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Cortical necrosis of kidneys associated with necrosis of pituitary in obstetrical shock
CORTICAL NECROSIS OF EXDHEYS AtlSOCIATED WITH NECM3SIS OF PITUITA.M?’ IN OB8TETMCAL SHOCK MAJOR WRAP (From
the Xoartl
J. TOMLINS~K of Health
(X.C.j,
T,ol~orntory,
A.I:.S.,
hcos,
Gorgfc,s fiospitd,
C-\KAL
.jwo~~,
(‘owtrl
Zosr; %@n,e!
P
OSTPARTIJM necrosis of the ant.erior lobe of the pituitary gland has been described numerous times and is becoming a well-known clinical entity. Likewise, the occurrence of bilateral renal cortical necrosis in pregnancy, in shock, in infections, :uul of undetcrmim~d origin has been described. So cases arc found in the literature available describing a combination ot necrosis of t,he ant.crior lobe of the pituitary gland and bilateral renal cortical necrosis following parturition. It is the object of this paper to report such a case. Case Report The patient,, a whit,e female: aged 2S, married, was first admitted to the hospital on July 14, 1942, when she had a spontaneous delivery of an anencephalic monster of 8 mont,hs’gestation, There were no complications during t.he pregnancy or delivery, At, this time she had one child, aged 22 months. She was next seen at the out,p&ient obstet,rical cIinic June 16, 1943; her last menstrual period was April 17, 1943, and the estimated date of confinement was January 24, 1944. Physical examination at this time was normal. She attended the clinic regularly and September 20, 1943, was admitted to t,he hospital for hack pain and nocturia of one day’s duration. Physical examination was negative. Hemogram revealed hemoglobin 70 per cent (Tallqvist,) , 3,850,OOO erythroeytes, 7,250 Ieucocytes ; differential, 74 neut,rophilcs, 1 eosinophile, and 25 lymphocytes. Blood serology was negative. Urine analyses for this admission are given in Table I. TABLE
I.
--l__l___ DATE
9/20 9/21 9/22 9/23 g/25 9/2G 9/27 9/28
AT,BlJN1N t
0 0 0 -t-40 0 0
URINE ~_--
Aaa~~srs,,
SUQAR 0 U U 0 I) 0 0
SEPTEMBER,
1943,
~DMISYI~~ _____I-_-_--~
MICROSCOPIC PUS CEILS - BLOOD .‘?-MTS 0 iitt U -: t i. L .: i', U U -i-t 0 +I+ (! 0 -Ntt 0 0 0 u ._ .~ ____ -- -.-. .-AL
____---.
CELL6 ~‘.\TIIETERI7~1) 0 No 0 Yes 1) hi G -t No NO 0 KGI -.- .---_-
!z.-_
She received sulfadiazine until hematuria appeared on September 24, 1943, when it was stopped and mandeiie acid therapy was started. She was discharged on September 2$ 1943, with a diagnosis of pyeloeystitis (right) of pregnancy. Following discharge, she was followed in the clinic with no recurrences or further difficulties until she returned to the 236
TOMLINSON:
NECROSIS OF KIDNEYS
ASD PITUITARY
GLASD
237
hospital on December 25, 1943, with fever, pain and tenderness in the right costovertebral angle of two days’ duration. Temperature on admission was 102OF., rapidly falling to normal in two days. Hemogram was hemoglobin 65 per cent (Tallqvist), 3,450,OOO erythrocytes, 5,250 leucocytes; differential was 68 neutrophiles, 2 eosinophiles,and 30 lymphocytes. The urine on admission showed three-plus pus cells with a few erythrocytes, no albumin, and it continued to show pus cells, but no more erythrocytes. She was placed upon sulfadiazine on admission with good response. Due to the holidays, the patient insisted upon discharge and went home December31,1943. Her last admission was on January 6, 1944, with complaint of cough, backache, fever, and sordes of mouth. IIcr condition had been fair during the interval, and the day of admission was the first time she had a fever (1OOOF‘.). Physical examination revealed multiple sordcrs of the tongue and mouth. Heart and lungs were negative. Blood pressure was 120 mm. of mercury systolic, and 80 mm. of mercury diastolic. The uterus was two fingerbreadths below the xighoid, deflected to the left, with the buttocks in the fundus and soft parts to the right. The head was floating above the symphysis. Fetal heart rate was 140 per minute. Chest roentgenogramwas negative. Sedimentation rate was 90 mm. per hour (Westergren) . Blood serology was negative. The clinical laboratory data are tabulated in Table II. Course in Hospital.