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Uric acid in the blood in the toxemias of pregnancy
KING AND DENIS:
409
URIC ACID IN BLOOD IN TOXEMIA
4. The capacity of the amniotic liquid to combine with ‘C’O, is considerably less than that of normal blood. 5. The increase of the nonprotein nitrogen in the amniotic fluid in advanced pregnancy suggests that the fetal urine ma.y be a partial source of the liquid. 6. The greater concentration of uric acid in the amniotic fluid over that in the blood suggests that in the toxemias of pregnancy the increased uric acid of the blood may arise in part from a more highly saturated amniotic fluid. REFERENCES S. and (1) Uyeno, D. : Jour. Biol. Chem., 1919, xxxvii, 77-103. (2) Amberg, .Rowntree, L. G.: Bioch. Centralbl., 1905, x, 237. (3) Polin, 0. ancl Wu, H.: Jour. :Biol. Chem., 1919, xxxviii, 81-110; ibid. Supplement I, 1920, xli, 367. (4) Au&in, ,J. H. and Pan Xlyke, D. D.: Jour. Biol. C’hem., 1920-1921, 461-463. (5) Van Slyke, .D. D. and Cullen, G. E. : Jour. Biol. Chem., 1917, xxx, 347-368. (6) Benediat, Sticnley R. and Osterberg, E. : Jour. Biol. Chem., 1921, xlviii, 511-57. (7) Clognq, R. and Reglade, J. : Compt. rend. Sot. de Biol., 1921, lxxxiv, 491-493. (8) .Labat, A. and Favreazs, M.: Jour. de med. de Bordeaux, 1921, Ii, 341-342. (9) Labruhe : Quoted by Labat and Favreau, Lot. cit. (10) Uyeno, D.: Lot. cit. (11) Lab& and Favreazc: Lot. cit. (12) Proohownick and Rarnack: Quoted by Hammarsten and Hedin, 1914, 642. 2650
RIDGE
AVENUE.
URIC ACID
IN THE BLOOD
IN THE TOXEMIAS
OF
PREGNANCY BY E. L. KING, (Prom
the Department
M.D., AND W. DENIS, PH.D., .of ObBstetrics and the Laborat,ory of the School
A
of Me&tine,
NEW
ORLEANS,
of Physiological
LA.
C’hewistry
Tulane University.)
BOUT two years ago Williams1 published the results of a series of observations on the blood of pregnant walmen suffering from various types of toxemias, as a result of which he was led to the conclusion that in the blood of patients with eclampsia, hyperemesis gravidarum, and with the symptoms of preeclamptic toxemia together with arterial hypertension, the uric acid is markedly increased, that on delivery and recovery this constituent of the blood of such patients declines to a normal figure, and finally that the toxic vomiting of pregnancy is associated with an increase in the urie acid in the blood, whereas the nervous or physiologic vomiting is not. Shortly after the appearance of Williams’ paper, Caldwell and Lyle2 and’ Killian and Sherwin3 published the results of extensive series of observations on the nonprotein constituents of the blood of norm1al pregnant women and of patients suffering from toxemias of various types, and reported that in many of these latter cases notable increases in blood uric acid were found.
URIC CASE NO.
