Thomas Tate.

The American journal of obstetrics and diseases of women and children online

. (page 87 of 123)
Online LibraryThomas TateThe American journal of obstetrics and diseases of women and children → online text (page 87 of 123)
Font size
QR-code for this ebook


tablets at each period with equally good results.

Here again it is possible that a deficiency in the normal thyroid
secretion was responsible for the bleeding during the pregnancy and
' the subsequent abortion. It has been shown that goats after
removal of the thyroid gland may become pregnant but invariably
bleeding and abortion occur. I believe we have here a fruitful
field of investigation for those doing obstetrics.

Case V. — Mrs. C. S., thirty-six years old, widow, has one child
seventeen, no other children. For the past year and half she has
menstruated every two weeks, and usually more profusely than for-
merly. She is tired constantly and as she earns a livelihood as a
clerk in a store and in addition takes care of her home, she is fast
going down hill physically.

She is a strongly built, apparently healthy woman, with no organic
lesions in chest or abdomen. Pelvic examination also fails to reveal
anything pathological The patient was therefore put upon thy-
roid tablets. She began immediately after a bleeding period and
went along twenty-four days before the next menstruation appeared.
She was put upon iron and arsenic. Her normal strength and health
soon returned and by continuing with one tablet daily her normal
periods were reestablished.

Case VI. — Miss J. R., nurse, forty-six years old, complains of
dizziness and pains about the ears, headache and general malaise.
Her menstrual periods are gradually becoming longer and more pro-
fuse. She is gaining in weight rapidly.

Examination revealed a peculiar thickening about the skin of the
face and body which does not pit upon pressure. No edema about
the eyelids. Lungs negative. Heart slightly enlarged to the left,
tones soft but no murmurs present. After slight exercise a slight



Digitized by



Google



816 salzman: certain types op uterine hemorrhage

systolic blow at the apex can be heard, and the pulse is rapid and
slightly irregular.

Abdomen negative. Urine negative and blood pressure 130 sys-
tolic; 70 diastolic. Pelvic examination negative. A diagnosis of
myxedema and myocarditis was made, and the patient was put
upon tincture of digitalis and three tablets of thyroid gland daily.
The next period which began four days later was slight and lasted
four days. The patient soon felt stronger and better and the pecu-
liar thickening became less noticeable. By continuing with one
tablet daily and two during the menstrual periods, they have become
normal and the patient feels better in every way than she has for
some time.

These cases of uterine hemorrhage are not uncommon, and the
instances reported represent the various types that I have seen.

Suggestions hinting at the value of the thyroid substance in these
cases are not wanting, but except for one case reported by Dr. G. H.
Mallet {Jour. A. M. A., Nov., 1897). I have been unable to find
any report of its actual use.

Sehrts' cases quoted above would certainly suggest a trial of this
treatment. Dudley (Principles of Gynecology, 1904), classifies un-
known hemorrhages from (lie uterus, into hemorrhage of puberty
and of the menopause, and states that it is at these times that dis-.
turbances are apt to be found in the thyroid gland. However, he
makes no mention of having used the gland substance in clinical
cases.

Falta in his recent book on Diseases of the Ductless Glands, on
page 118 states: "Chronic benign hypothyroidism is accompanied
by disturbances of sleep, lassitude especially in the morning and
menstrual disturbances, especially menorrhagia and amenorrhea."
Most of the books on gynecology make brief mention of the fact
that excessive bleeding may be due to disturbed thyroid secretion.
The reference is too brief to be of any value.

Most cases of uterine hemorrhage can undoubtedly be accounted
for by some local pathologic condition such as infected endometrium,
retained placental tissue, fibroid tumors of the uterus, uterine cancer
or polyp, ovarian tumors or cysts, or diseased tubes.

However, there is a certain proportion of cases that cannot be
accounted for by any of these conditions and in which any and all
methods of treatment will not bring results. Every surgeon of large
experience has at some time done a hysterectomy on one of these
cases, as a life-saving measure.

The blood coming from the uterus in these cases is noncoagulable,
this being a distinguishing characteristic. The fact that menstrual
blood is noncoagulable would point to the fact that menstrua-



Digitized by



Google



salzman: certain types of uterine hemorrhage 817

tion is controlled by the secretion of a substance which inhibits
coagulation.

This has been conclusively shown to be the case by Sturmdorf in
an article {Jour. A. M. A., Feb. 14, 1914), entitled "Functional
Menorrhagia." He deplores the frequent and unnecessary use of
the curet and the removal of the pelvic organs in these cases. I
quote from his article.

