The Journal of the Philippine Medical Association

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Part of The Journal of the Philippine Medical Association

Title: The Journal of the Philippine Medical Association
Issue Date: Vol. XXII (Issue No. 8) August, 1946
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extracted text: THE JOURNAL OF THE Philippine Medical Association Devoted to the Progress of Medical Science and to the interests of the Medical Profession in the Philippines Manila, Philippines VOL. XXIJ AUGUST, 1946 COPYRIGHT, 1946, BY PHILIPPINE MWICAL ASSOCIATION @rigimd Articles PRESIDENTIAL ADDRESS' H. ACOSTA·SISON, M.D., F.P.C.S. NO. 8 The history of obstetrics and gynecology seems to follow the course of man's development in knowledge and attitude towards life. In primitive days, childbearing was considered a natural process and therefore was regarded with indifference if not with brutality. But d.ifficulties were encountered, and nature failed to remedy them. Nature, with all the wisdom attributed to it, does not always solve its problems wisely; and one cannot safely leave everything to her. In his early dawn of cognition, man was greatly impressed and awed by the great things in nature, such as the sun, the moon, the sky, and the stars. Primitive man was beset with many environmental difficulties that perplexed him and which seemed to him unsurmountable. He then postulated that there must be a superior and powerfol Being. a Creator of all things, to Whom he could appeal for aid in :he solution of his problems, and Who would liberate him from evil. Midwifery in those early days was solely in the hands of women; and, when trouble arose, priests were called in. These tried to cope with the situation by incantations allQ prayers. And so, in the early days, a childbearing woman was mostly left to nature. But during the height of the Egyptian and Greek civilization, when women were re· garded more than mere females, some consideration was given to parturients, so that instruments for extracting dead babies, the vaginal speculum, and podalic version, came into use. Later, instead of the priests, the barber-surgeons and still later, the regular surgeons were summoned when difficulties arose. Not until after the sixteenth cen· l Read at the Inaugural Meeting of the Philippine Obstetrical and Gynecological Society, held August 24, 1946 at the North General Hospital. 314 PRESIDENTIAL ADDRESS-Acosta-Sison Jour. P. M.A. August, 1946 1ury was there any progress in obstetric practice. This was not only because child· bearing was in the care of midwives, but also because of the general state of medical knowledge then existing. It is said tha·t the first hospital erected was the Hotel Dieu, built in Paris in 660, A.D. By the 16th century, it had 1220 beds, each one of which contained four to six patien·ts. Children were mixed with adults, including delivering women with infected cases or those dying from contagious diseases. The first outstanding obstetrical con•tribution is the revival of podalic version, which was practiced by Soranus as early as 200 A.D. It was Ambroise Pare, a famous French surgeon, who in 1572 revived the practice of podalic version after it had been in disuse for thirteen hundred years. However, he erred in continuing to adhere to the doctrine that birth could not take place unless the pubic bones gaped widely. And he failed to correct his error, although as early as 1543 An· dreas Vasalius had given the first accurate description of the pelvis and had stated that ·the pelvis is practically an unyielding bony ring. Because of Pare 's influence this erroneous belief persisted for a long time. Pare gave surgery ligature and the principle of drainage. He introduced to medicine the inductive and scientific or experimental methods. Prior to the sixteenth century, de· ductive reasoning alone was used. This was good when the premise was true. But the premise was often based solely on authority without proof. For instance, at that time the major premise was that 1he world or the earth was flat, and all con· clusions had to agree with that premise. The s.econd outstanding contribution which gave impetus to the study of obstetrics is the introduction of the obstetric forceps. This instrument was invented by the elder Peter Chamberlen; but it remained a secret until Hugh, the great grandson of the younger Peter, allowed the secret to leak out so that it was well known by 1733. The Chamberlen forceps had only the cephalic curve. Independently, Levret of France, in 1747, and Smellie of England, in 1751, added ·the pelvic curve and increased the length of the forceps. In 1877, Tarnier introduced -the princip!e of axis traction. During Pare 's time and before the current use of forceps, male obstetricians were not called in unless difficulty arose. The changes in public sentiment in this regard were gradually effected in England by Smellie and his pupil, William Hun· ter; in Ireland, by Sir Fielding Ould; in Germany, by Roderer; in France, by Baudelocque and Levret; and, in Vienna, by Boer. The third outstanding contribution to obstetrics is the introduction of anesthe· sia. Ether was the first anesthetic discovered, and it was first used in surgery on March 30, 1842, by Dr. Crawford Long of Georgia, one of the first graduates of the University of Pennsylvania. But he did not publish his discovery; and, for a long time, he was not given any credi·t for it. Dr. William Morton, a Boston dentist, used ether anesthesia for extracting teeth. He was the first to give a public demonstration of the anesthetic effects of ether in the removal of a vascular tumor, an operation performed by Surgeon Warren on October 16, 1846. James Young Simpson of Edinburgh introduced chloroform anesthesia in obste· tries after his famous experiment of November 4, 1847. He met stiff opposition on the part of the clergy, for it was against the Biblical injunction, "In sorrow thou shalt bring forth children." But Simpson very cleverly answered his critics with Volume XXll Number 8 PRESIDENTIAL ADDRESS-Acosta-Sison 315 another Biblical quotation, "And the Lord God caused a deep sleep to fall upon Adam and he slept. And he took one of his ribs, and closed up the flesh." Simp· son ended by saying, "Wh!tt God himself did cannot be sinful." Thus he presented God as the first anesthetist. The discussion raged for six years until 1853 when Queen Victoria accepted chloroform anesthesia during the birth of her eighth child, Prince Leopold. From that time on, chloroform anesthesia during parturition became popular in England. France soon accepted it; and, in honor of the Queen, called it "amsthesie a la Reine." The next . drug used to assuage labor pains after ether and chloroform was nitrous oxide and oxygen in 1880 by Klikowitsch of Petrograd. In America nitrous oxide was first used in obstetrics in 1909 by J. Clarence Webster. Then came ·the era of Dammerschlaf or what is popularly known as "twilight sleep," which was much publicized in 1918. Twilight sleep, which became a fad and led women to demand it during labor, was accomplished by the use of scopolamin and morphine analgesia as was first suggested by Steinbuchel of Gratz in 1902. Gaus of Freiburg made the first report of its use in 1906. William H. Knipe was the first American to report its. use in a large number of cases in 1914. Jaeger was the first to use pantopon, alone or in combination with scopolamin. Then came the era of barbiturates as analgesics in obstetrics. This began when Emil Fischer of Berlin syntheticized veronal and called it barbital. Hamlin of Vir· ginia first reported the use of barbiturates in 50 cases. A great variety of barbi·tu· ra:es have been used both in Europe and in America. In January, 1933, Irving and his associates reported a year's clinical research with a number of the more popular analgesic methods. They observed that nembutal with scopolamin was the most effective. In accordance to American experience, the barbiturates are safer when adminis· tered orally than when given intravenously; but Rucker in Virginia and Calvo in Bogota, Columbia, champion the intravenous use of sodium pentothal for delivery. All conclude that the barbiturates are more effective when supplemented by scopo· Jamin. Demerol aided by scopolamin is an · effective analgesic in obstetrics. Another popular method of analgesia is the rectal instillation of ether in olive oil as proposed and practiced by Guathmey in 193 I. Kane combined the oral and rectal rou·tes, using paraldehyde instead of ether. At about the same time, caudal analgesia was first used in obstetrics by Stoeckel (1909) and Schlimpert (1911) of Germany. Following the method of Sicard and Cathelin of France (1901), who first used caudal anesthesia in urology, they injected novocain in the extradural space at the sacral hiatus to block the nerves transmitting pelvic pain. Many in Europe and America reported success with this form of anal· gesia during parturition; but, along with ·the successes, came also reports of death so that many enthusiasts abandoned it. Other forms employed in obstetrics are: the pudenda! block anesthesia in which 5 cc. of one per cent of procaine adrenalin solution is injected in the region of the pudic nerve; and the parasacral anesthe.'\ia where the anesthetic drug is infiltrated in the region of the anterior surface of the sacrum and coccyx and block the anterior 316 PRESIDENTIAL ADDRESS-Acosta-Sison Jour. P. M.A. August. U111: sacral branches, the sacrococcygeal plexus, and the sympathetic chains on the anterior aspect of the sacrum. When obstetric analgesia was first introduced, many 0objected to it, on religious grounds. Now the objection lies on the effect of the analgesic drug on the health of the mother and the vitality and life of the fetus. No drug has yet been discovered that would entirely eliminate labor pains and at the same time not adversely affect the fetus. Whenever any analgesic is used, the patient should be constantly watched and instantly revived with oxygen and stimulants, should any complication arise. Strange as i•t may seem, after much clamoring of women for drugs to relieve their pain, and the energetic search/ of physicians for a safe drug, so tha·t now the rule in most American obstetric clinics is that mothers be entirely' oblivious and unconscious of the birth of their babies, there are a few brave women who refuse to be unconscious when their babies come. They wish to experience the joy of hearing the first cry of their baby. They are willing to undergo the pain of a normal labor for the sake of their infants. If it is at aH possible, the ideal method of analgesia during labor which should be developed by every obstetrician is that of Dr. Grantly Dick Read, an English obstetrician, who can effect painless delivery by elimina·ting fear in the parturient by encouraging her and focusing her mind on her baby. There seems now to be a move in the opposite direction - from making almost all deliveries interventional with the use of drug analgesia and anesthesia, to allowing normal labors to ·take their course without any analgesic drug to impair the vitahty of child and mother. The one important advance in obstetrics throughout its course is that of asepsis. In the 18th century, the care of the parturient passed from the midwife to the trained accoucheur. Even after such important procedures as podahc version, forceps extraction, and Cesarean sections were followed by surgeons and later by trained obstetricians, the maternal mortality continued to be high. Indeed, the mortality of lying-in women taken care of by physicians was even higher than among those cared for by midwives. In 1652 puerperal infection was rampant in Europe and was at its zenith in 1789, especially in the Maternite of Paris where the maternal mortality was 33 per cent. The lowest maternal mortality in hospita·ls was 10 per cent. The first one who called the attention of the profession to the contagiousness of puerperal fever was Dr. Alexander Gordon of Aberdeen, Scotland, in 1795. He said it was a specific contagion that physicians, nurses, and midwives transmitted from one pertient to another. No one paid attention to him. Half a century later, especially in 1840, puerperal infection also became rampant in the United States. In 1843, Oliver Wendell Holmes, who, besides being a literary man, was also a Professor of anatomy in Harvard University, wrote a moving essay on the con·tagiousness of puerperal fever and on the way it was transmitted by ·the physician or the midwife from one patient to another. He met, not only indifference on the part of the profession in general, but even violent opposition in the person of Meigs, the same prominent obstetrician who had strenuously attacked Simpson for introducing chloroform anesthesia during labor. In 1847, Semmelweiss, a Hungarian obstetrical instructor at the Allgemeine Kran· kenhaus in Vienna, clearly demonstrated the contagiousness of puerperal fever and Volume XXII Number 8 PRESIDENT/AL ADDRESS-Acosta-Sison 317 introduced the first disinfiectant - chloride of lime. It troubled him greatly to note that the women assisted by midwives in another division of the same hospital had a much lower mortality than those assisted by him and his medical students. The death of his friend Kolletschka from infection after a pupil had accidentally pricked his finger with the knife while performing an autopsy, at once gave Semmelweiss the idea that the cause must be a pu·trid or dirty material. He as well as his medical students regularly performed or attended autopsies; and, from the autopsy room, they examined parturient women or assisted deliveries without even washing their hands. He then established the rule that all those who were to examine or attend deliveries, should first soak their hands in a solution of chloride of lime, a disin· fectant closely akin to the modern Carrel·Dakin solution. Immediately the mortal· ity in his division fell down to less than 3 per cent, even lower than the mortality among those assisted by midwives. But the obstinate unbelieving medical profes· sion did not only refuse to listen to him, but also derided and mocked him. He was so much affected by his failure to convince his colleagues who continued to decimate the pa.rturients that he lost his mind and died in the psychopathic section of the same Allegemeine Krankenhaus from wound infection, the very illness he had so zealously tried to combat. And why was medical profession so obdurate in its ignorant, if not criminal, practice in the face of clear facts demonstrated successively by three prominent observers? It was because Pasteur had not yet knocked out the old belief in spon• taneous generation. In 1773, Charles White, a Manchester surgeon, anticipating Lister, emphasized absolute cleanliness in obstetrics. Profiting from Pasteur's finding of the cause of the fermentation of wine, Lister, in 1867, presented ro the world the principle of antisepsis in surgery. He first used carbolic acid on ·the stump of fractures and on his hands, then boiled all gauze and instruments. Years afterwards, by ingenious experiments, Pasteur succeeded in disproving the theory of spontaneous generation. In 1877, Pasteur, though not a medical man, definitely demonstrated the cause of puerperal infection. By inoculating media in test tubes with the lochia of wo· men dying from puerperal fever, he found pure cultures of what are now called cocci - staphylococci in some. and in other streptococci. It was only then that obstetricians became convinced of the truth of the observations of Gordon. Holmes. and Semmelweiss, ~ whose frantic appeals to the medical profession on behalf of the parturient they had scoffed. So it was not until the second half of the 19th century that asepsis dawned on surgery and obstetrics. Obstetrics at the beginning was part of surgery; for, whenever dystocia was observed, the midwives called in the surgeons. The first course of lectures in mid· wifery to men was given by Gregorie the younger in 1733. Three years later, Smellie, who founded obstetrics in England, gave private ·lectures in London. He was soon followed by doctors in Strassburg, Berlin, and Gothenburg. In the second half of the 18th century, obstetrics became part of clinical instruction and gradually 318 PRESIDE/\'TIAL ADDRESS-Acosta-Sison Jour. P. M.A. August, 1946 became separated from surgery. This was brought about by the introduction of forceps and by the writings of independent 1eachers. In America, obstetrical practice began in the same manner as in Europe. It was at first in the hands of midwives, 1hen in the hands of surgeons. The same pre· judice against man midwives and against anesthesia in obstetrics existed. Puerperal fever too, exacted a high -toll of women's lives, notwithstanding Holmes' clarion call to the contagiousness of puerperal fever and to the roll of the accoucheur in its causation. James