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The Relation of the Endometrium to Ovarian Function
618
THE AMERICAN JOURNAL 0~' OBSTETRICS AND GYNECOLOGY
the cause is elsewhere. Our results with the use of radium for menorrhagia have been that the bleeding has not been controlled unless an amenorrhea has been produced; when the menstruations have become reestablished the bleeding almost invariably has recurred. DR. GEORGE GRAY WARD, NEW YORK CITY.-We have used radium at the Woman's Hospital in a certain proportion of these cases, appreciating its dangers as Dr. Koone brought out, and always endeavoring to underradiate rather than over· radiate. We seemed to get satisfactory results from 100 to 200 mghr., but rarely more than 400 mghr., with the understanding' that we might have to repeat that dosage later on. I want to speak of one case that came under my observation, of membranous dysmenorrhea in a young girl in whom a cast of the uterus, practically perfect, was shed each month. She was curetted for her dysmenorrhea and excessive bleed· ing without benefit, and I gave her 400 mghr. with good results in stopping the dysmenorrhea and reducing the flow. As to the point brought out by Professor Frankl, it makes a difference whether you use a tube of 50 milligrams or 100 milligrams and where. I use two tubes of 50 milligrams each, place one tube above the other in tandem, thus giving 50 milligrams to the upper part of the uterus, and 50 milligrams to the lower uterine segment in order to cover the entire endometrium. DR. MATTHEWS (closing).-In reference to Dr. Stone's and Dr. Bailey's remarks, I think these gentlemen fail to grasp my idea. I spoke of the effects after radiation of the follicle and not the effects after irradiation of the impreg· nated ovum or embryo. The German and French literature is full of reports of monstrosities due to radi.ation after impregnation. I mentioned nothing about this phase of the subjoot. All the work I have done has reference to the changes in the follicular apparatus after irradiation. The work of Bagg is very interesting, and I am sure it will prove something of very great value. However, the effects of irradiation in the lower animals--mice, guinea pigs, rabbits, etc.,--cannot be assumed to be identical with those in the human being, at le·ast at the present stage of our knowledge. In reference to what Dr. Bailey said, I did not recommend in these younger women doses of 800 to 1200 mghr. for relief of uterine bleeding. I showed char· acteristic changes in the histopathology of the ovary that has been exposed to these larger doses of radium (800 to 1200 mghr.) We do not use these larger doses. We use 200 to 400 mghr., the same as Dr. Bailey ·and Dr. Healy do, for the c·ondition under discussion.
DR. CHARLES C. NORRIS AND DR.
M.
VooT,
Philadelphia, Pa., read
paper on The· Rela.tion of the Endometrium to Ova.ria.n
a
Function~
abstract of which follows: The theory that the endometrium possesses an endocrin.al function 1s at present. based only upon physiologic and clinical proof. The fact that the endometrium differs histologically from other endocrinal glands is no argument against the theory, since all other endocrinal glands differ one from the other, in this respoot. The endometrium probably possesses a definite endocrinal function, which like other endocrinal glands, acts in conjunction with certain so-calloo ductless glands, par· ticularly the ovary, to which it is most likely subservient. The endocrinal function
AMERICA:"' GYNECOLOGICAL SOCIETY
619
of ithe endometrium probably fluctuates with the menstrual cycle, being most active du:ring the premenstrual period. The chief clinical evidence on which this theory is hased lies in the established fact that the proportion of women who suffer from nervous phenomena subsequent to hysterectomy, ·with conservation of one or both ovaries, is much greater than that of those who exhibit painful or palpable change& in the conserved ovary. The most conclusive evidence is found in those patients who have been treated with radium for the arrest of benign hemorrhages. It is difficult to conceive that in almost every ease so treated both ovaries are rendered functionless. Furthermore, there is much experimental evidence that tends to show that in these cases the action of radium is limited to the uterus. In operations upon the uterus ovarian conservation is of distinct value, even if panhysterectomy is performed; the ovaries function better, however, and have a longer functional life, if a portion of the endometrium can be preserved. The thickened and permanent premenstrual stage of the endometrium, so frequently present in eases of uterine. myomata, is the result of stimulation of the endometrium by the prsence of the tumor, and accounts for the prolonged bleeding that is often present. DISCUSSION DR. J. WESLEY BOVEE, WAsmNG:TON, D. C.-The menstruation habit seems to be so strong in some women that after removal of the ovaries and the uterus irn toto, it continues. I have in two cases failed to permanently stop it, though employing astringents and the cautery to the sear in the vaginal roof, from which the ftow escaped. In several cases I have noticed periodical bleeding for several months from the rectum, the nose, the throat, the breast or the axilla. This in each instance followed menopausal cessation of the menses, and exploration and sub· sequent history and events :failed to account for the bleeding. In one patient, of 48 years, the epistaxis was so profuse and prolonged that a rhinologist packed her nose for forty-eight hours. PR. CAREY CULBERTSON, CHICAGO.