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The leucocyte count in labor
WOLFF
:
LEUCOCYTE
COUNT
IN
611
LABOR
DR. CARTER (closing).-With regard to manual dilatation of the cervix at the time of cesarean section, I do not attempt to put a finger through the cervix in those patients who have been in labor, but I do in all patients in whom the section is elective. The reported se&ion was comparable to an elective one, since there was no opening in the cervix and marked edema masked the structures. Some years ago when I served as House Surgeon in the New York Lying-in Hospital, under the late Dr. Asa B. Davis, I assisted Dr. Davis in performing a cesarean section in which the cervix was left undisturbed. In this patient there was an absence of drainage through the vagina. On the third day she developed a temperature of 105’. I made a vaginal examination and found a dimple in the external OS, through which I inserted my finger. Immediately there occurred a 2 cm. dilatation with a drainage of about 2 tablespoonsful of pus. The patient then ran :I normal convalescence. The same thing occurred in one of my patients at the Baptist Hospital in New Orleans, in whom the cervix failed to dilate after cesarean section. Vaginal examinat,ion disclosed a closed cervix through which the finger was inserted, resulting in evacuation of pus. The convalescence of this patient was also normal thereafter.
TEE
LEUCOCTTE
JOHX (From.
the Department
a. of
WOLFF,
COUNT KD.,
IN LABOR”
CHICAGO, ILL.
Obstetrics and Gynecology, College of Medicine)
Oniversity
of
Illinois
T
HE leucocyte count is a valuable laboratory procedure. It is a de% nite aid to the diagnosis, prognosis, and management of many disease processes. Its adaptation to obstetrics has largely been in the field of the associated medical and surgical complications. The occurrence of a leucocytosis during labor has been known since the observations of Moleschattl in 1854 and Reider* in 1892. Although many individuals have studied the problem, t,he detailed relationship of the leucocyte rise to the clinical course of labor has not been determined. The following observations are reported in order to establish a “norm” beeause of the clinical significance the count might have when considering complicated cases. In 1898 Hibbard and Whites noted that during labor the leucocyte count rose This leucocytosis diminishes to 15,000 in primipara and 11,700 in multipara. with a slight elevation on the sixth day and a rapidly during the puerperium, normal count thereafter. In 1902 Habla studied 36 cases in the last months of pregnancy, during labor, He stated that there is a slight increase in the and the first week post partum. leucoeyte count in the last few days of pregnancy, followed by a marked leucoThis diminishes rapidly and is normal by the cytosis at the beginning of labor. end of the first week post partum. The rise is in the polymorphonuclear cells. Cartons in 1903 found that a polymorphonuclear leucocytosis occurs during the last month of pregnancy, increases during labor, and is normal shortly afterwards. He found that the rise is more marked when the child is born dead or macerated, or when twins are present. Given6 (1906) reported the average count to be 10,500 before labor, 16,000 twenty-four hours afterwards, and 7,000 by the twelfth day. *presented before the Twelfth Annual stetricians and Gynecologists, Indianapolis.
aieeting of the Central Association Ind., October 10, 1940.
