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CHILDBIRTH CHILLS
215
fully conscious; her abdomen was slightly protuberant but with no palpable mass; and she was bleeding slightly per vaginam, which was considered normal, menstruation having started five days before. Haemonhagic pancreatitis seemed unlikely, since the serum-amylase concentration was 200 units. The signs and symptoms suggested a diagnosis of intraperitoneal haemorrhage. The possibility of a ruptured ectopic pregnancy was considered, but there were no symptoms or signs of pregnancy, and pregnancy tests of urine (’ Pregnosticon’ and ’Gravindex’) were negative; pelvic examination was not done. After 3 pints (1700 ml.) of blood the patient’s B.P. rose to 110/70, and laparotomy was performed at 9 P.M. 3 pints (1700 ml.) of free and clotted blood were removed from the peritoneal cavity. Arising from the fundus of the uterus was a large soft, fleshy, vascular tumour which had ruptured and given rise to the profuse intraperitoneal haemorrhage. The ovaries and tubes seemed healthy. Total hysterectomy was performed. The patient had a further pint (570 ml.) of blood and her general condition gradually improved. She made an uneventful recovery and was discharged home after two weeks, when her haemoglobin was 14.4 g. per 100 ml. The pathological report was as follows: the specimen is a total uterus, 13 x 9 x 7 cm., with a soft haemorrhagic mass of growth, 20 x 5 x 7 cm., projecting from a crater in the fundus and having no connection with the dilated uterine cavity, which contains polypoid pieces of endometrium; microscopically the endometrium has a normal secretory pattern with some cystic glands, and the tumour is a leiomyosarcoma. The patient is known to be well, eighteen months after the
operation. This was an unusual case of leiomyosarcoma of the uterus, without any gynaecological history, in a patient who presented as a case of acute abdomen. Copthorne Hospital, Shrewsbury, Shropshire.
JUBEIDA KHATOON.
CERVICAL CYTOLOGY SIR,-May I suggest that all gynaecologists record whether the patients they treat for carcinoma of cervix have had a Papanicolaou test, and if so when ? This might produce some figures, which the Royal College of Obstetricians and Gyn2ecologists might be asked to collect, on the value or otherwise of the test. MALCOLM DONALDSON 6
Queen Street, Oxford.
Hon. Secretary, Cancer Information Association.
CHILDBIRTH CHILLS SIR,-Dr. Goodlin and others (July 8, p. 79) report an important investigation into a much neglected phenomenon. As their review of the published reports shows, these chills have never been satisfactorily explained, and it is well that there has now been some work on them, for it is the opinion of experienced midwives with whom I have discussed them that they are now less common than previously. Probably more important as an antigenic factor in the mother than fectal red cells is amniotic fluid, or some cellular or chemical factor in it, and this is mentioned in the references discussed. We may find light thrown by this kind of work on the important syndrome of " amniotic fluid infusion ", which now offers the main unsolved problem in obstetrics. A chill is often an important initial symptom, and it may well be that there is a " spectrum " of sensitisation ranging from minor chills to the major and highly mortal features of grave shock, acute pulmonary hypertension, or a hasmorrhagic state, of this syndrome. The clinical features in patients with the serious manifestations suggest the possibility of sensitisation. The patients are typically older multigravid2e, pregnant after a long interval, or perhaps a remarriage, and the shock has often been described as " anaphylactoid Your leading article on in the same issue (p. 84), discussing the
possibilities and difficulties of finding circulating cancer cells in the blood, gives us hope that it might be possible to develop a technique for detecting circulating foetal squamous cells in the blood in labour, and thus assess the frequency or occasion of sensitisation, or diagnose the major forms of the syndrome in its early stages, when treatment might be more effective. The development of such a technique would be a major advance in obstetrics, and could make a significant contribution to a further reduction of maternal mortality. Middlesbrough.
BRYAN WILLIAMS.