ACID AGE
36 49 62 42 40 63 1 3 5 23 26 2 4 a 9 51 60 29 6 16 17 19 20 24 31 35 41 44 48 53 56 55 46 33 11 12 13 16 22 25 27 28 32 38 39 43 45 52 54 58 59 47 8 14 15 18 21
20
ii 37 50 57
zz
IN
THE
BLOOD
GRAVIDA II
18 18
2.0
II IV
25 21 17 30 18 27 24 25 22 19 18 22 18 19 22 17 37 23 38 18 17 23 20 35 19 22 16 17 19 37 17 24 30 20 21 18 25 21 18 15 24 21 21 22 20 18 37 21 22 23
I I I r11 I III II VI III II II I ii I I 1X I II I I IV II VIII I I I I I VIII I I VI I IV I V I 3: IKC II II
II
I
-2 I II IV
18 Iii
21 27 17
GESTATION MONTE 2.0 2.0
I I
22 31
OF NORXAL
II I IT1 I
2: 4.0 4.0 4.0 4.0 5.0 5.0 6.0 6.0 6.0 6.0 6.0 6.0 6.0 7.0 7.0 7.0 7.0 7.0 7.0 7.0 7.0
7.0 7.0 7.0 7.0 7.0 7.5 7.5 7.5 8.0 8.0 8.0 8.0 8.0 8.0 8.0 8.0 8.0 8.0 8.0 8.0 8.0 8.0 8.0 8.0 2: 9.0 9.0 9.0 9.0 9.0 9.0 9.0 9.0 9.0 9.0
PREGXANT WOVEN -- .ZZZZ YG. PER 100 I - C.C. NONPROTEIN 1SRIC ACID NITROGEN
27.6 29.2 21.7 22.6 24.5
2.0 3.2 2.4 2.1 2.7
25.5 25.0 25.4 22.6 20.8 24.0 29.8 31.2 29.4 22.2 22.2 24.0 24.1 30.6 28.X 24.5 25.7 25.5 25.5 26.0 27.2 29.9 24.9 23.5 24.9 23.5 24.6 23.1 23.0 21.8 28.5 24.0 25.7 22.21 27.2 22.9 23.0 24.4 24.9 21.4 23.5 20.3 24.9 20.3 25.5 24.9 30. 21.4 2.9.2 25.7 21.8 29.6 26.6 23.5 30.7 22.6
2.9 2.8 2.9 1.9 2.1 2.8 2.7 2.6 2.8 2.9 2.1 2.1 2.8 3.0 2.9 2.8 2.6 2.8 2.4 2.5 2.5 3.0 2.5 2.3 2.16 3.3 2.2 2.3 2.5 2.2 2.7 2.6 2.2 2.4 2.7 2.1 1.9 2.1 2.7 2.5 3.0 2.1 2.5 2.1 3.3 3.2 3.2 t"1 219 2.0 2.6 3.2 2.5 3.2 3.2
KING
TJRIC ACID
AND
DENIS:
IX THE BLOOD
URIC
5
DATE -
7/
9/21
LIG. PER loo C.C. NONURIC 'ROTEIN ACID [ITROGET‘ 8.1 25
24
S/18/21
33
6.5
24 24
B/26/21 8/30/21
28 25
5.1 5.0
30
S/26/21
32
4.6
39
10/23/21
24
7.6
39
ll/
3/21
39
5.6
42
llj
9/21
33
5.0
42
11/29/21
35
3.9
43
llJ29J21
130
10.2
43
12/16/21
100
10.1
45
u/29/21
30
3.0
46
u/29/21
60
10.2
62
4.4
75
6.6
56 49
2J 9/22 12~10/21
IN
BLOOD
TABLE II OF PATIENTS S~UUPFERING FROM OF PREGNANCY
ZZ
CASE NO.
ACID
53
2/
z/22
32
5.0
54
2/
2/22
28
2.5
= I
IN
TOXEMIA
VARIOTJS
TYPES
411 OF TOXEMIAS
HISTORY
A multipara, age 40 years, had 2 convulsions and died 12 hours after admission. Had been under treatment for albuminuria and hypertension. Blood sample taken shortly before dehvery. t) A primipara, 19 years old, colored, admitted in labor, 3 convulsions after admission, delivered in 75 minutes, had been edematous for 4 to 5 weeks, but without toxic symptoms.. Blood taken on day of delivery. b) Convalescent, urine still shows albumin. :) This sample taken just before patient wa.s discharged from the hospital. Urine still ,shows albumin. A multipara, age 22 years, slight edema for 4 months, normal delivery 23/ hours after admission. B.P. systolic, 220. Urine showed a large trace of albumin and many casts. Recovery, but with persistent hypertension. Blood #sample taken the day after delivery. A primipara, age 21 years, edema for one week with some toxic symptoms with 1 convulsion 16 hours before labor was inBlood sample taken shortly beduced. fore labor. The second sample was taken shortly before discharge, at which time the patient still showed hypertension and albuminuria. A multipara with a history of 2 normal pregnancies. Marked albuminuria and hypertension. Labor induced 11/14/21. At this time, although the patient’s condition was good, albuminuria still persisted. A multipara, with a history of previous normal pregnancies admitted in coma, 4 convulsions in 8 hours, 1 convulsion 1 hour after cesarean section. Blood taken before delivery. Urine still contains, a large Convalescent. trace of albumin. B.P. Systolic, 190. A multipara, hypertension and albuminuria, normal delivery lZ/lO/Zl., recovery. A multipara, age 44. Urrne shows much albumin and many casts. Delivered of a stillborn child (macerated) 3 days after the sample of blood was taken. Recovery. Primapara, age 18 years, urine showed albumin and casts, labor induced. Died. A multipara, age 26 years, admitted in coma, several convul,sions in 10 hours, delivered a few hours after the sample of blood was taken. Died. A primipara, 18 years old, general edema, urine shows a large trace of albumin and a few casts. Delivered 2/29/22. Recovered. A primipara, albuminuriat, and slight toxic symptoms on admission. Delivered 2/26/22. Recovery.