Lloyd and William Shippen of Philadelphia were the first obstetricians in America. Shippen delivered the first course of 'lectures on obstetrics in 1762. The first teaching clinic in America is said to have been in Buffalo. But the first systematic clinical instruction in obstetrics was given by Rohes in Baltimore in 1874. Teachers in obstetrics had always endeavored to gain for obstetrics 1he same recog· nition enjoyed by surgery and medicine, but until now training in obstetrics in most medical schools is the weakest in the curriculum. Gynecology was at first attached to medicine, then to surgery. Now it is co· ordinated with obstetrics. Simpson, in 1839, made the earliest systematic study of diseases of women. Tai•t, who was called by William Mayo the father of abdominal surgery, was the first to perform a pelvic operation, which was the removal of an ovarian tumor. He was also the first to perform salpingectomy for diseased or preg· nant ·tubes. Before the advent of anesthesia, quickness of performance was a neces· sity. After anesthesia came, dexterity and finesse were developed; but many cases were lost because of infection. The early Americans who contributed to gynecology were McDowell (1809). Marion Sims, Robert Batten, Nathan Bozeman, Emmet, and the brothers Atlee. As in other countries, obstetrics in the Philippines was first in the hands of midwives. who possessed no knowledge of technique or of asepsis; then in the hands of general practitioners who took also some surgery and gynecology. As late as 1910, when I returned from the United States, obstetric cases were delivered »t home under the care of hilots, who had no instruction whatsoever as to ;;sepsis, and who~e main claim in their trade was that they had delivered so many cases. The Fi'lipino women, much more than those of other races, were ashamed of being seen by men and would often rather die than be a·ttended by them. At that time, it was true, we had the old San Juan de Dios Hospital, the oldest hospital in the Philippines; but women did not deliver there. On my arriva'l in Manila in 1910, the Philippine Government had already estab· lished a medical school with teaching clinics in surgery, obstetrics, and pediatrics at St. Paul's Hospital. Most of the members of the faculty were Americans. The only Filipino members were Dr. Ariston Bau~ista, Chief of Medicine; Dr. Jose Al· bert, Chief of Pediatrics; Dr. Luis Guerrero of the Department of Tropical Medicine; Dr. Fernando Calderon, Chief of Obstetrics; and Dr. Baldomero Roxas, Associate in Obstetrics. Drs. Potenciano C. Guazon and Antonio G. Sison were respectively the residents in surgery and medicine. The Department of Obstetrics was the only one entirely manned by Filipinos. The residents and instructors in obstetrics were then Dr. H. Acosta ·Sison and Dr. Marfori. Gynecology was then part of surgery, whose staff was entirely composed of Americans, with the exception of Dr. Guazon. v•.ume xxn Number 8 PRESIDENTIAL ADDRESS-Acosta-Sison 319 In obstetrics, we had both hospital and outside service. Most of our cases were delivered at home, for the patients were prejudiced against, and had a great fear of, the hospital. It meant separation from ·their families and perhaps, they thought, the end of their lives. The general population had not then yet realized the benefits conferred by a hospital. Our monthly admissions to the obstetric clinic barely reached eight to ten cases, which usually were so abnormal as to necessitate opera·tions. The vast majority of parturients, both rich and poor, preferred ·to deliver at home, assisted by hi!ots. It was only when something abnormal happened which the hi!ot could not remedy 1hat physicians were called in. I saw the complications that resulted from the hi!ot practice of salag, sara, pulling on the cord for hastening 1he delivery of the placenta, and the insanitary dressing of the cord. Babies did not infrequently die of tetanus. I well remember the case to which I was called because of the baby's high fever. On opening the cord dressing, I found the cord ten inch.:s long coiled several times around the umbilicus and covered with black earth. It was the common practice among liilots to leave ·the cord as long as its lower extremiti~s. The abdomen of the baby was greenish in color from severe infection. No amount of disinfectan( could remedy the infection that had already become generalized. The remedy of hilots for difficult delivery is salag or the forceful pushing downward of the fundus, done preferably by two persons, one on each side. No wonder rupture of ·the uterus from this outrage was common. Even today, we see cases of rupture of the uterus from this cause. Sara is another hi!ot practice which leaves 1errible consequences. This consists of making the woman squat over hot embers a few days after delivery. One of the women so treated came to us wi1h severe bums of the vulva and buttocks. The hilot practice of treating postpartum hemorrhage is to elevate 1he head to the height of six fat pillows, if 1hese are available. After all is said against the hilots, however, there is one thing to be said for 1hem. They are very solicitous for the comfort of the patient. As soon as ~he placenta is out and her soiled clothing removed and changed, the patient is fed with a hot bowl of lugao and two soft boiled eggs, which parturien1s find soothing and satisfying. This is something our nurses do not give, especially since the Japanese occupation. Another comfort parturients told me they derive from the hilots is that they feel strengthened after the daily massages given them by hilot for ten days. Massage in the back and extremities in 1he absence of puerperal infection must be helpful. But -! have seen a case of embolism resulting from uterine massage done after the first day of puerperium. To attract our poor parturients to the hospital, we u~ed to go around the poor districts of Manila; and, whenever we saw any pregnant woman, we stopped her, talked to her, and invited her to see us at St. Paul's Hospital - and later at the Philippine General Hospital. when this institution was ready to receive patients. Dr. Calderon used also to give Tagalog lectures to gatherings of women in poor districts. In this way, we gradually won their ccnfidcnce, so that a few years afterwards, instead of going out of our way ·to make patients enter the hospital, we had to discharge them earlier than usual to accommodate new applicants. And today 320 PRESIDENTIAL ADDRESS-Acosta-Sison Jour. P. M.A. August, 194-6 in spite of the many hospitals in Manila and in the provinces, there is lack of beds to receive those who would like to be treated. The College of Medicine of Sto. Tomas University and the San Juan de Di06 Hospital are to be credited for the early introduction of Western medicine among Filipinos. These centers produced such men as Singian, Miciano, Quirino, Jacinto, and Gerardo Vasquez in surgery; Quintos in pediatrics; Ariston Bautista and the Guerreros of ·two generations in medicine; Ramon Lopez, Zamora, Blanco, Delgado, and Herrera in obstetrics; and Enrique Lopez, Jose Genato, and Alfredo Hocson in gynecology. These men have been topnotchers in their respective fields and reflect glory on the institution that gave them light. Many of them are still doing active work. The era of scientific medicine and its practical application, however, really be· gan with the advent of the Americans, when the Philippine Government established the Bureau of Health and created the School of Nursing, the Philippine Medical School, and the Philippine General Hospital. The Philippine Medical School later became the College of Medicine and Surgery which was the first unit of the present University of the Philippines. It was only then that the era of modern sanitation began. Al·though the people were still deeply religious and attributing to the will of God the cause of their miseries, yet they began to take interest in medical science; and gradually our women went, not only to the physician, but also the obstetrician, when they became pregnant. The free service given in government hospitals and the great number of medical graduates, nurses, and midwives are gradually doing away with hilot system - though I believe it to be still prevalent among the lower classes and in remote barrios where physicians and nurses are very few, if there are any at all. The changes in obstetrical practice since 1910 have been many. We abandoned the use of Bossi's dilator to dilate the cervix forcibly - a favorite procedure with the first chief of the obstetrical department. We never performed accuchement force, an operation mentioned only to be condemned. We no longer perform Cesarean section as a routine in cases of eclampsia. We perform it only in the interest of ·the child when the conservative treatment fails, or when there is cephalopelvic disproportion. Pituitrin, when first introduced into ·the Philippines, had quickened the expulsion of the child in many cases. The drug had been popular, not only among physicians bu~ also among midwives and hilots. It is because ofo ignorance as to its contraindica· tions that not a few cases succumbed to uterine rupture caused by its injudicious use. We were responsible for the enactment of a law which prohibited non·physi· cians from using the drug before the birth of the child. We have become radical in the management of cases of placenta previa and ablatio placenta where the cervix is undilated or very slightly dilated, and in cases of rupture of the uterus. This, with the aid of blood transfusions, has reduced our mater'!al mortality in these complications. The mortality for Cesarean sec·tion has been reduced, not only because of the selection of cases and its timely performance, but also because of the employment Vd.ume XXII Number 8 PRESIDENTIAL ADDRESS-Acosta-Sison 321 of •the low Cesarean te~hnique, which had been introduced into the Philippines for the first time in 1927. Asepsis, the use of rubber gloves, and of late the sulfa drugs and penicillin have markedly reduced our mortality in puerperal infection. The sulfa drugs and penicil· lin are so effective that they even make unnecessary the performance of extra· peritoneal Cesarean section. Symphyseotomy in place of pubiotomy is being done in cases of not too great cephalopelvic disproportion where the baby is alive and where the mother has been exposed to infection, as in cases of an unsuccessful attempt at forceps, especially when this has been done by an outsider in the patient's home. The operation is delicate, on account of the danger of injuring the bladder and urethra; but in trained hands it is a life·saving procedure, notwithstanding its disrepute in the United States. This I mention as a tribute to Dr. Baldomero Roxas, the second Chief of our Obstetric Department, who revived the operation and whose zeal in its timely performance in indicated cases have saved many an infant's life which otherwise would have been mutilated. Beriberi as a complication of pregnancy was formerly of frequent occurrence. We are endeavoring to pay grea·ter attention to prenatal care. The weight scale, urinalysis, sphygmomanometer, and stethoscope are of great help in this regard. But until now most of our abnormal cases have had either very inadequate prenatal care or none at all. This means that greater instruction should be given to the public and to medical students who are later to take charge of puericulture centers. In teaching obstetrics to medical students who are not expected to become obstetricians, great emphasis should be placed on prophylaxis and the early recognition of patho· logic condi·tions. In hospitals where asepsis is obtainable, greater use of low forceps and episio· tomy in primipara is being made. This, of course, requires greater skill in technique and care on the part of the accoucheur. Analgesia in labor and anesthesia in the perineal stage are gaining ground among highly sensi·tive nervous women. We favor analgesia in hypertensive women, but we do not find it necessary as a routine on all parturients. We have also become more liberal in allowing parturients whose perineum has not been sutured to be out of bed two or three days after delivery. We were able to present to the medical profession two new instruments, namely, a pelvimeter for accurately measuring the posterior sagittal diameter and a one· bladed forceps-for extracting a non-engaged head in low cesarean section. PECULIAR PHILIPPINE OBSTETRICAL CONDITIONS I. The pelvis of the Filipino woman is smaller than that of the American or the European. But we have our own normal standard and also tha~ of different contracted varieties as described by Caldwell and Moloy. Because of our own nor· ma! standard, one cannot agree with Williams who considers all pelves with dia· meters shorter than that of the American as contracted or abnormal pelves. 2. Placenta previa is four times more frequent in the Philippines than in Arne· rica. This may be due to the greater number of children the Filipino woman· bears, 322 PRESIDENTIAL ADDRESS-Acosta-Sison Jour. P. M.A. August, 1946 to her habit of carrying heavy loads, and to the squatting position she frequently assumes. 3. These conditions may also be the reason that procidentia uteri is frequent in Filipino women after 40. This complication was specially noted towards the latter part of the Japanese occupation when women had to run about carrying heavy bundles or large water container. 4. For still unknown reason hydatidiform mole and chorioepithelioma have an unusual frequency here. Because of ·this, Philippine obstetrics has contributed, in a small way, the method of early diagnosis of both of these conditions, thus making possible their complete eradication provided the patient is seen early. Gynecology in the University of the Philippines, as in Europe and in America, began as part of surgery, but in 1918, after the return of A. G. Sison and H. A. Sison from the United States, it became separated from surgery to constitute a new department. Calderon who was then the Dean of the College of Medicine and Surgery appointed himself as the Chief of the Department. Noris had said that "gynecology being sired by surgery and the legitimate offspring of obstetrics has shed off its swaddling clothes and is destined to be one of the foremost specialties of our time." True enough the personnel of the staff of the new department of Gynecology were taken from the staffs of both rnrgery and obstetrics. Besides Chief Calderon himself who was also the obstetrician, the other members were Carmelo Reyes, Ani· ceto Mandanas, Cecilio D. Franco, Jose R. Reyes from the surgical staff and H. Acosta·Sison from the obstetric staff. When Dr. Calderon resigned in the latter part of 1936 because of illness, Dr. C. Reyes became his worthy successor. As already mentioned, in Europe and America, gynecology was part of surgery; but now it is being related to ob£-tetrics. Indeed, obstetrics and gynecology must go hand in hand; for perhaps 60 per cent of gynecology is a sequel of obstetrics, and gynecologic conditions complicate obstetrics. The studies and deliberations of this obstetrico·gynecologic society will, I am sure, help much to elucidate problems that confront both. GERIATRICS AND GYNECOLOGY: THE ROLE OF SURGERY IN THE AGED 1 CONSTANTINO P. MANAHAN, M.D. Department of Obsu:rics and Gynecology N,orth General Hospital. B;.ireau of Health There has swept into prominence a new specialty in medicine to which has been given the name Geriatrics. Its definition varies. To some, it means the cure of the aged alone. To others, its scope is wider. It does not merely mean the palliation of ·the ills that seem to come with senility, it also includes the cure of the aging. l·t thus attempts to prolong life by protecting the senescent from the infirmities of the old. To the already aged, it tries to give vitality, by extending to them the benefits of medicine and giving the lie to the remark so often made "the patient is too old to live long anyway." Irving Fisher has happily put ·this thought in the remark, "There is a breadth of life as weli as length, and there is no area in a straight line." In no field is this attitude of mere palliation so often used as in surgery, which has, for a long time, denied its benefits to ·the old, thus relegating the aged each to his own particular limbo because "the patient is too old". lncapaci·tating hernias, for example, are treated palliatively when a repair properly done might not only give relief from the localized disturbance, but also give the individual a greater sense of general well being and usefulness. Surgery in the aged should not be withheld if it could be given with safety. A more complete and ·thorough evaluation of the physical status of the patient and a ·more careful preoperative understanding of the limitation of the cardio·vascular and urinary reserves in each particular case are required. The nutritional state should be well checked, and the necessity of the operation should be properly appraised. Against these, are we;ghed the risks made up by ·the type of operation, the kind of anesthesia, and the surgeon's particular skill. Lastly, shock should be prevented, for the prevention of shock is still its best treatment. In the aged, the venous and arterial pressures. should not be subjected to sudden decreases, for the cardio·vascular systems are no longer res:lient. Moreover, hypotension is in many instances the start of thrombosis, embolism, infarction, and pneumonia. It is, therefore, a good precaution to Narc intravenous fluids or plasma in the major procedures. A review of 287 major surgical operations performed in the Department of Gyne· cology of the North General Hospital reveals ·that, during the period from April l, 1945 to July 31, 1946, fifty major surgical procedures, comprising 17 'Jc of the total, were on women fifty years old or older. The average of the group is 58.2 years. 