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patients who came to post-mortem or laparotomy within three weeks of the examination compared to 47*5 per cent for isotope examination. In many such patients, as in the case presented here, the ultrasound result was totally diagnostic. Ultrasound has two advantages over other diagnostic procedures: it is a successful means for differentiating between a solid or fluid consistency and the enhanced resolution of the grey-scale technique produced evidence of active invasion on which the diagnosis of malignancy depended. In all the patients described here, it was found that the metastases were found on the surface of the liver. From these observations and from experience in general pathology, it seems almost certain that these tumours commence growth on the peritoneum after transcoelomic spread and later invade the liver substance. They must be differentiated from cystic secondaries due to central necrosis which may be visualized by ultrasound (Howry, 1965; Taylor, 1974). Necrotic metastases are usually smaller, multiple and intrahepatic and, in the author's experience, most frequently occur from breast primaries. Considerable interest is focused on the possibility of determining tissue identity by analysing the information content of the return echo (Hill, 1974). In the present state of knowledge, this appears a distant objective but experience to date indicates that certain tumours, such as the lymphomas and Hodgkins' disease, produce a characteristic appearance on ultrasound liver examination which indicates their cell

type (Taylor, 1974). To these few tumours, the secreting cystadenocarcinoma can be added. ACKNOWLEDGMENTS

I thank the Department of Health and Social Security who financed the instrumentation and David Carpenter of the National Acoustic Laboratory, Sydney, Australia, who built the equipment. REFERENCES DONALD, I., MCVICAR, J., and BROWN, T. G., 1958. Inves-

tigation of abdominal masses by pulsed ultrasound. Lancet, 1, 1188-1194. HILL, C. R., 1974. Interaction of ultrasound with tissues. Ultrasonics in Medicine, pp. 14-20 (Excerpta Medica). HOWRY, D. H., 1965. A brief atlas of diagnostic ultrasonic radiologic results. Radiologic Clinics of North America, 3, 433-452. KOSSOFF, G., 1974. Display techniques in ultrasound pulse echo investigations: A review. Journal of Clinical Ultrasound, 2, 61-72. LEYTON, B., HALPERN, S., LEOPOLD, G., and HAGEN, S.,

1973. Correlation of ultrasound and colloid scintiscan studies of the normal and diseased liver. Journal of Nuclear Medicine, 14, 27-33. MCCARTHY, C. F., DAVIES, E. R., WELLS, P. N. T., Ross, F. G. M., FOLLETT, D. H., MUIR, K. M., and READ, A.

E. A., 1970. A comparison of ultrasonic and isotopic scanning in the diagnosis of liver disease. British Journal of Radiology, 43, 100-109. TAYLOR, K. J. W., 1974. Ultrasonic patterns of tumors of the liver. Journal of Clinical Ultrasound, 2, 7A—77. TAYLOR, K. J. W., CARPENTER, D. A. and MCCREADY, V. R.,

1973. Grey-scale echography in the diagnosis of intrahepatic disease. Journal of Clinical Ultrasound, 1, 284— 287. TAYLOR, K. J. W., and CARPENTER, D. A., 1974. Compari-

son of ultrasound and radioisotope examination in the diagnosis of hepatobiliary disease. In Ultrasound in Medicine, ed. D. White, Vol. 1, pp. 159-167 (Plenum Press, New York).

Congenital syphilis diagnosed in utero By B. J. Cremin, F.R.C.R.A., F.R.C.R., and M. I. Shaft, M.B., D.M.R.D. Department of Radiodiagnosis, Groote Schuur Hospital, Observatory 7925, Cape Town, South Africa (Received March, 1975)

Obstetrical radiography that uses a prone oblique film, compression band and high mAs technique (Russell, 1973) is simple, effective and has negligible radiation hazards. Using this technique, we have diagnosed intra-uterine osteogenesis imperfecta, fibrous dysplasia and various forms of lethal dwarfism (Cremin and Beighton, 1974). Recently a case of fetal rickets (Russell and Hill, 1974) was reported. This communication concerns a case of fetal syphilis and its progression in utero. We are unaware of any previous report on this subject in recent radiological literature.

Case history The patient, a 37-year-old African female, Para 4, Gravida 5, gave birth to a stillborn child at 36 weeks gestation. She had initially attended ante-natal clinic at an estimated gestational age of 30 weeks. Polyhydramnios was present and a radiograph was taken to confirm fetal maturity and exclude fetal abnormalities. The radiograph (Fig. 1) showed symmetrical periosteal cloaking of both tibiae and humeri. Because of the symmetry and multiplicity of the lesions, congenital syphilis was suspected and this was confirmed by a maternal VDRL that was positive to a titre of 256 and a RPCFT positive to a titre of greater than 80. The patient was given 2-4 mega units of Bicillin intramuscularly. She did not attend again till three weeks later when a further radiograph (Fig. 2) showed that the changes in the tibiae had markedly resolved. At 36 weeks fetal

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FIG. 1. Radiograph taken at 30 weeks demonstrating periosteal cloaking of both tibiae and humeri.

FIG. 3. Post-delivery appearances of the stillborn fetus with normal appearances of tibiae and fibulae.

