DIAGNOSIS OF HYDATIDIFORM MOLE BY BIOLOGICAL ASSAY

1428 weeks before death, though it was absent 9 months previously. The deposition of calcium salts in the skin is quite common in scleroderma, especially in the fingers in sclerodactylia (Thibierge Weissenbach syndrome), and according to Petges (1933) it has been seen occasionally in dermatomyositis. Hunter (1930-31) found that controlled radiograms some

in exophthalmic goitre revealed poverty of calcium in less than half the cases examined, and he quotes Aub, Heath and Ropes, who found that hyperthyroidism is associated with greatly increased excretion of calcium in the urine. These authors found also that the administration of thyroid to two normal subjects produced the same result. Hunter also quotes several recorded instances of severe osteoporosis in hyperthyroidism. In symmetrical scleroderma the calcium and phosphorus balances were studied in two cases by Cornbleet and Struck (1937). They found a positive balance in both, and thought that the retention of calcium and phosphorus could be accounted for by diminished excretion of these elements in the urine. The calcium and phosphorus in the blood of our patients has been normal ; according to Hunter normal figures are also found in

exophthalmic goitre. CONCLUSION

Dermatomyositis

and

progressive

symmetrical

scleroderma are one and the same disease, a process which involves chiefly the blood-vessels, the skin and the skeletal muscles throughout the body. It has been shown that the muscles in both conditions undergo the same histological alteration. The muscular symptoms also are the same in both diseases,

consisting

of mild to

extremely

severe

myasthenia.

The cutaneous and vascular changes are of the same order. Raynaud’s symptoms arise in both, though more frequently in scleroderma with sclerodactylia than in the type of case that is usually termed dermatomyositis. The initial cutaneous symptoms in both conditions is usually oedema, and the same regions are affected with remarkable constancy ; when the cedematous phase settles down the skin becomes densely or superfieially sclerosed. In both muscle and skin the changes are degenerative, not

inflammatory. Both progressive

scleroderma and dermatomyositis have certain characteristics in common with thyroid disease and myasthenia gravis. The common factors may be summarised as follows : (1) the skeletal muscles show exactly similar pathological changes in both thyrotoxicosis and myasthenia gravis, and the muscular changes in dermatomyositis are of the same order ; (2) clinically, the muscular symptoms in

dermatomyositis and thyrotoxicosis are similar, though different in degree ; (3) creatinuria is common to toxic and, in many cases, non-toxic goitre, myasthenia gravis and dermatomyositis ; (4) certain disturbances in carbohydrate metabolism in thyroid disease have their counterpart in dermatomyositis, and calcium metabolism is anected in both ; and (5) histologically normal thyroids are not found in any case of progressive scleroderma. These facts seem to be sumciently striking to suggest that there is possibly a link between dermato-

myositis or progressive scleroderma, thyrotoxicosis and myasthenia gravis. We should like to express our indebtedness to Mr. K. S. MacDonald, photographer to University College Hospital, for making the photomicrographs.

(References at foot of

next

column)