-The patient ran a fairly even course on January 7, 8, and 9, with her temperature gradually &mbing to 103” I?., when she was placed on a sulfadiazine routine. January IO.-Tempera.ture 104O F. Few ut,crine contractions, head not engaged, fetal heart fast,. Transfusion (citrate method) of 500 cc. of blood at 2 P.M., with no reactions. January 21.--Temperature 103.5OF. Condition unchanged. Januav-y l2.-Temperature 103O F. Fetal heart tonrs have disappeared, and cervix was dilating slowly. Sulfadiazine discontinued. Jmuwy 13.-Taken fo operating room at 9:50 A.M. and under ether and ethylene anesthesiamidforceps extraction of a female stillborn child was performed at lo:12 A.M. wit,h an episiotomy. The placenta was not expelled, and was manually removed in fragments at 11:20 A.M. It was estimated that the blood loss did not exceed300 cubic centimeters. The patient went into severe shock, almost dying on the table, and was given blood, plasma, fluids, and cardiorespiratory stimulants. Blood pressure was not recorded in operating room; on return to ward it was 90 mm. of mercury systolic and 60 mm. of mercury diastolic. At 10 :00 P.M. blood pressure was 95 mm. of mercury systolic and 60 mm. of mercury diastolic and the patient was comatose. January Id’.---The patient vomited at. intervals. Temperature fell from 101” F. at 1:00 A.M. to 97OI”. at midight and 96” F. at 4:00 A.M. the following morning. Janumy S.-Vomiting, drowsy, condition critical. Anuric. TJreters lavaged, but no crystals were obtained, and no obskuction was encolmtered. January lG.-Patient almost totally anuric. Blood pressure 120 mm. of mercury systolic and 72 mm. of mercury diastolic. Involuntary liquid stools today.
AM ERICAN .JOURNdL
01' OBS1'151'RICS AND GYNECOLOGl
SHmcI,,SV:IJ’
---
-
’-
I,
-
-
TOMLINSON :
NECROSIS OF KIDSEYS
AND PITUITARY
GLAKD
239
January 17.-Voided 80 to 100 C.C. of urine. Some dyspnea and cyanosis present. Given oxygen. Januury 18.-Still partially anuric (voided 250 C.C.in twclvc hours). Condition very grave. Janwwy lg.-At 2:00 P.M. a transfusion of 500 C.C.01 blood (citralc method) was given, with no reaction, The patient expired at 6:13 Iax. Autopsy Pin.din.qs.-The body weight was 128 pounds and length, 66 inches. The breasts were engorgedand milky fluid was easily expressed. There was massive perineal ecchymosis and a posterior episiotomy snturc> line. The brain showed no gross softening, congestion, or hemorrhage. The ventricles were not dilated. Cerebrospinal fluid was clear and of normal amount. The pituitary gland was swollen, tense, and impinging on the infundibulum. It measured 2.3 by 1.5 centimeters. l~‘ollowing fixation in formol-alcohol, sectioning revealed a narrow 2 to 3 mm. rim of darkcl* viable tissue around the anterior lobe surrounding the central soft, vellow-white, necrotic area (Figs. 1 and 2). The sella turcica showed no Llargement.
Fig.
1.---Cut
surface of anterior (Formol-alcohol
lobe of pituitary gland showing fixation.) (Magnification x 6.1
central
necrod.
There were no gross changesin the throat or neck. The thyroid was symmetrical and weighed 35 grams. The pleural spaces were clear. The lungs showed congestion with terminal bronchopneumonia involving the upper and middle lobes of the right lung. There were no infarcts and the pulmonary artery contained no emboli. There was no increase in pericardial fluid. The heart weighed 300 grams and showed no gross changesor anomalies. The aorta was smooth, elastic, and showed no stenosis or dilatation. There were no adhesions or increased fluid in the abdominal cavity. The liver protruded 4 cm. below the costal border. The diaphragm was not elevated. The liver was tense, pale red brown, and the cut edgesbulged. There was no gross hemorrhage or infection. The spleen was congested, swollen, and soft; it weighed 320 grams. The capsule was smooth, blue purple; the cut surface was dark, soft, and semifluid. There was no gross hemorrhage, infarction, or infection.