of Ob-
612
AMERICAN
JOURNAL
OF
OBSTETRICS
AND
GYNECOLOGY
Blumenthali (1907) noted that the leucocytosis was more marked after separaof the placenta than in the first stage and that the count lessened after rupof the membranes. In 1910 Horvaths stated that the pedc of the leucocytosis occurred three to seven hours after delivery. Baers in 1916 studied 100 cases in which he took counts during labor and one In primiparas the average count daily thereafter for ten consecutive days. was 18,225 during labor, with 19,887 as t,he high point on the first postpartum day. Multiparas revealed 13,467 cells during labor, with a high of 15,062 on the first puerperal day. He found the count to be higher during obstructed labor and after There was a gradual decrease to a normal count withrupture of the membranes. in seven to ten days. Jarrho, Fawcett,rl Cabot,ia and others reached similar r~nnclusions. Gibsoni: in IRS7 investigated the subject in 38 normal cases. She recorded findings at the end of pregnancy, the height of labor, several times during the first twenty-four hours following delivery, and daily for two weeks in the puerperium. She observed a slight rise at the end of pregnancy and a much greater rise at the end of labor, with the highest average in the “birth to two-hour” period. Counts ranging from 10,000 to 39,800 occurred during the first six hours after delivery in normal women. The same type of leucocytosis was observed in l~rirniparas as in multiparas. hut in t.he former it tended to be higher and 10 last longer. tion ture
E’ifty normal women were observed shortly following the onset of labor to the termination of the eight-day hospital puerperium. Twenty-five were primiparas and 55 were multiparas. Leueocyte counts were made at intervals of one to two hours short,lp following the onset of labor until delivery. Counts were then made at delivery, before and after the use of oxgtocics, and after the delivery of the placenta. The hemoglobin and erythrocyte counts were likewise observed in 10 patients, but as these factors remained constant regardless of the change in the leucocytes further observations were not made. The standard technique of making a leucocyte count from blood obtained by capillary puncture of the ear or finger, as described in all texts, was followed. Several eases of rapid labor, primary uterine inertia, secondary uterine inertia, and “obstructed” labor were also ohserved. RESULTS
Twenty-one of the 50 normal patients were seen during the last weeks of pregnancy. In these patients the counts varied from 5,750 to 12,200. The average count was 8,054. All patients were seen from one to four hours following the onset of the symptoms of labor. In the L’l patients who had been ohxerved before labor began, the caounts at this time varied from 7,600 to 12,850. In all cases there was a slight rise over the previous figure. The remainder of the 50 cases revealed similar counts, the average for this time of labor being 10,24i. As labor progressed the leueocytes gradually increased. When the cervical OS hecame dilated 4 cm. and the average labor pain was occurring every five minutes and lasting thirty to seventy seconds, the leucoeyte counts varied from 8,240 to 14,050, the average being 11,456. When the dilatation of the cervix had increased to 8 cm., the counts varied between 10,450 and 15,620. The average count was 13,635. At approximately the onset of the second stage of labor the average count was 15,150. At this time the leucocytes ranged from 11,120 to 23,650. Many leucocpte counts were made before, during, and after uterine contractions during t.he first and second stages of labor. No appreciable difference was noted. Rupture of the membranes in itself did not influence the count; that is, the general pattern of the leucocyte rise, as observed in all cases, continued regardless of the time of the rupture of the membranes. Cases of so-called dry labor (14 of the 50 eases) likewise did not show any difference from the normal.
WOLFF
:
LEUCOCYTE
COUNT
IN
LABOR
613
Primiparas were observed every fifteen to twenty minutes during the second stage of labor. The leucocytosis continued, but in a more rapid fashion, The second stage of labor averaged two hours and eight minutes in these cases. The average count at the time of delivery was 22,250, with counts ranging from 14,760 to 27,640.
Fig.
l.-The
leucocyte
count
in labor
in primiparas.
Fig.
Z.-The
leucocyte
count
in labor
in multiparas.
This leucocytosis was also observed in multiparas. Counts taken near the end of pregnancy and shortly following the onset of labor revealed changes as reported above. As labor progressed, the leucocytosis continued. The counts gradually rose to 13,754 (11,980 to 14,640) when 6 to 8 cm. cervical dilatation had been reached. Because the progress was usually rapid after. this stage of labor had been reached, counts were then usually taken just before, during, and after delivery. The count at the time of delivery varied from 13,250 to 16,880, the average being 15,270. The third stage of normal labor did not affect the leucocyte count.
614
AXWRICAS
.JOURNi;\I.
OF
OBSTETRICS
.\IZD
(;YSECOLOG1
I?ollowiny delivery, counts were taken lIefore, during, an11 at various inlervals after the routine use of pituitrin and ergot. No change was noted. The majority of women were also examined during the puerperium. The leucocyte count gradually returued to normal by the seventh dar. Nine patients had a count slightly higher than that notr(l at delivery on the irst puerperal day. Eleven cases of short lalmrs (three to seven hours) were observed. Six were multiparas and fi\-e were primiparax. In all cases a slight increase in the leucocytes occurred shortly following the onset of labor, :I gradual rise continued, and at delivery the count, varied from 13,600 to 17,430, the average being 14,9SO. Four cases of primary uterine inertia were studied, all in primiparaa. The labors varied from fifty-four to sixty-eight hours. They were all characterized by weak, infrequent, and irregular ut-erine contrartions tluriug the first stage of labor. Progress was slow until a cervical dilatation of 5 tu 7 cm. was reached, when the labor pains increase{1 so that tlelivery followed shortly. (lonservativr thnapeutic~ mr~asures were until. 7’1~ count ros,’ slightly foilowing the onset of labor. IJuring the slow and prolong-et1 first stage tllr caount remained at this same level. After good uterine (*ontractions oc*cxrrrll, tllfa (*aunt xlowl~ rose so that :I normal pattern was then followed until delivery. *Seven cases of secondary uterine inertia were seen. In al I cases the uormal pattern of leucocptosis was ohserved until the uterine contractions became weak and ineffectual. The leucocyte count then remained at the level it had reachecl at this time. In two cases strong contractions recurred spontaneously, and in these the leucocptes resumed their normal march to a higher level. Six cases of what might Ibe termed obstructed labor were ohserve(1 (persistent occiput posterior, 1: deep transverse arrest, 2; disproportion, 3). The leucocyte count follolyrd the normal pattern, except t,hat, the rise Jras higher in all cases.