OF HYDATIDIFORM BY BIOLOGICAL ASSAY

DIAGNOSIS

BY MURIEL

MOLE

BOYCOTT, M.B., B.Sc. Lond.*

ASSISTANT ON THE OBSTETRIC UNIT, UNIVERSITY COLLEGE HOSPITAL, LONDON ; AND

J. M. SMILES, M.B. Lond. LATE HOUSE-SURGEON OF THE UNIT

1927 Aschheim and Zondek described the of the urine of pregnant women on the ovary of the mouse. Later Aschheim (1930) stated that in cases of hydatidiform mole a positive reaction could be obtained with a twelfth of the amount of urine usually necessary to produce this effect. Since the introduction by Friedman (1929) of the test bearing his name, it has been widely used as a more rapid and convenient method for the diagnosis of pregnancy than the Aschheim-Zondek (A.-Z.) reaction. Various workers have used the Friedman test for the diagnosis of hydatidiform mole or of chorionepithelioma, but there has been a wide divergence of opinion as to the technique and interpretation of both tests in this application. Zondek (1931) described a technique by which each of ten mice received a slightly different dose of urine, In this way concentrations of gonadotropic hormone of 27,770-250,000 mouse units per litre (M.U./L.) could be estimated ; he stated that any value above 50,000 M.U./L was abnormal in pregnancy. In 1937 he stated more precisely that early pregnancies showed 5000-30,000 M.U./L., that 200,000 M.U./L. must be present before hydatidiform mole could be diagnosed, and that the presence of the hormone must be demonstrated in the cerebrospinal fluid. Crew (1936, 1937) from his experience of 7000 pregnancy tests deduced that an A.-Z. test positive in a dilution of 1 in 10 was so rare that the presence of abnormal tissue should be suspected ; he considered a test positive in a dilution of 1 in 100 to be diagnostic of hydatidiform mole. IN

biological effect

*

Holding the British Drug Houses research fellowship.

DRS. DOWLING AND GRIFFITHS : REFERENCES Bamber, G. (1936) Brit. J. Derm. 48, 648. Bonham-Carter, R. E. (1938) Proc. R. Soc. Med. 32, 89. Brain, W. R., and Turnbull, H. M. (1938) Quart. J. Med. 7, 293. Cornbleet, J., and Struck, H. C. (1937) Arch. Derm. Syph., N.Y.

35, 188. Dowling, G. B. (1936) Brit. J. Derm. 48, 380. (1939) Proc. R. Soc. Med. 32, 256. - and (1938) Brit. J. Derm. 50, 519. Dudgeon, L. S., and Urquhart, A. L. (1926) Brain, 49, 182. Evans, P. R. (1937) Brit. J. Derm. 49, 122. Gordon, H. (1929) Ann. intern. Med. 2, 1309. Gordon, Hugh (1937) Proc. R. Soc. Med. 31, 262. Gray, A. M. H. (1936) Brit. J. Derm. 48, 630. Griffiths, W. J. (1939) Quart. J. Med., n.s. 81, 23. Hektoen, L. (1897) J. Amer. med. Ass. 28, 1240. Hendry, A. W., and Anderson, T. E. (1939) Lancet, Jan. 14, p. 80. Heuer, G. J. (1916) Amer. J. med. Sci. 41, 339. Hudelo, L., and Rabut, G. (1929) Bull. soc. franç. Derm. Syph. 36, 899. Hufschmidt (1929) Ibid, 35, 188. Hunter, D. (1930-31) Quart. J. Med. 24, 393. Ingram, J. T., and Stewart, M. J. (1934) Brit. J. Derm. 46, 53. Lortat-Jacob, Fernet, P., and Bureau, Y. (1929) Bull. soc. franç. Derm. Syph. 36, 902 and 906. Matsui, S. (1924) Mitt. med. Fak. Tokio, 31, 1. Nixon, J. A. (1903) Bristol med.-chir. J. 21, 328. (1907) Lancet, 1, 79. Petges, G. (1933) Arch. derm.-syph. Paris, 5, 177. Rake, G. (1931) Bull. Johns Hopk. Hosp. 48, 212. Semon, H. (1937) Brit. J. Derm. 49, 120. Sequeira, J. H. (1916) Ibid, 28, 31. Sheldon, J. H., Young, F., and Dyke, S. C. (1939) Lancet, Jan. 14, p. 82. Starling, H. J., Darke, C. S., and Hunt, M. B. (1938) Guy’s Hosp. Rep. 18, 117. Stuckey, E. S. (1935) Brit. J. Derm. 47, 85. Weber, F. P., and Gray, A. M. H. (1924) Ibid, 36, 544. Weissenbach, R. J., Steward, W. M., and Hoesl (1938) Ann. Derm. Syph., Paris, 9, 81 and 198. -

-

Freudenthal, W.

