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OBSERVATIONS ON THE CHEMISTRY OF THE LIQUOR AMNII
415 and the control characteristic.
cases
cases
with
CONCLUSIONS
From this
regard
to this
the
comparison of 150 cases having a history of diphtheria with 100 cases having no history of disease, it is at once evident that there is nothing to suggest the occurrence of gross cardiac lesions as the result of a previous attack of diphtheria. Age-grouping was therefore considered unnecessary, and although
Clinical and Laboratory Notes OBSERVATIONS ON THE CHEMISTRY OF THE LIQUOR AMNII
*
BY J. F. D. SHREWSBURY, M.B. LIVERP., D.P.H. BACTERIOLOGIST TO THE
QUEEN’S HOSPITAL,
BIRMINGHAM
THE following short series of chemical examinations of the liquor amnii was carried out in collaboration with Mr. W. E. Barnie Adshead, hon. assistant obstetrical officer to the Queen’s Hospital, Birmingham. Except in one fatal case of pneumonia, in which the liquor amnii was obtained from the gravid uterus at autopsy, a subtotal hysterectomy was performed on each of the patients in this series, and the liquor amnii was withdrawn from the intact uterus as soon as possible after the removal of that organ from the body. Each uterus was sent directly from the operating theatre to the laboratory, where I withdrew as much of the fluid as I could obtain by aspiration with a sterile needle and syringe, after searing the surface of the organ. The chemical examinations were made upon the fluid very shortly. after its
removal. The papers that I have been able to consult do not contain much detailed information about the chemical composition of the normal liquor amnii, and I have not found any reference to the chemistry of the fluid in the presence of maternal disease.
the number of cases in the two groups was unequal the average ages were used. The difference of two years between the average ages is mainly accounted for by a small group of young adults who were examined as "post-diphtheritic heart" cases. In a study of the electrocardiogram during the acute phase of diphtheria 11 it was often found that the T wave in lead III. varied considerably during the course of the disease, and a patient might apparently recover clinically and functionally before the T wave in lead III. of the electrocardiogram became positive. This observation was made on an independent group of cases, but in view of the findings in the present series the question is raised as to how long such T wave changes might persist after diphtheria. It is widely accepted, however, that inversion of the T wave in lead III. is of no pathological significance, and whatever may be the cause of an increased frequency of this feature in persons who have had diphtheria, there can be no doubt that there is no coexistent clinical abnormality.
De Leegives the reaction of the liquor amnii as faintly alkaline or neutral, and the freezing-point as slightly higher than that of the maternal blood. Sandmeyer found 0-22 per cent. of albumin
present, comprising serum-albumin,
and an ovo-vitelline-like substance. The salts of the liquor amnii are present in about the same proportions as the salts in the blood-serum-i.e., 0-5 per cent. They are the chlorides, phosphates, sulphates, and carbonates of sodium and calcium, with very little potassium. The urea content ranges from 0-02 to 0-4 per cent., and increases towards the end of pregnancy. Fairbairn2 states that the normal liquor amnii is a slightly turbid, straw-coloured fluid, with a specific gravity of 1002 to 1020, and a faintly alkaline reaction. It contains a variable amount of albumin (6 to 8 parts per 1000, Esbach) ; urea (usually in very small quantity), creatin, and salts. Sugar is said to be present in the liquor amnii of diabetic mothers. Edengives the following details : a clear, pale fluid of low specific gravity ; albumin, 0-19 per cent. ; inorganic salts, 0.59 per cent. ; extractives, 0-81 per cent. The amount of albumin may reach 10 per cent. in the early I am indebted to Dr. Claude Rundle, the medical months of pregnancy. The most important extractive is which is present in traces from the sixth week onwards. superintendent of Liverpool City Hospitals for Infectious urea, Diseases, for allowing free access to all the hospital registers Glucose may be found in cases of maternal diabetes. and case-records for the past ten years. Dr. E. Noble In the accompanying Table all the figures for the Chamberlain, senior honorary assistant physician at the various chemical estimations represent mg. per cent. Royal Southern Hospital, Liverpool, kindly gave assistance in reporting on the electrocardiographic records, and the The method of estimation is included in the Table, X ray department of the hospital carried out the photo- because different methods of estimation may yield graphic work for this part of the investigations. For help different values when performed in parallel by the in the statistical analysis of the records I am grateful to Mr. John H. Smith, assistant lecturer in the mathematics same worker. It is therefore necessary to state the method of estimation used in any series of biodepartment of the University of Glasgow.