CORTICOSTEROIDS IN INFLUENZA to thank Dr. Breen 1 for his interesting comments on the effects of corticosteroids on acute upperrespiratory infections of viral or other xtiology. From my own experience, I can claim a dramatic improvement of acute febrile infections of the upper respiratory tract and of the lungs as well, by corticosteroids, in patients in whom the administration of the proper antibiotic, as judged by culture and sensitivity of organisms in the sputum, failed to improve the course of the illness within a reasonable period of time. In such patients, the addition of steroids to the antibiotic treatment has, as a rule, beneficial results, which are not obtained in patients with acute febrile infections of other systems. However, in my letter2I dealt with the good results of corticosteroids upon the course of influenza, regardless of whether there was any localisation in the respiratory tract. As I have noticed in my patients with this viral disease, the sooner the corticosteroid administration begins, the more effective is the treatment in aborting the illness. Nevertheless, if glucocorticoids are discontinued prematurely, localised objective signs may appear in the oropharyngeal mucosa, the trachea, or even the bronchi and the lungs. The early administration of corticosteroids for the treatment of influenza, preferentially by the intravenous route, did not fail even in very old patients.
SIR,-Ishould like
Department of Internal Medicine, University School of Medicine, Hippocration Hospital, Athens
610, Greece.
E. DANOPOULOS.
SIR-I have no experience in the use of intravenous dexamethasone sodium phosphate (’Decadron Injection’) at the onset of symptoms of influenza as described by Professor Donopoulos.2 How does he make a diagnosis of influenza at the onset of symptoms ? This angel fears to tread. Thousand Islands Medical Group, Edward John Noble Hospital, Alexandria Bay, New York.
ROBERT E. BURTCH.
HYPERSENSITIVITY TO PENICILLIN SIR,-In your annotation3 you state: " Serological tests involving agglutination and hsemagglutination have been developed, and haemagglutinating techniques in particular show a high degree of specificity 4; but the tests are difficult and costly, and unsuitable for routine investigations ". I suggest that this comment does not mention the most relevant point. The hsemagglutination tests so far reported can detect penicilloyl-specific antibodies, which prove only the occurrence of an immunological response to penicillin but do not provide evidence of allergy. The immunological response to penicillin is heterogeneous in two respects. The first heterogeneity is that of the antigenic determinants derived from penicillin, of which the penicilloyl group (hence called the " major " determinant) forms the largest proportion. The " minor " determinants may, however, play an important 1. Breen, G. E. Lancet, 1967, i, 1277. 2. Danopoulos, E. ibid. p. 1103. 3. ibid. 1967, i, 1204. 4. Schwarts, R. H., Vaughan, J. H. J. Am. med. Ass.
1963, 186, 1151.
fully conscious; her abdomen was slightly protuberant but with no palpable mass; and she was bleeding slightly per vaginam, which was considered normal, menstruation having started five days before. Haemonhagic pancreatitis seemed unlikely, since the serum-amylase concentration was 200 units. The signs and symptoms suggested a diagnosis of intraperitoneal haemorrhage. The possibility of a ruptured ectopic pregnancy was considered, but there were no symptoms or signs of pregnancy, and pregnancy tests of urine (’ Pregnosticon’ and ’Gravindex’) were negative; pelvic examination was not done. After 3 pints (1700 ml.) of blood the patient’s B.P. rose to 110/70, and laparotomy was performed at 9 P.M. 3 pints (1700 ml.) of free and clotted blood were removed from the peritoneal cavity. Arising from the fundus of the uterus was a large soft, fleshy, vascular tumour which had ruptured and given rise to the profuse intraperitoneal haemorrhage. The ovaries and tubes seemed healthy. Total hysterectomy was performed. The patient had a further pint (570 ml.) of blood and her general condition gradually improved. She made an uneventful recovery and was discharged home after two weeks, when her haemoglobin was 14.4 g. per 100 ml. The pathological report was as follows: the specimen is a total uterus, 13 x 9 x 7 cm., with a soft haemorrhagic mass of growth, 20 x 5 x 7 cm., projecting from a crater in the fundus and having no connection with the dilated uterine cavity, which contains polypoid pieces of endometrium; microscopically the endometrium has a normal secretory pattern with some cystic glands, and the tumour is a leiomyosarcoma. The patient is known to be well, eighteen months after the
operation. This was an unusual case of leiomyosarcoma of the uterus, without any gynaecological history, in a patient who presented as a case of acute abdomen. Copthorne Hospital, Shrewsbury, Shropshire.
JUBEIDA KHATOON.
CERVICAL CYTOLOGY SIR,-May I suggest that all gynaecologists record whether the patients they treat for carcinoma of cervix have had a Papanicolaou test, and if so when ? This might produce some figures, which the Royal College of Obstetricians and Gyn2ecologists might be asked to collect, on the value or otherwise of the test. MALCOLM DONALDSON 6
Queen Street, Oxford.
