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Obstetrical Society of Philadelphia Stated Meeting November 3, 1921
540
THE AMERICAN JOURNAL OF OBSTETRICS ASD GYNECOLOGY
As subinvolution is very frequently present in large uteri removed at operation, one might also ask the question, ''If this condition has anything to do with the causation of adenomyoma, why do we not find it more frequently~" I feel that this might be explained by the fact that frequently in subinvoluted uteri we have an endometrium which is rather atrophic and it might be expected that such an endometrium would have less tendency to invade these clefts than a normal or more active endometrium might have. In regard to the clinical aspect considerable data are embodied in the paper which I neglected to n1ention. In our series there were only six nulliparous uteri; in Cullen's series there were fifteen. Menorrhagia was found most frequently in those cases with hyperplasia of the eadometrium, which occurred in about twenty-six cases of my series. In every instance where hyperplasia was very definite the menorrhagia was quite profuse. This was also true of the eases of hyperplasia in Cullen's series. In the cases of subinvolution in my series only one-half gave a history of increased bleeding. In the cases of myoma alone, both nulliparous and multiparous, there was no hemorrhage in several.
OBSTETRICAL SOCIE'rY OF PHILADELPHIA STATED MEETING NOVEMBER 3, 1921 THE PRESIDENT, DR. JoHN
A.
McGLINN, rN THE CHAIR
VR. AUGUSTUS KORNDOERFFER
read (by invitation) a paper entitled Further Experiences with Pituitary Extracts in Obstetrics.
After enumerating the clinica.l indications for the employn1ent of pituitary preparations, Dr. Korndoerffer stated that an exhaustive search of the literature failed to disclose any references to the use of this substance for the control of after-pains. Without attempting to enter into a prolonged discussion of the etiology of this condition, Dr. Korndoerffer stated his belief that an altered endocrine function or disturbance existed as the basal cause of the same. He assumed that if ergot had a sphere of action in this condition, the pituitary preparations would possess a similar one and it is therefore logical to inquire whether any objection could be offered to the use of pituitrin for the control of afterpains. In his own experience a variety of remedies usually employed for this pur· pose had proved unsatisfactory or disappointing. Dr. Korndoerffer based his indications on a study of the physiological action of the drug obtained from the literature. A routine order was issued in the maternity department of the Children's Homeopathic Hospital of Philadelphia that all cases of after-pains be treated with pituitrin. It was given in one mg. doses and while. some cases suffered a short tempomry aggravation, all others were relieved. As for contraindications, Dr. Korndoerffer 's experience included neither uncompensated heart lesions, threatened respiratory colla,pse, nor arteriosclerosis. It was also given in cases of high blood pressure without ill effects. In the latter case he based his indications on the statement made by Heaney, of Chicago, who showed that in healthy individuals there is no rise in blood pressure if the injection is n1ade subcutaneously and that it only occurs if intramuscular or intravenous injections are employed. In cases of acute nephritis in pregnancy pituitrin was administel·ed in 1 mg. doses w;thout bad results. In no instance was a:ny depression
OBSTETRICAL SOCIETY OF PHILADELPHIA
541
noted. Convalescence seemed to be uninfluenced during the employment of the drug and the essayist concluded that pituitrin was a most useful and praeti0ally harmless means of relievh,g troublesome after-pains. DISCUSSION DR. vVILLIAM E. PARKE.-I have never given pituitrin vvith the distinct purpose of controlling the after-pain. I have given it for bleeding and, so far as I know, the nurse has given it practically always intramuscularly and not subcutaneously. The occasions on which I would give it would be after long, tedious labors when I feared postpartum hemorrhage, or when there was actually an excessive amount of bleeding without a distinct hemorrhage. I have not thought of it along this line enough to know whether it was a factor in controlling after-pains in these particular instances. DR. DANTEL LONGAKER.-With reference to the use of pituitrin after a.elivery, during the last six months it has been my practice routinely to administer 1 e.e. of pituitrin intramuscularly immediately on the delivery of the baby. I do believe in the speaker's contention that there has been less after"pain than when not given. DR. LIDA S'l'EWART COGILL.-I would like to ask Dr. Korndoerffer how he explains the action of pitui.trin in relieving the pain, He spoke of the pituitrin producing muscle contraction and yet not being followed by any ex· pulsion of clots, of its making the uterus firm and causing involution to go on much more rapidly. In the Maternity at the Woman's Hospital, we have not used pituitrin for after"pains. In fact we have very few of our multiparae complain· ing of after-pain where we are sure the uterus is kept free of clots. We are using less and less after"pain medication of any kind. DR. J. E ..JAMES.-! think one can readily agree upon the dearth of material relative to any accurate data or consideration upon the subject of after-pains, which necessarily, therefore, makes the present· consideration of the subject a most important one. PatientB oftentimes will complain more bitterly of afterpains than of the actual suffering during the eoursCj of labor. I think we can all readily agl·ee, likewise, that the usual agents recommended, namely, ergot and opium, prove failurPs in the constant control of this most annoying condition of the puerperium. In my own clinic we have been using pituitrin for the past :vear or two in plaee of the different preparations of ergot as administered by mouth and rectum, but, in more or less of a haphazard fashion. Our attention has recently been called to the possibilities of this therapeutic agent by Dr. Korndoerffer in varied dosage and type of administration. Acting upon his recommendation for its use, I have been very agreeably surprised in many instances in the almost immediate effect in the control of the after-pain. Like e1·got, it l1as not proved to be a specific or a panacea, but in the majority of 'lustanees, it has either immediately controlled, or produced amelioration. In ·two very rec:ent eases .• for example, after the administration of pituitrin, there ·1vas noted an aggravation for a period of one hour, but subsequent to this time, the patients were absolutely comfortable and remained so. In another case, .even though the pituitrin was repeated several times, there was absolutely no ,effect on the pains. In a general way, in my own experience, it l1as seemed that pituitrin offers itself as a much more potent therapeutic agent under such circumstances than our former remedies. We naturally propose to continue its use in a series of cases in order to see comparative results.
