vessels, such occurrences are extremely rare. Mracek found changes in the cord present in only 10 out of 78 cases of lues, and Simmonds (1912) in 20 out of 40 full-term labors in which the presence of maternal lues had been established. Moreover, Simmonds found inflammatory changes in the cord present in 32 cases in which lues was excluded, and the fact that vascular changes have been found to be uncommon near the placental, and spirochaetae near the abdominal end of the cord still waits for explanation.


If such changes as these alone could be regarded as pathognomonic of lues, it would be a relatively easy matter to determine its presence. Thomsen also laid great stress on the presence of abscesses in the placenta, accompanied by hyperplasia of the stroma, and stated that he had never observed such a coincidence in any condition except lues, adding that although he found placental abscesses only 8 times in 100 cases in which maternal or fetal lues had been established, he never found them present in 1,250 placentae in which lues could be excluded with considerable certainty. Thomsen further stated that infiltration of the membranes, although not specific, nevertheless is quite characteristic of lues, and is most marked when the s} r philitic infection is severe.


If Thomsen's conclusion were justified, one would be compelled to believe that fetal lesions which are pathognomonic of lues nevertheless exist. It may be recalled in this connection that Schwab (1905) also emphasized the necessity for considering the "tout ensemble" and claimed that a fairly reliable diagnosis. of lues can be made from an examination of the placenta alone. According to Schwab, the lesion complex consists of (1) a disproportion in weight between the fetus and the placenta, with an excess in weight of the latter; (2) hypertrophy of the villi; (3) perivascular cirrhoses; (4) inconstant proliferation of the syncytium; and (5) arteritis of the decidual vessels. Schwab recognized that any of these lesions may be present in other conditions, and laid special emphasis on the total picture. Solowij (1902) had gone much farther than this, however, for he held that lues is the cause of most placental lesions, even in the cases in which neither parent shows evidence of the presence of the disease in active form. Solowij even regarded this as established clinically, and held that lues alone produced the changes in the arteries described by him.


Slemons believed that the most trustworthy evidence of the existence of fetal lues is found in the chorionic villi, which are clubbed and the vessels of which are not apparent in luetic cases. Slemons asserted that "when delivery occurs prematurely, the placental findings are significant; for in that case the question of syphilis may always be fairly raised." Since Slemons found placental evidences of lues in 10 per cent of 400 placenta? accompanying a living child of the fifth or later months, it would seem that a higher percentage of cases from the earlier months would contain evidences of lues, unless it can be assumed that early conceptuses are more resistant to infection. The failure to find spirochaeta? in conceptuses before the fifth month would seem to suggest that no lesions can be expected before this time unless they can result from the influence of toxins. Should this be considered as impossible and the failure to find spirochaetas be accepted as conclusive evidence of their absence, then lues apparently must be excluded as a cause of abortion before the fifth month, except in so far as the disease may affect the health of the mother adversely, or cause changes at the implantation site.


While considering the probable factors in the termination of gestation in the case of abortuses in the Carnegie Collection, it became evident that mechanical interference therapeutic or otherwise and hydatiform degeneration seemed to be the predominating causes. These can be recognized with some certainty, but the customary difficulty was encountered regarding lues. Consequently, a series of abortuses from the group of fetus compressus, in which lues was present in mother or offspring, were selected for special study. From the findings in these cases, and taking the entire specimen as well as the clinical history into consideration, an attempt was made to isolate a group of specimens which might be regarded as probably luetic.


Even if it be incorrect, as variously stated, that a large percentage even up to 95 per cent of all long-retained macerated abortuses are luetic, the mere fact that a very large percentage of luetic fetuses are retained for some time before being aborted introduces a special difficulty into the examination of them. It is relatively rare that a satisfactory teased preparation of the villi can be obtained even in early conceptuses. Hence, for this reason alone, the existence of clubbing of the villi, even if present in early cases, is much more difficult to determine. This is true of all specimens which have been retained sufficiently long so that the villi have become macerated, glued, and more or less compressed. Such glueing, or matting, apparently can arise in a relatively short time, for it is present in placentae which accompany fetuses which are not markedly macerated. Although often not due to lues, this glueing makes a gross examination of the villi very difficult and unsatisfactory.


So-called typical, granular hyperplasia of the stroma of the villi can be found present in very small chorionic vesicles and probably can be caused by other things than lues. But obliterative arteritis was not seen in any very young chorionic vesicles, although present much earlier than the fifth month. In some of these cases the obliterative changes were present not only in the vessels of the villi, but in those of the chorionic membrane as well. It was noticed but rarely in the umbilical vessels, but since the entire cord was included in relatively few specimens, no thorough examination could be made regarding this matter. Considerable thickening of the chorionic and amnionic membranes as a result of fibrosis was quite common, however. When present in a marked degree, the fibrous change in the stroma of the villi and the obliterative changes in the vessels, both of those in the membranes and of the larger villous stems, often were so typical that on the basis of these alone, especially when they were accompanied by some infiltration with mononuclear leucocytes, one is justified, I believe, in regarding these specimens as very probably luetic. The placentae of such of these specimens as had been retained for some time after fetal death showed the presence of coagulation necroses so-called infarction with the presence of considerable masses of degenerate trophoblast, and usually also of some calcification. The accompanying decidua also not infrequently showed the presence of fibrosis and later also of endarteritic changes in the decidual vessels.