1.12
THE
AMERICAN
JOKJBXAL
W
OBSTETRICS
AND
GYNECOLOGY
About two years ago, we were led by the observations contained in illiams’ paper to make a collection of results of uric determinations in the blood of normal pregnant women and of patients with various toxemic conditions, with a view to testing out the diagnostic and prognostic value of uric acid determination in the blood in such eonditions. The earlier determinations of uric acid, and all of the nonotein nitrogen figures were obtained by the methods of Folin and u;” the revised uric aeid method of Folin5 was employed in all the later analyses. Our blood samples were obtained from the out-patient clinic and the obstetric wards of the New Orleans Charity Hospital. In Table I are presented the results obtained on the blood of 62 normal pregnant women, in which collection examples of early, late and middle pregnancies are represented. In these eases the lowest uric acid value obtained was 1.9 and the highest 3.2, while the great majority were between 2.2 and 2.5 milligrams per 100 e.c.,-values which are well within normal limits. As far as could be determined parity, age and the stage of gestation were without demonstrable effect on the concentration of the blood eonstituent. In Table II are collected the results obtained on eleven eases of eclamptic and preeelamptic toxemia. In these cases an attempt was made to obta,in a sample of blood before delivery: and one or more samples after delivery and during convalescence; but in many of the patients this was not possible, so that in a number of cases our observations are limited to a single analysis, Our results may be considered as a confirmation of the observations of Williams, of Caldwell and Lyle, and of Killian and Sherwin regarding the accumulation of uric acid in eclamptic and preeclamptic toxemias, although we feel unable, either from a study of the clinical manifestations, or from an analysis of the blood to make (without the assistance of an autopsy) a differential diagnosis between hepatic and renal toxemias as have the latter investigators. We believe that the determination of blood uric acid promises to be of considerable value in diagnosis and prognosis in eclamptic and preeclamptie conditions. Our experience has been that in preeclamptie toxemias the increased blood uric acid may serve as a useful test in doubtful cases. In our rather short series of easeswe have invariably found that the more severely toxic patient showed extremely high uric acid values, a condition which was assoeiated with little or in most eases a relatively small rise in the nonprotein nitrogen, and in eases of recovery with a relatively slow decline towards normal values. We therefore believe we are justified in making the statement that after a suflicient time has elapsed to allow fop the collection of
HEYD, MACNEAL,
AND ICILLIAN:
413
HEPATITIS
a,dequate data it may be found that this determination may prove of a,t least equal value with the clinical tests now in use. REFERENCES (1) WiEzims, J. L. : Jour. Am. Med. Assn., 1921, Ixxvi, 1297. (2) Cal&weZI, W. F. anzd Lyle, W. G.: AN. JOUR. OBST. AND GYNEC., 1921, ii, 3. (3) Ejiian, S. A. and Shertin, C. P. : AM. JOUR. OBX? AND GYNEC., 1921, ii, 2. (4) Folin, 0. ami! Wu, H. : Jour. Biol. Chem., 1919, xxxviii, 81. (5) Folin, 0. : Jour. Biol. Chem., 1922, liv, 153. 512
HIBERNIA
BUILDING.
