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Blood chemistry study in normal pregnancy and eclamptogenic toxemia
CHICAGO GYNECOLOGICAL It is presumed that of the pregnant uterus
SOCIETY
the trauma one yea.r later was sufficient to produce through one of the weakened scars in that organ.
761 a rupture
DR. Sor, LITT reported a case of Double Uterus. S. T. a girl fourteen and one-half years of age, entered the Michael Reese Hospital on June 3, 1931, complaining of excessive vaginal bleeding for the past seven months. The menses began at thirteen years, were regular every 30 days and lasted five to six days for the first seven months. The last normal period was in November, 1930. Three weeks later the patient had a severe hemorrhage from the genitalia lasting three days. Since then she flowed every two weeks for six to seven days with spotting in the intervals. The past history was not significant. Physical examination revealed a large, well developed girl appearing older than fourteen years and weighing 67.74 kilograms. General examination was negative. The introitus readily permitted vaginal examination which revealed a cystic mass 3 by 4 cm. in diameter in the anterior vaginal wall encroaching on the vaginal canal and obliterating the anterior fornix. The cervix was behind the mass. The adnexa were normal to palpation. The provisional diagnosis was congenital cyst of the vaginal wall, possibly Gartner type. In order to visualize the corpus uteri and appendages, a transuterine pneumoperit.oneum and lipiodol instillation was performed. The interpretation of the film was unicorn uterus with right tube patent. On June 13 an operation under spinal anesthesia was performed by Dr. Lackner. A left paravaginal incision was made, and the vaginal mueosa over the cystic mass incised and dissected away. In attempting to free the mass from the anterior wall of the cervix, the tumor was opened and about 100 C.C. of tarry black mat.erial escaped. The dissection was completed and a double uterus was found. There was no connection between the two uteri. The internal os of the left uterus was represented by a deep constriction and communicated with the sacculated hematocervix which protruded downwards and anteriorly in front of the cervix of the right uterus The right uterus deviated sharply to the right and formed the mass felt vaginally. The urinary bladder was situated in and was connected to the vagina by the cervix. Each uterus had a tube extending from its the depression between the two uteri. eornu. Two ovaries were present, each in normal relation to its tube. The left hematocervix and uterus were excised, leaving the tube and ovary. The right uterus, tube, and ovary were left in situ.
DRS. RALPH
Separation DR. SAMUEL
Chemistry
A. REIS AND JOSEPH L. BAER presented a paper entitlrd
of the Symphysis KAPLAN
Pubis Following
(by invitation)
Study in Normal
Spontaneous
Labor.
presented a paper entitled Blood
Pregnancy
and Eclamptogenic
Toxemia.
(See page 673.) presented a paper entitled Modifications of Pregnancy. (For article see page 721.)
DR. R. A. LIFVENDAHL
Hormone
Tests for the Diagnosis
of the original
DISCUSSION DR. SYDNEY S. SCHOCHET.-We are not blind to the virtues of all these tests. but it seems to me that the gynecologists are losing sight of the fact that the elinical history and physical findings are often sufficient to make an early diagnosis of pregnancy. Chipman called attent.ion many years ago to the softening of the uterus
This with the :~nd undue pulsation of the uterine vessels in rely e:~rly prt’gn:lllc3-. cl~sical textbook findings should suffice in the making of :I diagnosis of prf?gn~~~~. rGlr in the ding!These tests m:r~ IW vssrrrtinl in rert,:Gn cases :~nd pla: :m imlm$:~nt nosis but to make it :I routine procedure is not to be s:lnctionwl. This test is exceedingly valuable in eases of chorionepitllelio~nn.
