1. That syphilis of bones and joints has been largely overlooked in the past from the relatively small number of cases in our hospital records and in the literature. This is naturally more noticeable in the period before the x-ray and Wassermann were in general use. At the present time we exclude syphilis either as a primary or complicating factor, in all cases of bone and joint disease.
2. Syphilis is often present as a complicating factor, or may be merely coincidental, in cases where the bone or joint disease under consideration has some other etiological factor as tuberculosis, osteomyelitis, or rachitis, so that a history of syphilis, the presence of other manifestations of the disease, or a positive Wassermann does not prove that the bone or joint disease under consideration is syphilitic. In our case No. XIX., a positive history of syphilis was present and a positive Wassermann, but the patient did not improve under antisyphilitic treatment, but became progressively worse, and the bone disease later proved to be tuberculous. A tubercular spine did not improve under treatment, and syphilis was later demonstrated as a complicating factor. One must not forget that a positive Wassermann on one hand or a positive von Pirquet on the other is not prima facia evidence that the disease alone exists: that syphilis is an excellent medium for the implantation of tubercular infection, or any other infection.
3. A history of syphilis or the presence of other manifestations of the disease is of value in suggesting the presence of syphilis, but not of any absolute diagnostic value, as it does not exclude the presence of tuberculosis or other bone and joint diseases.
4. In studying symptoms and physical signs alone we have been unable to differentiate syphilis of joints from those due to other etiological factors.
5. We consider the Wassermann reaction very valuable, but only as one point in the diagnosis. In many of our cases the Wassermann reaction was negative, and they were undoubted syphilis, as shown by the x-ray, and their response to antisyphilitic treatment. We have also cases in which the Wassermann was positive and in which the cases proved to be some other bone or joint disease. In some of these cases syphilis was undoubtedly a complicating factor because improvement was not marked until antisyphilitic treatment was instituted. A routine Wassermann is taken on all our cases of bone and joint disease, and in those which are negative but in which the clinical symptoms or roentgenograms suggest syphilis, a provocative Wassermann has been found in some cases.
6. We have found the luetin test of value also, as it is sometimes positive when the Wassermann reaction is negative.
7. The finding of a negative von Pirquet in doubtful cases is of value.
8. We consider the roentgenogram the most valuable factor in the diagnosis of syphilis of bones and joints and in differentiating it from other conditions. In one of our cases there was a history of a primary infection and the Wassermann was positive, but the roentgenogram showed nothing suggestive of syphilis but was suggestive of tuberculosis. On section of bone and pathological examination it was reported tuberculosis. In our cases we have not found syphilitic arthritis without bone involvement, as the roentgenogram of the joint involved may show nothing, while a roentgenogram of other bones or those contiguous to the joint may show a typical syphilitic osteoperiostitis. In one of our cases where the knee was complained of, a roentgenogram showed typical syphilitic involvement of the radius and ulna. In studying the roentgenogram of cases we have been unable to discern any difference between acquired and congenital cases, with the possible exception of congenital syphilitic osteochondritis.
9. The so-called therapeutic test is also of some value in the diagnosis of obscure bone and joint lesions where an absolute diagnosis cannot be made from the clinical and laboratory findings.
In 38 cases of bone and joint syphilis, 22 cases were congenital and 16 were acquired. In 34 cases having x-ray examinations, only 8 cases had an involvement of one bone alone, and 16 cases had involvement of joint as well as bone.
(C) 1919 All Rights Reserved.The Journal of Bone and Joint Surgery, Inc.