HEPATITIS
IN ITS RELATION
TO INFLAMMATORY
OF THE ABDOMEN: LABORATORY BY
A CLINICAL
DISEASE
AND
STUDY%
CHARLES GORDON HEYD, A.B., M.D.; WARD J. MAXNEAL, PH.D., M.D. ; JOHN A. KILLIAN~ M.A., PH.D., NEW YORK, N. Y. CLINICAL
DISCUSSION (DR. HEYD)
I
N considering hepatitis1 we shall define that form of hepatitis that is associated with, or sequential to, the more chronic inflammatory diseases of the abdomen, particularly those affections involving the right upper quadrant and the appendix. Abscess, infarct, and embolism of the liver as complications of suppurativa conditions, either in the abdomen or elsewhere, a,re not included. We refer specifically to the low grade inflammatory changes in or about the small bile radicals, the interlobular septa, the periportal veins and intrinsic degeneration of the hepatic cells. We have recognized for a number of years a eholecystic toxemia2 which manifests itself by changes in organs quite remote from the liver. During this period of time we have also been impressed with the macroscopic picture of the liver in patients operated upon for chronic disease of the biliary tract. There was a well founded idea that many of these casesshow definite liver changes, either subsequent to infection of the gall-bladder or coincident with gall:-bladder infection. From time to time in checking up our after-results we have been impressed with the clinical fact that those patients who showed gross demonstrlable change,s in the liver at laparotomy vvere those least benefited by surgery. We are convinced that there are certain types of liver change that Iare associated with chronic abdominal infection, and which re,nder the patient somewhat of an invalid even after successful surgical intervention. *Read
,stetricians, 19-21. 1923.
at
thee
Thirty-sixth
Gynecologists
and
Annual
Meeting
Abdominal
of
Surgeons,
the
American
Philadelphia,,
Association
Pa.,
of
Ob-
S,eptember
409
URIC ACID IN BLOOD IN TOXEMIA
4. The capacity of the amniotic liquid to combine with ‘C’O, is considerably less than that of normal blood. 5. The increase of the nonprotein nitrogen in the amniotic fluid in advanced pregnancy suggests that the fetal urine ma.y be a partial source of the liquid. 6. The greater concentration of uric acid in the amniotic fluid over that in the blood suggests that in the toxemias of pregnancy the increased uric acid of the blood may arise in part from a more highly saturated amniotic fluid. REFERENCES S. and (1) Uyeno, D. : Jour. Biol. Chem., 1919, xxxvii, 77-103. (2) Amberg, .Rowntree, L. G.: Bioch. Centralbl., 1905, x, 237. (3) Polin, 0. ancl Wu, H.: Jour. :Biol. Chem., 1919, xxxviii, 81-110; ibid. Supplement I, 1920, xli, 367. (4) Au&in, ,J. H. and Pan Xlyke, D. D.: Jour. Biol. C’hem., 1920-1921, 461-463. (5) Van Slyke, .D. D. and Cullen, G. E. : Jour. Biol. Chem., 1917, xxx, 347-368. (6) Benediat, Sticnley R. and Osterberg, E. : Jour. Biol. Chem., 1921, xlviii, 511-57. (7) Clognq, R. and Reglade, J. : Compt. rend. Sot. de Biol., 1921, lxxxiv, 491-493. (8) .Labat, A. and Favreazs, M.: Jour. de med. de Bordeaux, 1921, Ii, 341-342. (9) Labruhe : Quoted by Labat and Favreau, Lot. cit. (10) Uyeno, D.: Lot. cit. (11) Lab& and Favreazc: Lot. cit. (12) Proohownick and Rarnack: Quoted by Hammarsten and Hedin, 1914, 642. 2650
RIDGE
AVENUE.