1429

Using rabbits, Mazer (1933) corrected his earlier statement (Mazer and Goldstein 1932) that a positive Friedman test with less than 1 c.cm. of urine was diagnostic of hydatidiform mole, and he substituted the figure 0.06 c.cm.. which amount was confirmed by Dabney et al. (1933, 1934), who showed that a fiftieth of the amount of urine usually employed (0.4 c.cm. instead of 20 c.cm.) gave a positive Friedman test in a case in which no hydatidiform mole was found ; and that in a case of hydatidiform mole a positive reaction was obtained with 0.06 c.cm. Schoeneck (1936) obtained a curve of the excretion of gonadotropic hormone at different periods of pregnancy, using the minimal reactive dose in the immature rabbit as his method of assay. He reported only one normal pregnancy which gave a positive reaction with as little as 0.05 c.cm. of urine. Sixteen patients with pernicious vomiting of pregnancy gave positive reactions with 0.025-0.0125 c.cm. Two cases in which hydatidiform-mole tissue was found gave positive reactions with 0.0066 and 0.0063 c.cm.

Owing to the different methods of assay employed comparison of these findings is impossible, but there seems to be general agreement that the excretion of gonadotropic hormone in normal pregnancy can reach higher levels than was at first thought. The case

and on

which follows illustrates some of the difficulties dangers of a diagnosis of hydatidiform mole based

biological

assay.

17 weeks. The uterus was less tender. Bloodpressure 105/50. On the 15th radiography showed that the foetus

considerably larger and the foetal parts normal. Friedman tests were : 1 in 200 (0-1 c.cm.) negative and undiluted (20 c.cm.) positive. On the 22nd a ten-inch foetus of 18 weeks’ development and a blood-clot (110 g.) were expelled. The foetus had been dead two or three days. The placenta was examined macroscopically and sections were cut from several areas ; no evidence of any vesicular degeneration could be found (cf. Masani 1937). The urine of this patient never showed any albumin, and all renal-function tests were normal. The Wassermann reaction was negative when repeated. Friedman tests since discharge have been negative on two occasions (Jan. 1 and April 23, 1938). was

FURTHER

INQUIRIES made to investigate the upper

An attempt was limit of normality for the excretion of gonadotropic hormone in pregnancy. In view of the findings of Browne and Venning (1936) that the urinary excretion of these substances during pregnancy was at its maximum at 10-12 weeks, five consecutive cases attending the antenatal clinic at this stage of pregnancy were subjected to assay (see table). Later, FRIEDMAN TESTS IN NOBMAL AND IN ABNORMAL PREGNANCIES

INVESTIGATION OF A CASE

The Friedman test was done on immature rabbits (dealer’s stock) isolated for at least three weeks. Two intravenous injections of 10 c.cm. of urine were given at 24 hours’ interval, the animal being killed 48 hours after the first injection. Fresh earlymorning specimens of urine without preservative were used ; any dilutions of urine were made with normal saline, the total amount and timing of the injections being kept as before. All tests were done in duplicate and the results expressed as the minimal reactive dose. In an attempt to express the results in mouse units the modification of the A.-Z. test recommended by Zondek (1931) was used in seven cases but the individual variation in sensitivity was too great in the mice at our disposal for this test to be of any value in this inquiry. The patient was a nullipara, aged 27, with no abnormalities in past, family, or menstrual history. She first attended at the antenatal clinic on Oct. 26, 1937. The date of her last menstrual period was July 30. Her pregnancy was then 11 weeks old and considered normal except for a history of brown vaginal discharge for one day on Oct. 23. Wassermann reaction negative. Blood-pressure

120/60. On Nov. 17 she returned with a history of bleeding per vaginam since the last examination, and headache and visual disturbance for forty-eight hours.

Blood-pressure

140/80.

detected in her urine.