globulin,
I
I
chemical investigations in order to make the work of value for comparative purposes. 1. White, F. W., and Smith, H. H.: Jour. Amer. Med. Assoc., The reaction and the specific gravity of the fluids 1905, xlv., 1245. examined conform to the accepted values for the 2. Hoskin, T. Jenner : THE LANCET, 1926, i., 1141. 3. Jones, T. D., and White, P. D. : Amer. Heart Jour., 1927, normal liquor amnii. In seven out of the eight iii., 190. fluids tested was present in estimable quantity, glucose 4. Sutherland, G. A. : In Thursfield and Paterson’s Diseases of and in one fluid the sugar content lay within the Children, 1929, p. 431 (quoted by Rolleston (ref. 5) ). 5. Rolleston, J. D.: Acute Infectious Diseases, London, 1929, normal range of the blood-sugar. It is not possible p. 31. to an opinion upon the relationship of this express 6. Butler, S., and Levine, S. A.: Amer. Heart. Jour., 1930, v., 592. comparatively high sugar content in the liquor amnii 7. Parkinson, J.: Heart, London, 1915, vi., 13. to the clinical condition, especially in the absence of 8. Reid, W. D. : Amer. Heart Jour., 1930, v., 524. a coincident blood-sugar estimation, but the finding REFERENCES
9. O’Donovan, P. : THE LANCET, 1923, i., 607. 10. Chamberlain, E. N., and Alstead, S.: Ibid., 1931, i., 970. 11. Alstead, S.: Quart. Jour. Med., 1932, n.s., i., 277.
* From the Biochemical Laboratory of the Queen’s Hospital,
Birmingham.
416 CHEMICAL ESTIMATIONS OF
*
All fluids gave
I lower level thanthe readings for thenormal serum I and calcium, but it must be remembered that the fcetus
is
drain upon the maternal stores of calcium that, in consequence, the serum calcium tends to fall towards the end of pregnancy, so that the readings obtained on this series of fluids are possibly only very slightly lower than the readings of the maternal serum calcium. The high phosphorus reading of 8 mg. per cent. was obtained on a fluid removed at autopsy, and cannot be compared with the other readings in the series. The total protein content shows much variation, and the variations are difficult a
AMNII
negative reaction.
a
is of interest in comparison with the low readings obtained on the remaining fluids in the series. Urea was present in estimable quantity in all the fluids. The single high reading of 73 mg. per cent. is not comparable with the other readings, because this fluid was obtained at autopsy several hours after the death of the patient, when some degree of decomposition had undoubtedly occurred. The high uric acid reading of 5-7 mg. per cent. is of interest, though its significance is not understood. The relatively constant values obtained for the creatinine content of the liquor amnii, even in the presence of maternal renal disease, are of much interest in connexion with the known stability of this substance in the blood and the urine. The chloride content does not vary much from the normal content of the blood, and seems to be, like the creatinine, one of the relatively stable chemical constituents of the liquor amnii. The absence of cholesterol is of interest in view of the known importance of this substance to the body, and the precautions taken by the body to conserve its supplies. Whatever may be the value of the liquor amnii to the foetus—and conflicting opinions are held-it is certain that the fluid is a waste product to the mother, and the absence of cholesterol in the fluid may possibly be associated with this fact. Ther calcium readings are fairly constant at a slightly
LIQUOR
to explain, especially the low reading of 50 mg. per cent. in the second case of maternal phthisis. This short series of chemical examinations suffers from two serious disadvantages: (1) the absence of coincident blood chemical analyses, and (2) the absence of any normal standards for the chemical constituents of the liquor amnii. It is not possible to rectify the second defect in a general hospital that does not cater for normal cases of labour, but it should not prove difficult to obtain an accurate knowledge of the chemical composition of the normal liquor amnii from the material available in one of the large maternity hospitals, and the above series of observations has been published chiefly in the hope that it will stimulate the prosecution of this useful work.
In conclusion I wish to express my thanks to my
colleague, Mr. Adshead, for his generous collaboration, and to acknowledge my indebtedness to my technical assistant, W. R. Hackett, who has carried out most of the estimations under my supervision. REFERENCES 1. De Lee, J. : Principles and Practice of Obstetrics, New York, 1915, p. 53. 2. Fairbairn, J. S. : Encyclopædia of Midwifery and Diseases of Women, London, 1921, p. 117. 3. Eden, T. W. : Manual of Midwifery, London, 1925, p. 44.
OSTEOMYELITIS OF THE PATELLA BY RICHARD A. HOUSE SURGEON, ST.
MANCLARK, M.R.C.S. ENG. JOHN’S HOSPITAL, LEWISHAM, S.E.