URIC ACID
IN THE BLOOD
IN THE TOXEMIAS
OF
PREGNANCY BY E. L. KING, (Prom
the Department
M.D., AND W. DENIS, PH.D., .of ObBstetrics and the Laborat,ory of the School
A
of Me&tine,
NEW
ORLEANS,
of Physiological
LA.
C’hewistry
Tulane University.)
BOUT two years ago Williams1 published the results of a series of observations on the blood of pregnant walmen suffering from various types of toxemias, as a result of which he was led to the conclusion that in the blood of patients with eclampsia, hyperemesis gravidarum, and with the symptoms of preeclamptic toxemia together with arterial hypertension, the uric acid is markedly increased, that on delivery and recovery this constituent of the blood of such patients declines to a normal figure, and finally that the toxic vomiting of pregnancy is associated with an increase in the urie acid in the blood, whereas the nervous or physiologic vomiting is not. Shortly after the appearance of Williams’ paper, Caldwell and Lyle2 and’ Killian and Sherwin3 published the results of extensive series of observations on the nonprotein constituents of the blood of norm1al pregnant women and of patients suffering from toxemias of various types, and reported that in many of these latter cases notable increases in blood uric acid were found.
URIC CASE NO.
ACID AGE
36 49 62 42 40 63 1 3 5 23 26 2 4 a 9 51 60 29 6 16 17 19 20 24 31 35 41 44 48 53 56 55 46 33 11 12 13 16 22 25 27 28 32 38 39 43 45 52 54 58 59 47 8 14 15 18 21
20
ii 37 50 57
zz
IN
THE
BLOOD
GRAVIDA II
18 18
2.0
II IV
25 21 17 30 18 27 24 25 22 19 18 22 18 19 22 17 37 23 38 18 17 23 20 35 19 22 16 17 19 37 17 24 30 20 21 18 25 21 18 15 24 21 21 22 20 18 37 21 22 23
I I I r11 I III II VI III II II I ii I I 1X I II I I IV II VIII I I I I I VIII I I VI I IV I V I 3: IKC II II
II
I
-2 I II IV
18 Iii
21 27 17
GESTATION MONTE 2.0 2.0
I I
22 31
OF NORXAL
II I IT1 I
2: 4.0 4.0 4.0 4.0 5.0 5.0 6.0 6.0 6.0 6.0 6.0 6.0 6.0 7.0 7.0 7.0 7.0 7.0 7.0 7.0 7.0
7.0 7.0 7.0 7.0 7.0 7.5 7.5 7.5 8.0 8.0 8.0 8.0 8.0 8.0 8.0 8.0 8.0 8.0 8.0 8.0 8.0 8.0 8.0 8.0 2: 9.0 9.0 9.0 9.0 9.0 9.0 9.0 9.0 9.0 9.0
PREGXANT WOVEN -- .ZZZZ YG. PER 100 I - C.C. NONPROTEIN 1SRIC ACID NITROGEN
27.6 29.2 21.7 22.6 24.5
2.0 3.2 2.4 2.1 2.7
25.5 25.0 25.4 22.6 20.8 24.0 29.8 31.2 29.4 22.2 22.2 24.0 24.1 30.6 28.X 24.5 25.7 25.5 25.5 26.0 27.2 29.9 24.9 23.5 24.9 23.5 24.6 23.1 23.0 21.8 28.5 24.0 25.7 22.21 27.2 22.9 23.0 24.4 24.9 21.4 23.5 20.3 24.9 20.3 25.5 24.9 30. 21.4 2.9.2 25.7 21.8 29.6 26.6 23.5 30.7 22.6
2.9 2.8 2.9 1.9 2.1 2.8 2.7 2.6 2.8 2.9 2.1 2.1 2.8 3.0 2.9 2.8 2.6 2.8 2.4 2.5 2.5 3.0 2.5 2.3 2.16 3.3 2.2 2.3 2.5 2.2 2.7 2.6 2.2 2.4 2.7 2.1 1.9 2.1 2.7 2.5 3.0 2.1 2.5 2.1 3.3 3.2 3.2 t"1 219 2.0 2.6 3.2 2.5 3.2 3.2
KING
TJRIC ACID
AND
DENIS:
IX THE BLOOD
URIC
5
DATE -
7/
9/21
LIG. PER loo C.C. NONURIC 'ROTEIN ACID [ITROGET‘ 8.1 25
24
S/18/21
33
6.5
24 24
B/26/21 8/30/21
28 25
5.1 5.0
30
S/26/21
32
4.6
39
10/23/21
24
7.6
39
ll/
3/21
39
5.6
42
llj
9/21
33
5.0
42
11/29/21
35
3.9
43
llJ29J21
130
10.2
43
12/16/21
100
10.1
45
u/29/21
30
3.0
46
u/29/21
60
10.2
62
4.4
75
6.6
56 49
2J 9/22 12~10/21
IN
BLOOD
TABLE II OF PATIENTS S~UUPFERING FROM OF PREGNANCY
ZZ
CASE NO.