Nothing abnormal

She

was

admitted at once. a 20 weeks’ pregnancy The estimated duration was

Her fundus uteri suggested and was hard and tender. of pregnancy was 15 weeks. On Nov. 21 Friedman tests gave the following results : undiluted (20 c.cm.) positive, 1 in 100 (0,2 c.cm.) positive, 1 in 200 (0’1 c.cm.) positive, and 1 in 300 (0-06 c.cm.) negative. On the 26th radiography showed a foetus aged 16, weeks. Friedman tests were repeated and confirmed. A.-Z. tests were : 1 in 10 positive and I in 100 positive. Several small amounts of blood were lost, but no vesicles were seen. A diagnosis of hydatidiform mole in a twin pregnancy was considered, but expectant treatment was continued. On Dec. 6 the uterus was of the size normal for a 22 weeks’ pregnancy. Amenorrhaea had continued

* Case reported in this article. t These were the only assays made

on

this date.

urine was obtained from two cases of hydatidiform mole. Although in one case expulsion of the mole had begun, the Friedman test was positive with 0-033 c.cm. and negative with 0-028 c.cm. of urine. Assay in mice showed more than 200,000 M.U./L. of gonadotropic hormone. In the other case., in which the mole was actively growing, the Friedman test was positive with 0-01 c.cm. and negative with 0-005 c.cm. of urine. One case of hyperemesis gravidarum of moderate severity was investigated, the patient being 11 weeks pregnant. The Friedman test was positive with 0-04 c.cm. of urine. One week later it was positive with 0-06 c.cm. and negative with 0-05 c.cm. urine. The quantitative test in mice was inconclusive. DISCUSSION

The peak of the excretion of gonadotropic hormone during pregnancy has been reported at times as far apart as the thirtieth day of pregnancy (Evans,

Kohls, and Wonder 1937) and the seventh month (Kennedy 1933). Browne and Venning (1936) and Schoeneck (1936) agree in finding the peak between the eighth and tenth weeks ; this is supported by the previous findings of one of us on the gonado-

1430

tropic hormone in the blood (Boycott and Rowlands 1938). This peak lasts only a very short time in any one woman ; according to Schoeneck, during this peak period as little urine as 0.1 c.cm. or rarely 0-05 c.cm. will produce a positive test in a rabbit. It is at this period of pregnancy that the diagnosis of hydatidiform mole is often mooted. Higher values than those at the peak period of normal pregnancy are obtained in hyperemesis in which the minimal reactive dose may vary from 0.06 to 0-012 c.cm. That high values are found in all forms of vomiting in pregnancy (Schoeneck 1936) suggests that there is a causal relationship between the two phenomena ; but reduction of the urinary output is often considerable in these cases, and the hormone output should be calculated on a daily basis rather than per litre. The concentration caused by the diminished output of urine does not, however, account entirely for the higher figures

gravidarum,

obtained. Such comparable evidence as there is goes to show that some women with hydatidiform mole excrete more gonadotropic hormone than is found in any other disorder of pregnancy. On the other hand, cases of hydatidiform mole have been reported which gave a negative test in a rabbit (Reeb, Neerson, and Klein 1934) and showed such large minimal reactive doses as 5.0 c.cm. and 0’5 c.cm. (Schoeneck 1936) ; these were all cases in which it was stated that active proliferation was at an end. The overlap which evidently occurs is wide ; it will be at its widest in cases in which there is vomiting and which are between the eighth and tenth weeks of pregnancy or are complicated .by a hydatidiform mole which is not growing rapidly. As far as can be ascertained from the small number of observations published, the majority of cases of active hydatidiform mole give values not very far outside this zone of overlap. The case described in detail in this article showed a maximal excretion one-tenth of that found in the case of active hydatidiform mole and one-third of that in the case in which the mole was in process of expulsion. That the patient was not treated as a case of hydatidiform mole was mainly on the grounds of the absence of the characteristic " doughy" uterus, the general improvement in her condition, and the cessation of the haemorrhages ; the radiological evidence was of considerable value. Biological testing is used extensively for the diagnosis of the recurrence of hydatidiform mole or of chorionepithelioma. The case reported by Kobak (1938), in which a normal ten weeks’ pregnancy was mistaken for a recurrence on the evidence of a high level of gonadotropic hormone in the urine and hysterectomy was performed, shows that even in this connexion biological testing has its dangers. The use of the method of the minimal reactive dose in single rabbits is quick and gives surprisingly good results ; our tests were done on these cases in duplicate, and there was no instance of absolute disagreement between the pair. It would obviously be preferable to employ the method depending on the increase in ovary weight in the immature rat, using batches of 10-20 animals (Boycott and Rowlands 1938) ; it is, however, rather lengthy and intricate when an answer is needed to assist in diagnosis. CONCLUSIONS