1 Read at the Inau~ural Meeting of the Philippine Obstetrical and Gynecological Society~ held August 24, 1946 at the North General Hospital. 324 GERIATRICS AND GYNECOLOGY-Manahan Jour. P. M. A. August, 1946 Minor operations, like biopsies, dilatation and curettage, and so on, are excluded in this study, even though a considerable number were performed on elderly individuals. T.'BLE l·A.-Pelvic Operations performed on 33 patients agtd 50 years and over. The average age of the group is 58.7 years. PELVIC OPERATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Vaginal hysterectomy with anterior and posterior colporrhaphy and repair of enterocoele . . . . . . . . . . . 24 Manchester operation with colporrhaphy . . . . . . . . . . . . 3 Watkins Interposition .. . ... ...... .. . .. .. . ... .. . . Richardson-Spalding operation ... . . . . . . .. .. . .. . .. . Le Fort's Colpocleisis . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Repair urethro·vesico·vaginal fistula .. . .... . . . .... . Myomectomy ..... . . . ... . .. . . .. .. . . .. .. . ....... . TABLE l·B.-Abdominal operations performed on 17 patients aged 50 and over. The average age of the group is 56. ABDOMINAL OPERATIONS . . . . . . . . . . . . . . . . . . . . . . . 17 Hy~terectomy total with salpingo·oophorocystectomy or salpingo·oophorectomy ... .. . .. . . . . .... . .... . . Hysterectomy, subtotal with salpingo·oophorocystec· tomy or salpingo·oophorectomy .. .. .. . . ... .... . Hysterectomy, Wertheim .. ..... .. .. .. . .... . . . . . . Salpingo·oophorocystectomy . . . . . . . . . . . . . . . . . . . . . . 4 Incision and drainage . . . . . . . . . . . . . . . . . . . . . . . . . . . I Exploratory laparotomy . .. .. . ... . ... .. . . . . . ..... . Repair postoperative ventral hernia !he indications for the pelvic operations are clear, since these operations were mostly on cases of prolapse of the uterus, cystocoele, rectocoele, and associated en· terococles of varying degrees, which were treated in the different methods already mentioned. In one case of prolapse of the uterus, both a pelvic operation (vaginal hysterectomy and anterior and posterior repair) and an abdominal procedure (repair of ventral hernia) were performed. This was a case in which prolapse of the uterus had been treated ten years before by a ventrofixation. The uterus prolapsed within two months after the operation. The failure of ventrofixation as a treatment of prolapse of ·the uterus is well illustrated by the fact that the uterus had become markedly elongated and had prolapsed through the introitus, although the fundus was still well fixed to the anterior abdominal wall, which had dimpled inwards. The indications for the abdominal operations are outlined in Table 2. The diagnosis in each instance has been supported by histopathologic study of the ma• terial removed at operation. TABLE 2.-Indications for abdominal procedures carried out in 19 cases. Adenocarcinoma, endometrium ... . . .. . . . . . .... . . ... . . . Carcinoma, epidermoid, cervix ....... ... .. . ... .. • . . . . . Volume XXU Number 8 GERIATRICS AND GYNECOLOGY-Manahan Myoma, uterus . . . . . . . . . . . . . . . ..... . . . .......... . . . Cystadenoma, serous, ovary . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Cystadenocarcinoma, ovary . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Cystadenoma, papillary, benign . . . . . . .. . .... . ... . .. . . Cyst, dennoid, bilateral . . ..... . . . . ... . . . . . . . .. . .. . .. . Abscess, tubo·ovarian .. ...... . ... . .. ......... .. ..... . 325 Of these 49 patients whose average age is 58.2 years, twenty showed hyper· tensive·cardio·vascular disease. The renal function in all was within normal limits. The nutrition of all these patients was poor. All these considered, it is necessary to find out whether the relief from discomfort, pain, and invalidism is worth the price they may have to pay. The objective of surgery is to relieve the patient of th= ills and to hasten his return to health. The means used, therefore, should be safe; and ·the risk involved should not be more than that of the disease. Can surgery as practised today accomplish this, and if so, to what extent? The pelvic operations undergone by 33 patients are itemized in Table l·A. With two exceptions, the case of the submucous myoma and that of the urethro· vesico·vaginal fistula, the group composed of patients with prolapse of the uterus, cystocoele, and rectocoele were of such severity as to incapacitate them and, in many instances, to result in bleeding, ulcerated cervices. The indication for the myomec· tomy is obvious, and in gynecology nothing seems to surpass the relief and happiness of a patient whose vesical fistula is successfully repaired. There were no deaths in this group. A follow up of the repairs showed no recurrences. The urethro·vesico·vaginal fistula healed at the first sitting. There were seventeen abdominal procedures. The necessity for treatment in the cases of the malignant tumors cannot be gainsaid. The patients operated on for ovarian cysts represented a group where the size of the cyst was such as to cause mairked abdominal distention, dyspnea, and pressure symptoms. The only small cyst in this group was one in which operation was demanded because it had twisted itself on its pedicle. There was a death in this group, a 55 year·old patient, toxic and cachectic on admission. Exploratory laparatomy revealed ovarian malignancy with ex·tensive me· tastases. The mortality in this group is 5.8 'fo. On the credit side we have two patients who underwent the extensive Wertheim operation, Radium and X·ray thera· py not being available. To date, the postoperative result has been excellent. No evidence of rec!'rrence has been seen. It is, of course, too early to make any state· ment as to their ultimate prognosis; but today ·they are very much alive, they are free from symptoms, and they can look forward to the futun: at least with some hope and equanimity. The same statement, even with more justification, may be made of the patient with carcinoma of the endometrium. In the three cases of carcinoma of the ovary, although excision of the tumor and pelvic organs was carried out completely, only time will tell whether the operation was justified or not. True, the prognosis of ovarian cancer is, at best, poor. However, for the time being, these patients are up and about and asymptoma·tic. 226 GERIATRICS AND GYNECOLOGY-:lfonalwn Jour. P. M.A. August, 1946 COMMENT For the sake of straight thinking, the objective of surgery in the aged is reiteterated. Its purpose is to relieve pain, correct deformity, and attempt to make the patient ambulatory again. Not only is the localized disease corrected, but the pa· tients are given a new lease on life. They are placed on their own two feet, so to speak, unburdened by handicaps which would otherwise res.trict ·them. A review of our cases makes us feel justified in the claim that this can be done. All cases should be evaluated properly, anesthesia should be chosen wisely, shock should be prevented, and surgery should be employed with gentleness and respect for tissue and should be as conservative as the circumstances demand. We feel that in the aged especially, the vaginal approach is better and safer than ·the abdominal. The patients who underwent vaginal operations showed less morbidity, complications, anorexia, and distention; and in general presented a smoother convalescence. In· terestingly enough, s.ince we took special pains to observe the course of these aged individuals, we have noticed that on the whole ·there is a relative absence of severe postoperative systemic reaction in the aged. They exhibit less morbidi·ty and less prostration, and they feel better than a group of younger patients undergoing the same procedures. CONCLUSION I. A study of fifty major surgical procedures in patients handicapped by poor nutrition, by hypertensive vascular disease, whose average age is 58.2 years sugges.ts that surgery may be employed safely in the aged to expedite their return not only to heal-th but to usefulness as well. 2. Meticulous preoperative postoperative care, proper anesthesia, prevent:on of shock, gentleness in the handling of tissue, and early ambulation are important. MANAGEMENT OF PLACENTA PREVIA 1 With Special Reference to Willett's Method. GUILLERMO RUSTIA, M.D., AND GLORIA TANCINCO·YAMBAO. M.D. Department of Obstetrics, College of Medicine. V.P. This report covers 369 cases of placenta prcvia occurring in the Maternity Service of the Philippine General Hm.pi·tal from January I, 1930, to December 31, 1939, inclusive. During this period 42,472 obstetrical c<1ses were admitted, showing the incidence of placenta previa to be 0.86'/C . The results of the different methods of delivery in this s.eries are shown in Table I. TABLE METHOD OF DELIVERY Cases Maternal Fetal Mortality Mortality Willet's Method .. .. .. . ... ... ......... . . . .. .... . 61 1.63% 69.46% Spontaneo•Js delivery. rupture of membranes and tamponade .. . . ..... . ...... . . . .. . ... .. . .. . • 124 2.41 51.67 Braxton· Hicks version ...... . . . . . ... ............ . . 67 5.97 91.05 Podalic version and extraction .. .. . . . . . .... . . . . . . D 15.39 84.61 Breech extraction .. . ..... ...... .. . .. ... . .. .. .. . . 17 5.88 88.24 Forceps .. . .. . .. ... . .. . . . ............ .. ...... . . 10 l0.00 90.91 Embryotomy . . .. • ...• . ... . ... . .. . . ... .. . ... . ... 0.00 100.00 Cesarean section (57 low; 16 classical) ... .. ... . .. . n 2.74 n.77 Cesarean section, postmortem . . . . . . . .. . .. . ... ... . 100.00 The results obtained from this Hudy are not sufficient ·to enable one to deter· mine the superiority of any of the methods of delivery employed in 1his series, on ac.:ount of variations in the preliminary treatment and in the condition of the patients upon admission. Nevertheless, this analysis may serve as a guide in 1he sclcc· tion of a safer method, both for the mother and for the child. Table I shows that Willet's method of treatment of placenta previa had betta resuhs for the ..!l10ther but showed a very high fetal mortality. Out of 61 cases oi Willet's method of delivery, only one mother died, or 1.63 % . Of the children, 37 were stillborn and 5 died within ten days following delivery, a fetal mortality of 69.46'/r. Spontaneous delivery, following rupture of the membranes gave 2.41 per cent maternal mortality, and 51.67 per cent fetal mortality. Cesarean section had 2.74 per cent maternal mortality and 32.77 per cent fetal mortality. The deaths of the 2 patients from Cesarean section were due to infection. These patients were wbjected to internal examination s.everal times before the operation was done. Brax· 1 Read at the 39th Annual Meeting of the Philippine Medical A ssociation, held May 10. 1946. ::128 PLACENTA PREVIA-Rustia et al. Jour. P. M.A. August, 1946 ton-Hicks version showed 5.97 per cent maternal mortality and 91.05 per cent fetal mortality. Podalic version and extraction gave 15.39 per cent maternal mortality and 84.61 per cent fetal mortality. Forceps application showed 30.00 per cent ma· ternal mortalit}' and 90.91 per cent fetal mortality. Out of 56 cases of placenta previa centralis, 4 died, or 7.14 per cent; of 187 cases of placenta previa lateralis, there were 9 deaths, or 4.81 per cent; and, of 125 cases of placenta previa marginalis, there were only 3 deaths or 2.49 per cent. In this series, 80 women were admitted in a state of shock and in an almost dying condition from loss of blood. These patients were advised by their physicians or midwives to apply for admission only after the bleeding had continued for days and weeks. The common belief among the lay people that such hemorrhage from the genitalia during the course of pregnancy is merely a maternal relief of an exces.s of heat or of blood was also responsible for the delay in their aprlying for admis· sion to the hospital. Out of these 80 patients who were admitted in a serious con· dition, 16 died; 2 died before delivery; 5 died of puerperal infection; and 9 died a few hours after delivery from acute anemia. These 16 deaths represent a maternal mortality of 4.34 per cent in 369 cases of placenta previa occurring among 42,472 obstetrical cases. The gross fetal mortality is 61.24 per cent; the stillbirth rate is 52.33 per cent; and 8.94 per cent died within the first ten days. TREATMENT While we agree with Henkel in the individualization bf cases of placenta pre· via and that each case should be treated as an individual case, we also believe tha·t trea-tment of placenta previa can be standardized. The treatment of this condition may be outlined as follows: The first thing to be done in the treatment of placenta previa is to stop the hemorrhage, and the only sure way to stop it is to termina·te the pregnancy. There is no room for conservative treatment in a condition as treacherous as this, in the words of Miller. Which method of delivery is best, however, may be decided by taking into consideration the period of pregnancy, the degree of dilatation of the cervix, the type of placenta previa, and the condition of both mother and child. Every patient who has placenta previa must be sent to a hospital. Nowadays, with the large number of hospitals available and with the aid of Army vehicles which greatly facili·tate transportation, there is practically no excuse for treating a patient with placenta previa in her home. Upon admission of a patient with placenta previa to the hospital, her blood must be properly typed and matched so that, if blood transfusion is indicated, a donor may be ready to supply the necessary blood. Plasma, which is now available, can be used as a substitute. De>rtro saline solution should be given while waiting for the donor. Vaginal examination under the greatest aseptic precaution should be made; and, if ·the cervix is closed and rigid and the hemorrhage rather profuse, the vagina must be firmly packed with rolled yellow gauze that fill up the fornices, thereby exerting pressure upon the blood vessels running along the bases of ·the . broad ligaments. Counter pressure should also be applied from above with a firm abdominal binder. Votume XXJI Number 8 PLACENTA PREVIA-Rustia et al. 329 This tamponade of the vagina must be done only as a measure 10 control the bleeding at a time when other methods are not available. However, if the bleeding is not con1rolled, the best indication is Cesarean section (either classical or low) regardless of the condition of the fetus. If the cervix is sufficiently dilated to admit two fingers, the head is presented, and the amniotic sac can be felt by the examin· ing fingers, it is best to rupture the membranes. Then the policy of watchful wait· ing must be observed. If, following the rup1ure of the membranes, the bleeding is not controlled, and the fetus is either dead or alive, the Willet's method should be preferred to the Braxton-Hicks version. Willct's method of treating placenta previa has found wide· spread use in European Clinics as well as in America and has been used in our Maternity Service with good results since 1935. Its value lies largely in its sim· plicity, which extends its usefulness to the general practitioner, who still delivers the large majority of the babies. The technic is as follows : "An assistant forces the head down into the pelvic inlet. Two fingers are inserted into the vagina, and the membranes are ruptured with a hook or with scissors in a clear area 10 ·one side of the placental tissue which is felt by the examining fingers. Without withdrawing the fingers in the vagina, a strong double volsella is inserted into the vagina, guided up to 1he fetal scalp, opened, pressed firmly against the scalp, and closed tightly. Before the fingers are with· drawn 1he grip on the scalp should be tested by traction on the volsella. Bleed· ing usually ceases immediately. A Hring carrying a weight of I