ACID
53
2/
z/22
32
5.0
54
2/
2/22
28
2.5
= I
IN
TOXEMIA
VARIOTJS
TYPES
411 OF TOXEMIAS
HISTORY
A multipara, age 40 years, had 2 convulsions and died 12 hours after admission. Had been under treatment for albuminuria and hypertension. Blood sample taken shortly before dehvery. t) A primipara, 19 years old, colored, admitted in labor, 3 convulsions after admission, delivered in 75 minutes, had been edematous for 4 to 5 weeks, but without toxic symptoms.. Blood taken on day of delivery. b) Convalescent, urine still shows albumin. :) This sample taken just before patient wa.s discharged from the hospital. Urine still ,shows albumin. A multipara, age 22 years, slight edema for 4 months, normal delivery 23/ hours after admission. B.P. systolic, 220. Urine showed a large trace of albumin and many casts. Recovery, but with persistent hypertension. Blood #sample taken the day after delivery. A primipara, age 21 years, edema for one week with some toxic symptoms with 1 convulsion 16 hours before labor was inBlood sample taken shortly beduced. fore labor. The second sample was taken shortly before discharge, at which time the patient still showed hypertension and albuminuria. A multipara with a history of 2 normal pregnancies. Marked albuminuria and hypertension. Labor induced 11/14/21. At this time, although the patient’s condition was good, albuminuria still persisted. A multipara, with a history of previous normal pregnancies admitted in coma, 4 convulsions in 8 hours, 1 convulsion 1 hour after cesarean section. Blood taken before delivery. Urine still contains, a large Convalescent. trace of albumin. B.P. Systolic, 190. A multipara, hypertension and albuminuria, normal delivery lZ/lO/Zl., recovery. A multipara, age 44. Urrne shows much albumin and many casts. Delivered of a stillborn child (macerated) 3 days after the sample of blood was taken. Recovery. Primapara, age 18 years, urine showed albumin and casts, labor induced. Died. A multipara, age 26 years, admitted in coma, several convul,sions in 10 hours, delivered a few hours after the sample of blood was taken. Died. A primipara, 18 years old, general edema, urine shows a large trace of albumin and a few casts. Delivered 2/29/22. Recovered. A primipara, albuminuriat, and slight toxic symptoms on admission. Delivered 2/26/22. Recovery.