Before one call labor, the changes
ass~w~e
must
that the patterri of be compared lvith
leucocytosis
the leucoeyte
is clefinitc
for
count in the
normal nonpregnant individual. The normal count of man is stated to be from 5,000 t,o 10,000, with 7,500 as the average count. Supposedly there is a physiologic lc~wocytosis following digestion and exercise. and the count, is said to vary at different times of the day. These lat,ter facts have lately been open t,o question. Smith and McDowell,‘” Kenyon and Macy,‘” and Ponder’” all noted that the white blood cell count is relatively stable t,hroughout the day. Slight, variations do occurs’, aud an increase in the count in the afternoon is an inconsistent though fairly frequent phenomena. These changes do not appea,r to be due to an increase in new cells but to a redistribution of old ones. Each individual shows a slight curve of daily rhythm that is no6 modified by digestion. mild fatigue, moclerate exercise, or menstruation. The results reported show that a phpsiologir leuc*ocytosis occurs during normal labor. It is also apparent that a definite pattWJ1 of leuc+ cytosis is present. The onset of labor caauses a slight inczrease in the leucocyte count. J’ollowin~ this, tht> leucocyte rise appears to be definitely related to the uterine contractions. Although the individual contraction does not, influence the c*onnt, the sum total of many uterine contractions does. This is well exemplified by t,he course of the leucocyte count during normal labor, as compared to that in the uterirlr inertia series. One cannot observe these changes without wondering what the (‘:IIISC may be. Previous workers have shown hhat the rise is only ill the
WOLFF
:
LEUCOCYTE
COUNT
IN
LABOR
615
polymorphonuclear elements (primarily the neutrophiles) and that the cells morphologically represent mature and aged cells and not newly developed ones. Although many theories have been advanced, the present accepted one is that the count is the result of the muscular activity of the uterus.17 Whereas prolonged exercise does not affect the white blood cell count, severe activity can lead to a 60 to 100 per cent increase in the leucocytes.18 Since there has been no experimental work done here to decide this question, I can only state that the work of the contracting uterine muscle appears to stimulate the mobilizing of the polymorphonuclear leucocytes into the systemic circulation. SUMMARY
.4ND
CONCLUSIONS
1. The leucocytosis of labor follows a constant definite pattern. 2. Normal values of the leucocyte count during the course of labor are established. 3. This pattern of leucocytosis is characteristic of both primiparas and multiparas, except for the higher numerical values during the longer second stage of labor of the former. 4. Comparison of the pattern in normal and abnormal cases shows the relationship of the leucocytosis to the uterine contractions. REFERENCES
(1) Moleschatt and Nasse: Wien. med. Wehnsehr. 8: 114, 1854. (2) Reide?: BeitrPge zur Kentniss der Leucocyten und verwandter Zustilnde des Blutes, Leipzig, 1892. (3) Hibbard and White: J. Exper. Med. 6: 35, 1898. (4) Hahl, C.: Arch. f. Gyngk. 67: 485, 1902. (5) Carton, P.: Ann. de gym%. et d’obst. 30: J. Obst. & Gynaec. Brit. Emp. 9: 261, 1906. (7) 161, 1903. (6) Given, J. C. M.: Blumenthal, R. : Beitr. z. Geburtsh. u. Gynlk. 9: 414, 1907. (8) Horoath: Sixteenth International Congress of Medicine Transactions, 8: 711, 1910. (9) Baer, 6. L.: Surg. Gynec., & Obst. 23: 567. 1916. (10) Jarcho, Julius: AM. J. OBST. t% GYNEC. fi: 1% l&9. (11) Fawcett: E.: M&a&hr. f. Geburtsh. u. Gvn%k. 90: 220, 1932. (12) Cabot: Clinical Examination of the Blood, Baltimire, 1904, William Wood & Co. (131 Gib.son, Anne: On Leucocvte Changes During Labor and the Puerperium, J: Obst. & Gynaee. Brit. Emp. h: 500, 1337. (14y Smith, C., and McDowell, A.: Normal Rhythm of White Blood Cells in Women, Arch. Int. Med. 43: 68, 1929. (15) Kenyon, F., and Macy, 1. G.: Hourly Physiologic Variations in Peripheral Hemoglobin, Red, and White Blood Counts of Women: Effect of Pregnancy Upon Blood Counts, Human Biol. 18: 511, 1938. (16) Ponder, Eric, and ethers: Variations in the White Cell Count of Man, Quart. J. Physiol. 21: 21, 1932. (17) Diefrich, H. A.: Arch. f. Gyngk. 94: 383, 1911. (18) Bookman, 6. D., and Fread, D. J.: Effect of Prolonged Exercise on the Polynuclear Count in Man, J. Biol. R; Exper. Med. 33: 18:1, 1935. 30
N.
