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Report of a case of hyperemesis gravidarum with necropsy
REPORT
OF A CASE OF ABNORMAL FETUS RADIATION OF THE MOTHER BY IRA I. KAPLAN,
(Director
Division
of
Cmwr,
FOLLOWING
B.S., M.D., NEW YORK, N. P.
Drparhwnt Ecllerue
of Hospitals,
and
Ratliatio,~
l’kerapist,
Rospitcz7)
T
HE effect of radiation on the oncoming progeny remains a much mooted yuestion. Various suppositions have been offered as explanations for the birth of abnormal children of radiated mothers. Abnormal children have been born following the radiation of the mother, but then, too, radiated mothers have given birth to normal offspring as reported by Williamson, Rubin, Ka.ne and myself. It is axiomatic in radiation therapy that the more embryonic the tissue the more sensitive it is to the effect of the x-rays. A fetus, being obviously most embryonic in character, should therefore be extremely sensitive to x-rays. The age of the fetus has a great deal to do with the degree of sensit,iveness as is evident from the report of the births of a number of children following radiation applied to them in utero. Moreover, examination of several fet,nses removed from the uterus following irradiation of the mother showed the embryo unharmed by the rays. It is no doubt reasonable, however, to assume t,hat. a very early fetus formation in utero is definitely destroyed by the x-rays, Parkes claims that the termination of pregnancy is the most striking result at that period. This has been shown in such cases where the x-rays had been used to abort a pregnant mother, as reported by Wyser and others. In the treatment of amenorrhea and sterility the x-rays have been used as a stimulating agency and children born following such treatment of the mother had been normal and healthy. For this reason the birth of the abnormal child in the case herewith reported is of especial interest. has one child four years old. Since age of L. M., married, aged twenty-seven, eighteen had been under treatment by a competent gynecologist for irregular menShe miscarried in March, 1929, menstruated struation, miscarriage, an d sterility. in May, 1929, and September, 1929, her last menstruation occurring in November, Radiation was suggested in that 1929, and none appearing up to April, 1930. Before receiving x-ray treatment she was examined by her gynecologist month. and the presence of gestation in the uterus was not noted. The patient herself stated she was not pregnant. Accordingly x-rag therapy was given on April 9, 15, and 22, a total dose of 12 per cent being delivered to the ovaries. A month later the patient reported that evidently no action had followed the x-ray treatment. In June she reported being pregnant, went into labor November 1, and mas delivered of a stillborn child which was abnormal in form. Described by the attending physician as follows : Rtillboru monstrosity, hydrocephalic, distorted atrophic features, rudimentary nares, body fairly well developed, extreme polyhydramnios present. 4%
HARRISON
:
HYPEREMESIS
429
GRAVIDARUM
The most notable observation was obstinate constipation. In fact not one entirely satisfactory bowel movement was recorded. Examination on December 5 at 1:30 A.M. disclosed an emaciated colored woman who answered questions rather slowly and who seemed more or less dazed. The skin was dry and the feet cold. Her blood pressure was 100/88; temperature 97.8” ; pulse 140 and respirations 26. The lips were dry and fissured. There was no glandular enlargement in the neck. The lungs were clear and other than a rapid rate the heart appeared normal. The abdomen was distended. The percussion note was tympanitic. Above the symphysis could be felt the upper border of an oval mass. The cervix was soft and deep in the pelvis. The uterus was outlined above the cervix and was approximately 15 cm. in diameter. The clinical diagnosis was hyperemesis gravidarum, with a very discouraging
Fig. Fig. 3.-Liver, (Low power.) Fig. I.-Liver,
3
Fig.
showing areas of marked fatty degeneration (These areas are numerous throughout organ.) showing fatty change. (High power.)
4 and
infiltration.
outlook. Intensive supportive measures were instituted. For about twelve hours there was some improvement after which she began to decline and died about twenty-four hours later. Three hours after death a necropsy was performed by Dr. J. C. Norris whose report follows: The heart was not enlarged. The right side was soft and dilated. The liver was normal in size but was pale and flabby. The cut surface had a greasy appearance. The spleen was soft and was slightly enlarged. The kidneys were swollen and showed cortical petechiae. There was a moderate nephritis. The uterus was soft, 16 cm. in diameter and contained a four months’ fetus. The placenta, overlies the internal OS. The anatomic diagnoses were: (1) Generalized toxemia : (a) Toxic myocarditis dilatation, (b) congestive pneumonitis, (c) toxic hepatitis, (d) toxic splenitis, toxic nephritis. (2) Dehydration, (3) anemia, (4) pregnancy at four months placenta previa. Blood chemistry : Sugar 60 mg. per 100 cc. Nonprotein nitrogen 100 mg. per 100 cc. The histologic diagnoses are: Congestion of pulmonary alveoli, edema ; cloudy swelling of heart cells; fatty degeneration and infiltration of liver, with cloudy swelling ; cloudy swelling and hyperplasia of spleen; cloudy swelling with degenerative changes of kidneys, marked in the tubules. The glomeruli are hypertrophied. The vessels are empty.
with (e) with
1111
MEDICAL
ARTS
BUILDING.