240
AMERICAN
JOURSAI,
OF (JRSTETRICS \Nl)
(;Y SI*:(‘OIAN~\
Fig. Z.--Cut surfaces of kidneys (left), anterior lobe nf pituitary gland (cente~‘J and I Slightly 1rduced. ;b uterine wal,l (right). ( Fom,c>l.. alcohol flxation.l
The urinary bladder contairrcd 10 C.C. of Icnlon-yellow, cloudy urine. The mucosa around ihc tjrigonc~ was injected. There were multiple retroperitoneal organized hrmorrhagcs ~~wsent aiwund the hladdw. The uterus measured 25 cm. flwtn fundus to wrrical constriction, 20 cm. betweeii the Fallopian fubw, and 12 cm. in dt:pth ill the midportion. The serwa was thickened, whitt:, and free f~vonr esudatc~ or hemorrhage. The Fallopiall tubes and ovaries were normal, postpartum in character. There was marked hemorrhage beneath the peritoneal covering at, the
TOMLISSON
:
SECROSIS OF KIDNEYS
AND PITUITARY
Fig. I.-Section
through edge of anterior lobe of pituitary and jrmction of necwsis. (Magniflcatlon
Fig.
through necrotic area in anterior lobe of pituitary thrombosis of vessels. (Magnification x800.)
I.--Section
GLAND
241
gland showin:: viable cells X X(10.)
gland showing
TOMLINSOK
Fig. &-Section
Fig.
6.-Section
:
NECROSIS OF KIDSEYS
of kidney showing thrombosis (Magnification
oP kidney thrombosed
AXD I’ITUITARY
and rupture X 800.)
GLASD
of an intralobular
243
artery.
showing thrombosis of a&rent arteriole at A, onterjnglomerulus at B. (Magnification X 800.)
TOMLINSQN
:
NECROSIS
OF KIDNEYS
AND
PITUITARY
GLAND
245
sure that any bacterial or toxic factor could be excluded, and that shock was the direct cause. Penner and Bernheim13in a series of experiments with dogs produced severe shock by the intraperitoneal and intrapleural injection of epinephrine hydrochloride. In some of their animals, they found cases of bilateral cortical necrosis of the kidneys which were similar to those that had been reported in human beings and to the human casesthey had studied. They felt that the vasospasmwhich occurs in shock was of sufficient intensity and duration to result in the kidney lesions in some instances. In the case reported here, there were no signs of eclampsia and no autopsy evidence of the usual toxemias of pregnancy. The patient had a severe operative delivery with considerablefrank bleeding, and more concealed bleeding internally. Severe shock developed and following this anuria, drowsiness, fall of temperature, and a persistent hypotension occurred. There was a steady rise in the nonprotein nitrogen and creatinine, with onset of vomiting and diarrhea. The gradual loss of hemoglobin and erythrocytes must have occurred as a result of bleeding from the kidneys, inasmuch as the icterus index was not elevated and there were no other bleeding points. Summary In the case reported here, there was combined necrosisof the anterior lobe of the pituitary gland and the cortices of the kidneys. The histologic picture of the pituitary and kidney changeswas compatible with five to six days’ thrombosis. The clinical picture was typical, and no evidence of other factors was found at autopsy. The collapse and shock at delivery was extreme, and it is felt that the changesfound were initiated then. Added support is given to the belief that postpartum necrosis of the anterior lobe of the pituitary gland and bilateral renal cortical necrosismay be caused,in many instances, by severeshock in reporting here a case showing both of these conditions occurring simultaneously in the same patient,. References 1. Gotshalk, H. C., and Tilden, I. L.: J. A. M. A. 114: 33, 1940. 2. Brown, Clark E., and Eder, Lawrence F.: Am. J. M. SC. 198: 166, 1939. Reekie, R. D.:
West. J. Burg. 50: 293, 1942.
2 Cunningham, J. F., McGrath, J., O ’Donovan, D. K., and de Valera, E.: Irish J. M. SC. 519, September, 1942. Sheehan, H. L.: J. Path. & Bact. 45: 189, 1937. t!: Sheehan, H. L., and McLetohie, N. G. B.: J. Obst. & Gynaec. Brit. Emp. 50: 27, 1943. 7. Hutchinson, H. E.: J. Path. & Bact. 51: 442, 1940. 8. Ash, J. E.: Am. J. M. SC. 185: 71, 1933. 9. De Navasquez, S.: J. Path. & Bact. 41: 385, 1935. 10. Dunn, J. S., and Montgomery, G. L.: J. Path. & Bact. 52: 1, 1941. 11. Godwin, B., and McCall, A. J.: Lancet 2: 512, 1941. 12. McFarlane, D.: J. Path. & Bact. 52: 406, 1941. 13. Penner, A., and Bernheim, A. I.: Arch. Path. 30: 4&j, 1940.
the Xoartl
J. TOMLINS~K of Health
(X.C.j,
T,ol~orntory,
A.I:.S.,
hcos,
Gorgfc,s fiospitd,
C-\KAL
.jwo~~,
(‘owtrl
Zosr; %@n,e!