lb. over a pulley or the foot of the bed is attached to the handles of 1he volsella. When abdominal and rectal examination indicate 1hat the fetal head has passed through the cervix, the vols.ella is removed. This mode of treatment combines the ad· vantages of simple rup1ure of the membranes and maintenance of continuous pressure on the denuded portion of the placental site." On the other hand, Braxton-Hick's version is rapidly losing populari1y in most clinics. The ·technical difficulties of the procedure limit its use to trained obstetri· cians, so that it rarely can be resorted to by the general practitioner when faced with a patient who is bleeding profusely. In this operation, one foot is brought down with the fingers or wi·th a long placental forceps. The breach of the fetus is thus used as a tampon to control the bleeding. The obstetrician must wait for na· ture -to expel the child, and he should not leave the patient until the child and the placenta· have been delivered and bleeding has stopped. If the placenta is found to cover the internal os of the partially dila1ed cervix -either the .Willet's mcthod or Cesarean section may be considered. In this. par· ticular case. Cesarean section should be preferred to the Willet's method. because the former can be done in a very short time and therefore it can avoid the dangers of slow dilatation and save the patient from loss of great amount of blood; whil~ the latter method, if done in this case, usually causes much bleeding, following per· foration of the placenta with forceps. If the patient is in labor and there is complcte dilatation of the cervix, artificial rupture of the membrane is indicated, and spontaneous delivery can be waited for; but, if, following 1he rupture of the membranes, there is a long time to wait before 330 PLACENTA PREVIA-Rustia et al. .Jou1·. P. M.A. August, 1946 spontaneous delivery takes place, the child may be delivered either by forceps or by version and extraction, depending upon the station of the head. In this condition, if the case is clean and the head is high, particularly if there is malposition. of ·the fetus, Cesarean section is to be preferred. Cesarean section is, we may say, absolutely indicated in all cases of placenta previa centralis; and, inasmuch as this condition can be diagnosed only after com· plete dilatation of the cervix, i·t is suggested that Cesarean section, either classical or low, must occupy a prominent place in the treatment of placenta previa in all cases in which the placenta is found to cover the internal os of the partially dilated cervix, regardless of the condition of the fetus. In conclusion, we wish to state that Willet's method as well as Cesarean section has its own place in the management of placenta previa. Willet's method is particularly indicated in cases of placenta previa lateralis and marginalis in which. following the rupture of the membranes, the bleeding is not controlled. Cesarean section, on the other hand, is the choice when the placenta is found to occlude the internal os of the partially dilated cervix regardless of the condition of the fetus. PYELONEPHRITIS OF PREGNANCY' J. R. VILLANUEVA, M.D., G. P. MARCELO, M.D., AND L. F. TORRES, JR., M.D. From the Department of Obstetrics and Department of Surgery, College of Medicine , University of the Philippints and the Philippine General Hospital Although pyelonephritis complicating pregnancy and puerperium has long been recognized, it appears that it has not been given in this coun1ry the attention that it deserves; and the dangers to which it can expose both mother and the fetus have not been fully appreciated until recently. Our main object in presenting this preliminary report on 40 cases is to invite attention to 1his condition, which many obstetricians abroad have now considered one of the major complications of pregnancy from the point of view of its frequency and its potential hazards. Etiology-Certain fundamental concepts, fully established by clinical obo. ervation and research on experimental animals. must be emphasized in the consideration of the etiology of pyelenophri1is of pregnancy. Three conditions usually pre-exist in the pregnant or puerperal woman that predispose to the development of pyelonephritis. These are urinary stasis, presence of bacteria pathogenic to the urinary tract, and trauma. Urinary stasis found in 80 './'o 01 of pregnant women, is induced mainly by (a) hormonal 12 1 changes leading to a tonic dilatation of ·the kidney pelvis, calyces, and ureters; (b) hyperplastic and hypertrophic changes in :he fibromuscular wall of 1he ureters, especially marked in the juxtavesical region; (c) mucosa! congestion and adema also marked in the lower portion of the pelvic ureters leading actually to strictures in many cases; ( d) angulation of the right ureter at the distal end of i-ts juxtavesical portion following the frequent dextrotorsion of the pregnant uterus, probably explaining in part the more frequent involvement of the right side; (e) and later on, as the enlarging uterus presses on the pelvic brim, mechanical compression of the ureters. Bacteria, which are pathogenic to the urinary tract, and which are represented in the majority of instances by the colon bacillus group, are normal inhabitants of the human large intestine. Constipation, hemorrhoids, and anal fissures, frequently associated with pregnancy, allow for 1he rapid multiplication of the colon bacillus. Trauma of 1he lower urinary tract is practically inevitable during labor, especially if it has been . dystocic. Scott has shown conclusively that the simple passage of the catheter in males may cause enough excuriation of the mucosa to permit large numbers of micro-organisms to gain entrance to the blood stream and to produce the well known ca1heter fever. The routel3) of infection seems to be usually the blood steam; the lymphatics have been pointed out by many workers as the next probable avenue of kidney 1 Read at the 39th Annual Meeting of the Philippine Medical Association, held May 10, 1946. 332 PYELONEPHRITIS OF PREGNANCY-Villanueva et al. J~':.'~u~i.~·9Z,; invasion. In the postpartum period, ascending infection from the bladder is not probably uncommon, especially in the presence of urinary retention and stasis. Cur· rent bacteriologic studies, however, tend to refute this conception. The pyelonephritic disease in pregnancy may be also an acute exacerbation <?f a pre-existing, latent, or asymptomatic chronic condition. The latter may be a left· over from a previous pregnancy, or from childhood. Diagnosis-The diagnosis of the cases has been based mainly on pyuria and bacteruria. Chills and fever, tenderness at the costovertebral angle, changes in the architecture of the urinary tract, and anemia have also been considered as suspicious signs of the disease. The peculiarities(4l of pyelonephritis associated with pregnancy are distinct from those of the non·pregnant state, as Eastman has poin·ted out; and De· Lee has warned against the pitfalls in the diagnosis of pyelitis from urinary findings in puerperium. These peculiarities were given due regard in the analysis of the cases herein presented. Pyuria is said to exist when more than 5 pus celts to the high·power micros· copic field are found in a catheterized uncentrifuged specimen of bladder urine. The same findings from a specimen of kidney urine obtained by ureteral catheterization have been considered highly diagnostic and confirmatory. When the pus cells ap· pear clumped together, non-draining pockets of pus very probably exist. The bacteriologic studies require a stained smear of the urine sediment as a first step; this would reveal the organisms present actually, confirm the results of subsequent cultures, and explain occasional negative results by culture. Because we have found quite a number of cases of apparently normal pregnant women with positive cultures from the urinary bladder, we have not considered bac· teruria of diagnostic significance, unless it is coupled with pyuria. As a matter of fact, Eastman believes that another factor may be considered in the etiology of pyelonephritis of pregnancy. This factor is individual resistance to infection. For, although bacteruria is common in pregnancy and urinary stasis the rule, yet pyelitis is not a very common complication. The bacillus coli organisms are known to grow more luxuriantly than coca! or· ganisms. Hence the smear, which may show both the two types present in the kid· ney urine, will not always agree with the cultural results. In the latte"r, B. coli may grow to the exclusion of the others; or - this may seem paradoxical - no growth may be obtained. Such cases are occasionally termed "amicrobic pyuria." Amicrobic pyuria is also explainable by the cicatrizing and stenosing effects of chronic urinary infections of the kidney tissues. No organisms are thus isolated from the urinary tract. Although the bacteria may actually have disappeared, the pyuria remains as the residual manifestation of toxic or chemical action. Incidence.- The local incidence of ·the disease has been found to be 2.10 % , which is about the same as the incidence in New York Lying·in Hospital as reported by H. Traut in 1937C5 >. According to this report, pyelonephritis ranks with cnronic nephritis and cardiac disease in pregnancy. A rather close association between pyelonephritis and ·the toxemias of pregnancy (eclampsia and preeclampsia) seems to be shown by the fact that, of the 133 cases of toxemia admitted during the period of study, 21 had pyelonephritis; and, out of the 40 cases of pyelonephritis, 21 had, of course, an associated form of toxemia. The ~=•~ ~xn PYELONEPHRITIS OF PREGNANCY"'-Vil!anueva et al. 333 limited period of observation and the limited number of cases >tudied do not warrant any statement for or against Peter's contention that there is an etiologic relation between pyelonephritis and the toxemias of pregnancy, or for or against the contrary view of C. M. Mclane and many others. Mortality.- The maternal mortali·ty is quite high, about 10 % . A disturbing factor, however, is to be considered in the coexisting eclampsia in one of the cases of death. The fetal mortality is also high ( 18 '.lo) and is brought about mainly by al:ior· tions and premature labors. Only 24 cases terminated a·t term; 14 ended in abortions or premature labors. There were two cases of hydatidiform mole, which were curetted. Distribution.-Most of the cases were met among primiparous pa·tients, 24 hav· ing been among the primipara and only 16 among the multipara. Most of the cases were bilateral, 62.5% having been on both sides, 25% in the right side and 12.5% in the left only. The kidney function, was impaired, only in the chronic cases except in two subacute, where there was a rather marked hydronephrosis. It was also in tfiese ·two and in the chronic cases that marked hypertension was noticed even in the early stages of gestation. Organisms.-The offending organism was found to be B. coli in 50 % , B. coli in combination with some other pyogenic organisms in 20 % , staphylococcus albus in 15 % , and staphylococcus aureus in 3 % of the cases. 'Treatment.-The treatment consisted of rest; administration of plenty of fluids per os and parenterally alkalies of potassium and calcium, sulfa drugs; kidney pelvis lavage and drainage (insertion of an indwelling ureteral catheter for 24 hours); and blood transfusion. Remar~s.-No single case of cure was effected with the product of conception remaining intact. Practically all ~e cases, except one, came to our notice already with signs of threatened or imminent abortion or premature labor. Most patients had sought admis..'>ion mainly for bleeding labor pains or symptoms of toxemia. We believe that many of the early and milder cases are missed, because the possibility of pyelonephritis is not kept in mind, especially among those that are first called to see the patients. The similarity in manifestation between chronic pyelone· phritis and pregnancy toxemia; and the rather frequent association of the two can very easily lead one to consider only the more common complication and overlook the less frequent but equally serious accident in pregnancy. BIBLIOGRAPHY I. Curtis, A. H.; - Obstetrics and Gynecology, Vol. I, pp. 614•120, 19l7. 2. Van Vagenon, G. and Jenk-ins, R. H .; - Factors Causing Ureteral Dilatation of Preg• nancy, J. Urol. 42: 5, November 19l9. ~- Eastman, H. J.; - Pyelitis in Pregnancy. A Review: International Clinics, Vol. 111 New Series One (Old' 48) September 19l8, p. 294. 4. Eastman, N. J.; - Pyeliiis in Pregnancy, The West Virginia M. Journal, Vol. l5: 1, 2 January 19l9. 5. Traut, H .; - Pyeleureteritis of Pregnancy, Am. Journal of Obstetrics and Gynecology, H: l92·41},4, Septembet 19l7. THE INCIDENCE OF ERYTHROBLASTOSIS FETALIS AMONG FILIPINOS1 CONSTANTINO P. MANAHAN; M.D. AND MAMERTA ANDAYA, M.D. Depa11zment of Obstetrics and Gynecology North General Hospital, Bureau of Health In a previous study of 182 Filipinos picked at random, we found that 177 or 97.3 % were Rh positive. The incidence of Rh negative individuals was 2.7% . Since then, we have tested a total of 285 persons and found eight Rh negative bloods or an incidence of 2.5 % . This comparative infrequency of Rh negative individuals among Filipinos is the explanation for the few intra-group transfus·on reactions and for the relatively few cases of erythroblastos.is fetalis in the Islands. This low incidence of Rh negative individuals seems to be an Oriental characteristic. Erythroblastosis is a rare phenomenon among ·the Chinese. Although the possibility of danger assoc:ated with transfusion is not so formidable in ·the k lands, however. the presence of Rh negative individuals cannot be neglected or shrugged off completely. Moreover, cases of enthroblastosis are seen in our Obs· tetrical wards. The Rh factor, first demonstrated by Landsteiner and Weiner, received rts name from the fact that the first serum for testing this blood cha"cteristic was prz· pared by immunizing an animal with the blood of ·the Rhesus monkey. Using this serum, it was possible to divide individuals irrespective of their blood groups into two types - those whose red cells possess the Rh factor and are described as being Rh positive. and those who do not have it and are. therefore, Rh nega·tive. The factor is transmitted as a Mendelian dominan-t. A constant characteristic of the individual. it is fully developed at birth and is present in the red blood cells during fetal life. Clinically, the factor has become important. For some individuals, it is a good antigen; and it has been found to be responsible for most intra·group transfusion reactions and for most of the cases of crythrohlastosis fetalis. Its role in intra·group t~ansfusion reactions is readily understood now tha·t we know its properties. By the ordinary cross matching tests. the presence or absence of the factor is not demonstrable. An Rh negative individual may be given Rh positive blood. If this individual has not been previously sensitized to the factor. no reaction occurs. Antibodies against the Rh factor arc. however, developed; and these produce a re· action at the second transfusion. These transfusion reactions are invariably severe and result in complete or almost complete kidney shut•down and uremia. I Read at the Inaugural Meetini:: of the Philippin: Ohstetrical and GyneC"oloj!ical Society, held Aug. 24, 1946 at the North General Hospital. 