DR. EDWAKI) I,. CORNETIT,.--At the, Coclk County Hospital, WV used the Schneider test in 14 cases of prrguancy :ttrrl (me of h$:ltid molt'. 1.5 C'FIWN in :III. The hydatid mole gave a very strongly positive result. A week afterwards we IV tested the same pxtic~ut am1 the toast was still strongly positivc~. 1 n~:~d~~ :I Iliagnosis I want to IWWY~ two failures. IIf choriollepitheliom:r which was later confirnlc~l. One woman :ipparcutly had a thrre months ’ l>r~~gnancy compli~atc~d lry :t fibroid tumor. The rtlport came Imck after thirty-six hours negative. I saw the ol-aries :md there were nbsolutcly no hcmorrhayc~ of :I ny ~~haracter. The r:tI)l)its hnd rectG\-ed 5 cc. of urine. On those findings the> surgeon opcaratrd. TTe made a diagnosis Th? test was made of pregnancy c>omplicated bp a fibroid and closed the abdomcm. last March nut1 the paticlnt was still prqn:tut at, the time of reporting. The second patient had :t tumor the sizcl of a four and out-half months ’ pregnancy. WP used the t,& as a. routiuc lmt also checked her with thr s-lny. The films showed a fetus. The test was negative in the rabbit. From tllrsr findings we decided that ihr labbit test was not as accurate as it, might, lx. DR. P. I?. HC1ISELI)I%.-III the USC of this test it sec’ms there is :I ctLr+:ciu unavoidable perccntnge of error. To avoid that and not cause serious mistakf~s it seems ndrisable to follow the suggcstiou of Dr. Schochr~t and use the cl inieal history and I~hysical findings to check the test. Occasionally the source of CWO~ can be traced to the rabbit. Some r:tlll)its havcl very small flat (1v;rrit.s whic~h hart, no visible grxnfian follicles. If at :rutoIqflat ovaries are found, it should 1~ knoru th:ct the :~uimal is uot a proper test auimnl and another animal should bc used and the test repeated. The test has its limitations. In a series of between 400 and .?M IXSCS, WC haTe had three cases iu which :I positive dinguosis was made hefore tllc ImtiCnt had rrcn missed a period. On the other hand, there wvcrc sc,yer:rl cases in which a negntivta diagnosis was obtained fire to sercu days after 2 menstrual period h:rd Ixen misspd. Repetition of the, test serrral days I:rtcr ~:LW :,. Imsitire result ill t,arh instauec. This indicates, with son~e othclr cases iu which we knew the definite datt? of the int,ctr~ course responsiblt~ fur the preguancy, that tlrc~ rt~:lction ljecornes positirta about threr> weeks followiug the datC of iutercoursr. DR. ALFONS K4C’OS.-Afttsr deducting our initial fxilures (!I eases) with the Ascheim-Zondek test and deducting 29 more for failure to submit reports berausc, of death of the mice aud iual)ilitp of obtniniuy follow-up reports, I will trport on 7G cases in which the rcpf&s weye later c~ontirnit~d 1,~ thr patients or tloctors. 1 II ,‘;1seR in which the mice dicad, the GIUSC was :~lrutrst :I~W:I~S to he fouud in cystitis or :I ppelitis 01’ the specimens had Ivxn srut through the mail az~d became highlp toxic. Of the 76 cases, :%i or 8 per cent were positi\-c, which wer6’ correct; 34, o1’ 45 per cent, wt’re negative, which were correct, :lnd 5. 01' Ii per cent, wew incorrect reports. Of the iucorr?ct rel~rts all I)ut oue wcw uegatire which should havrl hvn positive. The single exeept,iou (uumher 42) was in the c:rse of a woman of forty-fivra who was going through the meuol,ause and in her C:W on+ one of the four micr used showed :L true posit,ivtn rencticlu. I have included in these figures a few special cases which I wish to meutiou. Sumber 43 was a patient with a hyda,tid n~olr who had lxeu currtted n felt days previously and she g:lv~ an unusually stroug positive re:rrtion. This, of VOWW, was to be expected.