MICHIGAN
AVENVE DISCUSSIOS
DR. JOHN I. BREWER, CHICAGO, &L.-The most int.eresting part of this paper to me is the demonstration that with uterine inertia, or when the uterine contractions are reduced in intensity, the white blood cell count does not increase; if the uterine contractions become more severe, the white blood cell count begins to rise. On this basis it has been concluded that the rise in the leucocyte count is the result of uterine contraction. It seems, however, that there have been some factors that have been overlooked. With the increase in intensity of uterine contractions excessive exertion occurs and that alone will increase the leucocyte count. Another factor is the pain which itself will increase the leucocyte count to as high as 20,000. There is also an increase in adrenalin output which will increase the leucocyte count presumably b>- contraction of the spleen with extrusion of the leucocytes into the
616
dblERIC4N
JOURNAL
OF
OBSTETRICS
AND
iiYNECOLOGY
blood stream. Another fact is the anoxemia which probably increases the count by opening up the blood sinuses. Anesthesia and analgesia of various kinds will produce anoxemia, thereby raising the leucocyte count, There is no mention in the paper of the type of anesthesia or analgesia used. Most reports have shown that the leucocyte counts are higher after the termination of labor. That has been thought due to the fact that hemorrhage raises the leucocyte count. Yet the work done here shows no increase in the leucocyte With this in mind, I would like to ask how count after the t,ermination of labor. much blood loss occurred in the patients reportetl here. DR. WOLFF (closing).-As to the cause of t,he leucoeyte rise we must admit It has been shown that excessive exertion, that there are many possible factors. such as walking up and down six flights of stairs or lifting a 1,400 pound weight, until exhausted, will raise the count, whilr rno
SOLID
TERATOMA MERRILL
(From tLe Dtitiova
of
OF THE
OVARX
IN THE
YOUNG
GIRL”
SMELTZER, Gynecology
M.D., L)ETROIT, MICH. ad Obstetrics, Lienry FOR% Ho@titai)
T
HE solid teratoma of the ovary is a highly malignant growth when found in the adolescent or preadolescent girl. It occurs infrequently. The incidence of tumor is higher in t,he ovary than in any other organ of the growing girl. This tumor is more likely to be benign than malignant. The cystadenomas, the fibromas, and the cystic teratomas or dermoids are benign. The malignant tumors are either carcinoma, sarcoma, or the solid or combined cystic and solid teratoma. Among the malignant tumors, the solid teratoma occurs least frequently. The gross and microscopic appearance of solid ttratomas rarely suggests malignancy, but subsequent data indicate that they are more malignant than carcinomas or sarcomasoccurring in ovaries of girls. An ovarian tumor is not, suspected until it produces subjective symptoms. Steel1 states that its presence may be made hmown in one or more of the following ways : (1) (2) (3) (4)
Increasing growth giving rise to abdominal deformity. Constitutional disturbances, as precocious sexual changes. Mechanical effects causing pressure on surrounding viscera. Complications, e.g., torsion of the pedicle.
The latter complication is present in almost a third of the cases reported. Steel found 25 cases of cysts with twisted pedicle in which and
*Read before Gynecologists.
the
Twelfth Indianapolis,
Annual Ind..