336 ERYTHROBLASTOSIS FETAL/S-Manahan et al. Jour. P. M.A. August, 1946 The infrequency of ·these intra·group transfusion reactions in the Islands may be explained by the low incidence of Rh negative Filipinos. Moreover, not all Rh negative individuals can be sensitized upon exposure to the antigen. Lastly, blood transfusions are comparatively rarely given in the Islands, although recently the use of blood as a therapeutic agent has become more widely adapted. The production of erythroblastosic infants, like intra·group 1ransfusion reactions, depends on the iso·immunization of an Rh negative individual by the Rh factor. Through some break in the placental barrier, fetal Rh positive red cells enter the maternal circulation. The mother who reacts ·to this "transfusion" of fetal red cells, produces immune bodies which readily cross the placental barrier and agglu· tinate and destroy the fetal red cells. The fetus responds to this by increasing its productions of red cells as evidenced by the extra medullary centers of erythro· poiesis and an abundance of nucleated red cells in the circulation. The severity of the damage received by the infant finds expression in the clinical picture it presents. The severest ·type is the hydrops gravis variety; next, is the so·called icterus gravis; and the mildest is the congenital anemia of the newborn. Our interest in the subject has been renewed by the recent finding of four cases of hemolytic anemia of the fetus and the newborn. Three of these, all represent· ing the hydrops variety. are 0.18 o/o of 1619 deliveries during the period from Jan· uary 1, 1946 to August 10, 1946. In the Obstetrical· Service of the St. Luke's Hos· pita! during the same period, ·there was a case of hydrops gravis in 511 deliveries or 0.18 o/o. Thus at the North General Hospital, h.emolytic anemia of the newborn was found once in every 540 cases. This figure is almost identical to the incidence of one in 511 cases at the St. Luke's Hospital. These cases of erythroblastosis fetalis found at the North General Hospital and at St. Luke ·s were all premature deliveries; one on the sixth month and three on the seventh month. All resulted in the delivery of markedly bloated infants with marked edema and ascites., splenomegaly and hepatomegaly. All died a few minutes after delivery. The placenta was characteristically larger than it should be for this corresponding gestational month and was extremely friable. Histopathology revealed nucleated red cells in ·the fetal vessels. which seemed few. The stroma was markedly edematous, and the syncitium was well preserved. The mother's red cells in all four cases were Rh negative. The presence of anti Rh agglutinins was demonstra·ted in all but one of these cases by cross matching the mother's serum with known Rh positive bloods of the same type. However, the ·titre in all was weak. COMMENT In a previous report we found the incidence of Rh negative Filipinos ·to be 2.7 7o. We have continued to test a few more running up the total of tested individuals to 285; and we have found the incidence to be 2.5 7'o. During this same period of observation, three cases of erythroblastosis, hydrops gravis type, were found. This means an incidence of one in every 540 cases. The figure of one in every 511 cases is given for St. Luke's. These established cases of erythroblastosis should be a warning against the indiscriminate use of blood trans· fusion, espec.ially in pregnancy. Votume XXII Number 8 ERYTHROBLASTOSIS FETALIS-Manahan et al. 337 Since ·the testing serum is still difficult to obtain, in practice we may follow the advice given by Weiner. who divides the cases into three groups. He believes that blood transfusion may be given safely if the individual has not been exposed to the antigen. This group is made up of males who have never received a transfusion. or females who have not had either a transfusion or a pregnancy. The second group is made up of cases who have been exposed to the Rh antigen, but which show no clinical evidence of sensitization - i.e., individuals who have had repea·ted blood transfusions without reaction and women who have borne only normal children. To obviate any accident, the biologic ·test of giving 50 cc of blood first and allowing an hour to elapse before the rest of the blood is given, is recommended. The third group comprise patients who have been exposed to the Rh antigen, and who show signs suggestive of sensitization. These should not be transfused unless first tested for ·the Rh factor. or unless they can be given Rh negative blood. The incidence of hemolytic anemia of the fetus and newborn in the Philippines is curiously high compared to the rather low incidence of Rh negative Filipinos. }avert in New York gives a figure of one in 438 cases; Burton and McDuff, one in 516; Wolfe and Neigus', one in 568 cases. These findings should be a strong warning against the thoughtless and indiscriminate administration of blood ·to any woman or girl, since this would be enough to sensitize the susceptive individual. Levine goes even further and suggests that this immunization may have arisen in many as the result of the common practice of giving blood intramuscularly, especially to the newborn. CONCLUSION I. Hemolytic disease of the newborn (Erythrobla9tosis fetalis) has been found once in 540 cases at the North General Hospital and once in 511 cases at St. Luke's. 2. The incidence of Rh nega·tive individuals among Filipinos is 2.5 % . STUDIES ON HYDATIDIFORM MOLE H. ACOSTA·SISON, M.D., F.P.C.S. AND G. T. ARAGON, M.D. Department of Obstetrics, University of the Philippines Hydatidifcnn mole is an aberrant condition of the chorionic cells in the early months of pregnancy, in which the choricnic cells unduly proliferate while the mew· dermic chore of the villus undergoes cystic degeneration. It is because hydatidiform mole has been the precursor in 68 per cent of 72 cases of chorioepithelioma previous· ly reported by us, that this study has been undertaken, especially with the view of detecting the early signs of malignancy. Etiology. The et'ology is unknown, but all are agreed that the pathology lies in the ovum and not in the endometrium. Incidence. In 1he Philippine General Hospital, there have been 137 cases of hydatidiform mole from 1940 to 1943 inclusive among 17,321 cases of pregnancy, showing an incidence of I for every 126 pregnant women. This is rather a high incidence when compared with Mathiew's figure of 1 for every 2,000.' According to Mathiew, mole is most common afrer 40. We have found the age incidence to coincide approximately with the age incidence of pregnancy. It has been found in as young as 15 and in as old as 50, but most frequently between the ages of 20 and 29, and a little less frequently between 30 and 39. However, after 40, though the actual number of cases of mole is less than the other ages, its incidence is rela· tively higher than that of pregnancy. The following table shows the relative frc· quency of mole cases according to age. Age 15·19 20·29 30·39 40·49 50·59 Consecutive cases of pregnancy admitted in 1943 15 74 46 3 Cases of mole in 1940 to 1943 22 62 31 20 Though mole was found in primigravida, it was most common among multipara. Clinical History. Uterine bleeding was usually the complaint that brought the patient to the physician; and, though the bleeding began as early as the first month or as late as the six1h month, it appeared most f..-equently at the end of the third month: and only a little less often in the fourth and in the second month. The bleed· ing was either of red or o-fl dark chocolate color. The uterus was larger than in the corresponding age of amenorrhea in 63 per cent. In moles that subsequently proved to be malignant, the undue enlargement of the uterus was found in 92 per cent. And, in many of the malignant cases, the uterine enlargement took place in 340 HYDATIDIFORM MOLE-Acosta-Sison et al. Jour. P. M.A. August, 1946 a relatively shorter time. Many of the cases that exhibited no undue uterine en· largement gave a history of having expelled mole outside. As is to be expected, none of the cases showed signs of a fetus, except in one case of twins wherq one twin of 4 months with its placenta was normal and the other, a mole. Diagnosis. The correct diagnosis of mole was made in 72.7 per cent. The wrong diagnosis given in order of frequency was as follows: Threatened abortion or miscarriage, incomplete abortion, premature labor, fibromyoma, and placenta pre· via. The correct diagnosis was later made when the patient discharged mole cysts. The test for increased gonadotropic serum as shown by Fr;edman 's test or by Del f's method when used in doubtful cases gave a higher value than in normal pregnancy. Size of mole cysts. The mole cysts were either o~ the small mongo·sized variety or of grape-sized type. In some cases both sizes may co-exist in the same patient. It was found that the small variety had greater tendency to be malignant, though in I casci of malignancy the cysts were of the large type. Further observa·tion will be recorded along this line. Character of mole. In 721 cases, the last curettings were examined microscopic· ally for the detection of malignancy. We labeled this method of detecting malig· nancy as early microscopy, to differentiate it from diagnos.tic curettage, which is done sometime after mole expulsion to explain the cause of uterine bleeding. By the early microscopy method, out of 72 cases of mole, 24 or 33.33 per cent were f'ound to be- malignant. The examination of the uterus of those that were hysterec· tomized showed early chorioepithelioma, thus confirming the diagnosis of malignancy by early microscopy. Of the 48 cases that were reported as benign, 4 subsequently developed chorioepithelioma. So the safest method for not missing malignancy in those reported as benign would be their follow-up for a·t least three or fourl months. And in those that approximate menopause, they should be followed for at least three years. Clinical signs of malignancy. As already mentioned, though the uterus is usually larger than what is warranted by the age of amenorrhea, one should be on the lookout for malignancy when there is much over-distention of the uterus or when the distention takes place suddenly. The small cysts also more often give rise ta malignant changes. Of course, the microscopical examination of the curet· tings is the final determinants of malignancy; and, in case the examination fails to show anything, there should be a follow-up, in order to detect any clinical signs of H ·B·E·s. Complications. Anemia was found in 106 cases or in almost 78 per cent; in· fection. in 59 cases or 43 per cent. We classified under intlection all thooe who had fever after the evacuation of the uterus. One of the infected cases, who was admitted with fever and who was curetted outside the hospital, had a ruptured ap· pendiceal abscess besides bilateral ovarian cysts. One case had malaria and liver necrosis. Signs of toxemia in the form of edema, albuminuria, cylinduria, and hyper· tension were found. in 7 .81 per cent of the cases. 'Treatment. We advocate a thorough immediate evacuation of the uterus per vaginam on the establishment o~ the diagnosis. This is to be preceded or accom· panied by either hypodermoclysis or blood ·transfusion, depending oo the general con-' Votume XXII Number 8 HYDATIDIFORM MOLE-Acosta-Swon et al. 341 dition of 1he patient. Since 1941 w~ have followed the routine of sending the last curettings to the pathologist for the determina1ion of the type of chorionic cell~, whether 1hey be benign or malignant. Benign case are instructed to return for follow-up every month or when the)' have a recurrence of bleeding not due to menstruation. By thi& procedure, 4 of the reported benign cases who later developed chorioepithelioma were diagnosed. Of the 30 malignant cases, 17 were hysterectomized; 3 were treated by X-ray; and 10 refused any treatment after the D & C. These cases were lost sigh1 of. The uteri of the hysterectomized cases all showed early chorioepi1helioma growths which corroborated the diagnosis of malignancy by early microscopy. Mortality. Of the 136 cases of mole, 4 died. One died of acu1e anemia 1 hour after D & C. The histopathology of the mole in this cases was malignant. At autopsy, the uterine musculature was found to be infil1rated with syncytial cells. One died of lobar pneumonia two days after D & C. The histopathology of the mole was also malignan1. One died from acute hemorrhage due to advanced uterine chorioepithelioma 14 months after the D & C fon mole. The histopathology of the mole in this case was reported as benign. One case died from colon bacillemia and pyonephritis due to the colon bacillus. Conclusion. 1 . Exce.."5ive uterine enlargement or its sudden occurrence in a mole has the 1endency ttj become malignant. 2. Every case of mole should be examined by early microscopy for malignancy. Benign cases should be followed up in young women for three months, and in women approaching menqpause, tor three years, for clinical evidence of chorioepithelioma. NOTE.-Grateful acknowledgment is due to Drs. De Leon and Sta. Cruz who made the microscopic examinations of the last curettings obtained from moles and the biopsy of the hysterectomiied uteri. AXIAL TORSION OF THE UTERUS CONSTANTINO P. MANAHAN, M.D. AND JOVITA CORONADO, M.D. Department of Obstetrics and Gynecology North General Hospital The aswciation of pregnancy to myoma of the uterus has given rise to numerous complications. One of the most bizarre and striking of these is axial tors.ion of the pregnant myomatous uterus. Torsion, while not a frequent finding, is seen in the non·pregnam uterus comparatively oftener. The diagnosis is generally made at laparatomy; for, in most instances, the tors.ion is so gradual that the symptoms produced are of.ten masked by others associated with the enlarged myomatous uterus. In contrast, torsion of the pregnant myomatous uterus gives rise to symptoms and signs of an acute abdomen. A review of the lit.erature is interesting. Most of the standard texts in gyne· cology state that torsion may be found in the myomatous uterus. They disagree, however, as to the incidence. Curtis says that the occurrence is fairly common. Wharton, on the other hand, has found it a rare complication. Crossen makes no mention of it. Kelly states the poss.ibility and describes two cases in his operative gynecology. Masciottra and Baldi found two cases of acute torsion of a fibroid uterus in six years. These cases, though clai;.sified as acute, had shown symptoms intermittently for six months and for two years respectively before operation. Our experience in the Gynecologic Service of the North General Hospital, four :ases of axial torsion of the myomatous non-pregnant uterus were found in 244 laparatomies. These torsions were all partial as the cervix was not involved in the process and they were incomplete, as the rotation was le~ than 360 degrees but at least 180 degrees. Lei;.ser degrees of torsion as for example, a quarter of a turn are often observed. It is obvious that, although axial torsion of the myomatous uterus is not quite a rarity, still a torsion of 180 degrees or more is rare enough to merit special mention. In contrast to the review ofl the gynecologic literature, we find that none of the standard texts in obstetrics mention axial torsion· of the uterus as a complication of pregnancy in a myomatous uterus. The texts of De Lee-Greenhill, W illiams·Stander, and Beck do not mention this occurrence. A review of medical reports is unavailable. Duckering recently reviewed 361 cases of myoma in 22,283 pregnancies during a seven-year period in the Woman's Clinic of the New York Hospital and did not find this complication. A. Duran describes a case in a 38-year old woman who had a nodular myoma of the uterus complicated by a pregnancy of one and a half months. Myomectomy was carried out and the patient went to term uneventfully. Duran makes the statement that a review of the literature has brought to light only two addi·tional cases. To these three cases, we add two of our own. 344 AXIAL TORSION OF THE UTERUS-Manahan et al. Jour. P. M.A. August, 1946 The first case is that of a 30·year old, Gravida II, Para I, who was admitted on August 4, 1945, complaining of intense lower abdominal pain of three days duration and giving history of two months amenorrhea. Soon after missing the first period, she noticed a mass about five centimeters in diameter in the right iliac region. The pertinent findings on examination were: pallor; rapid pulse; prostration; marked ab· dominal tenderness; rigidity; and the presence of a hard, very tender mass in the lower abdomen. On vaginal examination, the cervix was soft, and the uterus was irregularly enlarged. There was a hard, tender mass ten by ten centimeters to the lef: of the uterus. The mass could not be separated from the uterus. Exploratory laparatomy revealed the uterus to have undergone a 180·degree dextro·torsion, so that a nodular myoma situated on the right cornu was now on the left and towards the front. The uterus was markedly cyanotic. Myomectomy could not be considered, as the tumor was subserous·intramural in type. For this reason hysterectomy was resorted to. The postoperative course was uneventful, and the patient was discharged fourteen days later. The second case is that of a 32·year old, Gravida III, Para I, who ·was admitted on May 13, 1946, with a history of amenorrhea since January 20, 1946. Two days before admission, she experienced severe lower abdominal pain and for the first time noticed a mass in the left iliac region. Abdominal examination showed a marked muscular defense and tenderness of the lower abdomen. The cervix was found soft and directed towards the vaginal axis. The uterus was irregular and deviated to the right, enlarged to the size of a four·month pregnancy. On the left was a smaller mass which could not be separated from the uterus. The patient, with all the sign,. and symptoms of an acute abdomen, was subjected to laparotomy, which showed the uterus to be markedly congested. Occupying the left lower quadrant was a large intramural myoma 15 cm. by 10 cm. On close inspection, the uterus was found to have undergone a 180·degree torsion to the left, so that the myoma which was now on the left lateral, was, on restitution of the uterus,· situated on the right postero·lateral cornu of the uterus. This fibroid was the mass that had so sud· denlY' appeared on the left sde of the lower abdomen at the onset of the acute ab· dominal pain. Because of the marked congestion of the uterus which presented a cyanotic and mottled appearance, and because the fibroid was such that a myomec· tomy could not be done, hysterectomy was carried out. The postoperative course was uneventful. COMMENT The factors concerned in torsion of the uterus are its weight, size, location, and the degree of softening of its isthmic portion brought about by pregnancy. An assy• metrically placed myoma of considerable size may, by its weight alone, produce torsion of the corpus on the softened lower segment. Predisposing to this is the laxness of the anterior abdominal wall found in multigravidae and the relative laxity of the round ligaments. Straining, bending down, and other conditions, which increase and suddenly decrease the intraabdominal pressure, aid in bringing about the torsion. Increased intestinal peristalsis, and adhesions of the omentum or intestines to the • tumour may help in producing the torsion. Volume XXU Number 8 AXIAL TORSION OF THE UTERUS-Manahan et a/. 