"It must suffice here to state that the endometrium during men-
struation and in the hemorrhagic cases receives normal coagulable
blood from the general circulation and sheds this blood in a non-
coagulable state. This loss of coagulability is not due to the
absence or deterioration of any element essential to the coagulation,
but to the presence of an inhibiting substance that is periodically
secreted by the corporeal endometrium from which it may be
expressed. Such expressed endometrial juice is capable of inhibiting ,
in any normal blood."

"The endometrium is activated to the secretion of this inhibiting
substance by a hormone generated in the Graffian follicle. To the
present time we have not succeeded in isolating this substance, nor
have we discovered its specific antagonist. We have, however,
learned to circumvent it by effectual measures."

The measures referred to by Sturmdorf are the use of vaso-dilators,
and the local application of acetone, liquor formaldehyde, and the
D'Arsonal spark, the treatment to extend over a period of several
months.

There can be no denial of the fact that a treatment which works
blindly and must be carried over a period of several months is not
an ideal one for such a serious condition as hemorrhage, even though
it be successful in the end.

We can scarcely hope or expect that such local methods of treat-
ment will replace or even activate the formation of the anti-inhibit-
ing substance, which depends upon or is controlled by a hormone
formed in another part of the body.

From the clinical results in the cases reported above I feel that the
thyroid gland is in some way responsible for the deficiency of the
specific antagonist to the inhibiting substance referred to by
Sturmdorf.

Whether this substance is directly elaborated by the thyroid gland
or by one of. the other of the ductless glands which depends upon the
thyroid for stimulation, I am not in a position to state. However,
our knowledge of the inter-relationship of the ductless glands would
lead us to suppose that the thyroid gland is directly at fault.



Digitized by



Google



818 finkelstone: cholelithiasis complicating pregnancy

In conclusion I would like to state the following:

There is a type of hemorrhage from the uterus not caused by
any discernable pelvic disease or pathology, nor related to any of the
so-called hemorrhage states, but due to an alteration or lack of one
or more of the hormones which control the normal flow of blood from
the uterus.

This alteration is due to a deficiency in the secretion of the
thyroid gland, and such hemorrhage can therefore be controlled by
a judicious exhibition of the dried glandular thyroid substance.

Finally I would caution against the indiscriminate use of this
substance. It must be used only when the diagnosis is assured, for
bleeding may occur in cases of hyperthyroidism.

Much harm might be done if given such a case.

234 Michigan Street.



REPORT OF A CASE OF CHOLELITHIASIS COMPLICATING

PREGNANCY.

BY

B. B. FINKELSTONE, M. D.,

Bridgeport, Conn.

Cholelithiasis, quoting Osler(i), is an exceedingly common
condition, being found at necropsy in from 5 to 10 per cent, of sub-
jects dead from all causes. It occurs at all ages but the incidence
increases progressively with advancing age, — 75 per cent, or more of
the cases are found in persons over forty years of age and less
than 1 per cent, in those under twenty. Rarely, the disorder is
encountered in infancy or childhood. The majority of cases found
in infancy are doubtless due to intrauterine infection. Gall-stones
are more common in women than men.

Gall-stones are especially common in those who lead a sedentary
life as contrasted with laborers and others who work much out-
doors, in woman as contrasted with man, etc.; as part of a general
muscular inactivity, the abdominal muscles and the diaphragm
contract feebly and the bile, inefficiently expelled, stagnates in the
gall-bladder. Similar consequences ensue upon obesity and disorders
which interfere with the free movement of the diaphragm.

In women a number of factors contribute: in addition to a
more sedentary life, they are more often the subject of hepatoptosis
or nephroptosis, brought on by repeated pregnancies and other
factors that occasion more or less continuous distention of the
abdomen and interfere with the movements of the diaphragm.



Digitized by



Google



finkelstone: cholelithiasis complicating pregnancy 819

In consequence of the prolapse of the liver, the gall-bladder becomes
dependent and the cystic or common bile duct kinked, or perhaps
has considerable traction brought to bear upon it and becomes
obstructed, so that the gall-bladder is less easily emptied than in
health and is more disposed to infection. The association of
cholelithiasis with pregnancy is undeniable, but its importance
is difficult to estimate, since the great majority of middle-aged
women, whether or not they suffer from gall-stones, have been
pregnant. There is some evidence, however, that gall-stones are
more common in those who have been pregnant, especially repeatedly
pregnant, than in those who were never pregnant. Perhaps in
some cases puerperal infections are the cause of gall-stones. Some*
times the biliary infection, though often misinterpreted, can be
definitely determined to have been acquired during the puerperium.
No doubt the beginning of the gall-stones in case cited by Rufus
B. Hall(2) at American Association of Obstetricians and Gynecolo-
gists September, 1915, started from the puerperal infection.
Osler(3) quoting Naunyn states that 90 per cent, of women with
gall-stones have borne children.