CHICAGO
GB1VECOI~OGICA1,
SOCIETP
763
Number 46 was the same patient two weeks after t,he curettement. It was like a normal positive reaction. Number .55 was the same patient six weeks after operation and the result was negative. In this case we made a diagnosis of no chorionepithelioma developing. Number 84 was another case of hydatid mole, two weeks after operation, which gave a negative reaction. In this case the same diagnosis was made. Sumber 99 was a case of missed abortion done seventeen days after the initial hemorrhage, giving a negative result. The curettage following the test confirmed this result. We also had a case (number 94) similar to the one Dr. Cornell reported, where the diagnosis of pregnancy with fibroid was made with the aid of this test. When we operated, we found this to be correct. In several cases we have had the opportunity, because of negative reports, to save patients from operations which had been planned on account of suspected pregnancies. Another suggested application of this test is in case of sterility after performing a tubal insufflation, when, for fear of disturbing a pregnancy which may have just started, this test is applicable in helping to determine whether another insufflntion may be attempted or not. In looking over our figures, I fmd the majority of incorrect results t,o be among the first half of the cases I have just reported. From several cases we have learned that individual mice will not react true to form; hence, the advisability of using several of these test nnimnls. I cannot see why such experiences may not occur with other test nnimals. DR. SIDNEY KLEIN.-In ported of ectopie pregnancy Davis two; so, to date, there
reviewing the literature, I found but with positive A-Z tests. I then reported are eight cases with positive results.
five cases reone and Dr.
DR. R. A. LIFVENDAHL (closing).--Whatever the method of exposure, it shouhl be kept in mind that little manipulation of the ovary or its blood supply should be done in order not to produce artefacts. Repeated use of the animals calls for certain precautions. Jf the ovary has responded with a positive reaction the animal should not be used for at least a period of three weeks. Experimentally, it has been demonstrated that the hemorrhagic bodies have an inhibitory affect upon the development of further pseudopregnancy reactions for this period of time. Dr. Priest’s suggestion of isolation of the rabbit for at least ten hours before performing the test is well taken, and I agree that this precaution should be carried out. I have used sodium amytal and chloroform but these forms of anesthesia, in my hands, have not proved as satisfactory as ether. \~II,LIAM d. HIMUNICH presented a paper entitled A Comparison of the Sedimentation and Ruge Virulence Tests in ‘150 Gynecologic Cases. (For original article we page 724.)
11~.
SOCIETY
the trauma one yea.r later was sufficient to produce through one of the weakened scars in that organ.
761 a rupture
DR. Sor, LITT reported a case of Double Uterus. S. T. a girl fourteen and one-half years of age, entered the Michael Reese Hospital on June 3, 1931, complaining of excessive vaginal bleeding for the past seven months. The menses began at thirteen years, were regular every 30 days and lasted five to six days for the first seven months. The last normal period was in November, 1930. Three weeks later the patient had a severe hemorrhage from the genitalia lasting three days. Since then she flowed every two weeks for six to seven days with spotting in the intervals. The past history was not significant. Physical examination revealed a large, well developed girl appearing older than fourteen years and weighing 67.74 kilograms. General examination was negative. The introitus readily permitted vaginal examination which revealed a cystic mass 3 by 4 cm. in diameter in the anterior vaginal wall encroaching on the vaginal canal and obliterating the anterior fornix. The cervix was behind the mass. The adnexa were normal to palpation. The provisional diagnosis was congenital cyst of the vaginal wall, possibly Gartner type. In order to visualize the corpus uteri and appendages, a transuterine pneumoperit.oneum and lipiodol instillation was performed. The interpretation of the film was unicorn uterus with right tube patent. On June 13 an operation under spinal anesthesia was performed by Dr. Lackner. A left paravaginal incision was made, and the vaginal mueosa over the cystic mass incised and dissected away. In attempting to free the mass from the anterior wall of the cervix, the tumor was opened and about 100 C.C. of tarry black mat.erial escaped. The dissection was completed and a double uterus was found. There was no connection between the two uteri. The internal os of the left uterus was represented by a deep constriction and communicated with the sacculated hematocervix which protruded downwards and anteriorly in front of the cervix of the right uterus The right uterus deviated sharply to the right and formed the mass felt vaginally. The urinary bladder was situated in and was connected to the vagina by the cervix. Each uterus had a tube extending from its the depression between the two uteri. eornu. Two ovaries were present, each in normal relation to its tube. The left hematocervix and uterus were excised, leaving the tube and ovary. The right uterus, tube, and ovary were left in situ.