345 One other condition which may give rise to the accident is pregnancy in one horn of a uterus didelphys. In the non-pregnant uterus, tor&ion is invariably a chronic process and rarely presents the picture of an acute abdomen, as seen in the pregnant myomatous uterus. In this non-pregnant state, the location and size of the tumor plays a large factor in producing torsion. Thus, a -tumor placed anterolaterally and growing between the bladder and broad ligament, may come to occupy a more central position - pushing the uterus upwards, rotating i-t pmteriorly, and bringing about axial rotation of the uterus of greater or lesser degree, depending on the size of the tumor. The development of acute torsion being gradual, however; its symptoms are rarely seen; and the diagnosis is often missed. Acute torsion of the uterus presents signs and symptoms of an acute abdomen. Pallor, a rapid pulse, abdominal tenderness and rigidi·ty are present. A tumor is palpable; and, on vaginal examination, the pulsation of an artery felt anteriorly is diagnostic. We were particularly impressed by the exquisite tenderness of the myoma upon palpation, although the rest of the uterus is not qui·te so tender. The "treatment is hysterectomy, when myomectomy may not be safely carried out. We feel that a mere reduction of the torsion carries with it the possibility of recurrence. CONCLUSION I. Axial torsion of the pregnant myomatous uterus is a rare occurrence and usualy presents all the signs and symptoms of an acute abdomen. 2. Two cases are briefly described. 3. Axial torsion of the non-pregnant myomatous uterus is more often seen than that of the pregnant uterus. And the development of the torsion is w gradual, that its symptoms may easily escape notice. BIBLIOGRAPHY Masciottra. E. and Baldi, E. M. : Rev. med. quir. pat. fem. B. Air. 13 : 512, 1945. Duran, A. : Bo!. Soc. Chilena Obst. gin. 10 : 119, 1045. Duckering, F. A. : Am. J. Obst. and Gynec. SI : 819, 1946. STUDIES ON THE EARLY DIAGNOSIS OF CHORIOEPITHELIOMA H. ACOSTA·SISON, M.D., F.P.C.S. AND G. T. ARAGON, M.D. Obstetrical Departmen ~. University of the Philippines All concede 1he importance of early diagnosis of uterine chorioepithelioma, for on it largely depends the success of the treatment. But the criteria for diagnosis offered by 1he obstetrical literature extant are inadequate. These criteria are the much·hailed biologic test (Aschneim·Zondek or its modification, Friedman test) and the findings in what is called diagnostic curcttage. Mathieu, who has compiled all the literature concerning chorioepithelioma for the years 1935 10 1937 inclusive, quotes Teacher's opinion that "during the early stages, chorioepithelioma presents nothing characteristic either in symptoms or in physical signs. In order •to establish diagnosis, exploratory measures must be made." That seems to be the consensus of obstetricians abroad, who also believe that early diagnosis is fraught with grea1 difficulty. Mathieu gives much importance to the verdict of the biologic test on either the uterine or 1he spinal fluid ; Novak, to the biopsy of what is called the diagnostic curettage. Neither of them gives much weight to the clinical method, which is to us early enough for diagnosis, if done conscientiously. We have found that ·the Friedman test would not give a positive result even when 12 cc. of urine is used, unless the tumor is fairly well advanced. On the basis of the clinical method, we have operated on two cases of uterine chorioepi·the· lioma (E. de la C . and P. Diz.). one of which was of the size of a corn grain; and the other, the size of a fifty-centavo piece, which gave a negative Friedman test with 10 cc. of urine. The Friedman test on :he spinal fluid, a test which is supposed to be of diagnostic value, was employed twice in an advanced inoperable case where the tumor had involved the pelvic organs and had metastasized into the lungs. Ten cc. of spinal fluid was used. On both occasions the resul·t was negative. Our ex· perience Shows that the test is more sensitive when urin'e is used. By diagnostic curettage, we mean the curettage done for the purpose of deter· mining the ca~ of uterine bleeding in a patient, with or without the history of an abortion or mole expulsion having occurred some weeks or months previously. In other words, it is not the curettage done for the purpose of completing a recen1 abortion or mole evacua1ion. The diagnostic curettage is of diagnostic value if the tumor is in the uterine cavity. But if it is in the uterine musculature beyond the endometrium, 1he negative finding would give a misleading report. It may be pertinent to mention here what one of us wrote in another paper on chorioepi1helioma, stating why we object to the so-called diagnostic curettage when positive diagnosis has already been made by the clinical method. I. If -the result is positive, it merely confirms the diagnosis already made by 348 DIAGNOSIS OF CHORJOEPITHELIOMA-Acosta-Sison et a~ Jour. P. M. A. August, 1946 the data HBEs (the clinical method to be explained later) and nothing new is gained. 2. If the result is nega·tive, it would alter neither the positive diagno&is arrived at through the data HBEs nor the decision for radical treatment. In many of our cases, the tumor was found 10 be in the muscular wall far beyond the reach of the curette, so that uterine s.crapings invariably gave a negative finding. 3. The use of the curettc may give rise to infection in a uterus that, because of its softness. would be susceptible to germ growth. 4. The curette may perforate the uterus in cases where the growth has extended throughout the thickness of the uterine wall and thus increase the dan1<er of a radical operation. 5. It may incite the rapid flaring up of metastasis. 6. At best, it is an unnecessary, if not dangerous., waste of time and energy, simply delaying •the performance of a radical operation which should be done as early as possible. However, though we condemn the diagnostic curettage when po&itive diagnosis has already been made by HBEs, we do resort to it in cases when 1he group data HBEs are so vague that we cannot, to our satisfaction, make a po&i1ive diagnosis by the clinical method. But, in 1he few cases that we have employed it, the result has always been negative. The clinical method of diagnosis of uterine chorioepithelioma is described b)' Acosta-Sison as consiHing of a group of data which are found to be so frequently associated that, when present, are of diagnostic significance even in the face of a negative Friedman or a nega1ive microscopic finding of the so-called diagnostic curct' tage. These data are labelled as HBfa. H stands for the history of having aborted or having passed hydatidiform mole from a few weeks to .as long as three or four years; B for uterine bleeding coming on from a few days to within 4 weeks after the termination of the las.t pregnancy; and Es for the enlargement and softening of the uterus. Nonregression or rapid development of ovarian cysts after curettage for mole may also be indicative of uterine chorioepithelioma. The first three conditions represented by the letters HBEs are the mom constant, the most frequently found. and the ones described in our second series of cases. The fourth condition which is the rapid development of ovarian cysts after mole expulsion is an additional clinical finding which we n01ed in 2 of our P.resent or third series of 30 cases. One of these cases had no uterine bleeding; but the ovaries, which at first were cystic, grew so large that the abdomen which had become small after the mole curettage attained the size of a 7-month pregnant uterus at the end of 3 weeks. In 1he second case, the ovarian cysts, which were only as large as half of a pomelo at the end of two weeks after the curettage for mole, were accompanied by uterine bleeding. Jn other words, this patien1 had HBEs in addition to the grow!h of the ovarian cysts. The other case had no uterine bleeding, but the ovarian cysts were as large as an aduh head. This case was negative for Friedman test with I 0 cc. urine. No diagnostic curettage was made and the diagnosis of uterine chorioepithelioma was based simply on the history of having been curetted for mole within 3 weeks; the enlargement and softening of the uterus; uterine bleeding in one case; and, in the ~:=, ~xn DIAGNOSIS OF CHORIOEPITHELIOMA-Acosta-Sison et al. 349 other, the presence of large ovarian cysts which were not evident when the pati~nt was discharged from the hospital. Both were immediately subjected to double sal· pingectomy, double cophorectomy, and subtotal hysterectomy. On section, the hys· terectomized uterus of both patients showed chorioepi·thelioma on the posterior wall; one had the size of a com grain below the entrance of the left fallopian tube; and the other, two excavated tumor growths each of which was of the size of a fifty-centavo piece below the entrance of both fallopian tubes. As a marter of routine and for the sake of record, we used the Friedman test in our cases. Because we disregarded its negative verdict after having made a positive diagnosis by the clinical method, it does not mean that we consider the Friedman test unimportant. As a matter of fact, we believe it to be a valuable indicator of a de· veloping metastasis or recrudescene of the disease in our follow-up cases. We also resort to it in cases of doubt when the clinical method is not clear. In the few cases where we resorted to both the Friedman test and diagnostic curet>tage because we could not establish a positive diagnosis by HBEs, the result were always negative. However, although HBEs, with or without the development of the ovarian cyst, is able to diagnose uterine chorioepithelioma withil\ two to three weeks (much ahead of the Friedman test), we believe there is still another method by which we can diag· nose uterine chorioepithelioma much ·earlier; and this is the microscopic examination of the uterine curettings obtained immediately after mole expulsion or after an in· comple<te abortion. We have called this the early microscopy method; and its cf. ficiency depends on the ability of the pathologist to detect malignancy in the chorionic cells and to make an early report. According to Novak, the criteria for malignancy are: I. Large masse3 of trophoblasts growing in bulk with few or no villi and Je· stroying the uterine muscle. 2. Anaplastic activity. According to Hertig, •the pathologist of the Boston, Lying in Hospital, the criteria are: I. Invasion of the villous stroma by relatively undifferentiated chorioepithclial elements. 2. Moderate or marked anaplasia of the epithelium either with or without mi· totic activity. 3. Tissue culture-like growth of detached chorioepithelial elements, usually in fairly large masses and growing upon the surface of a blood clot. In the 2ncf5eries of 34 case..<., 26 (or 76.47 per cent) were of uterine chorioepithe· lioma, and all of these manifested the diagnostic group data of HBEs. Six were cases of metastatic brain chorioepithelioma the symptoms of which were referable to brain rather than pelvic pathology. Two cases, because of acu:e internal hemorrhage caused by uterine perforation, were preoperatively diagnosed as cases of ruptured tubal preg• nancy. In our 3rd series, of 30 cases admitted from November I, 1940, to October 31, 1941, 26 were of uterine chorioepithelioma. Six of these were diagnosed by the group ::lata of HBEs. The diagnosis of these cases was confirmed by biopsy. Of the re• maining 4 cases, I was of brain metastasis without uterine involvement; I was of 350 DIAGNOSIS OF CHORIOEPITHELI01l/A-Acosta-Siso11 et al. Jour. P. M.A. August. 194•i vaginal metastatic chorioepithelioma, resulting from a rupture 1Ubal pregnancy; I was of ovarian chorioepithelioma resulting from an ovarian pregnancy, and of lung metasta· sis without uterine involvement. It is in the metastatic chorioepithelioma with· out uterine involvement that the Friedman test is of great value. Because of the early microscopy method used for the first time in 1941, we were able to treat 6 cases at the earliest stage of ·the disease. Four of these were treated by x·ray and 2 by hysterectomy as soon as we had received the report within nine days after the moie curettage. One case which was hysterectomized 3 days after the mole curettage showed darkish punctate growths on the endometrium. The second case was one of twins terminating in a miscarriage of 4 months. One twin was a normal fetus and a normal placenta, 1he other twin degenerated into a hydatidiform mole and coincident uterine chorioepithelioma. The uterus, which was removed 9 days after the miscarriage, showed through the uterine wall many foci of wine-colored chorioepithelioma growths varying in size from a corn grain to a cala· mansi. This case shows strikingly the necessity of early diagnosis and treatment. Ai1d, if by the operation we succeeded in freeing this case from the occurrence of metastasis, we owe our success 10 the pathologist who gave us the correct diagnosis. A negative report for malignancy, however, should not be taken as fin<rl. The patient should be followed up every three to four weeks for the presence of HBEs and for the Friedman test for at least three months, if not for four years. The following ca>es are representative of the different methods of diagnosis !mployed. The firs.t 7 cases were diagnosed by HBEs. Case 8 was diagnosed by the early microscopy method. Case 9 was diagnosed by the rapid growth of the ovarian cysts (which normaHy should have regressed) within 25 days after the mole curettage. Case One: E. C .. 49 years old, Para XI, Gravida XVI, was admitted to Dra. Acosta·Sison ·s service, Ohs·tetrics Department, Philippine General Hospital, on June 29, 1937, with the complaint of intermittent vaginal bleeding and hypogastric pain, which had started three weeks after s.he was curctted for mole on May 14, 1937. She had 11 full term labors, 4 abortions, and I hydatidiform mole, which was her last pregnancy. On admission, the uterus was soft and had the size of I month pregnancy. RBC, 4,450,000; WBC, 9,800. Polymorphonuclears, 69 per cent. Blood pressure, 99/48. On the basis of HBEs, the diagnosis of chorioepithelioma in the uterus was made. Accordingly, on July 7, 1937, under local anesthesia, one of us (HAS) performed eupravaginal hysterectomy, double salpingectomy, and left cophorectomy. Longitudi· ~.al section en the anterior wall of the hystcrectomized uterus revealed a calamansi· sized growth on the endometrium. which also had extended amply into the myometrium. Histologic section of the growth was positive for chorioepithelioma. The patient made an uneventful recovery, was negative for Friedman's test, and was discharged in good condition one month after the operation. Comment: This case shows the efficiency of HBEs as a method of diagnosis. Fortunately, this case was operated on before metastasis or extension of the tumor heyond the confines of the myometrium had developed. Hence, the favorable result. Case 'Two: J. Y., 31 years, Para IV, Gravida V, was admitted on- January I, Volume XXII Number 8 DIAGNOSIS OF CHORIOEPITHELIOMA-Acosta-Sison et al. 351 1939, to Dra. Acosta·Siwn's service, Obstetrics Department, Philipp.nc General Ho'· pita!, with the complaint of vaginal bleeding since her last abortion about a year before. She had had four full·term labors. Her fifth and last pregnancy had terminated ir, abortion in the third month. Since her abortion about 1 year ago, she had been having intermittent bleeding which varied in amount from slight to profuse. On admission she was pale. RBC, 2,300,000. Hb. 50 per cent. WBC, 8,500. Polymorphonuclears, 64 per cent; blood pressure, 138/80. X·ray of lungs showed no evidence of metastasis. The uterus was soft and had the size of a. two·month preg· nancy. On the basis of HBEs, we diagnosed her as a case of uterine chorioepitheliomo. On January 4, 1939, we made a supravaginal hysterectomy, left salpingectomy, left oophorotomy, and right salpingo·oophorectomy. The abdominal wound was closed with rubber drainage. She was febrile for the first 6 days after the operation, but she finally recovered. She was negative for Friedman's test and was discharged in good condition from the hospital. Section of the hysterectomized uterus revealed a chorioepithelioma growth filling the whole endometrium. The right ovary was cystic. Comment : This case also shows the efficiency of HBEs as a clinical method of diagnosis. Case 'Three: F. N., 40 years, Para XII, Gravida XIV, was admitted to the Phil· ippine General Hospital on August 29, 1940, with the complaint of intermittent bleed· ing, which had been growing more profuse since she aborted on July 1, 1940. H~r first 12 pregnancies had term:nated in full·term deliveries. Her last two pregnancies, however, had terminated in 3·month abortions, having occurred respectively in Nov· ember. 