Meeting October
of the Central 12, 1940.
Association
of Obstetricians
:
LEUCOCYTE
COUNT
IN
611
LABOR
DR. CARTER (closing).-With regard to manual dilatation of the cervix at the time of cesarean section, I do not attempt to put a finger through the cervix in those patients who have been in labor, but I do in all patients in whom the section is elective. The reported se&ion was comparable to an elective one, since there was no opening in the cervix and marked edema masked the structures. Some years ago when I served as House Surgeon in the New York Lying-in Hospital, under the late Dr. Asa B. Davis, I assisted Dr. Davis in performing a cesarean section in which the cervix was left undisturbed. In this patient there was an absence of drainage through the vagina. On the third day she developed a temperature of 105’. I made a vaginal examination and found a dimple in the external OS, through which I inserted my finger. Immediately there occurred a 2 cm. dilatation with a drainage of about 2 tablespoonsful of pus. The patient then ran :I normal convalescence. The same thing occurred in one of my patients at the Baptist Hospital in New Orleans, in whom the cervix failed to dilate after cesarean section. Vaginal examinat,ion disclosed a closed cervix through which the finger was inserted, resulting in evacuation of pus. The convalescence of this patient was also normal thereafter.
TEE
LEUCOCTTE
JOHX (From.
the Department
a. of
WOLFF,
COUNT KD.,
IN LABOR”
CHICAGO, ILL.
Obstetrics and Gynecology, College of Medicine)
Oniversity
of
Illinois
T
HE leucocyte count is a valuable laboratory procedure. It is a de% nite aid to the diagnosis, prognosis, and management of many disease processes. Its adaptation to obstetrics has largely been in the field of the associated medical and surgical complications. The occurrence of a leucocytosis during labor has been known since the observations of Moleschattl in 1854 and Reider* in 1892. Although many individuals have studied the problem, t,he detailed relationship of the leucocyte rise to the clinical course of labor has not been determined. The following observations are reported in order to establish a “norm” beeause of the clinical significance the count might have when considering complicated cases. In 1898 Hibbard and Whites noted that during labor the leucocyte count rose This leucocytosis diminishes to 15,000 in primipara and 11,700 in multipara. with a slight elevation on the sixth day and a rapidly during the puerperium, normal count thereafter. In 1902 Habla studied 36 cases in the last months of pregnancy, during labor, He stated that there is a slight increase in the and the first week post partum. leucoeyte count in the last few days of pregnancy, followed by a marked leucoThis diminishes rapidly and is normal by the cytosis at the beginning of labor. end of the first week post partum. The rise is in the polymorphonuclear cells. Cartons in 1903 found that a polymorphonuclear leucocytosis occurs during the last month of pregnancy, increases during labor, and is normal shortly afterwards. He found that the rise is more marked when the child is born dead or macerated, or when twins are present. Given6 (1906) reported the average count to be 10,500 before labor, 16,000 twenty-four hours afterwards, and 7,000 by the twelfth day. *presented before the Twelfth Annual stetricians and Gynecologists, Indianapolis.
aieeting of the Central Association Ind., October 10, 1940.