542
'THE cl.~IERICA".f JOURXAL 0_,;' ;)BSTETRICS ~'>-XD GYSEOOLOGY
:;)R.. KORRDOEHFFJDR (elosing-)~-i an1 perfectly frank to say I CfU.lllU~ oxplain the action of pituitrin in this condition. I will say that where ;: llave given ergot we have seen absolutely no blood clots come from the uterus !allowing its administration. I think it is begging the question when obstetcicians state that the after-pains are due to retention of minute clots. The fact :·omains that I have seen severe after-pains where no membrane was discharged tt any time and it is that fact which makes me believe there is a deeper cause .;xplaining the after-pains. It is my impression that these pains are due to CJ:tered condition of the posterior lobe and although we know it is the anterior 'obe of the pituitary which most actively participates in the hypertrophy of )regnancy, I cannot but believe that the anterior is closely correlated to the 'JOsterior lobe. I believe there exists a condition of what may be described as 'lypopituitarism although I believe the word is poorly chosen and does not express ~he thought we wish to convey. I believe there is an altered pituitary secretion. Whether that is altered in quantity or quality I do not stand willing to say and ' believe that that primarily is the way the after-pain is relieved.
A Symposium on the Treatment of Cancer of the Uterus with Radhun DR. WILLIA::i-f L. CLARK.-When I first engaged in the study of electricity '.n '.·elation to the treatment of malignant disease nearly fifteen years ago the Jnly serious methods employed by gynecologists for the treatment of cancer Radium at that 'ime was not considered a potent agent in the treatment of malignant disease. Che curette and cautery were extensively employed as a palliative agent to get :id of the gross diseased mass, to stop bleeding, to deodorize, and to inhibit the Jisease. This treatment was invariably followed by recurrence, since the super'icial action of the curette and cautery was inadequate to remove all the disease, out the use of these measures was, however, amply justified as a palliative in 'he absence of any more potent remedial measure. The results obtained by ·adical operative s~rgery, even in the early cases were unsatisfactory except :n a very small percentage, hence treatment of cancer of the uterus was in a :l1aotic state and any improvement of these eases by any means was considered xue gain. My studies with the high frequency currents led me to believe that these c-ould be used to advantage as a substitute for the eurette and cautery as a yalliative and possibly in selected cases, if seen early enough, could effect a cure. The reason for this belief was based upon the following observations: 1. The heat penetration and deep destruction of tissue could be accomplished :Jy this means, whereas the effect of· the ordinary cautery application was eom:_,aratively superficial. 2. That the gross mass of cancerous tissue could be coagulated to any depth -1uickly and thoroughly. 3. That this treatment was not accompanied by bleeding; indeed, that severe 'H~morrhage could be stopped immediately. 4. Thnt hlooc1 and lymph channels could be senled, thereby avoiding reinfec:~ion, and inhibiting extension of disease and metastasis. 5. Results of experiments seemed to indicate that the heat penetration beyond UJe area actually coagulated had an inhibitory or destructive effect upon caneerous cells in the broad ligaments and even in the pelvic glands. This belief was based upon the fact that cancer cells succumb to a lower degree of heat :;i1an normal cells with recovery of normal cells. 6. That, owing to thorough sterilization of the cancerous mass, it could be Jeodorized.