FIG. 2. Radiograph taken at 36 weeks demonstrating marked resolution of the tibial periosteal reaction.

death was suspected and a radiograph at this time showed that the changes in the legs of the dead fetus had almost completely resolved. This was confirmed by a post-mortem radiograph taken after delivery of a stillborn fetus (Fig. 3). DISCUSSION

The bone changes of congenital syphilis appear to be non-specific (Engeset, Eek and Gilje, 1953). Cremin and Fisher (1970) reviewed a series of 122

infants and noted that periosteal cloaking was the commonest abnormality. It was presumed that this was due to a disorder of diaphyseal circumferential bone growth, so that osteoid was formed without a preformed cartilage scaffolding. The reasons for this symmetrical manifestation of disturbed bone growth in the fetus and infant are not obvious, but appear to be evidence of a vascular or immunological reaction in the growing portions of fetal bone to maternal infection. The other more florid changes of syphilis

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are usually seen at the age of six weeks to three months and are mainly concerned with the effects of trauma on the weakened atrophic areas of the metaphysis. Further observations on cases seen since 1970 have led us to the conclusion that any classification based on these appearances is of little value except as an indication of the frequency of common manifestations. The bone lesions of congenital syphilis are remarkable in that they are bilateral and we have noted that there is apparent healing by approximately six months regardless of treatment. The appearances are entirely variable and depend on how the limb is handled. Even when under treatment the lesions may initially appear more florid as repair takes place. We have found no previous reference to the ante-natal radiological features of congenital

syphilis but this one case shows that even though the infant was stillborn, the intra-uterine bone lesions changed after maternal treatment.

REFERENCES CREMIN, B. J., and FISHER, R. M., 1970. The lesions of

congenital syphilis. British Journal of Radiology, 43, 333— 341. CREMIN, B. J., and BEIGHTON, P., 1974. Dwarfism in the

newborn: The nomenclature, radiological features and genetic significance. British Journal of Radiology, 47, 77-93. ENGESET, A., EEK, S., and GILJE, O., 1953. On the signifi-

cance of growth in the roentgenological skeletal changes in early congenital syphilis. American Journal of Roentgenology, 69, 542-556. RUSSELL, J. G. B., 1973. Radiology in Obstetrics and Antenatal Paediatrics. (Butterworths, London). RUSSELL, J. G. B., and HILL, L. F., 1974. True foetal

rickets. British Journal of Radiology, 47, 732-734.

Book reviews Medical Oncology — Medical Aspects of Malignant

Disease.

Edited by K. D. Bagshawe, pp. 588, 1975 (Oxford and London, Blackwell Scientific Publications), £13-50. This book makes no attempt at presenting a comprehensive account of oncology. As the editor states, "In selecting subjects for consideration in this volume, it was necessary to omit some aspects of malignant disease which are the subject of many standard texts. Histopathology, cytology, epidemiology, carcinogenesis, radiotherapy, surgical management and disease staging are not included as topics in their own right, although they are discussed as facets of the many subjects which have been brought together. Even without these, the area of cancer studies is vast and its long and active frontiers provide ample opportunity for original minds which are less attracted by the well-trodden paths of the long-established medical specialities." Those aspects chosen for discussion are grouped into four sections, general aspects of cancer, diagnosis, principles of therapy and the treatment of some specific cancers. The section on general aspects includes genes and chromosomes in cancer, immunology, vascular structure and metabolic processes, cell kinetics and structure, haematological and endocrine disturbances and steroid hormones. Neurological manifestations are also included in this section but cutaneous manifestations are included in the second section together with arteriography, lymphangiography, thermography, radioisotope scanning and immunological diagnosis and monitoring. The principles of therapy are the subject of the next section, clinical organization, trials, supportive therapy, mechanisms of action and pharmacology of cytotoxic drugs and their integration with other treatment regimes. The final section is devoted to the treatment of some specific cancers, the leukaemias, myeloma, lymphomas, trophoblastic tumours and teratomas, paediatric and gynaecological cancers and malignant effusions. The somewhat optimistic note achieved in the description of some end results is countered by the final chapter on terminal care. This is a multi-author book where each chapter is written by an author who has a particular expertise, knowledge or interest. There is some overlap between chapters but this has the advantage of highlighting certain aspects and looking

at common problems from different points of view. These days we are sometimes presented with the multi-author book where the editor has done little more than collate and arrange the order of the chapters. Not so here, Professor Bagshawe's interest is evident throughout the w7hole book in which he has taken an active part in writing no fewer than eight of the twenty-eight chapters. The book reiterates the current thinking that there should be close co-operation between all who are concerned in any way with the management of malignant disease. It provides a very useful survey of some aspects of oncology and will make a useful addition to the medical library. T. J. DEELEY.

Ultrasound in Medicine. Vol. 1. Edited by D. N. White, pp. xxii + 611, 1975 (London and New York, Plenum Press). S56.50. There is a strong case for considering that publication in extenso of proceedings of meetings should be prohibited by law. Happily, the present volume, which covers the 1974 annual meeting of the American Institute of Ultrasound in Medicine, is one of the better examples of its kind and provides some stimulating indications of the rapid development of the subject. Of a total of 180 papers presented at the meeting only 60 met the editor's deadline and appear here in full, rather than as abstracts. In sharp contrast to what one would have expected a few years ago, and in spite of the widespread routine clinical application of ultrasound in the specialty, only a handful of the papers that have been included here are concerned with obstetrics, whereas cardiolgy and abdominal investigations are clearly subjects of widespread current research interest. There is a prolific supply of new technical methods and ideas: some of these will undoubtedly prove to be disappointments, as seems to be the case now with ultrasonic holography, but many others, such as grey-scale imaging of tissue structure and real-time imaging of the heart, are evidently well set to make major contributions to diagnostic technology.

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Congenital syphilis diagnosed in utero.

1975, British Journal of Radiology, 48, 939-941 NOVEMBER 1975 Case reports patients who came to post-mortem or laparotomy within three weeks of the...
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