of Ob-
612
AMERICAN
JOURNAL
OF
OBSTETRICS
AND
GYNECOLOGY
Blumenthali (1907) noted that the leucocytosis was more marked after separaof the placenta than in the first stage and that the count lessened after rupof the membranes. In 1910 Horvaths stated that the pedc of the leucocytosis occurred three to seven hours after delivery. Baers in 1916 studied 100 cases in which he took counts during labor and one In primiparas the average count daily thereafter for ten consecutive days. was 18,225 during labor, with 19,887 as t,he high point on the first postpartum day. Multiparas revealed 13,467 cells during labor, with a high of 15,062 on the first puerperal day. He found the count to be higher during obstructed labor and after There was a gradual decrease to a normal count withrupture of the membranes. in seven to ten days. Jarrho, Fawcett,rl Cabot,ia and others reached similar r~nnclusions. Gibsoni: in IRS7 investigated the subject in 38 normal cases. She recorded findings at the end of pregnancy, the height of labor, several times during the first twenty-four hours following delivery, and daily for two weeks in the puerperium. She observed a slight rise at the end of pregnancy and a much greater rise at the end of labor, with the highest average in the “birth to two-hour” period. Counts ranging from 10,000 to 39,800 occurred during the first six hours after delivery in normal women. The same type of leucocytosis was observed in l~rirniparas as in multiparas. hut in t.he former it tended to be higher and 10 last longer. tion ture
E’ifty normal women were observed shortly following the onset of labor to the termination of the eight-day hospital puerperium. Twenty-five were primiparas and 55 were multiparas. Leueocyte counts were made at intervals of one to two hours short,lp following the onset of labor until delivery. Counts were then made at delivery, before and after the use of oxgtocics, and after the delivery of the placenta. The hemoglobin and erythrocyte counts were likewise observed in 10 patients, but as these factors remained constant regardless of the change in the leucocytes further observations were not made. The standard technique of making a leucocyte count from blood obtained by capillary puncture of the ear or finger, as described in all texts, was followed. Several eases of rapid labor, primary uterine inertia, secondary uterine inertia, and “obstructed” labor were also ohserved. RESULTS
Twenty-one of the 50 normal patients were seen during the last weeks of pregnancy. In these patients the counts varied from 5,750 to 12,200. The average count was 8,054. All patients were seen from one to four hours following the onset of the symptoms of labor. In the L’l patients who had been ohxerved before labor began, the caounts at this time varied from 7,600 to 12,850. In all cases there was a slight rise over the previous figure. The remainder of the 50 cases revealed similar counts, the average for this time of labor being 10,24i. As labor progressed the leueocytes gradually increased. When the cervical OS hecame dilated 4 cm. and the average labor pain was occurring every five minutes and lasting thirty to seventy seconds, the leucoeyte counts varied from 8,240 to 14,050, the average being 11,456. When the dilatation of the cervix had increased to 8 cm., the counts varied between 10,450 and 15,620. The average count was 13,635. At approximately the onset of the second stage of labor the average count was 15,150. At this time the leucocytes ranged from 11,120 to 23,650. Many leucocpte counts were made before, during, and after uterine contractions during t.he first and second stages of labor. No appreciable difference was noted. Rupture of the membranes in itself did not influence the count; that is, the general pattern of the leucocyte rise, as observed in all cases, continued regardless of the time of the rupture of the membranes. Cases of so-called dry labor (14 of the 50 eases) likewise did not show any difference from the normal.
WOLFF
:
LEUCOCYTE
COUNT
IN
LABOR
613
Primiparas were observed every fifteen to twenty minutes during the second stage of labor. The leucocytosis continued, but in a more rapid fashion, The second stage of labor averaged two hours and eight minutes in these cases. The average count at the time of delivery was 22,250, with counts ranging from 14,760 to 27,640.
Fig.
l.-The
leucocyte
count
in labor
in primiparas.
Fig.
Z.-The
leucocyte
count
in labor
in multiparas.
This leucocytosis was also observed in multiparas. Counts taken near the end of pregnancy and shortly following the onset of labor revealed changes as reported above. As labor progressed, the leucocytosis continued. The counts gradually rose to 13,754 (11,980 to 14,640) when 6 to 8 cm. cervical dilatation had been reached. Because the progress was usually rapid after. this stage of labor had been reached, counts were then usually taken just before, during, and after delivery. The count at the time of delivery varied from 13,250 to 16,880, the average being 15,270. The third stage of normal labor did not affect the leucocyte count.
614
AXWRICAS
.JOURNi;\I.
OF
OBSTETRICS
.\IZD
(;YSECOLOG1
I?ollowiny delivery, counts were taken lIefore, during, an11 at various inlervals after the routine use of pituitrin and ergot. No change was noted. The majority of women were also examined during the puerperium. The leucocyte count gradually returued to normal by the seventh dar. Nine patients had a count slightly higher than that notr(l at delivery on the irst puerperal day. Eleven cases of short lalmrs (three to seven hours) were observed. Six were multiparas and fi\-e were primiparax. In all cases a slight increase in the leucocytes occurred shortly following the onset of labor, :I gradual rise continued, and at delivery the count, varied from 13,600 to 17,430, the average being 14,9SO. Four cases of primary uterine inertia were studied, all in primiparaa. The labors varied from fifty-four to sixty-eight hours. They were all characterized by weak, infrequent, and irregular ut-erine contrartions tluriug the first stage of labor. Progress was slow until a cervical dilatation of 5 tu 7 cm. was reached, when the labor pains increase{1 so that tlelivery followed shortly. (lonservativr thnapeutic~ mr~asures were until. 7’1~ count ros,’ slightly foilowing the onset of labor. IJuring the slow and prolong-et1 first stage tllr caount remained at this same level. After good uterine (*ontractions oc*cxrrrll, tllfa (*aunt xlowl~ rose so that :I normal pattern was then followed until delivery. *Seven cases of secondary uterine inertia were seen. In al I cases the uormal pattern of leucocptosis was ohserved until the uterine contractions became weak and ineffectual. The leucocyte count then remained at the level it had reachecl at this time. In two cases strong contractions recurred spontaneously, and in these the leucocptes resumed their normal march to a higher level. Six cases of what might Ibe termed obstructed labor were ohserve(1 (persistent occiput posterior, 1: deep transverse arrest, 2; disproportion, 3). The leucocyte count follolyrd the normal pattern, except t,hat, the rise Jras higher in all cases.