DRS. RALPH
Separation DR. SAMUEL
Chemistry
A. REIS AND JOSEPH L. BAER presented a paper entitlrd
of the Symphysis KAPLAN
Pubis Following
(by invitation)
Study in Normal
Spontaneous
Labor.
presented a paper entitled Blood
Pregnancy
and Eclamptogenic
Toxemia.
(See page 673.) presented a paper entitled Modifications of Pregnancy. (For article see page 721.)
DR. R. A. LIFVENDAHL
Hormone
Tests for the Diagnosis
of the original
DISCUSSION DR. SYDNEY S. SCHOCHET.-We are not blind to the virtues of all these tests. but it seems to me that the gynecologists are losing sight of the fact that the elinical history and physical findings are often sufficient to make an early diagnosis of pregnancy. Chipman called attent.ion many years ago to the softening of the uterus
This with the :~nd undue pulsation of the uterine vessels in rely e:~rly prt’gn:lllc3-. cl~sical textbook findings should suffice in the making of :I diagnosis of prf?gn~~~~. rGlr in the ding!These tests m:r~ IW vssrrrtinl in rert,:Gn cases :~nd pla: :m imlm$:~nt nosis but to make it :I routine procedure is not to be s:lnctionwl. This test is exceedingly valuable in eases of chorionepitllelio~nn.
DR. EDWAKI) I,. CORNETIT,.--At the, Coclk County Hospital, WV used the Schneider test in 14 cases of prrguancy :ttrrl (me of h$:ltid molt'. 1.5 C'FIWN in :III. The hydatid mole gave a very strongly positive result. A week afterwards we IV tested the same pxtic~ut am1 the toast was still strongly positivc~. 1 n~:~d~~ :I Iliagnosis I want to IWWY~ two failures. IIf choriollepitheliom:r which was later confirnlc~l. One woman :ipparcutly had a thrre months ’ l>r~~gnancy compli~atc~d lry :t fibroid tumor. The rtlport came Imck after thirty-six hours negative. I saw the ol-aries :md there were nbsolutcly no hcmorrhayc~ of :I ny ~~haracter. The r:tI)l)its hnd rectG\-ed 5 cc. of urine. On those findings the> surgeon opcaratrd. TTe made a diagnosis Th? test was made of pregnancy c>omplicated bp a fibroid and closed the abdomcm. last March nut1 the paticlnt was still prqn:tut at, the time of reporting. The second patient had :t tumor the sizcl of a four and out-half months ’ pregnancy. WP used the t,& as a. routiuc lmt also checked her with thr s-lny. The films showed a fetus. The test was negative in the rabbit. From tllrsr findings we decided that ihr labbit test was not as accurate as it, might, lx. DR. P. I?. HC1ISELI)I%.-III the USC of this test it sec’ms there is :I ctLr+:ciu unavoidable perccntnge of error. To avoid that and not cause serious mistakf~s it seems ndrisable to follow the suggcstiou of Dr. Schochr~t and use the cl inieal history and I~hysical findings to check the test. Occasionally the source of CWO~ can be traced to the rabbit. Some r:tlll)its havcl very small flat (1v;rrit.s whic~h hart, no visible grxnfian follicles. If at :rutoIqflat ovaries are found, it should 1~ knoru th:ct the :~uimal is uot a proper test auimnl and another animal should bc used and the test repeated. The test has its limitations. In a series of between 400 and .?M IXSCS, WC haTe had three cases iu which :I positive dinguosis was made hefore tllc ImtiCnt had rrcn missed a period. On the other hand, there wvcrc sc,yer:rl cases in which a negntivta diagnosis was obtained fire to sercu days after 2 menstrual period h:rd Ixen misspd. Repetition of the, test serrral days I:rtcr ~:LW :,. Imsitire result ill t,arh instauec. This indicates, with son~e othclr cases iu which we knew the definite datt? of the int,ctr~ course responsiblt~ fur the preguancy, that tlrc~ rt~:lction ljecornes positirta about threr> weeks followiug the datC of iutercoursr. DR. ALFONS K4C’OS.-Afttsr deducting our initial fxilures (!I eases) with the Ascheim-Zondek test and deducting 29 more for failure to submit reports berausc, of death of the mice aud iual)ilitp of obtniniuy follow-up reports, I will trport on 7G cases in which the rcpf&s weye later c~ontirnit~d 1,~ thr patients or tloctors. 