DeLeeU) says that it seems pregnancy is a factor in the develop-
ment of gall-stones and it is not rare that the gravida have attacks
of biliary colic. These seldom occur before the fifth month and
jaundice with chills and fever is more common than in the non-
pregnant state. Berkeley and Bonney(s) claim that in 30 per cent,
of the cases, the attack occurs in the first five months of pregnancy.
Cholecystitis is easily mistaken for appendicitis and pyelitis.

author's case.

History. — Female twenty-seven, American, housewife. Delivered
of a male child three years ago. Patient seen for first time December
7, 19 1 4. She was bleeding from vagina and passing clots. Vaginal
examination showed a rectocele and a poorly repaired perineum —
no muscle in perineum and was full of pin-point holes from the skin
into the vagina. It was like a sieve. Patient had a perineorrhaphy
following labor and a secondary perineorrhaphy the following year
by the same physician with the above result. Found uterus pro-
lapsed into vagina, cervix patent and easily dilatable and vagina
full of clots. Diagnosis: Inevitable abortion. Manual delivery of a
fetus — size 3^ months. Patient up and about in ten days.

January 12, 1915, operated on by Dr. Ross McPherson assisted
by Dr. Finkelstone. Dilatation of cervix, perineorrhaphy, append-
ectomy and suspension of uterus was done. Jan. 14, had a calomel
run which "distressed" her verj; much — did not know patient had
an idiosyncrasy to calomel, which gives her a marked gastric dis-
turbance. Menses on Jan. 17. Allowed to sit up in bed with a



Digitized by



Google



820 finkelsione: cholelithiasis complicating pregnancy

back-rest, Jan. 18, for two hours after which she complained
of "aching pain throughout the chest." Vomited about 5 oz. of
fairly well digested food at 8 p. m. Morph. sulph. gr. % did not stop
pain. Temperature 98 ; pulse 86; respiration 22 January 19.
In morning vomited 4 oz. of thick brown fluid — particles of undigested
food. Sutures removed. Complained of same "aching pain
throughout chest," relieved at times by belching. Urine examination
negative.

January 20, complained of pain at upper right side of incision.
Temperature 100; pulse 100; respiration 22. Blood examination:
W. B. C. 6000; P. 80; L. M. 15; S. M. 5; E. O. B. O. Patient not
jaundiced. Diagnosis: Cholecystitis (due either to lighting up
of an old lesion in gall-bladder from gall-stones, calomel idiosyncrasy
or following an appendectomy. In those cases following an ap-
pendectomy, the gall-bladder was no doubt involved at some
previous time). Patient denies former gall-bladder attacks or even
gastric disturbances — although she does say that ten years ago she
had typhoid-malaria (?) and that she was "always taking calomel
and quinine to drive away malaria." Patient seen in consultation
by Dr. Ross McPherson in the evening, who concurred in the
diagnosis of cholecystitis.

Pain somewhat relieved by hot flaxseed poultice and became less
severe until January 24, when there was slight pain in the upper
region of the wound for about five minutes.

January 26, 7.00 a. m. another severe attack of pain. About
6.00 p. m. vomited undigested food and pain was relieved.

January 28, patient up in a chair. Had slight lumbar pain.

February 8, discharged in good condition — wound healed by first
intention.

April 1, rontgenogram by Dr. McKee showed dilated duodenum.
Diagnosis: adhesions around gall-bladder or gall-stones, though
picture showed no stones.

Recourse to s-ray is seldom of much diagnostic utility since choles-
terin stones show scarcely any shadow, usually not more than the
adjacent liver, though Cole(6) says biliary calculi can be detected in
50 per cent, of the cases by rontgenograms. In another article^)
he writes that gall-stones may be detected sufficiently often to justify
a rontgenographic search for them, but the absence of any direct
evidence does not justify one in making a negative diagnosis, and
should not prevent surgical intervention provided it is clearly
indicated by the history.