1939. and July 1. 1940. Five days after her l>'t abortion. the bleeding had stopped; but had returned on July 20, 1940. For this she had heen curetted on Augus.t 2, 1940. The bleeding had stopped 4 days after the curettage, and she had been discharged in good condition. Since August 15. however, she had been having intermittent bleeding, varying in amount from slight to profuse, and since 9 days before admission, she had been having continuous bleeding. On admission, the uterus was soft and enlarged to the size of a 2·month prcg· nancy. The bleeding was so marked that the resident who first saw her had to introduce 5 vaginal packings. RBC, 3,900,000; WBC, I 1,700; polymorphonu· clears, 68 per cent. Blood pressure, 100/60. On the basis of HBEs, she was diag· nosed as a case of uterine chorioepithelioma. Under local anaesthesia, one of us (HAS) made a subtotal hysterectomy and double salpingectomy. The abdomen was ck,ed with a cigarette drain. The patient had s.light fever for the first three days, accompanied by marked ileus. She, however, subsequently recovered and wa.. dis· charged in good condition on the 20th day after operation." Friedman's test one month after the operation was negative. Section of the removed uterus showed a walnut-sized growth on the upper part of the posterior wall beneath the endometrium. Histologic section of the growth was positive for chorioepithelioma. Comment: Had we made a diagnostic curettage of the case, the result would have been negative; for the growth was beyond the endometrium. The diagnosis was based solely on the HBEs. Case Four: G. F., Para VIII, Gravida IX, was admitted to the private service 352 DIAGNOSIS OF CHORIOEPITHELIOMA-Acosta-Sison et al. Jour. P. M.A. August, 1940 of Dra. Acosta-Sison, Philippine General Hospital, on September 7, 1940, for intermittent slight uterine bleeding since she expelled a hydatidiform mole on August 10, 1940. She had had 8 full-term deliveries, each occurring every two years. Her last menstruation had been on May 5, 1940. On July 17, 1940, she had begun to have intermittent uterine bleeding, which had increased in amount culminating in the expulsion of a hydatidiform mole of the small cyst variety on August 10, 1940. The bleeding had completely ceased 5 days after the mole expulsion, only to recur after the lapse of 11 days. She consulted one of us (HAS) on Sept. 6, 1940, because of the intermittent attacks of bleeding. At this time, she showed a walnut sized violet-colored cystic tumor in the right lower portion of the vaginal wall. The uterus was soft and was enlarged as if she were one month pregnant. On the basis of HBEs, she was diagnosed as a case of uterine chorioepithelioma with vaginal metastasis. On the same day of admission in the private ward, she was operated on under local anesthesia. First, the vaginal tumor, which consisted of a dark blood friable tissue, was enucleated; and the cavity where it had been embedded was curetted off and closed by layers of sutures. Laparotomy under local anesthesia showed the uterus to be enlarged, congested, and soft. The blood vessels in the broad ligaments were much congested and dilated. Small metastatic areas having the size of a com grain were found in the broad ligaments, especially on the right side. The ~varies were enlarged, cystic, and much congested. A supra-vaginal hysterectomy, double salpingectomy, and double oophorectomy were made, taking care to remove those portions of the broad ligaments that contained metastatic growths. The abdominal wound was closed without drain. She was given 150 cc. of blood transfusion after -the operation. A longitudinal section of the uterus on its anterior wall revealed a dark bloody tumor at the posterior wall near the right lateral margin and below the insertion of the fallopian tube. It was much smaller than the tumor removed from the vagina. The blood vessels of the cut surface of the uterus were atheromatous. The patient had an uninterrupted recovery and left the hospital 18 days after the operation. She was followed up every month for 1 year for any symptom of metastasis or return of the growth, but apparently her recovery had been ~~mplete. Friedman's test was negative 12 days after the operation. Commrnt: This is a case of a rapidly malignant mole, which, after barely 6 weeks after its expulsion, had undergone chorioepitheliomatous growth with metastasis in the vagina and broad ligaments. The metastasis in the broad ligaments were, however, early. Fortunately, there was no metastasis in the lungs or brain or other organs. The diagnosis of this case was simply based on HBEs. The presence of vaginal metastasis, of course, made the diagnosis easier. Case Five: M. B., 24 years old, Para II, Gravida III, was admitted to the service of Dra. Acosta-Sison, Obstetrics Department, Philippine General Hospital, on September 5, 1941, for profuse vaginal bleeding. She was curetted for mole of the small cysts variety in the Philippine General Hospital on A~gust 20, 1941, and , was discharged 10 days afterwards. On her 5th day at home or 15th day after ~e~~.~- ~xn DIAGNOSIS OF CHOR/OEPITHELIOMA-Acosta-Sison et al. 353 the curettage (Sept. 4), she had begun to have vaginal bleeding, which had been slight at first, but which had become profuse on the day of admission. Abdominopelvic examination showed an enlarged wft uterus, as if the patient were two months pregnant, and bilateral ovarian cysts. On the basis of HBEs, she was diagnosed as a case of uterine chorioepithelioma. X·ray of the lungs was ncga· tive for metastatic shadows. Microscopy of the expelled mole was positive for cho,-ioepithclioma; but the report was not received until after positive diagnosis had been made by the clinical method of HBEs upon the second admission of the patient. On September 29, 1941, she w•& laparotomized under local anesthesia. Both ovaries were cystic, having the size of half a large pomelo. Double salpingectomy, double oophorectomy, and supra·vaginal hysterectomy were performed, leaving an iodoform gauze drain through the cervical canal into the vagina. Longitudinal section on the anterior wall cf thei uterus showed soft thick walls; and, in both horns at the entrance of the tubes, there were caiamansi·sized, ulcerative, ragged, wine·colored growths that had .Penetrated the thickness of -the muscular walls. Microscopy of the growth showed chorioepithelioma with predominance of the syncytial cells. Friedman test on 10 cc. of the urine taken just before the operation gave a moderately positive result. The patient made an eventful recovery from the operation and was discharged on October 16, 1941 (18 days after operation) apparently in good condition. On October 23, or after 1 week's stay at home, she returned because of pro· fuse bleeding. Examination showed a black cherry·s.ized bleeding growth in the right upper wall of the vagina. Under local anesthesia, the growth as well as many small blackish metastatic growth>. in the right parametrium was extirpated. Only the infravaginal cervix was cut off because of mucn bleeding in the parametrium. The bleeding was controlled by packing the vagina. Biopsy by Dr. Sta. Cruz of the vaginal growth consisted of syncytial cells sur· rounded by fibrin and blood clot. (Friedman test with 10 cc. urine on October 31 gave a positive result). She survived the operation well, and the bleeding per vaginam was completely controlled. Treatment of the pelvis by deep X·ray was begun on November 3, 1941. Aftu the X·ray treatment, she was checked monthly for at least 2 years with Friedman test or for any sign of developing metastasis. Comment: ..This very malignant case showed the importance of microscopic diagnosis of the tissue removed on curettage for hydatidiform mole. The diagnosis of uterine chorioepithelioma was based simply on HBEs manifesting itself I 5 days after she was curetted for mole. The HBEs method of diagnosis wa~ substantiated by the biopsy of the tumor in the hysterectomized uterus. The belated pathologic report of the biopsy of the uterine curettings obtained from mole, although it delayed the radical treatmenb which would perhaps have ob· viated the occurrence of metastasis, showed at least one encouraging ~act - that the pathologist is able to detect malignancy in the tissue obtained from cases of mole or incomplete abortion. The clinician can rely on his verdict and not hesita·te to make a radical operation on the basis of early microscopy. The only othe11 condi· 354 DIAGNOSIS OF CHORIOEPITHELIOMA-Acosta-Sison et al. Jour. P. M. A. August, 1946 tion ncces~.ary is tha·t we obtain the report within 5 days after request, in order :o save the patient from possible metastasis. Case Six: P. M., 32 years old, Para I, Gravida III, was admitted to the service of Dra. Acosta·Sison, Obstetrics Department, Philippine General Hospital, for :he second time, on October 4, 1941, because of profuse vaginal bleeding. Her first pregnancy had ended in a t'ull·term spontaneous delivery, the second in a/ 4·month miscarriage, and the third, in the curettage for hydatidiform mole on September 6, 1941, after a 3·month amenorrhea. Microscopy of the hydatidiform mole, a great deal of which was a placentalike tissue, was reported by Dr. Sta. Cruz as "mole with some activity of the trophobla&ts ... The report was not definitely chorioepithelioma, so the patient was allowed to l(O home on the 11th day. But at home, on the 16th day after the curettage, she began to bleed. The bleeding became so profuse on the 23rd day after the curettage that she again sought admission to the Hospital. The uterus was enlarged and ;oft as if l· l / 2 months pregnant. Friedman test on October 6, 1941, on the day of the operation, with 10 cc. urine was negative. On the basis of HBEs, we performed subtotal hysterectomy, double salpingec· tomy, and right oophorectomy on October 6, 1941. No drainage was introduced. The right ovary was removed because it was cystic. Section of the removed uterus showed a ~alamansi·sized, wine·colored growth at the entrance of the right tube and involving the fundus, and the anterior and posterior walls of the uterus. The patient had an uneventful recovery and was discharged with the instruc· :ion to return at the end of I month for follow·up. Biopsy report of the uterine growth was positive for chorioepithelioma. Comment: This is another example showing that the clinical method of diag· nosis in the form of HBEs is more sensitive than the Friedman test. Case Seven: P. D., aged 31, Para VI, Gravida VII, was admitted to the service of Dra. Acosta·Sison, Obstetrics Department, Philippine General Hospital, on Oct· ober I 0, 1941, for much bleeding and fever. She had been curetted for mole in the Philippine General Hospital on September 18, 1941, after a 2·month amep,orrhea. Histopathology of the mole was positive tbr malignant changes, but thei report was not received until after the third week when the patient had entered the hospital for the second time on her own accord because of vaginal bleeding. On the second admission, her temperature was 37.8°C.; and the uterus was enlarged, especially on the posterior wall, as if I month pregnant. Positive diagnosis of uterine chorioepithelioma was made on the basis of HBEs before the histo· pathology report was known, so that the patient was immediately subjected to lapa· rotomy. On operation, it was found that the slightly enlarged uterus had punctate hemorrhagic spots in the region of the fundus and tubes. Both ovaries were not much enlarged but had hemorrhagic cysts. Subtotal hysterectomy, double salpingec· tomy, and double oophorectomy were performed. Section of the anterior uterine wall revealed an ulcerative chorioepithelioma 3 cm. wide at the fundus and posterior wall near thd entrance of the left tube. Biopsy report of the growth was positive for chorioepithelioma. Friedman test on October 15, the day of admission, was negative with 10 cc. of urine. ~:~~· ~JtH DIAGNOSIS OF CHORIOEPITHELIOMA-Acosta-Sison et al. 355 The patient made an uneventful recovery from the operation. Because, however, of profuse hemorrhage before laparotomy, she was subjected 10 X-ray treatment of the lower abdomen for possible presence of chorioepithelioma in the broad ligaments. Comment: This patient would have been immediately laparotomized had the biopsy report of the mole curettage been received during the first stay of the patient in the hospital. However, the belated repon was not altogether 10 be deplored; for the fact that the patient showed signs of chorioepithelioma 3 weeks after the curettage shows the ability of the pathologist to detect malignancy at ·the first curettage. And, if we could only receive the biopsy within five days, we would be able to treat cur patients much earlier. This case shows again that the Friedman test cannot give an early diagnosis of chorioepithelioma. The following is a case diagnosed by the Early Microscopy Method: Cas,. Eight: M. B., aged 28, Para V, Gravida VI, was admiued to the seivice of Dra. Acosta-Sison, Obstetrics Department, Philippine General Hospital, on July 14, 1941, for profuse vaginal bleeding. She had missed her menstruation for 2 momhs, and the size of her uterus was that of a 7 -month pregnancy. She was curetted for hydatidifbrm mole on July 18, 1941, and histopathologic examination of the curettings was positive for chorioepithelioma. On July 21, 1941 , a subtotal hys:erectomy, double s.alpingectomy, and double oophorectomy were performed. Both ovaries were cystic, having the size of an American orange. Section of the removed uterus showed in various places dark pin-head dots. The cut vessels of the uterus were cirrhotic. Microscopy of the endometrium, as reported by the pathologist (Dr. Sta. Cruz), showed: Active proliferation of syncytium which had inftltrated the muscular wall. Surrounding the syncytial cells were degenerated cells. The syncytial cells were irregular and darkly pigmented with a formation of giant cells. There were neither chorionic villi nor mole. Histopahologic diagnosis. was chorioadenoma destruens. No Friedman test was requested for i1 was thought it would be positive because of her recent curettage for hydatidiform mole. Comment: The positive microscopic finding of the first curcttage is the ideal method of diagnosis, for the treatment can be ins.ti·tuted early. However, a negative finding is not an insurance that choricepithelioma may not develop later. Hence the importance cf the follow-up. An example of this is the case (No. 6) wh05e mde curettings were negative for chorioepithelioma, but who had ~terine bleeding 16 days after the mole curettage, because of uterine chorioepithelioma. The diagnosis of the following case was based on the rapid growth of ovarian cyst after mole curettage. Case ]\{ine: E. de la C., 26 years old, Para III, Gravida IV, was admitted to the seivice of Dra. Acosta-Sison, Obstetrics Department, Philippine General Hospital, for the 1hird time on July 18, 1941, because of rapid enlargement of her abdomen. From June 2 until June 10, 1941, she had been treated in the hospital for hyperemesis gravidarum. On June 16, 1941, she had been readmitted for bleeding ;.vhich ended in the curettage of a hydatidiform molet of the small cyst variety after an amenorrhea of 4 months. The uterus before the curettage had been of the size 356 DIAGNOSIS OF CHORIOEPITHELIOMA-Acosta-Sison et al. Jour. P. M.A. August, 1946 of an 8-month pregnancy. On July 10, 1941, she had been dis.charged in good oondition with a normally involuted uterus and an abdomen that was small. On the 5th <lay after her discharge she had noticed her abdomen to be growing in size. ·when she was readmirted to the hospital on July 18, 1941, or the 25th day after her curettage, her abdomen was bulging as though she were 7-month pregnant, and both her lower extremities were