-Dr. Norris' remarks relative to the relatjon between the mucous membrane of the corpus uteri and ovarian function, particularly ovulation, opens up a vast field o£ speculation. We .have been teaching now for some years that menstruation is a phenomenon expressing a retrograde prooess in its hemorrhagic. stage and that its real function appears in the pre· menstrual stage of vaseu1arization. This edema is apparently carried to its highest de"''!elopment in the formation of decidua, as it appears in pregnancy, and some years ago various investigators, among them Gentili, ascribed the production of a hormone to the decidua vera. If this could be proven for decidua it would equally true, though in less degree, for the vascularized structure of the premenstruum. We believe that the young woman is better off for the preservation of menstruatiolll, and we agree with Dr. Norris that the nervous phenomena following hysterectomy with ovarian conservation is proportionately more frequent than is suffering due to changes in the ovaries themselves. We agree, further, that conserved ovaries are of more value, their function better, if the endometrium is likewise preserved. We believe that the highly vascular mucosa., as it appears in the premel!lstrual stage, represents this tissue at the height of its function, as function is expressed short of pregnancy. The old theory, that menstruation represented one. of the processes of elimination, though still retained by a :few writers, has been generally discarded. We may have to reconsider this idea, or revamp it in such a way as to make it comprehend a secretion rather than an excretion. ~r. Norris' reference to the phenomena following ovarian ablation brings up a poi*t in differentiation, that must be made with respect to the climacteric. Theclin!lacterie is due to changes which take place in the endocrine system as a whole,
oo
620
THE AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY
according to the most generally accepted theory, these changes occurring in the hypophysis, the thyroid, chiefly, possibly in the adrenals as well, and as a result the ovarian function gradually dwindles away. The changes taking place as the result of ovarian ablation in young women represent an entirely different process. Here the ovaries are extirpated and their function cut off at once. The climacteric changes in. the other glands have not occurred and the reaction, as expressed by the patient, is accordingly different. We should think of this reaction as castration phenomena rather than as the pre· mature climacteric.
DR. BROOKE M. ANSPACH, Philadelphia, Pa., read a paper entitled The Trend of Modern Obstetrics. What Is the Da.uger? Bow Oan It Be Oh&nged? (For original article see page 566.) DISCUSSION DR. GEORGE W. DOBBIN, BALTIMORE, MARYLAND.-! feel that the aggressive methods of urgent obstetrics that have come up in. the last few years have been. developed more for the benefit of the accoucheur than for the woman herself, and I cannot but feel quite strongly that the promise of relief from the pains of labor is used by the advocates of these procedures to in.crease the material gains of their practice. Version can be an extremely difficult operation and no obstetrician can do many without realizing that under the best conditions a certain number of children will inevitably be lost. In 1915 I found that a rapidly increasing obstetric practice suggested form· ing a partnership with a well-trained obstetrician, and up to the present the alliance has been highly successful. What Dr. Anspach suggests concerning the difficulty of having a patient satisfied in getting the services of an obstetrician that she did not directly engage is much more fanciful than real when one ia dealing with f'_, partnership. We have little or no difficulty in educating our patients to this effect; in fact, many of our patients realize we are working together and ask that both of us be present at the time o:f delivery. Whenever possible, the physician to whom the patient has originally applied conducts the delivery, but in the care during pregnancy which frequently covers six or seven months, every effort is made to explain to her the workings of the partnership, so when she actually falls in labor we have rarely experienced any difficulty whatsoever. I have no hesitancy in stating that our efficiency has very materially increased as the result of the partnership. Two trained men working together can handle any case far better than one working alone, and in the event of complications · the advice and moral support of a coworker is most comforting. Dr. Anspach's results are certainly remarkably good. Before leaving Baltimore I looked up our records and find that his are somewhat better than ours. He pre· sents an actual fetal mortality of 0.76 per cent. Our mortality is larger than that. In the last three years we have delivered 817 women with a total loss of 48 children, about 7 per cent. This, however, includes all maeerated babies, and death that can in no way be attributed to the obstetric management of the case. When these are eliminated we have only 10 deaths, a corrected fetal mort&lity of 1.22 per cent. I must also note that I have been a little more liberal in calculating this obstetric fetal mortality, as I have considered one ease where death was due to compression of the umbilical cord, a condition which I think Dr. Anspach eliminated in his statistics.