1.12
THE
AMERICAN
JOKJBXAL
W
OBSTETRICS
AND
GYNECOLOGY
About two years ago, we were led by the observations contained in illiams’ paper to make a collection of results of uric determinations in the blood of normal pregnant women and of patients with various toxemic conditions, with a view to testing out the diagnostic and prognostic value of uric acid determination in the blood in such eonditions. The earlier determinations of uric acid, and all of the nonotein nitrogen figures were obtained by the methods of Folin and u;” the revised uric aeid method of Folin5 was employed in all the later analyses. Our blood samples were obtained from the out-patient clinic and the obstetric wards of the New Orleans Charity Hospital. In Table I are presented the results obtained on the blood of 62 normal pregnant women, in which collection examples of early, late and middle pregnancies are represented. In these eases the lowest uric acid value obtained was 1.9 and the highest 3.2, while the great majority were between 2.2 and 2.5 milligrams per 100 e.c.,-values which are well within normal limits. As far as could be determined parity, age and the stage of gestation were without demonstrable effect on the concentration of the blood eonstituent. In Table II are collected the results obtained on eleven eases of eclamptic and preeelamptic toxemia. In these cases an attempt was made to obta,in a sample of blood before delivery: and one or more samples after delivery and during convalescence; but in many of the patients this was not possible, so that in a number of cases our observations are limited to a single analysis, Our results may be considered as a confirmation of the observations of Williams, of Caldwell and Lyle, and of Killian and Sherwin regarding the accumulation of uric acid in eclamptic and preeclamptic toxemias, although we feel unable, either from a study of the clinical manifestations, or from an analysis of the blood to make (without the assistance of an autopsy) a differential diagnosis between hepatic and renal toxemias as have the latter investigators. We believe that the determination of blood uric acid promises to be of considerable value in diagnosis and prognosis in eclamptic and preeclamptie conditions. Our experience has been that in preeclamptie toxemias the increased blood uric acid may serve as a useful test in doubtful cases. In our rather short series of easeswe have invariably found that the more severely toxic patient showed extremely high uric acid values, a condition which was assoeiated with little or in most eases a relatively small rise in the nonprotein nitrogen, and in eases of recovery with a relatively slow decline towards normal values. We therefore believe we are justified in making the statement that after a suflicient time has elapsed to allow fop the collection of
HEYD, MACNEAL,
AND ICILLIAN:
413
HEPATITIS
a,dequate data it may be found that this determination may prove of a,t least equal value with the clinical tests now in use. REFERENCES (1) WiEzims, J. L. : Jour. Am. Med. Assn., 1921, Ixxvi, 1297. (2) Cal&weZI, W. F. anzd Lyle, W. G.: AN. JOUR. OBST. AND GYNEC., 1921, ii, 3. (3) Ejiian, S. A. and Shertin, C. P. : AM. JOUR. OBX? AND GYNEC., 1921, ii, 2. (4) Folin, 0. ami! Wu, H. : Jour. Biol. Chem., 1919, xxxviii, 81. (5) Folin, 0. : Jour. Biol. Chem., 1922, liv, 153. 512
HIBERNIA
BUILDING.
HEPATITIS
IN ITS RELATION
TO INFLAMMATORY
OF THE ABDOMEN: LABORATORY BY
A CLINICAL
DISEASE
AND
STUDY%
CHARLES GORDON HEYD, A.B., M.D.; WARD J. MAXNEAL, PH.D., M.D. ; JOHN A. KILLIAN~ M.A., PH.D., NEW YORK, N. Y. CLINICAL
DISCUSSION (DR. HEYD)
I
N considering hepatitis1 we shall define that form of hepatitis that is associated with, or sequential to, the more chronic inflammatory diseases of the abdomen, particularly those affections involving the right upper quadrant and the appendix. Abscess, infarct, and embolism of the liver as complications of suppurativa conditions, either in the abdomen or elsewhere, a,re not included. We refer specifically to the low grade inflammatory changes in or about the small bile radicals, the interlobular septa, the periportal veins and intrinsic degeneration of the hepatic cells. We have recognized for a number of years a eholecystic toxemia2 which manifests itself by changes in organs quite remote from the liver. During this period of time we have also been impressed with the macroscopic picture of the liver in patients operated upon for chronic disease of the biliary tract. There was a well founded idea that many of these casesshow definite liver changes, either subsequent to infection of the gall-bladder or coincident with gall:-bladder infection. From time to time in checking up our after-results we have been impressed with the clinical fact that those patients who showed gross demonstrlable change,s in the liver at laparotomy vvere those least benefited by surgery. We are convinced that there are certain types of liver change that Iare associated with chronic abdominal infection, and which re,nder the patient somewhat of an invalid even after successful surgical intervention. *Read
,stetricians, 19-21. 1923.
at
thee
Thirty-sixth
Gynecologists
and
Annual
Meeting
Abdominal
of
Surgeons,
the
American
Philadelphia,,
Association
Pa.,
of
Ob-
S,eptember