1 II ,‘;1seR in which the mice dicad, the GIUSC was :~lrutrst :I~W:I~S to he fouud in cystitis or :I ppelitis 01’ the specimens had Ivxn srut through the mail az~d became highlp toxic. Of the 76 cases, :%i or 8 per cent were positi\-c, which wer6’ correct; 34, o1’ 45 per cent, wt’re negative, which were correct, :lnd 5. 01' Ii per cent, wew incorrect reports. Of the iucorr?ct rel~rts all I)ut oue wcw uegatire which should havrl hvn positive. The single exeept,iou (uumher 42) was in the c:rse of a woman of forty-fivra who was going through the meuol,ause and in her C:W on+ one of the four micr used showed :L true posit,ivtn rencticlu. I have included in these figures a few special cases which I wish to meutiou. Sumber 43 was a patient with a hyda,tid n~olr who had lxeu currtted n felt days previously and she g:lv~ an unusually stroug positive re:rrtion. This, of VOWW, was to be expected.
CHICAGO
GB1VECOI~OGICA1,
SOCIETP
763
Number 46 was the same patient two weeks after t,he curettement. It was like a normal positive reaction. Number .55 was the same patient six weeks after operation and the result was negative. In this case we made a diagnosis of no chorionepithelioma developing. Number 84 was another case of hydatid mole, two weeks after operation, which gave a negative reaction. In this case the same diagnosis was made. Sumber 99 was a case of missed abortion done seventeen days after the initial hemorrhage, giving a negative result. The curettage following the test confirmed this result. We also had a case (number 94) similar to the one Dr. Cornell reported, where the diagnosis of pregnancy with fibroid was made with the aid of this test. When we operated, we found this to be correct. In several cases we have had the opportunity, because of negative reports, to save patients from operations which had been planned on account of suspected pregnancies. Another suggested application of this test is in case of sterility after performing a tubal insufflation, when, for fear of disturbing a pregnancy which may have just started, this test is applicable in helping to determine whether another insufflntion may be attempted or not. In looking over our figures, I fmd the majority of incorrect results t,o be among the first half of the cases I have just reported. From several cases we have learned that individual mice will not react true to form; hence, the advisability of using several of these test nnimnls. I cannot see why such experiences may not occur with other test nnimals. DR. SIDNEY KLEIN.-In ported of ectopie pregnancy Davis two; so, to date, there
reviewing the literature, I found but with positive A-Z tests. I then reported are eight cases with positive results.
five cases reone and Dr.
DR. R. A. LIFVENDAHL (closing).--Whatever the method of exposure, it shouhl be kept in mind that little manipulation of the ovary or its blood supply should be done in order not to produce artefacts. Repeated use of the animals calls for certain precautions. Jf the ovary has responded with a positive reaction the animal should not be used for at least a period of three weeks. Experimentally, it has been demonstrated that the hemorrhagic bodies have an inhibitory affect upon the development of further pseudopregnancy reactions for this period of time. Dr. Priest’s suggestion of isolation of the rabbit for at least ten hours before performing the test is well taken, and I agree that this precaution should be carried out. I have used sodium amytal and chloroform but these forms of anesthesia, in my hands, have not proved as satisfactory as ether. \~II,LIAM d. HIMUNICH presented a paper entitled A Comparison of the Sedimentation and Ruge Virulence Tests in ‘150 Gynecologic Cases. (For original article we page 724.)
11~.