If spirochffitae are absent in the conceptus before the fifth month, then it would be unjustifiable to assume that the cases showing these changes were definitely leutic, unless fetal lesions can arise in the absence of the specific organism within the conceptus. Nevertheless, I feel justified in emphasizing that these morphologic changes seem to be characteristic even if not pathognomonic of lues.


Whether they could be produced before the advent of the organism itself I am not in a position to say. But if lues can lead to the premature birth of a living child and also to retention of conceptuses which died because of the existence of maternal infection, it would seem that the presence of this serious disease in the mother could be expected to affect the life of the conceptus more profoundly in other ways than through the direct effect of the characteristic lesions themselves. Moreover, it would seem that when other causes can be excluded clinically, one would be justified in suspecting the existence of maternal lues. I am aware of the fact that retention alone, wholly regardless of the cause of death of the conceptus, has been suggested as responsible for changes similar to those attributed to lues, but I am quite certain that the changes in some of the cases here concerned undoubtedly are not due to retention.


The gross appearance of these specimens is so well known that a full description is unnecessary. The fresh decidua is frequently markedly macerated, the placental area of the chorion, when differentiated, is pale and firm and its maternal surface furrowed, the ridges being formed by fibrinoid masses and badly preserved decidua and the sulci by pink, better-preserved decidua. The membranes are degenerate or necrotic even, and thickened, especially in the placental area. The amniotic fluid usually is reduced considerably in quantity and the fetus greatly macerated. The cut surface of the fixed placenta shows the presence of some intervillous blood, in spite of the existence of large waxy areas, which, upon microscopic examination, are found to be composed of degenerate decidua, trophoblast, so-called infarcts, and apparently fibrous areas constituted by large villous stems and coalesced villi.


As is well known, a history of repeated abortion is common in these cases and the presence of lues frequently unsuspected. In one such case, in which attention was directed to the probable nature of the specimen, further inquiry and examination revealed the existence of relatively recent maternal lesions, including mucous patches. Although this may be a mere coincidence, I am quite certain that the subject deserves further attention.


The placental changes in most of these specimens remind one somewhat of the placenta accompanying a fetus 12 cm. long, reported by Welch (1888) under the caption, "Hyaline metamorphosis of the placenta," and it is interesting that Welch stated that the changes in the stroma of the villi in this case reminded him of those attributed to lues by Fraenkel. Although the few cases in the Carnegie Collection in which the infant was known to be definitely leutic were of considerable value in this matter, those in which lues was suspected or even reported, or in which the Wassermann test was negative or positive, were of little value, because of the well-known disagreements between the clinical findings and the occurrence of luetic lesions in the fetus.


Embryology - 21 Oct 2019    Facebook link Pinterest link Twitter link  Expand to Translate  
Google Translate - select your language from the list shown below (this will open a new external page)

العربية | català | 中文 | 中國傳統的 | français | Deutsche | עִברִית | हिंदी | bahasa Indonesia | italiano | 日本語 | 한국어 | မြန်မာ | Pilipino | Polskie | português | ਪੰਜਾਬੀ ਦੇ | Română | русский | Español | Swahili | Svensk | ไทย | Türkçe | اردو | ייִדיש | Tiếng Việt    These external translations are automated and may not be accurate. (More? About Translations)

Mall FP. and Meyer AW. Studies on abortuses: a survey of pathologic ova in the Carnegie Embryological Collection. (1921) Contrib. Embryol., Carnegie Inst. Wash. Publ. 275, 12: 1-364.

In this historic 1921 pathology paper, figures and plates of abnormal embryos are not suitable for young students.

1921 Carnegie Collection - Abnormal: Preface | 1 Collection origin | 2 Care and utilization | 3 Classification | 4 Pathologic analysis | 5 Size | 6 Sex incidence | 7 Localized anomalies | 8 Hydatiform uterine | 9 Hydatiform tubal | Chapter 10 Alleged superfetation | 11 Ovarian Pregnancy | 12 Lysis and resorption | 13 Postmortem intrauterine | 14 Hofbauer cells | 15 Villi | 16 Villous nodules | 17 Syphilitic changes | 18 Aspects | Bibliography | Figures | Contribution No.56 | Contributions Series | Embryology History

Historic Disclaimer - information about historic embryology pages 
Mark Hill.jpg
Pages where the terms "Historic Textbook" and "Historic Embryology" appear on this site, and sections within pages where this disclaimer appears, indicate that the content and scientific understanding are specific to the time of publication. This means that while some scientific descriptions are still accurate, the terminology and interpretation of the developmental mechanisms reflect the understanding at the time of original publication and those of the preceding periods, these terms and interpretations may not reflect our current scientific understanding.     (More? Embryology History | Historic Embryology Papers)