(1) Excretion of gonadotropic hormone in normal pregnancy may reach a higher level than is usually

recognised. (2) The occurs

maximal excretion in normal pregnancy at about the stage of pregnancy when the

hydatidiform mole is likely to be suspected. (3) Although it is probable that in some cases of hydatidiform mole a larger excretion of gonadotropic hormone occurs than in any other condition (except chorionepithelioma), there is a wide range presence of

of excretion values in which no distinction between this and other conditions is possible. (4) Diagnosis of hydatidiform mole on the biological assay of gonadotropic hormone alone is unreliable. Our thanks are due to Prof. F. J. Browne for his advice and encouragement ; to Prof. James Young for the specimens of urine from the cases of hydatidiform mole ; and to the Medical Research Council fora grant to one of us (M. B.) for technical assistance. REFERENCES

Aschheim, S. (1930) Amer. J. Obstet. Gynec. 19, 335. and Zondek, B. (1927) Klin. Wschr. 6, 1321. Boycott, M., and Rowlands, I. W. (1938) Brit. med. J. 1, 1097. Browne, J. S. L., and Venning, E. M. (1936) Lancet, 2, 1507. Crew, F. A. E. (1936) Brit. med. J. 1, 993. (1937) Amer. J. Obstet. Gynec. 33, 989. Dabney, M. Y., and Dabney, E. B. (1934) Surg. Gynec. Obstet. 59, 185. Flinn, G. G., and Dabney, E. B. (1933) J. Amer. med. Ass. -

-

—

101, 771. Evans, H. M., Kohls, C. L., and Wonder, D. H. (1937) Ibid, 108, 287. Friedman, M. H. (1929) Amer. J. Physiol. 90, 617. and Lapham, M. E. (1931) Amer. J. Obstet. Gynec. 21, 405. Kennedy, W. P. (1933) Quart. J. exp. Physiol. 23, 367. Kobak, A. J. (1938) J. Amer. med. Ass. 110, 1179. Masani, K. M. (1937) J. Obstet. Gynœc. 44, 340. Mazer, C. (1933) J. Amer. med. Ass. 101, 1411. and Goldstein, L. (1932) Clinical Endocrinology of the Female, Philadelphia. Reeb, Neerson, and Klein (1934) Gynec. et Obstét. 30, 305. Schoeneck, F. J. (1936) Amer. J. Obstet. Gynec. 32, 104. Zondek, B. (1931) Die Hormone des Ovariums und des Hypophysenvorderlappens, Berlin, p. 553. (1937) J. Amer. med. Ass. 108, 607. —

-

-

MECHANICAL RESPIRATION TREATMENT OF TWENTY-ONE CASES BY URSULA

BLACKWELL, M.B. Lond., D.P.H.

SENIOR ASSISTANT MEDICAL OFFICER, LONDON COUNTY COUNCIL INFECTIOUS HOSPITAL SERVICE

OF 129 patients with poliomyelitis admitted to the Western Hospital (the L.C.C. centre for this disease) during the past four and a half years, 17 showed symptoms of respiratory embarrassment. Of these 14 were treated with an artificial respirator ; 6 patients with diaphragmatic paralysis due to diphtheria and 1 with toxic polyneuritis were also treated by this method. POLIOMYELITIS

Of these cases 5 were of the bulbar type ; all died. Of the remaining 9, 6 are alive and progressing favourably ; 3 of these, cases 8, 9 and 10 (see table), had intercostal paralysis only. Two had paralysis of the diaphragm and of some of the intercostals. One had paralysis of the diaphragm and weakness of the intercostals. much mucus Cases with bulbar 6M*