A GIRL, 7 years of age,
was
admitted to St. John’s
Sept. 3rd, 1932, with a swollen left knee, which had been painful for four days. There was no history of injury. Apparently the Hospital, Lewisham,
on
child had not seemed well for the last five weeksshe had " just sat about and did not want to play at all."
cases
cases
with
CONCLUSIONS
From this
regard
to this
the
comparison of 150 cases having a history of diphtheria with 100 cases having no history of disease, it is at once evident that there is nothing to suggest the occurrence of gross cardiac lesions as the result of a previous attack of diphtheria. Age-grouping was therefore considered unnecessary, and although
Clinical and Laboratory Notes OBSERVATIONS ON THE CHEMISTRY OF THE LIQUOR AMNII
*
BY J. F. D. SHREWSBURY, M.B. LIVERP., D.P.H. BACTERIOLOGIST TO THE
QUEEN’S HOSPITAL,
BIRMINGHAM
THE following short series of chemical examinations of the liquor amnii was carried out in collaboration with Mr. W. E. Barnie Adshead, hon. assistant obstetrical officer to the Queen’s Hospital, Birmingham. Except in one fatal case of pneumonia, in which the liquor amnii was obtained from the gravid uterus at autopsy, a subtotal hysterectomy was performed on each of the patients in this series, and the liquor amnii was withdrawn from the intact uterus as soon as possible after the removal of that organ from the body. Each uterus was sent directly from the operating theatre to the laboratory, where I withdrew as much of the fluid as I could obtain by aspiration with a sterile needle and syringe, after searing the surface of the organ. The chemical examinations were made upon the fluid very shortly. after its
removal. The papers that I have been able to consult do not contain much detailed information about the chemical composition of the normal liquor amnii, and I have not found any reference to the chemistry of the fluid in the presence of maternal disease.
the number of cases in the two groups was unequal the average ages were used. The difference of two years between the average ages is mainly accounted for by a small group of young adults who were examined as "post-diphtheritic heart" cases. In a study of the electrocardiogram during the acute phase of diphtheria 11 it was often found that the T wave in lead III. varied considerably during the course of the disease, and a patient might apparently recover clinically and functionally before the T wave in lead III. of the electrocardiogram became positive. This observation was made on an independent group of cases, but in view of the findings in the present series the question is raised as to how long such T wave changes might persist after diphtheria. It is widely accepted, however, that inversion of the T wave in lead III. is of no pathological significance, and whatever may be the cause of an increased frequency of this feature in persons who have had diphtheria, there can be no doubt that there is no coexistent clinical abnormality.
De Leegives the reaction of the liquor amnii as faintly alkaline or neutral, and the freezing-point as slightly higher than that of the maternal blood. Sandmeyer found 0-22 per cent. of albumin
present, comprising serum-albumin,
and an ovo-vitelline-like substance. The salts of the liquor amnii are present in about the same proportions as the salts in the blood-serum-i.e., 0-5 per cent. They are the chlorides, phosphates, sulphates, and carbonates of sodium and calcium, with very little potassium. The urea content ranges from 0-02 to 0-4 per cent., and increases towards the end of pregnancy. Fairbairn2 states that the normal liquor amnii is a slightly turbid, straw-coloured fluid, with a specific gravity of 1002 to 1020, and a faintly alkaline reaction. It contains a variable amount of albumin (6 to 8 parts per 1000, Esbach) ; urea (usually in very small quantity), creatin, and salts. Sugar is said to be present in the liquor amnii of diabetic mothers. Edengives the following details : a clear, pale fluid of low specific gravity ; albumin, 0-19 per cent. ; inorganic salts, 0.59 per cent. ; extractives, 0-81 per cent. The amount of albumin may reach 10 per cent. in the early I am indebted to Dr. Claude Rundle, the medical months of pregnancy. The most important extractive is which is present in traces from the sixth week onwards. superintendent of Liverpool City Hospitals for Infectious urea, Diseases, for allowing free access to all the hospital registers Glucose may be found in cases of maternal diabetes. and case-records for the past ten years. Dr. E. Noble In the accompanying Table all the figures for the Chamberlain, senior honorary assistant physician at the various chemical estimations represent mg. per cent. Royal Southern Hospital, Liverpool, kindly gave assistance in reporting on the electrocardiographic records, and the The method of estimation is included in the Table, X ray department of the hospital carried out the photo- because different methods of estimation may yield graphic work for this part of the investigations. For help different values when performed in parallel by the in the statistical analysis of the records I am grateful to Mr. John H. Smith, assistant lecturer in the mathematics same worker. It is therefore necessary to state the method of estimation used in any series of biodepartment of the University of Glasgow.