Before one call labor, the changes
ass~w~e
must
that the patterri of be compared lvith
leucocytosis
the leucoeyte
is clefinitc
for
count in the
normal nonpregnant individual. The normal count of man is stated to be from 5,000 t,o 10,000, with 7,500 as the average count. Supposedly there is a physiologic lc~wocytosis following digestion and exercise. and the count, is said to vary at different times of the day. These lat,ter facts have lately been open t,o question. Smith and McDowell,‘” Kenyon and Macy,‘” and Ponder’” all noted that the white blood cell count is relatively stable t,hroughout the day. Slight, variations do occurs’, aud an increase in the count in the afternoon is an inconsistent though fairly frequent phenomena. These changes do not appea,r to be due to an increase in new cells but to a redistribution of old ones. Each individual shows a slight curve of daily rhythm that is no6 modified by digestion. mild fatigue, moclerate exercise, or menstruation. The results reported show that a phpsiologir leuc*ocytosis occurs during normal labor. It is also apparent that a definite pattWJ1 of leuc+ cytosis is present. The onset of labor caauses a slight inczrease in the leucocyte count. J’ollowin~ this, tht> leucocyte rise appears to be definitely related to the uterine contractions. Although the individual contraction does not, influence the c*onnt, the sum total of many uterine contractions does. This is well exemplified by t,he course of the leucocyte count during normal labor, as compared to that in the uterirlr inertia series. One cannot observe these changes without wondering what the (‘:IIISC may be. Previous workers have shown hhat the rise is only ill the
WOLFF
:
LEUCOCYTE
COUNT
IN
LABOR
615
polymorphonuclear elements (primarily the neutrophiles) and that the cells morphologically represent mature and aged cells and not newly developed ones. Although many theories have been advanced, the present accepted one is that the count is the result of the muscular activity of the uterus.17 Whereas prolonged exercise does not affect the white blood cell count, severe activity can lead to a 60 to 100 per cent increase in the leucocytes.18 Since there has been no experimental work done here to decide this question, I can only state that the work of the contracting uterine muscle appears to stimulate the mobilizing of the polymorphonuclear leucocytes into the systemic circulation. SUMMARY
.4ND
CONCLUSIONS
1. The leucocytosis of labor follows a constant definite pattern. 2. Normal values of the leucocyte count during the course of labor are established. 3. This pattern of leucocytosis is characteristic of both primiparas and multiparas, except for the higher numerical values during the longer second stage of labor of the former. 4. Comparison of the pattern in normal and abnormal cases shows the relationship of the leucocytosis to the uterine contractions. REFERENCES
(1) Moleschatt and Nasse: Wien. med. Wehnsehr. 8: 114, 1854. (2) Reide?: BeitrPge zur Kentniss der Leucocyten und verwandter Zustilnde des Blutes, Leipzig, 1892. (3) Hibbard and White: J. Exper. Med. 6: 35, 1898. (4) Hahl, C.: Arch. f. Gyngk. 67: 485, 1902. (5) Carton, P.: Ann. de gym%. et d’obst. 30: J. Obst. & Gynaec. Brit. Emp. 9: 261, 1906. (7) 161, 1903. (6) Given, J. C. M.: Blumenthal, R. : Beitr. z. Geburtsh. u. Gynlk. 9: 414, 1907. (8) Horoath: Sixteenth International Congress of Medicine Transactions, 8: 711, 1910. (9) Baer, 6. L.: Surg. Gynec., & Obst. 23: 567. 1916. (10) Jarcho, Julius: AM. J. OBST. t% GYNEC. fi: 1% l&9. (11) Fawcett: E.: M&a&hr. f. Geburtsh. u. Gvn%k. 90: 220, 1932. (12) Cabot: Clinical Examination of the Blood, Baltimire, 1904, William Wood & Co. (131 Gib.son, Anne: On Leucocvte Changes During Labor and the Puerperium, J: Obst. & Gynaee. Brit. Emp. h: 500, 1337. (14y Smith, C., and McDowell, A.: Normal Rhythm of White Blood Cells in Women, Arch. Int. Med. 43: 68, 1929. (15) Kenyon, F., and Macy, 1. G.: Hourly Physiologic Variations in Peripheral Hemoglobin, Red, and White Blood Counts of Women: Effect of Pregnancy Upon Blood Counts, Human Biol. 18: 511, 1938. (16) Ponder, Eric, and ethers: Variations in the White Cell Count of Man, Quart. J. Physiol. 21: 21, 1932. (17) Diefrich, H. A.: Arch. f. Gyngk. 94: 383, 1911. (18) Bookman, 6. D., and Fread, D. J.: Effect of Prolonged Exercise on the Polynuclear Count in Man, J. Biol. R; Exper. Med. 33: 18:1, 1935. 30
N.
