5 19071 DIET AND THE DEVELOPMENT OF THE UrERUS 1229 thought further that the strain of another four months of pregnancy increasing as inevitably it must during the latter part of the term would be too much fo ID: 51121
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MAY.*5,1907.1DIETANDTHEDEVELOPMENT'OFTHEUrERUSJ1229thoughtfurtherthatthestrainofanotherfour,monthsofpregnancy,increasing,asinevita-blyitmust,duringthelatterpartoftheterm,wouldbetoomuchfortheweakenedheart,andthat,therefore,itwasjustifiabletoterminatethepregnancy.Ifyoudecidetoinduceabortioninoneofthesecases,thenthebestmethodistogiveananaesthetic,todilatethecervix,andtoemptytheuterusatonesitting.Theclassofcase,then,inwhichabortionthouldbeinduced,isthatinwhichordinarymedicinaltreatmenthasproducednooronlyverylittleimprovementinthegeneralsymptoms,andinwhichnofurtherimprove-mentinthecardiacconditionislikely,sothatitisessentialthatthestrainofalongpregnancyshouldbeavoidedifpossible.Thefollowingcaseisanillustrationoftheclassinwhichprematurelabourmaybeinduced.Thepatientwas25yearsofage,aprimiparawithdoubleaorticdisease.Shehadsomeoedemaofthelegs,wasmarkedlyanaemic,andhadseveresyncopalattacksfromtimetotime.Withtreatmentbyrestinbedandmedi-cinesheimprovedconsiderably,butwhenshegotoutofbedandaboutshehadfurthersyncopalattacks,sothatherconditionwasnotquitesatisfactory.Wetidedheroverherdifficultiesaslongaspossible,butatthethirty-eighthweekIdeterminedtoinducelabourbecausethesyncopalattackswerestillratherfrequent,anditwasthereforethoughtbesttoputanendtothepregnancy.AChampetierdeRibes'sbagwasintro-ducedunderananaesthetic,andwhenthefirststagewascompletedthepatientwasdeliveredunderetherwithforceps.Thechildisalive;themotherdidwell,andatthepresenttimehaslostallhercardiacsymptoms.Someauthorsholdthattheinductionofprematurelabourin-creasesthedangertothepatient;butIdonotthinkthatthisisso,becauseifyouinduceprematurelabouryoucanmakearrangementstocarryoutthedeliveryinthebestconditionsandwiththeadvantageofskilledassistance.Ithink,then,thatinthecaseofpatientswhodonotimproveunderordinarymedicinaltreatment,itiswisertoterminatethepregnancyratherthantoletthepatientgoontofullterm.ThisdoesnotagreewiththeconclusionsofHicksandFrenchbasedupontheobstetricalhistoriesoftheir300cases.Theycontendthattheinductionofprema-turelabourisnotnecessary,sincethegreatmajorityoftheirpatientsboreaconsiderablenumberofchildrenwithlittleornodanger.Nodoubtthatistrueofthegeneralrunofcases;justasitistruethatthemajorityofcasesofvalvularheartdiseasecomplicAtedbypregnancydoverywellwithordinarymedicinaltreatment.Butyouwillmeetwithexceptionalcasesfromtimetotimewhichrequirenotonlymedicinaltreatment,but,inordertolessenthestrainthrownupontheoverburdenedheart.require,fartherthanthis,theinductionofabortionorofprematurelabour.CONDUCTOFTHELABOUR.Thetreatmentoftheconditionatthetimeofthepatient'sconfinementisofsomeimportance.Youmustguardagainsttheriskofcardiacfailure,andiftherearesignsafterthedeliveryofthechildthattherightsideoftheheartisover-distended,youshouldencouragepost-partumhaemorrhage,oryoushouldactuallybleedthepatient.Suchamodeoftreatmentundoubtedlyyieldsgoodresultswheretherearesymptomsofover-distensionoftherightsideoftheheartandconsequentlydangerofparalysis.Wherethepatientispallidandthepulseverysmall,withnosignsofover-distensionontherightside,andwhereitisprobable,therefore,thatthebloodisaccumulatingintheabdominalveins,theintra-abdominalpressureshouldbemaintainedatthetimeofdeliverybytheuseofasandbagoratightbinder,andappropriatemeansmustbetakentostimulatetheheart'saction.THEPROHIBITIONOFMARRIAGE.Thereremainsnowforourconsiderationonlyonequestion,andthatisthetruthofthedictumlaiddownin,manybooks,thatapatientwithheartdiseaseshouldnotmarry,or-ifshedoesmarrysheshouldnothavechildren,orifshedoeshavechildrenaheshouldnotsucklethem.Suchadictum,youwillagree,is-toosweeping.The-majorityofwomenwithheartdiseasepassthroughtheirpregnancyandconfinementwithperfectsafetyandhavenosymptoms,andthereforeitisnotrighttosythatayoungwomanwhohasheartdiseaseshouldnevermarry.-Ifherheartdiseaseiscompensatedandtherearenosymptoms,shemaymarry.