•>f the uterus were the curette, cautery, and operative surgery.
THE AMERICAN JOURNAL OF OBSTETRICS ASD GYNECOLOGY
As subinvolution is very frequently present in large uteri removed at operation, one might also ask the question, ''If this condition has anything to do with the causation of adenomyoma, why do we not find it more frequently~" I feel that this might be explained by the fact that frequently in subinvoluted uteri we have an endometrium which is rather atrophic and it might be expected that such an endometrium would have less tendency to invade these clefts than a normal or more active endometrium might have. In regard to the clinical aspect considerable data are embodied in the paper which I neglected to n1ention. In our series there were only six nulliparous uteri; in Cullen's series there were fifteen. Menorrhagia was found most frequently in those cases with hyperplasia of the eadometrium, which occurred in about twenty-six cases of my series. In every instance where hyperplasia was very definite the menorrhagia was quite profuse. This was also true of the eases of hyperplasia in Cullen's series. In the cases of subinvolution in my series only one-half gave a history of increased bleeding. In the cases of myoma alone, both nulliparous and multiparous, there was no hemorrhage in several.
OBSTETRICAL SOCIE'rY OF PHILADELPHIA STATED MEETING NOVEMBER 3, 1921 THE PRESIDENT, DR. JoHN
A.
McGLINN, rN THE CHAIR
VR. AUGUSTUS KORNDOERFFER
read (by invitation) a paper entitled Further Experiences with Pituitary Extracts in Obstetrics.
After enumerating the clinica.l indications for the employn1ent of pituitary preparations, Dr. Korndoerffer stated that an exhaustive search of the literature failed to disclose any references to the use of this substance for the control of after-pains. Without attempting to enter into a prolonged discussion of the etiology of this condition, Dr. Korndoerffer stated his belief that an altered endocrine function or disturbance existed as the basal cause of the same. He assumed that if ergot had a sphere of action in this condition, the pituitary preparations would possess a similar one and it is therefore logical to inquire whether any objection could be offered to the use of pituitrin for the control of afterpains. In his own experience a variety of remedies usually employed for this pur· pose had proved unsatisfactory or disappointing. Dr. Korndoerffer based his indications on a study of the physiological action of the drug obtained from the literature. A routine order was issued in the maternity department of the Children's Homeopathic Hospital of Philadelphia that all cases of after-pains be treated with pituitrin. It was given in one mg. doses and while. some cases suffered a short tempomry aggravation, all others were relieved. As for contraindications, Dr. Korndoerffer 's experience included neither uncompensated heart lesions, threatened respiratory colla,pse, nor arteriosclerosis. It was also given in cases of high blood pressure without ill effects. In the latter case he based his indications on the statement made by Heaney, of Chicago, who showed that in healthy individuals there is no rise in blood pressure if the injection is n1ade subcutaneously and that it only occurs if intramuscular or intravenous injections are employed. In cases of acute nephritis in pregnancy pituitrin was administel·ed in 1 mg. doses w;thout bad results. In no instance was a:ny depression
OBSTETRICAL SOCIETY OF PHILADELPHIA
541
noted. Convalescence seemed to be uninfluenced during the employment of the drug and the essayist concluded that pituitrin was a most useful and praeti0ally harmless means of relievh,g troublesome after-pains. DISCUSSION DR. vVILLIAM E. PARKE.-I have never given pituitrin vvith the distinct purpose of controlling the after-pain. I have given it for bleeding and, so far as I know, the nurse has given it practically always intramuscularly and not subcutaneously. The occasions on which I would give it would be after long, tedious labors when I feared postpartum hemorrhage, or when there was actually an excessive amount of bleeding without a distinct hemorrhage. I have not thought of it along this line enough to know whether it was a factor in controlling after-pains in these particular instances. DR. DANTEL LONGAKER.-With reference to the use of pituitrin after a.elivery, during the last six months it has been my practice routinely to administer 1 e.e. of pituitrin intramuscularly immediately on the delivery of the baby. I do believe in the speaker's contention that there has been less after"pain than when not given. DR. LIDA S'l'EWART COGILL.-I would like to ask Dr. Korndoerffer how he explains the action of pitui.trin in relieving the pain, He spoke of the pituitrin producing muscle contraction and yet not being followed by any ex· pulsion of clots, of its making the uterus firm and causing involution to go on much more rapidly. In the Maternity at the Woman's Hospital, we have not used pituitrin for after"pains. In fact we have very few of our multiparae complain· ing of after-pain where we are sure the uterus is kept free of clots. We are using less and less after"pain medication of any kind. DR. J. E ..JAMES.-! think one can readily agree upon the dearth of material relative to any accurate data or consideration upon the subject of after-pains, which necessarily, therefore, makes the present· consideration of the subject a most important one. PatientB oftentimes will complain more bitterly of afterpains than of the actual suffering during the eoursCj of labor. I think we can all readily agl·ee, likewise, that the usual agents recommended, namely, ergot and opium, prove failurPs in the constant control of this most annoying condition of the puerperium. In my own clinic we have been using pituitrin for the past :vear or two in plaee of the different preparations of ergot as administered by mouth and rectum, but, in more or less of a haphazard fashion. Our attention has recently been called to the possibilities of this therapeutic agent by Dr. Korndoerffer in varied dosage and type of administration. Acting upon his recommendation for its use, I have been very agreeably surprised in many instances in the almost immediate effect in the control of the after-pain. Like e1·got, it l1as not proved to be a specific or a panacea, but in the majority of 'lustanees, it has either immediately controlled, or produced amelioration. In ·two very rec:ent eases .• for example, after the administration of pituitrin, there ·1vas noted an aggravation for a period of one hour, but subsequent to this time, the patients were absolutely comfortable and remained so. In another case, .even though the pituitrin was repeated several times, there was absolutely no ,effect on the pains. In a general way, in my own experience, it l1as seemed that pituitrin offers itself as a much more potent therapeutic agent under such circumstances than our former remedies. We naturally propose to continue its use in a series of cases in order to see comparative results.