P
OSTPARTIJM necrosis of the ant.erior lobe of the pituitary gland has been described numerous times and is becoming a well-known clinical entity. Likewise, the occurrence of bilateral renal cortical necrosis in pregnancy, in shock, in infections, :uul of undetcrmim~d origin has been described. So cases arc found in the literature available describing a combination ot necrosis of t,he ant.crior lobe of the pituitary gland and bilateral renal cortical necrosis following parturition. It is the object of this paper to report such a case. Case Report The patient,, a whit,e female: aged 2S, married, was first admitted to the hospital on July 14, 1942, when she had a spontaneous delivery of an anencephalic monster of 8 mont,hs’gestation, There were no complications during t.he pregnancy or delivery, At, this time she had one child, aged 22 months. She was next seen at the out,p&ient obstet,rical cIinic June 16, 1943; her last menstrual period was April 17, 1943, and the estimated date of confinement was January 24, 1944. Physical examination at this time was normal. She attended the clinic regularly and September 20, 1943, was admitted to t,he hospital for hack pain and nocturia of one day’s duration. Physical examination was negative. Hemogram revealed hemoglobin 70 per cent (Tallqvist,) , 3,850,OOO erythroeytes, 7,250 Ieucocytes ; differential, 74 neut,rophilcs, 1 eosinophile, and 25 lymphocytes. Blood serology was negative. Urine analyses for this admission are given in Table I. TABLE
I.
--l__l___ DATE
9/20 9/21 9/22 9/23 g/25 9/2G 9/27 9/28
AT,BlJN1N t
0 0 0 -t-40 0 0
URINE ~_--
Aaa~~srs,,
SUQAR 0 U U 0 I) 0 0
SEPTEMBER,
1943,
~DMISYI~~ _____I-_-_--~
MICROSCOPIC PUS CEILS - BLOOD .‘?-MTS 0 iitt U -: t i. L .: i', U U -i-t 0 +I+ (! 0 -Ntt 0 0 0 u ._ .~ ____ -- -.-. .-AL
____---.
CELL6 ~‘.\TIIETERI7~1) 0 No 0 Yes 1) hi G -t No NO 0 KGI -.- .---_-
!z.-_
She received sulfadiazine until hematuria appeared on September 24, 1943, when it was stopped and mandeiie acid therapy was started. She was discharged on September 2$ 1943, with a diagnosis of pyeloeystitis (right) of pregnancy. Following discharge, she was followed in the clinic with no recurrences or further difficulties until she returned to the 236
TOMLINSON:
NECROSIS OF KIDNEYS
ASD PITUITARY
GLASD
237
hospital on December 25, 1943, with fever, pain and tenderness in the right costovertebral angle of two days’ duration. Temperature on admission was 102OF., rapidly falling to normal in two days. Hemogram was hemoglobin 65 per cent (Tallqvist), 3,450,OOO erythrocytes, 5,250 leucocytes; differential was 68 neutrophiles, 2 eosinophiles,and 30 lymphocytes. The urine on admission showed three-plus pus cells with a few erythrocytes, no albumin, and it continued to show pus cells, but no more erythrocytes. She was placed upon sulfadiazine on admission with good response. Due to the holidays, the patient insisted upon discharge and went home December31,1943. Her last admission was on January 6, 1944, with complaint of cough, backache, fever, and sordes of mouth. IIcr condition had been fair during the interval, and the day of admission was the first time she had a fever (1OOOF‘.). Physical examination revealed multiple sordcrs of the tongue and mouth. Heart and lungs were negative. Blood pressure was 120 mm. of mercury systolic, and 80 mm. of mercury diastolic. The uterus was two fingerbreadths below the xighoid, deflected to the left, with the buttocks in the fundus and soft parts to the right. The head was floating above the symphysis. Fetal heart rate was 140 per minute. Chest roentgenogramwas negative. Sedimentation rate was 90 mm. per hour (Westergren) . Blood serology was negative. The clinical laboratory data are tabulated in Table II. Course in Hospital.-The patient ran a fairly even course on January 7, 8, and 9, with her temperature gradually &mbing to 103” I?., when she was placed on a sulfadiazine routine. January IO.