THE AMERICAN JOURNAL 0~' OBSTETRICS AND GYNECOLOGY
the cause is elsewhere. Our results with the use of radium for menorrhagia have been that the bleeding has not been controlled unless an amenorrhea has been produced; when the menstruations have become reestablished the bleeding almost invariably has recurred. DR. GEORGE GRAY WARD, NEW YORK CITY.-We have used radium at the Woman's Hospital in a certain proportion of these cases, appreciating its dangers as Dr. Koone brought out, and always endeavoring to underradiate rather than over· radiate. We seemed to get satisfactory results from 100 to 200 mghr., but rarely more than 400 mghr., with the understanding' that we might have to repeat that dosage later on. I want to speak of one case that came under my observation, of membranous dysmenorrhea in a young girl in whom a cast of the uterus, practically perfect, was shed each month. She was curetted for her dysmenorrhea and excessive bleed· ing without benefit, and I gave her 400 mghr. with good results in stopping the dysmenorrhea and reducing the flow. As to the point brought out by Professor Frankl, it makes a difference whether you use a tube of 50 milligrams or 100 milligrams and where. I use two tubes of 50 milligrams each, place one tube above the other in tandem, thus giving 50 milligrams to the upper part of the uterus, and 50 milligrams to the lower uterine segment in order to cover the entire endometrium. DR. MATTHEWS (closing).-In reference to Dr. Stone's and Dr. Bailey's remarks, I think these gentlemen fail to grasp my idea. I spoke of the effects after radiation of the follicle and not the effects after irradiation of the impreg· nated ovum or embryo. The German and French literature is full of reports of monstrosities due to radi.ation after impregnation. I mentioned nothing about this phase of the subjoot. All the work I have done has reference to the changes in the follicular apparatus after irradiation. The work of Bagg is very interesting, and I am sure it will prove something of very great value. However, the effects of irradiation in the lower animals--mice, guinea pigs, rabbits, etc.,--cannot be assumed to be identical with those in the human being, at le·ast at the present stage of our knowledge. In reference to what Dr. Bailey said, I did not recommend in these younger women doses of 800 to 1200 mghr. for relief of uterine bleeding. I showed char· acteristic changes in the histopathology of the ovary that has been exposed to these larger doses of radium (800 to 1200 mghr.) We do not use these larger doses. We use 200 to 400 mghr., the same as Dr. Bailey ·and Dr. Healy do, for the c·ondition under discussion.
DR. CHARLES C. NORRIS AND DR.
M.
VooT,
Philadelphia, Pa., read
paper on The· Rela.tion of the Endometrium to Ova.ria.n
a
Function~
abstract of which follows: The theory that the endometrium possesses an endocrin.al function 1s at present. based only upon physiologic and clinical proof. The fact that the endometrium differs histologically from other endocrinal glands is no argument against the theory, since all other endocrinal glands differ one from the other, in this respoot. The endometrium probably possesses a definite endocrinal function, which like other endocrinal glands, acts in conjunction with certain so-calloo ductless glands, par· ticularly the ovary, to which it is most likely subservient. The endocrinal function
AMERICA:"' GYNECOLOGICAL SOCIETY
619
of ithe endometrium probably fluctuates with the menstrual cycle, being most active du:ring the premenstrual period. The chief clinical evidence on which this theory is hased lies in the established fact that the proportion of women who suffer from nervous phenomena subsequent to hysterectomy, ·with conservation of one or both ovaries, is much greater than that of those who exhibit painful or palpable change& in the conserved ovary. The most conclusive evidence is found in those patients who have been treated with radium for the arrest of benign hemorrhages. It is difficult to conceive that in almost every ease so treated both ovaries are rendered functionless. Furthermore, there is much experimental evidence that tends to show that in these cases the action of radium is limited to the uterus. In operations upon the uterus ovarian conservation is of distinct value, even if panhysterectomy is performed; the ovaries function better, however, and have a longer functional life, if a portion of the endometrium can be preserved. The thickened and permanent premenstrual stage of the endometrium, so frequently present in eases of uterine. myomata, is the result of stimulation of the endometrium by the prsence of the tumor, and accounts for the prolonged bleeding that is often present. DISCUSSION DR. J. WESLEY BOVEE, WAsmNG:TON, D. C.-The menstruation habit seems to be so strong in some women that after removal of the ovaries and the uterus irn toto, it continues. I have in two cases failed to permanently stop it, though employing astringents and the cautery to the sear in the vaginal roof, from which the ftow escaped. In several cases I have noticed periodical bleeding for several months from the rectum, the nose, the throat, the breast or the axilla. This in each instance followed menopausal cessation of the menses, and exploration and sub· sequent history and events :failed to account for the bleeding. In one patient, of 48 years, the epistaxis was so profuse and prolonged that a rhinologist packed her nose for forty-eight hours. PR. CAREY CULBERTSON, CHICAGO.