Hon. Secretary, Cancer Information Association.
CHILDBIRTH CHILLS SIR,-Dr. Goodlin and others (July 8, p. 79) report an important investigation into a much neglected phenomenon. As their review of the published reports shows, these chills have never been satisfactorily explained, and it is well that there has now been some work on them, for it is the opinion of experienced midwives with whom I have discussed them that they are now less common than previously. Probably more important as an antigenic factor in the mother than fectal red cells is amniotic fluid, or some cellular or chemical factor in it, and this is mentioned in the references discussed. We may find light thrown by this kind of work on the important syndrome of " amniotic fluid infusion ", which now offers the main unsolved problem in obstetrics. A chill is often an important initial symptom, and it may well be that there is a " spectrum " of sensitisation ranging from minor chills to the major and highly mortal features of grave shock, acute pulmonary hypertension, or a hasmorrhagic state, of this syndrome. The clinical features in patients with the serious manifestations suggest the possibility of sensitisation. The patients are typically older multigravid2e, pregnant after a long interval, or perhaps a remarriage, and the shock has often been described as " anaphylactoid Your leading article on in the same issue (p. 84), discussing the
possibilities and difficulties of finding circulating cancer cells in the blood, gives us hope that it might be possible to develop a technique for detecting circulating foetal squamous cells in the blood in labour, and thus assess the frequency or occasion of sensitisation, or diagnose the major forms of the syndrome in its early stages, when treatment might be more effective. The development of such a technique would be a major advance in obstetrics, and could make a significant contribution to a further reduction of maternal mortality. Middlesbrough.
BRYAN WILLIAMS.
CORTICOSTEROIDS IN INFLUENZA to thank Dr. Breen 1 for his interesting comments on the effects of corticosteroids on acute upperrespiratory infections of viral or other xtiology. From my own experience, I can claim a dramatic improvement of acute febrile infections of the upper respiratory tract and of the lungs as well, by corticosteroids, in patients in whom the administration of the proper antibiotic, as judged by culture and sensitivity of organisms in the sputum, failed to improve the course of the illness within a reasonable period of time. In such patients, the addition of steroids to the antibiotic treatment has, as a rule, beneficial results, which are not obtained in patients with acute febrile infections of other systems. However, in my letter2I dealt with the good results of corticosteroids upon the course of influenza, regardless of whether there was any localisation in the respiratory tract. As I have noticed in my patients with this viral disease, the sooner the corticosteroid administration begins, the more effective is the treatment in aborting the illness. Nevertheless, if glucocorticoids are discontinued prematurely, localised objective signs may appear in the oropharyngeal mucosa, the trachea, or even the bronchi and the lungs. The early administration of corticosteroids for the treatment of influenza, preferentially by the intravenous route, did not fail even in very old patients.
SIR,-Ishould like
Department of Internal Medicine, University School of Medicine, Hippocration Hospital, Athens
610, Greece.
E. DANOPOULOS.
SIR-I have no experience in the use of intravenous dexamethasone sodium phosphate (’Decadron Injection’) at the onset of symptoms of influenza as described by Professor Donopoulos.2 How does he make a diagnosis of influenza at the onset of symptoms ? This angel fears to tread. Thousand Islands Medical Group, Edward John Noble Hospital, Alexandria Bay, New York.
ROBERT E. BURTCH.
HYPERSENSITIVITY TO PENICILLIN SIR,-In your annotation3 you state: " Serological tests involving agglutination and hsemagglutination have been developed, and haemagglutinating techniques in particular show a high degree of specificity 4; but the tests are difficult and costly, and unsuitable for routine investigations ". I suggest that this comment does not mention the most relevant point. The hsemagglutination tests so far reported can detect penicilloyl-specific antibodies, which prove only the occurrence of an immunological response to penicillin but do not provide evidence of allergy. The immunological response to penicillin is heterogeneous in two respects. The first heterogeneity is that of the antigenic determinants derived from penicillin, of which the penicilloyl group (hence called the " major " determinant) forms the largest proportion. The " minor " determinants may, however, play an important 1. Breen, G. E. Lancet, 1967, i, 1277. 2. Danopoulos, E. ibid. p. 1103. 3. ibid. 1967, i, 1204. 4. Schwarts, R. H., Vaughan, J. H. J. Am. med. Ass.
1963, 186, 1151.