-Tempera.ture 104O F. Few ut,crine contractions, head not engaged, fetal heart fast,. Transfusion (citrate method) of 500 cc. of blood at 2 P.M., with no reactions. January 21.--Temperature 103.5OF. Condition unchanged. Januav-y l2.-Temperature 103O F. Fetal heart tonrs have disappeared, and cervix was dilating slowly. Sulfadiazine discontinued. Jmuwy 13.-Taken fo operating room at 9:50 A.M. and under ether and ethylene anesthesiamidforceps extraction of a female stillborn child was performed at lo:12 A.M. wit,h an episiotomy. The placenta was not expelled, and was manually removed in fragments at 11:20 A.M. It was estimated that the blood loss did not exceed300 cubic centimeters. The patient went into severe shock, almost dying on the table, and was given blood, plasma, fluids, and cardiorespiratory stimulants. Blood pressure was not recorded in operating room; on return to ward it was 90 mm. of mercury systolic and 60 mm. of mercury diastolic. At 10 :00 P.M. blood pressure was 95 mm. of mercury systolic and 60 mm. of mercury diastolic and the patient was comatose. January Id’.---The patient vomited at. intervals. Temperature fell from 101” F. at 1:00 A.M. to 97OI”. at midight and 96” F. at 4:00 A.M. the following morning. Janumy S.-Vomiting, drowsy, condition critical. Anuric. TJreters lavaged, but no crystals were obtained, and no obskuction was encolmtered. January lG.-Patient almost totally anuric. Blood pressure 120 mm. of mercury systolic and 72 mm. of mercury diastolic. Involuntary liquid stools today.
AM ERICAN .JOURNdL
01' OBS1'151'RICS AND GYNECOLOGl
SHmcI,,SV:IJ’
---
-
’-
I,
-
-
TOMLINSON :
NECROSIS OF KIDSEYS
AND PITUITARY
GLAKD
239
January 17.-Voided 80 to 100 C.C. of urine. Some dyspnea and cyanosis present. Given oxygen. Januury 18.-Still partially anuric (voided 250 C.C.in twclvc hours). Condition very grave. Janwwy lg.-At 2:00 P.M. a transfusion of 500 C.C.01 blood (citralc method) was given, with no reaction, The patient expired at 6:13 Iax. Autopsy Pin.din.qs.-The body weight was 128 pounds and length, 66 inches. The breasts were engorgedand milky fluid was easily expressed. There was massive perineal ecchymosis and a posterior episiotomy snturc> line. The brain showed no gross softening, congestion, or hemorrhage. The ventricles were not dilated. Cerebrospinal fluid was clear and of normal amount. The pituitary gland was swollen, tense, and impinging on the infundibulum. It measured 2.3 by 1.5 centimeters. l~‘ollowing fixation in formol-alcohol, sectioning revealed a narrow 2 to 3 mm. rim of darkcl* viable tissue around the anterior lobe surrounding the central soft, vellow-white, necrotic area (Figs. 1 and 2). The sella turcica showed no Llargement.
Fig.
1.---Cut
surface of anterior (Formol-alcohol
lobe of pituitary gland showing fixation.) (Magnification x 6.1
central
necrod.
There were no gross changesin the throat or neck. The thyroid was symmetrical and weighed 35 grams. The pleural spaces were clear. The lungs showed congestion with terminal bronchopneumonia involving the upper and middle lobes of the right lung. There were no infarcts and the pulmonary artery contained no emboli. There was no increase in pericardial fluid. The heart weighed 300 grams and showed no gross changesor anomalies. The aorta was smooth, elastic, and showed no stenosis or dilatation. There were no adhesions or increased fluid in the abdominal cavity. The liver protruded 4 cm. below the costal border. The diaphragm was not elevated. The liver was tense, pale red brown, and the cut edgesbulged. There was no gross hemorrhage or infection. The spleen was congested, swollen, and soft; it weighed 320 grams. The capsule was smooth, blue purple; the cut surface was dark, soft, and semifluid. There was no gross hemorrhage, infarction, or infection.