globulin,
I
I
chemical investigations in order to make the work of value for comparative purposes. 1. White, F. W., and Smith, H. H.: Jour. Amer. Med. Assoc., The reaction and the specific gravity of the fluids 1905, xlv., 1245. examined conform to the accepted values for the 2. Hoskin, T. Jenner : THE LANCET, 1926, i., 1141. 3. Jones, T. D., and White, P. D. : Amer. Heart Jour., 1927, normal liquor amnii. In seven out of the eight iii., 190. fluids tested was present in estimable quantity, glucose 4. Sutherland, G. A. : In Thursfield and Paterson’s Diseases of and in one fluid the sugar content lay within the Children, 1929, p. 431 (quoted by Rolleston (ref. 5) ). 5. Rolleston, J. D.: Acute Infectious Diseases, London, 1929, normal range of the blood-sugar. It is not possible p. 31. to an opinion upon the relationship of this express 6. Butler, S., and Levine, S. A.: Amer. Heart. Jour., 1930, v., 592. comparatively high sugar content in the liquor amnii 7. Parkinson, J.: Heart, London, 1915, vi., 13. to the clinical condition, especially in the absence of 8. Reid, W. D. : Amer. Heart Jour., 1930, v., 524. a coincident blood-sugar estimation, but the finding REFERENCES
9. O’Donovan, P. : THE LANCET, 1923, i., 607. 10. Chamberlain, E. N., and Alstead, S.: Ibid., 1931, i., 970. 11. Alstead, S.: Quart. Jour. Med., 1932, n.s., i., 277.
* From the Biochemical Laboratory of the Queen’s Hospital,
Birmingham.
416 CHEMICAL ESTIMATIONS OF
*
All fluids gave
I lower level thanthe readings for thenormal serum I and calcium, but it must be remembered that the fcetus
is
drain upon the maternal stores of calcium that, in consequence, the serum calcium tends to fall towards the end of pregnancy, so that the readings obtained on this series of fluids are possibly only very slightly lower than the readings of the maternal serum calcium. The high phosphorus reading of 8 mg. per cent. was obtained on a fluid removed at autopsy, and cannot be compared with the other readings in the series. The total protein content shows much variation, and the variations are difficult a
AMNII
negative reaction.
a
is of interest in comparison with the low readings obtained on the remaining fluids in the series. Urea was present in estimable quantity in all the fluids. The single high reading of 73 mg. per cent. is not comparable with the other readings, because this fluid was obtained at autopsy several hours after the death of the patient, when some degree of decomposition had undoubtedly occurred. The high uric acid reading of 5-7 mg. per cent. is of interest, though its significance is not understood. The relatively constant values obtained for the creatinine content of the liquor amnii, even in the presence of maternal renal disease, are of much interest in connexion with the known stability of this substance in the blood and the urine. The chloride content does not vary much from the normal content of the blood, and seems to be, like the creatinine, one of the relatively stable chemical constituents of the liquor amnii. The absence of cholesterol is of interest in view of the known importance of this substance to the body, and the precautions taken by the body to conserve its supplies. Whatever may be the value of the liquor amnii to the foetus—and conflicting opinions are held-it is certain that the fluid is a waste product to the mother, and the absence of cholesterol in the fluid may possibly be associated with this fact. Ther calcium readings are fairly constant at a slightly
LIQUOR
to explain, especially the low reading of 50 mg. per cent. in the second case of maternal phthisis. This short series of chemical examinations suffers from two serious disadvantages: (1) the absence of coincident blood chemical analyses, and (2) the absence of any normal standards for the chemical constituents of the liquor amnii. It is not possible to rectify the second defect in a general hospital that does not cater for normal cases of labour, but it should not prove difficult to obtain an accurate knowledge of the chemical composition of the normal liquor amnii from the material available in one of the large maternity hospitals, and the above series of observations has been published chiefly in the hope that it will stimulate the prosecution of this useful work.
In conclusion I wish to express my thanks to my
colleague, Mr. Adshead, for his generous collaboration, and to acknowledge my indebtedness to my technical assistant, W. R. Hackett, who has carried out most of the estimations under my supervision. REFERENCES 1. De Lee, J. : Principles and Practice of Obstetrics, New York, 1915, p. 53. 2. Fairbairn, J. S. : Encyclopædia of Midwifery and Diseases of Women, London, 1921, p. 117. 3. Eden, T. W. : Manual of Midwifery, London, 1925, p. 44.
OSTEOMYELITIS OF THE PATELLA BY RICHARD A. HOUSE SURGEON, ST.
MANCLARK, M.R.C.S. ENG. JOHN’S HOSPITAL, LEWISHAM, S.E.
A GIRL, 7 years of age,
was
admitted to St. John’s
Sept. 3rd, 1932, with a swollen left knee, which had been painful for four days. There was no history of injury. Apparently the Hospital, Lewisham,
on
child had not seemed well for the last five weeksshe had " just sat about and did not want to play at all."