-Dr. Norris' remarks relative to the relatjon between the mucous membrane of the corpus uteri and ovarian function, particularly ovulation, opens up a vast field o£ speculation. We .have been teaching now for some years that menstruation is a phenomenon expressing a retrograde prooess in its hemorrhagic. stage and that its real function appears in the pre· menstrual stage of vaseu1arization. This edema is apparently carried to its highest de"''!elopment in the formation of decidua, as it appears in pregnancy, and some years ago various investigators, among them Gentili, ascribed the production of a hormone to the decidua vera. If this could be proven for decidua it would equally true, though in less degree, for the vascularized structure of the premenstruum. We believe that the young woman is better off for the preservation of menstruatiolll, and we agree with Dr. Norris that the nervous phenomena following hysterectomy with ovarian conservation is proportionately more frequent than is suffering due to changes in the ovaries themselves. We agree, further, that conserved ovaries are of more value, their function better, if the endometrium is likewise preserved. We believe that the highly vascular mucosa., as it appears in the premel!lstrual stage, represents this tissue at the height of its function, as function is expressed short of pregnancy. The old theory, that menstruation represented one. of the processes of elimination, though still retained by a :few writers, has been generally discarded. We may have to reconsider this idea, or revamp it in such a way as to make it comprehend a secretion rather than an excretion. ~r. Norris' reference to the phenomena following ovarian ablation brings up a poi*t in differentiation, that must be made with respect to the climacteric. Theclin!lacterie is due to changes which take place in the endocrine system as a whole,
oo
620
THE AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY
according to the most generally accepted theory, these changes occurring in the hypophysis, the thyroid, chiefly, possibly in the adrenals as well, and as a result the ovarian function gradually dwindles away. The changes taking place as the result of ovarian ablation in young women represent an entirely different process. Here the ovaries are extirpated and their function cut off at once. The climacteric changes in. the other glands have not occurred and the reaction, as expressed by the patient, is accordingly different. We should think of this reaction as castration phenomena rather than as the pre· mature climacteric.
DR. BROOKE M. ANSPACH, Philadelphia, Pa., read a paper entitled The Trend of Modern Obstetrics. What Is the Da.uger? Bow Oan It Be Oh&nged? (For original article see page 566.) DISCUSSION DR. GEORGE W. DOBBIN, BALTIMORE, MARYLAND.-! feel that the aggressive methods of urgent obstetrics that have come up in. the last few years have been. developed more for the benefit of the accoucheur than for the woman herself, and I cannot but feel quite strongly that the promise of relief from the pains of labor is used by the advocates of these procedures to in.crease the material gains of their practice. Version can be an extremely difficult operation and no obstetrician can do many without realizing that under the best conditions a certain number of children will inevitably be lost. In 1915 I found that a rapidly increasing obstetric practice suggested form· ing a partnership with a well-trained obstetrician, and up to the present the alliance has been highly successful. What Dr. Anspach suggests concerning the difficulty of having a patient satisfied in getting the services of an obstetrician that she did not directly engage is much more fanciful than real when one ia dealing with f'_, partnership. We have little or no difficulty in educating our patients to this effect; in fact, many of our patients realize we are working together and ask that both of us be present at the time o:f delivery. Whenever possible, the physician to whom the patient has originally applied conducts the delivery, but in the care during pregnancy which frequently covers six or seven months, every effort is made to explain to her the workings of the partnership, so when she actually falls in labor we have rarely experienced any difficulty whatsoever. I have no hesitancy in stating that our efficiency has very materially increased as the result of the partnership. Two trained men working together can handle any case far better than one working alone, and in the event of complications · the advice and moral support of a coworker is most comforting. Dr. Anspach's results are certainly remarkably good. Before leaving Baltimore I looked up our records and find that his are somewhat better than ours. He pre· sents an actual fetal mortality of 0.76 per cent. Our mortality is larger than that. In the last three years we have delivered 817 women with a total loss of 48 children, about 7 per cent. This, however, includes all maeerated babies, and death that can in no way be attributed to the obstetric management of the case. When these are eliminated we have only 10 deaths, a corrected fetal mort&lity of 1.22 per cent. I must also note that I have been a little more liberal in calculating this obstetric fetal mortality, as I have considered one ease where death was due to compression of the umbilical cord, a condition which I think Dr. Anspach eliminated in his statistics.