OF A CASE OF ABNORMAL FETUS RADIATION OF THE MOTHER BY IRA I. KAPLAN,
(Director
Division
of
Cmwr,
FOLLOWING
B.S., M.D., NEW YORK, N. P.
Drparhwnt Ecllerue
of Hospitals,
and
Ratliatio,~
l’kerapist,
Rospitcz7)
T
HE effect of radiation on the oncoming progeny remains a much mooted yuestion. Various suppositions have been offered as explanations for the birth of abnormal children of radiated mothers. Abnormal children have been born following the radiation of the mother, but then, too, radiated mothers have given birth to normal offspring as reported by Williamson, Rubin, Ka.ne and myself. It is axiomatic in radiation therapy that the more embryonic the tissue the more sensitive it is to the effect of the x-rays. A fetus, being obviously most embryonic in character, should therefore be extremely sensitive to x-rays. The age of the fetus has a great deal to do with the degree of sensit,iveness as is evident from the report of the births of a number of children following radiation applied to them in utero. Moreover, examination of several fet,nses removed from the uterus following irradiation of the mother showed the embryo unharmed by the rays. It is no doubt reasonable, however, to assume t,hat. a very early fetus formation in utero is definitely destroyed by the x-rays, Parkes claims that the termination of pregnancy is the most striking result at that period. This has been shown in such cases where the x-rays had been used to abort a pregnant mother, as reported by Wyser and others. In the treatment of amenorrhea and sterility the x-rays have been used as a stimulating agency and children born following such treatment of the mother had been normal and healthy. For this reason the birth of the abnormal child in the case herewith reported is of especial interest. has one child four years old. Since age of L. M., married, aged twenty-seven, eighteen had been under treatment by a competent gynecologist for irregular menShe miscarried in March, 1929, menstruated struation, miscarriage, an d sterility. in May, 1929, and September, 1929, her last menstruation occurring in November, Radiation was suggested in that 1929, and none appearing up to April, 1930. Before receiving x-ray treatment she was examined by her gynecologist month. and the presence of gestation in the uterus was not noted. The patient herself stated she was not pregnant. Accordingly x-rag therapy was given on April 9, 15, and 22, a total dose of 12 per cent being delivered to the ovaries. A month later the patient reported that evidently no action had followed the x-ray treatment. In June she reported being pregnant, went into labor November 1, and mas delivered of a stillborn child which was abnormal in form. Described by the attending physician as follows : Rtillboru monstrosity, hydrocephalic, distorted atrophic features, rudimentary nares, body fairly well developed, extreme polyhydramnios present. 4%
HARRISON
:
HYPEREMESIS
429
GRAVIDARUM
The most notable observation was obstinate constipation. In fact not one entirely satisfactory bowel movement was recorded. Examination on December 5 at 1:30 A.M. disclosed an emaciated colored woman who answered questions rather slowly and who seemed more or less dazed. The skin was dry and the feet cold. Her blood pressure was 100/88; temperature 97.8” ; pulse 140 and respirations 26. The lips were dry and fissured. There was no glandular enlargement in the neck. The lungs were clear and other than a rapid rate the heart appeared normal. The abdomen was distended. The percussion note was tympanitic. Above the symphysis could be felt the upper border of an oval mass. The cervix was soft and deep in the pelvis. The uterus was outlined above the cervix and was approximately 15 cm. in diameter. The clinical diagnosis was hyperemesis gravidarum, with a very discouraging
Fig. Fig. 3.-Liver, (Low power.) Fig. I.-Liver,
3
Fig.
showing areas of marked fatty degeneration (These areas are numerous throughout organ.) showing fatty change. (High power.)
4 and
infiltration.
outlook. Intensive supportive measures were instituted. For about twelve hours there was some improvement after which she began to decline and died about twenty-four hours later. Three hours after death a necropsy was performed by Dr. J. C. Norris whose report follows: The heart was not enlarged. The right side was soft and dilated. The liver was normal in size but was pale and flabby. The cut surface had a greasy appearance. The spleen was soft and was slightly enlarged. The kidneys were swollen and showed cortical petechiae. There was a moderate nephritis. The uterus was soft, 16 cm. in diameter and contained a four months’ fetus. The placenta, overlies the internal OS. The anatomic diagnoses were: (1) Generalized toxemia : (a) Toxic myocarditis dilatation, (b) congestive pneumonitis, (c) toxic hepatitis, (d) toxic splenitis, toxic nephritis. (2) Dehydration, (3) anemia, (4) pregnancy at four months placenta previa. Blood chemistry : Sugar 60 mg. per 100 cc. Nonprotein nitrogen 100 mg. per 100 cc. The histologic diagnoses are: Congestion of pulmonary alveoli, edema ; cloudy swelling of heart cells; fatty degeneration and infiltration of liver, with cloudy swelling ; cloudy swelling and hyperplasia of spleen; cloudy swelling with degenerative changes of kidneys, marked in the tubules. The glomeruli are hypertrophied. The vessels are empty.
with (e) with
1111
MEDICAL
ARTS
BUILDING.