542
'THE cl.~IERICA".f JOURXAL 0_,;' ;)BSTETRICS ~'>-XD GYSEOOLOGY
:;)R.. KORRDOEHFFJDR (elosing-)~-i an1 perfectly frank to say I CfU.lllU~ oxplain the action of pituitrin in this condition. I will say that where ;: llave given ergot we have seen absolutely no blood clots come from the uterus !allowing its administration. I think it is begging the question when obstetcicians state that the after-pains are due to retention of minute clots. The fact :·omains that I have seen severe after-pains where no membrane was discharged tt any time and it is that fact which makes me believe there is a deeper cause .;xplaining the after-pains. It is my impression that these pains are due to CJ:tered condition of the posterior lobe and although we know it is the anterior 'obe of the pituitary which most actively participates in the hypertrophy of )regnancy, I cannot but believe that the anterior is closely correlated to the 'JOsterior lobe. I believe there exists a condition of what may be described as 'lypopituitarism although I believe the word is poorly chosen and does not express ~he thought we wish to convey. I believe there is an altered pituitary secretion. Whether that is altered in quantity or quality I do not stand willing to say and ' believe that that primarily is the way the after-pain is relieved.
A Symposium on the Treatment of Cancer of the Uterus with Radhun DR. WILLIA::i-f L. CLARK.-When I first engaged in the study of electricity '.n '.·elation to the treatment of malignant disease nearly fifteen years ago the Jnly serious methods employed by gynecologists for the treatment of cancer Radium at that 'ime was not considered a potent agent in the treatment of malignant disease. Che curette and cautery were extensively employed as a palliative agent to get :id of the gross diseased mass, to stop bleeding, to deodorize, and to inhibit the Jisease. This treatment was invariably followed by recurrence, since the super'icial action of the curette and cautery was inadequate to remove all the disease, out the use of these measures was, however, amply justified as a palliative in 'he absence of any more potent remedial measure. The results obtained by ·adical operative s~rgery, even in the early cases were unsatisfactory except :n a very small percentage, hence treatment of cancer of the uterus was in a :l1aotic state and any improvement of these eases by any means was considered xue gain. My studies with the high frequency currents led me to believe that these c-ould be used to advantage as a substitute for the eurette and cautery as a yalliative and possibly in selected cases, if seen early enough, could effect a cure. The reason for this belief was based upon the following observations: 1. The heat penetration and deep destruction of tissue could be accomplished :Jy this means, whereas the effect of· the ordinary cautery application was eom:_,aratively superficial. 2. That the gross mass of cancerous tissue could be coagulated to any depth -1uickly and thoroughly. 3. That this treatment was not accompanied by bleeding; indeed, that severe 'H~morrhage could be stopped immediately. 4. Thnt hlooc1 and lymph channels could be senled, thereby avoiding reinfec:~ion, and inhibiting extension of disease and metastasis. 5. Results of experiments seemed to indicate that the heat penetration beyond UJe area actually coagulated had an inhibitory or destructive effect upon caneerous cells in the broad ligaments and even in the pelvic glands. This belief was based upon the fact that cancer cells succumb to a lower degree of heat :;i1an normal cells with recovery of normal cells. 6. That, owing to thorough sterilization of the cancerous mass, it could be Jeodorized.
•>f the uterus were the curette, cautery, and operative surgery.