240
AMERICAN
JOURSAI,
OF (JRSTETRICS \Nl)
(;Y SI*:(‘OIAN~\
Fig. Z.--Cut surfaces of kidneys (left), anterior lobe nf pituitary gland (cente~‘J and I Slightly 1rduced. ;b uterine wal,l (right). ( Fom,c>l.. alcohol flxation.l
The urinary bladder contairrcd 10 C.C. of Icnlon-yellow, cloudy urine. The mucosa around ihc tjrigonc~ was injected. There were multiple retroperitoneal organized hrmorrhagcs ~~wsent aiwund the hladdw. The uterus measured 25 cm. flwtn fundus to wrrical constriction, 20 cm. betweeii the Fallopian fubw, and 12 cm. in dt:pth ill the midportion. The serwa was thickened, whitt:, and free f~vonr esudatc~ or hemorrhage. The Fallopiall tubes and ovaries were normal, postpartum in character. There was marked hemorrhage beneath the peritoneal covering at, the
TOMLISSON
:
SECROSIS OF KIDNEYS
AND PITUITARY
Fig. I.-Section
through edge of anterior lobe of pituitary and jrmction of necwsis. (Magniflcatlon
Fig.
through necrotic area in anterior lobe of pituitary thrombosis of vessels. (Magnification x800.)
I.--Section
GLAND
241
gland showin:: viable cells X X(10.)
gland showing
TOMLINSOK
Fig. &-Section
Fig.
6.-Section
:
NECROSIS OF KIDSEYS
of kidney showing thrombosis (Magnification
oP kidney thrombosed
AXD I’ITUITARY
and rupture X 800.)
GLASD
of an intralobular
243
artery.
showing thrombosis of a&rent arteriole at A, onterjnglomerulus at B. (Magnification X 800.)
TOMLINSQN
:
NECROSIS
OF KIDNEYS
AND
PITUITARY
GLAND
245
sure that any bacterial or toxic factor could be excluded, and that shock was the direct cause. Penner and Bernheim13in a series of experiments with dogs produced severe shock by the intraperitoneal and intrapleural injection of epinephrine hydrochloride. In some of their animals, they found cases of bilateral cortical necrosis of the kidneys which were similar to those that had been reported in human beings and to the human casesthey had studied. They felt that the vasospasmwhich occurs in shock was of sufficient intensity and duration to result in the kidney lesions in some instances. In the case reported here, there were no signs of eclampsia and no autopsy evidence of the usual toxemias of pregnancy. The patient had a severe operative delivery with considerablefrank bleeding, and more concealed bleeding internally. Severe shock developed and following this anuria, drowsiness, fall of temperature, and a persistent hypotension occurred. There was a steady rise in the nonprotein nitrogen and creatinine, with onset of vomiting and diarrhea. The gradual loss of hemoglobin and erythrocytes must have occurred as a result of bleeding from the kidneys, inasmuch as the icterus index was not elevated and there were no other bleeding points. Summary In the case reported here, there was combined necrosisof the anterior lobe of the pituitary gland and the cortices of the kidneys. The histologic picture of the pituitary and kidney changeswas compatible with five to six days’ thrombosis. The clinical picture was typical, and no evidence of other factors was found at autopsy. The collapse and shock at delivery was extreme, and it is felt that the changesfound were initiated then. Added support is given to the belief that postpartum necrosis of the anterior lobe of the pituitary gland and bilateral renal cortical necrosismay be caused,in many instances, by severeshock in reporting here a case showing both of these conditions occurring simultaneously in the same patient,. References 1. Gotshalk, H. C., and Tilden, I. L.: J. A. M. A. 114: 33, 1940. 2. Brown, Clark E., and Eder, Lawrence F.: Am. J. M. SC. 198: 166, 1939. Reekie, R. D.:
West. J. Burg. 50: 293, 1942.
2 Cunningham, J. F., McGrath, J., O ’Donovan, D. K., and de Valera, E.: Irish J. M. SC. 519, September, 1942. Sheehan, H. L.: J. Path. & Bact. 45: 189, 1937. t!: Sheehan, H. L., and McLetohie, N. G. B.: J. Obst. & Gynaec. Brit. Emp. 50: 27, 1943. 7. Hutchinson, H. E.: J. Path. & Bact. 51: 442, 1940. 8. Ash, J. E.: Am. J. M. SC. 185: 71, 1933. 9. De Navasquez, S.: J. Path. & Bact. 41: 385, 1935. 10. Dunn, J. S., and Montgomery, G. L.: J. Path. & Bact. 52: 1, 1941. 11. Godwin, B., and McCall, A. J.: Lancet 2: 512, 1941. 12. McFarlane, D.: J. Path. & Bact. 52: 406, 1941. 13. Penner, A., and Bernheim, A. I.: Arch. Path. 30: 4&j, 1940.