April 8, 1915, saw patient for amenorrhea. Last menses March
5, 1915. Vaginal examination negative. Could not find Ladinski's
sign of early pregnancy due perhaps to unfamiliarity with sign.
From history made diagnosis of suspected pregnancy. Considered
an interruption of pregnancy on account of gall-bladder condition
plus the suspended uterus based on Kosmak's views(8). Kosmak
says that a patient with a suspended uterus is liable to difficult or



Digitized by



Google



pinkelstone: cholelithiasis complicating pregnancy 821

abnormal labor. McPherson advised that pregnancy not be inter-
rupted as he claimed that in his own cases of Giliam suspension,
his observations were at variance with Kosmak's. In fact he
claimed that in his experience quite often soon after a Giliam was
done, the patient became pregnant.

On May 15, diagnosis of pregnancy confirmed on vaginal examina-
tion. May 16, patient had slight attack of gall-stone colic. June
8, another attack of cholecystitis. Pain continued three days —
at no time was jaundice present. Tried all recognized medical
treatment with no relief. July 20, another attack of gall-stone
colic. August 24, another attack of pain in right epigastrium
which J£ gr. doses of morphine did not relieve. Saw patient
daily until Sept. 2, when writer threatened to withdraw from
case unless patient consented to operation as he feared making
an habitue of patient since she had received % to 1 gr. doses of
morphine daily since August 24, with an addition of 10 min. of
Magendie's sol. once or twice daily. (Magendie's sol. seemed to
have better effect than morphine sulphate.) Besides with such great
amount of narcotic, the effect on the fetus had to be considered.

Evidently the fetus in early pregnancy can withstand more
narcotic than the full-termed child or else the placenta does not
transmit the drug in early pregnancy as readily, which makes one
wonder whether it is not scopolamine that gives the untoward action
in so-called "Twilight Sleep," or the effect of morphine in combina-
tion with scopolamine. Editorial in Jour. Amer. Med. Ass'n.fo)
shows that, according to H. G. Barbour and N. H. Copenhaver,
studies of the combined action of these drugs on the central nervous
system exhibits a true synergism; i.e., the narcotic effect of the
combination has appeared more profound than the algebraic sum
of the effects of the same doses given separately. Barbour claims
in the case of direct action of these drugs on an isolated uterus, no
synergism or antagonism has been discovered. M. I. Smith(io)
says that the toxicity of the scopolamine-morphine combination in
the mouse is increased with the relative increase of the scopolamine
content of the combined dose. The fetus in utero may survive
despite the fact that large doses of morphine are taken into the
mother's circulation (Sajous)(n).

In August, 1915, patient seen by Dr. Howard Lilienthal, who
advised an immediate operation to relieve symptoms by incising
and draining gall-bladder and keeping fistula open, followed by a
cholecystectomy after labor. Patient and family refused operation
fearing it might interrupt pregnancy.

Various authorities claim that it is better to wait until after

delivery for operation if possible, but in the presence of a strict

indication, one may have to drain the sac before labor. Ross
5



Digitized by



Google



822 finkelstone: cholelithiasis complicating pregnancy

McPherson declared that cholecystectomy was no more liable to
produce abortion than any other abdominal operation in which the
uterus was not much disturbed. Berkeley and Bonney(s) say that
the coincidence of the symptoms and signs of gall-stones and
pregnancy does not alter the recognized treatment of the former
except in the latter month or two when owing to the diminished
accessibility of the gall-bladder by reason of the intestine being
crowded into the upper abdomen it is advisable to postpone, any
operation until after term unless the condition is urgent. They
continue by saying that the operation has no particular tendency
to cause miscarriage or premature labor, but if the child is just
approaching the period of viability the operation should be post-
poned for a short time, if possible, in its interest. The operative
mortality is returned in pregnancy as 13 per cent, and the puer-
perium as 10 per cent, in the latter operation. The later the opera-
tion, the more difficult it is technically due to the large uterine
tumor. Only that operation should be done which will quickest
remove dangerous conditions (Peterson). Operation should be
postponed, if possible, until after delivery, at least as late in preg-
nancy as possible because premature labor may occur and the child
be lost (DeLee)(4).