MICHIGAN
AVENVE DISCUSSIOS
DR. JOHN I. BREWER, CHICAGO, &L.-The most int.eresting part of this paper to me is the demonstration that with uterine inertia, or when the uterine contractions are reduced in intensity, the white blood cell count does not increase; if the uterine contractions become more severe, the white blood cell count begins to rise. On this basis it has been concluded that the rise in the leucocyte count is the result of uterine contraction. It seems, however, that there have been some factors that have been overlooked. With the increase in intensity of uterine contractions excessive exertion occurs and that alone will increase the leucocyte count. Another factor is the pain which itself will increase the leucocyte count to as high as 20,000. There is also an increase in adrenalin output which will increase the leucocyte count presumably b>- contraction of the spleen with extrusion of the leucocytes into the
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blood stream. Another fact is the anoxemia which probably increases the count by opening up the blood sinuses. Anesthesia and analgesia of various kinds will produce anoxemia, thereby raising the leucocyte count, There is no mention in the paper of the type of anesthesia or analgesia used. Most reports have shown that the leucocyte counts are higher after the termination of labor. That has been thought due to the fact that hemorrhage raises the leucocyte count. Yet the work done here shows no increase in the leucocyte With this in mind, I would like to ask how count after the t,ermination of labor. much blood loss occurred in the patients reportetl here. DR. WOLFF (closing).-As to the cause of t,he leucoeyte rise we must admit It has been shown that excessive exertion, that there are many possible factors. such as walking up and down six flights of stairs or lifting a 1,400 pound weight, until exhausted, will raise the count, whilr rno
SOLID
TERATOMA MERRILL
(From tLe Dtitiova
of
OF THE
OVARX
IN THE
YOUNG
GIRL”
SMELTZER, Gynecology
M.D., L)ETROIT, MICH. ad Obstetrics, Lienry FOR% Ho@titai)
T
HE solid teratoma of the ovary is a highly malignant growth when found in the adolescent or preadolescent girl. It occurs infrequently. The incidence of tumor is higher in t,he ovary than in any other organ of the growing girl. This tumor is more likely to be benign than malignant. The cystadenomas, the fibromas, and the cystic teratomas or dermoids are benign. The malignant tumors are either carcinoma, sarcoma, or the solid or combined cystic and solid teratoma. Among the malignant tumors, the solid teratoma occurs least frequently. The gross and microscopic appearance of solid ttratomas rarely suggests malignancy, but subsequent data indicate that they are more malignant than carcinomas or sarcomasoccurring in ovaries of girls. An ovarian tumor is not, suspected until it produces subjective symptoms. Steel1 states that its presence may be made hmown in one or more of the following ways : (1) (2) (3) (4)
Increasing growth giving rise to abdominal deformity. Constitutional disturbances, as precocious sexual changes. Mechanical effects causing pressure on surrounding viscera. Complications, e.g., torsion of the pedicle.
The latter complication is present in almost a third of the cases reported. Steel found 25 cases of cysts with twisted pedicle in which and
*Read before Gynecologists.
the
Twelfth Indianapolis,
Annual Ind..
Meeting October
of the Central 12, 1940.
Association
of Obstetricians