edematous. The enlargement was due to bila· teral ovarian cysts. Urinalysis was normal. Upon admission, she was · immediately operated on for double salpingoophorectomy and supravaginal hysterectomy. Each of ·the ovarian cysts was as large as an adult bead, and the uterus had the size of l · 1/2 month pregnanrv There was no symptom of unterine bleeding in this case, but the uterus was extirpated nevertheless. We reasoned that there must have been· chorioepithelioma in it to cause such rapid enlargement of the ovarian cysts, which we failed to notice on discharge. The longitudinaJ section of the uterus showed a small dark tumor the size of a mongo with a much dilated but intact blood vessel just below the entrance of the left fallopian tube. The urine, which was taken on the day of the last admission before the operation, was negative for Friedman's test. The patient made an uneventful recovery and was discharged in good condi· tion on August 5, 1941, with instruction to return monthly for follow·up or if, at any time, she had any bloody vaginal discharge. Microscopic examination of the small dark tumor was positive for chorioepitheilioma. Comment: This was the first case to come to our attention which showed rapid growth of the ovarian cysts after mole curettage. Ordinarily, the ovarian cysts regress after the expulsion of the mole. The diagnosis of chorioepithelioma in the uterus was based on their growth and on the enlarged uterus which should normally be completely involuted 25 days after curettage. It is interesting to note that, in spite of the presence of the large ovarian cysts, the Friedman test with 10 cc. of urine was negative. Of course, the chorioepithelioma had only the size of a mongo seed. This case clearly shows that the clinical method of diagnosis is much more sensitive than the Friedman test. OUR PROGRESS IN THE METHOD OF DIAGNOSIS OF UTERINE CHORIOEPITHELIOMA Prior to 1937, diagnosis was made: (1) At the operating room or at autopsy with the help of the pathologist. (2) By diagnostic curettage. This is unreliable when negative. (3) By Friedman test. This is positive only when the tumor is fairly well advanced. From 1937 to 1940, diagnosis was made : (1) By the clinical method HBEs. fhis makes earlier diagnosis than Friedman te&t. (2) By diagnostic curettage and Friedman test, in cases not positively diagnosed by HBEs. In 1941, diagnosis was made: ( 1) By the clinical method of HBEs with or without the rapid development of ovarian cyrts in cases sometime after mole expulsion or abortion. (2) By the micros.copic examination of the uterine curettings obtained from cases of mole or abortion. This is the earliest method. But its value depends on the ability of the pathologist to recognize the early signs of malignancy, and to give Volume XXll Number 8 DIAGNOSIS OF CHORIOEPITHELIOMA-Acosta-Sison et al. 357 an immediate report. ( 3) When the early microscopic examination is negative for malignancy, the patient is made to return at the end of 3 or 4 weeks or earlier in case there is uterine bleeding. She is examined for uterine enlargement and softening and for Friedman test. CONCLUSION I. The earliest method of diagnosis of uterine chorioepithelioma is by the early microscopy method; i.e., the microscopic examination of the tissue obtained from the curettage done 10 complete an abortion or mole expulsion. 2. The next best method of diagnosis of uterine chorioepithelioma is by the HBEs method. It may be employed as early as 3 or 4 weeks after abortion or mole expulsion. 3. The rapid development of ovarian cysts within 3 weeks after mole expulsion or their non-regression, especially when they are accompanied by an enlarged uterus, is another clinical sign of chorioepithelioma. 4, Friedman test is of value in the follow-up cases or in determining the presence of metastasis after the primary site of the tumor has been radically removed. It should be employed as a routine in all follow-up cases. 5. Diagnostic curettage is employed in cases where diagnosis cannot be made by HBEs. 6. Negative diagnostic curettage in the presence of HBEs is not signifi'cant, because the chorioepithelioma may be in the myometrium beyond the reach of the curette. REFERENCES I. Mathieu, A., Hydatidiform mole and Chorioepithelionia, Part II. Collective Review of the Literature for the years 19>5, 1936 and f9f7 . Surg. Gynec. & Obst. Feb. 1939, Vol. 68, No. 2, pp. 181-1961. ' Teacher, J. A. A Manual of Obst. & Gynec. Path. London: Oxford Univ. Press, 1935, pp. 137,152, quoted by Mathieu in the article above. 3. Novak's discussion of paper by Wilson, K. M., on "Chorioepithelioma". Am. Jour. Ohs. & Gynec. Vol. 38, No. 5, Nov. 1939, pp. 824-838. "· NO\:ak. E. in his discussion of paper by Mathieu, A., "Recent Developments in Diag..i nosis and Treatment of Hydatidiform Mole and Chorioepithelioma". Am. Jour. Obs. & Gynec. Vol. 37, No. 4, April, 1939, pp. 645-662. 5. Hertig, A. T., cited by Phlaneuf, L. in his discussion of ?vlathieu's article mentioned in Reference No. 4. THE JOURNAL OF THE Philippine Medical Association Published monthly by the Philippine Medical Association under the supervision of the Council. VOL. XXII Office of Publication, 547 Herran, Manila, Philippines Devoted to the progress of Medical Science and to the interests of the Medical Profession in the Philippines. AUGUST, 1946 The Council NO. 8 Officers of the Philippine Medical Association, 1946·1947 President: Dr. Januario Estrada Via·Pusidents: The Council consists of the President, the Vice-Presidents, the Secretary·Treasurer, and the following Councillors: Dr. Juan Z. Sta. Cruz Dr. Gonzalo Santos Secretary·T reasurer: Dr. W. de Leon Dr. A. Villarama Dr. Jose C. Locsin Dr. M. Cafiiz.ares Dr. Antonio S. Fernando Dr. Victorino de Dios ANTONIO S. FERNANDO, M.D., fdltor I. V. MALLARI, Copy fditor PeDRO M. CHANCO. Business Manager Associate Editors (alphabetically listed) V1cToR1No DE Dios. M. D. Jose G u mon, M. D. AGER1co B. M. S1so'I. M. D. RENATO MA. GUERRERO.MD. WALFRIDO DE LEON, M. D. ANTO'llO G. SISON. M. D. CARMELO Reves. M . D. Signed editorials express the personal views of the writer thereof, and neither the Asso· ciation nor the Journal assumes any responsibility for them. iE~itorial THE PHILIPPINE OBSTETRICAL AND GYNECOLOGICAL SOCIETY The Philippine Obstetrical and Gynecological Society was founded as a national organization as well as a section of the Philippine Medical Association on July 6, 1946. The minutes of the organization meeting and of the first scientific meeting appear elsewhere in this issue. The officers chosen are all distinguished members of their specialties, particularly the Pres360 EDITORIAL Jour. P. M. A. August, 1946 ident, whose brilliant record of achievements, whose substantial and notable contributions to medical literature, and whose very high standing in the community and in the profession are known, not only .throughout the length and breadth of our country, but also abroad. With such an array of able officers and prominent specialists in its membership, the future of the Society is indeed bright. We should like to take this opportunity to extend ltcJ the organizers, to the officers, and to the members of this new Society our sincerest congratulations. For the establishment of the Philippine Obstetrical and Gynecological Society js an important milestone in the history of Philippine medicine. The Council of the Philippine Medical Association, aware of its great responsibility to develop the medical science and to stimulate ':he progress of medical practice, has decided, upon recommendation of the Editor, to puplish this special number. It is hoped that this number will give an impetus to the progress of Obstetrics and Gynecology in our country. This is the first time that a special number of this kind has been conceived, and. it is hoped that it will be received favorably by our readers. The Journal will put out similar special numbers from time to time, as sections of other specialists are duly org~nized. The Editor would like to acknowledge his gratitude for the valuable assistance given to him by Dr. Jose Villanueva and by Dr. Jovita Coronado in putting out this number.-A. S. F. !Wli.arellanenu.s ABSTRACTS FROM CURRENT LITERATURE ABSTRACTORS Isabelo Concepcion, M . D. Walfrido de Leon, M. D. Felisa Nicolas· Fernando, M, D . Carmelo Reyes, M. D. Vitamin K and Infant M:ortality, by Edith L. Potter, American J. Obstetrics and Gyncco• logy, St. Louis, 50:235-352, (Sept.) 1945. The author studied two groups of infants: one of 6,500 infants weighing over 1,000 Gm. born in the two year period when vitamin K was given to the women before delivery and a group of 6,630 infants born during the next twenty·two months when vitamin K was not admi· nistered. The total fetal and infant mortality rate per thousand births of 29.8 for the first two years is higher than that of 25.8 for the last two years in spite of the fact that no change of sig· ni6cance occurred in the incidence of primiparity, premature deJivery. mode of deHvery or other known factor. The mortality rate for liveborn infants is identical in the two series as is the number of infants who showed evidence of hemorrhage on postmortem examination. The author concludes that no decrease in infant or fetal mortality can be expected to result from the routine administration of vitamin K.-F. N. F. Sulfathi4zole in Epidemic Diarrhea of •he Newborn , by M. Leff, American J. Obstetrics and Gynecology, St. Louis, 51 :1-50 (Jan.) 1946. The author describes the procedure used at the Central Maternity Hospital in New York for the treatment of epidemic diarrhea of the newborn. Nurses are instructed to be constantly on the alert for frequent or watery stools in the newborn. Treatment is instituted early and consist of 1 grain (0.06 Gm.) of suHathiaiole every three hours administered with a medi· cine dropper or teaspoon directly into the baby's mouth (a stock solutiion of 0.06 Gm. per 4 cc. is used) . After a few doses the diarrhea is usua.Jly controlled. If the diar· rhea does not subside, all food is withheld for twelve hours, and saline solution is given, by clysis and the medication is continued. Every baby in the nursery who has been ex•' posed is given 1 grain of sulfathiazole as a prophylactic measure. Sulfathiazole admi· nistered promptly at the onset of epidemic diarrhea in the newborn infant cures the disease in less than twen.trfour hours and prevents its spread in the newborn nursery.-F. N. P. Higll Dosage Progesterone 'Therapy of Amenorrhea, by A. E. Rakoff, American J. Obst. fi Gynec., St. Louis, 51 :447-594, (April) 11\46, p. 480. The author administered large doses of progesterone with or without additional es· trogen to 51 patients with primary and secondary amenorrhea. In 25 patients with ame· norrhea of more than two years' duration, only five responded with bleeding to proges· terone alone, whereas 24 of 26 patients with amenorrhea of le6ser duration bled. None of the patients with primary amenorrhea menstruated after 60 mg. of progesterone, while 5 of the 6 who were given progesterone after estrogen priming had induced bleeding. Only one spontaneous bleeding occurred after withdrawal therapy. The patient who failed to respond at all had an endometrial defect. Of the 44 patients with secondary amenor· rhea, 29 responded to progesterone alone. Many of these had subsequent spontaneous 362 ABSTRACTS FROM CURRENT LITER.4TURE Jnnr. P. M.A. August, 196' bleedings and 5 became pregnant. The remaining l S patients had induced bleeding with progesterone after estrogen priming. The patients with a gonadotrophic deficiency and a primary ovarian deficiency responded about equally well as far as induction of bleeding was concerned. In both of these groups there was a tendency for the hormonal status to improve immediately after treatment, as in.dicated by increased gonadotropic production in the first group and better ovarian response (increased estrogens and improved endome~ trium) in the second group eight of the thirty married women become pregnant fitlJloWt" ing therapy. An additional group of 18 patients with delayed menstruation or recent ame· norrhea who were suspected of pregnancy were treated on two or three successive days. As checked by the Friedman test, bleeding fajled to occur if pregnancy was present where· as in all but 1 instance bleeding was iriduced in the non•pregnant patients.-F. N. F. Effect of Postopenitive Exercises and Message on Pulmonary Embolism, by J. P. £rs .. kine, and I. C. Shires, j. Obst. IJ Gynec. of Brit. Empire, Manchester 52:411·544 (Oct.) 1945 p. 480. The authors stated that at Chelsea Hospital there was a massage team whose mero .. hers were to instruct and supervjse postoperative exercises and to carry out massage in all cases after abdominal operations and operations for the repair of genital prolapse. The incidence of fatal embolism decreased by more than 50 per cent during the oe*n year period subsequent to the introduction of the massage and exercise procedure. The mas sage department was established at the Chelsea Hospital at the beginning of 19l7.-F. N. F. Intractable Epi5taxis of Pregnancy. by W. F. Goff, Western j. Surg., Obst. & Gynecology, Portland, Ore., 54:177·216 (May) p. 198. The author reports two cases of severe epistaxis. In both cases the usual conservative measures of control were not successful. The decision to terminate pregnancy was based on the few cases in the literature which responded favorably. Jn the first of the two cases general anesthesia was employed for the interruption of pregnancy, and death followed. In the second patient local anesthesia was employed and the outcome was favorable. Be· cause of the dangers inherent in maintaining an open and free airway, local anesthesia is preferable to general anesthesia when termination of pregnancy is contemplated. Clinical proof is accumulating which indicates that a close relationship exists between the nose and the genital organs and that therefore treatment of severe ~pistaxis must be considered on an endocrine basis.-F. N. F. SOCIETY ACTIVITIES PHILIPPINE OBSTETRICAL AND GYNECOLOGICAL SOCIETY Minutes of the first meeting of the Philippine Obstetrical and Gynecological Society held on July 6, 1946 in the Philippine General Hospital. Dr. Constantino Manahan, acting as temporary chairman, called the meeting to order at 3:30 p.m. The first bu$iness taken up was the approval of the proposed Constitution and By· Laws of the organization. This was approved after a few amendments had been made. The officers were then elected. The result of the election was as follows: President: Vice· Pres: -Sec· Treas: Directors: Dr. Honoria Acosta·Sison Dr. Rafael Enrile Dr. Jose Villanueva Dr. Carmelo Reyes Dr. Guillermo Rustia Dr. Enrique Lopez Dr. Jose Delgado The newly·elected officers assumed their respecti\"e offices. The following committees were created : 1. Committee on Scientific Meetings: Dr. Constantino P. Manahan, Chairman. Dr. Jose R. Reyes. member Dr. Jose Villanueva, member 2. Committee on Publications and Library: Dr. Jose Delgado, Chairman Dr. Carmelo Reyes, member Dr. Jose Genato, member The meeting was adjourned at 5: 15 p.m. SCIENTIFIC MEETING The first Scientific Meeting of the Philippine Obstetrical and Gynecological Society was held August 24, 1946 at 2 :00 p.m. under the aegis of the Department of Obstetrics and Gynecology of the North General Hospital. Inaugural Address . . . . . . . . . . . . . . . • . . • . . . . . . . . . . . . Honoria Acosta-Sison, M .D. Geriatrics and Gynecology: The Role or-surgery in the Aged . . . . . . . . • . • . Constantino P. Manahan, M.D. Ax.ial Torsion of the Uterus . . . . . . . . . . . . . . . . . • . . . . Jovita Coronado, M.D. The Incidence of Erythroblastosis Foetalis . . . . . . . • . . . Mamerta Andaya, M.D. 364 .Jom. T'. ~1. A . Augu ~t . 1!1-11; IMPORTANT NOTICE Original articles are accepted for publication only with the understanding that they have not been and are not to be published elsewhere. The Editorial Board reserves the right to accept, reduce, or reject all manuscripts submitted for publication. Any number of reprints will be furnished at cost price provided that written request be made by the author at the time the article is submitted for publication. REFERENCES TO LITERATURE CITED SHOULD INCLUDE : FOR PERIODICALS: NAME OF AUTHOR, TITLE OF ARTICLE, FULL NAME OF PERIODICAL, VOLUME NUMBER, INCLUSIVE PAGING, MONTH AND YEAR OF PUBLICATION, ALL IN THE ABOVE ORDER. EXAMPLE FOLLOWS : Pio de Roda, Alfredo : Typhus Fever in the Philippines: Weil·Felix Reaction of 500 Cases, Journal Philippine Islands Medical Association, 17:147· 156 (March) 1936. REFERENCES TO BOOKS SHOULD INCLUDE: NAME OF AUTHOR, TITLE OF BOOK, PLACE OF PUBLICATION, NAME OF PUBLISHER, DATE OF PUBLICATION, VOLUME NUMBER, AND PAGES CITED, ALL IN THE ABOVE ORDER. EXAMPLE FOLLOWS: Peters, ]. P., and Van Slyke, D. 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