September 2, patient consented to operation. September 3,
cholecystostomy done by Dr. P. W. Bill assisted by B. B. Finkel-
stone. Gall-bladder marsupalized and eighty-six gall-stones of small
size removed. Patient discharged in twenty-one days; fistula healed
in twenty-four days. Allowed fistula to close as gall-bladder wall
at examination seemed in good condition. It also seemed that
the symptoms would clear up. That it might have been better
to allow it to remain open, only the future would show. Urine
negative. Stools never clay-colored since patient came under my
care. As far as could be ascertained at that time, patient had
made a complete and uneventful recovery, wound being healed by
first intention except where drain was inserted. Abdomen shows
a fetus nearly seven months in L. O. A. position. Fetal heart 124.
November 12, patient examined shows nine months pregnancy
L. O. A. Fetal pulse 128. Urine negative for sugar, albumen and
bile. December 1, urine negative.

December 11, 1915, patient in labor L. O. A. Fetal pulse 134.
Delivered of a full-termed healthy male child. During second
stage of labor when head was bulging perineum all of the vulva on
the left side from perineum to near the clitoris was drawn over the
child's head like a caul. It was impossible to push the labia on that
side off of the head with the result that the head pushed through
this obstacle as through wet paper, and the head, instead of being
extruded through the normal vaginal orifice, came through this
aperture tearing the left labium minus to the clitoris. With the



Digitized by



Google



finkelstone: cholelithiasis complicating pregnancy 823

head came the posterior shoulder. The birth of the anterior
shoulder was prevented by the separated labia blocking progress.
This was incised to allow completion of labor. After placenta was
delivered, trimmed off the posterior fragment of tissue as
far as perineum, taking only skin and mucous membrane.
Sutured the ant. flap; i.e., the labium minus sinistrum in situ.
Patient had a mucous tear of perineum which was repaired. Un-
eventful recovery for mother and child. Vaginal examination
tenth day showed perineum intact and incised and sutured part of
vulva intact — cervix one finger dilated, uterus free, movable and
in good condition. Patient discharged apparently well.

The separation of the labium minus was due perhaps to a not
easily dilatable vaginal orifice following the perineorrhaphy. Sepa-
ration of the labium minus is a rare condition. I have only seen
one case before which occurred in an instrumental delivery. In
spontaneous labor there is seldom more than slight abrasions on
the inner surfaces of the labia minora (Williams 12).

Subsequent History. — January 8, 1916, called to see patient.
Complained of slight pain in right epigastrium induced as her family
thought by lifting her boy four years of age out of crib. Consulta-
tion with Dr. P. W. Bill. Diagnosis: torn adhesions in region of
gall-bladder. January 9, slight pain just below the xiphoid. One
a. ii. January 10, patient in severe pain in same site, "felt as if it
was boring through to the back." Diagnosis: cholecystitis. Pain
was very severe and greater than before removal of gall-stones.
Pain liable to occur at any time and generally a few hours after
meals. Dr. J. C. Lynch saw patient in consultation and concurred
in diagnosis of pylorospasm due to pericholecystitis.

January 12, rontgenograms by Dr. W. A. LaField showed the
following:

Stomach. — Normal as to size and relative position, the lowest
point of the greater curvature is one inch above the umbilicus, the
pylorus is to the right of the median line and four inches above the
umbilicus. There is not any defect in the gastric outline. The
peristaltic activity of the stomach is increased, suggesting duodenal
irritation. At the end of six hours there is some residue.

Duodenum. — The duodenal cap is even in contour but consider-
ably distended; the diameter of the full duodenum exceeds two
inches. (Normally the duodenal cap is one inch to an inch and a
quarter in diameter.) The duodenum is fixed in the upper right
quadrant.

Intestine. — At the end of six hours the bismuth meal is scattered
through the small intestine, the head of the bismuth mass being
in the cecum. The motility of the intestine is normal.

Summary. — These findings contraindicate a gastric or duodenal
ulcer; they do suggest the presence of periduodenal adhesions
resulting from a cholecystitis with a resulting partial occlusion of
the duodenum at the junction of the first and second portions."

This day pain was very severe. Morph. sulph. gr. % to gr.



Digitized by



Google



824 finkelstone: cholelithiasis complicating pregnancy

i by mouth only gave slight relief. Patient seen on January 13,
and advised removal to hospital to try to relieve pyloric spasms by
rectal feeding and get patient in condition for a cholecystectomy.
January 14, admitted to hospital — seen daily thereafter by Finkel-
stone with J. C. Lynch. January 14, seemed weak and pale, as
she expressed it "washed out." No jaundice present. Urine



Online LibraryThomas TateThe American journal of obstetrics and diseases of women and children → online text (page 87 of 123)