-Cardiacfailureprobablywilloccursoonerorlater,asIRicksandFrenchpointout,whethershebecomespregnantornot.Thebadeffectproducedontheheartbypregnancyis,onthewhole,notsufficientlymarkedtojustifyyouinadvisingapatientstronglythatsheshouldnotmarry.Itistruethatifshemarriesitwillbebetterforhernottohavechildren,anditistruethatifshedoeshaveachildsheshouldnotsuckle,butitisnotrightthatawomanwithheartdiseaseshouldbeforbiddentomarry.Althoughthedangerisundoubted,andthemortalityisashighas12percent.,yetithasbeenexaggerated,andthe-majorityofthesepatientsdoperfectlywell,andrunnoverygreatextrariek.Sothatayounggirlwithheartdiseasewhichiscompensated,andwhichisnotcomplicatedbyanyaccom-panyingdiseaseofthelungsorotherviscera,maybeper-mittedtomarry.'Herheartwillprobablyfailsoonerorlater,whethershemarriesornot,butwhetherthetimeoftheonsetofsuchfailureoftheheartwillbeprecipitatedbychildbearingisamatterwhichadmitsofargument.Thereprobablywillbesomeprecipitation,butitisdoubtfolwhethertheriskofthisiasomarkedastojustifyyouindenyinghertherighttomarry.EFFECTSOFDIETONTHEDEVELOPMENTANDSTRUCrUREOFTHEUTERUS.BYMALCOLMCAMPBELL,M.A.,M.B.,CH.B.,F.R.C.S.EDIN.,LECTURERINMIIDWIFERYANDGYNAECOLOGY,SCHOOLOFMEDICINEOFTHBROYALCOLLEGES,EDINBURGH.(FromthePlhysiologicalLaboratory,EdinburghUniversity.)THEalarmingandpersistentdeclineinthebirth-rateisamatterofnationalinteresttheimportanceofwhichcanhardlybeover-estimated.ThepurelymedicalaspectofthisquestioniE,however,exceedinglydifficultofapproach,sincesocialfactorsandsocialselfishnesshaveun-doubtedlyamaterialinfluence.Duringthelastgenera-tion,however,therehasundoubtedlybeenamarkedchangeintherelativeproportionsoftheconstituentsoftheaverageman'sdiet.Cansuchachangeofdiethaveanyinfluenceonthebirth-rate?Thefollowinginvestigationwasundertakentodiscoverwhatchanges,ifany,wereproducedinthedevelopmentandstructureoftheuterusbyvariousdiets.Theanimalsemployedintheresearchwererate.Theuteriof86animalswereexaminedbothmacroscopicallyandmicroscopically.Thetissueformicroscopicexamina-tionwasremovedinallcasesfrom,asnearlyaspossible,thesamearea,thejunctionofthedistalandmidthirdsoftheuterus.Eightwildrats,invariousstagesofdevelopment,fromtheimmaturetotheadultanimal,wereexaminedinordertoformanopinionastothestructureoftheuterusinanimalsliving,presumably,undernaturalconditions.Theremaininganimalsweredividedintofiveseries,namely:(a)Aseriesof13animalsfed,fromweaning,forperiodsoffromninetofourteenweeksonanexclusivelymilkdiet.Inonesectionofthisseriesplainmilkwasused;inanother,Pasteurizedmilk;inthethird,-terilizedmilk.(b)Aseriesof27animalsfedforperiodsoffromtwenty-onedaystoninemonthsonbreadsoakedinmilk.(c)Aseriesof11animalsfedforperiodsoffromfourtofourteenweeksonaricediet.(d)Aseriesof5animalsfedforvaryingperiodsonadietofporridgeoroats.(e)Aseriesof22animaltfedfnrperiodsoffromtwentydaystoeightmonthsonarawmeatdiet.Inthecasesoftherawmeatandricediets,someanimalswereputonthedietassoonasweaned,othersaftertheyhadreachedvarious-stagesofdevelopment.Theuterusoftheadultwildratislinedbycolumnarepithelium.Thereareglandslinedbyepitheliumwhichvariesfromlowcubicaltocolumnarintype.Themucouscoatisboundedexternallybyamuscularcoat.Inthemucouslayfrthreevarietiesofcellsarefound:1.Acellwithalargeroundoroval,elativelyfaintly-stainingnucleuq.T-sare3rstobea3oungconnectivetis3uetypeo'cell. IW.2.Acellwithasmall,round,darkly-stainingnucleus,oomparabletoalymphoidcell.3.Acellwithanelongated,verydarkly-stainingnucleus,similartocellsgotinfibroustissue.Inthewildratthelargecellsaremostnumerous(Fig.1).Inthewildratthecellsoftheothertypesarefewinnumber,andarechieflyfoundinthepartofthemucosanearthemuscularcoat.Fromtheexaminationofthisseriesof86animalsitisevidentthatinanimalsofthesameageandapproximatelyofthesameweight,livingundersimilarconditions,theuterimayvarywithinalimitedrangeinsizeandde-velopment.Themuscularcoatisrelativelyuniform.,,_._fi.,~74-,''........11Fig.l.-Mucosaofadultwildrat,shiowingpredominanceoflargetypeofcells(x500).Themucosashowsthegreatestvariations.Whileinmosteasestheepithelumliningthecavityiscolumnar,insomeitiscubical,therearealsofoundmarkedvaria-tionsastothepositionofthenucleusanditsstainingreactions.Theanimalsfedonmilkandbreadsoakedinmilkapproximatemostnearlytothetypeofstructuregotinthewildrat(Figs.1and2.Intheothergroups,fedonwhatwemayterm"abnormaldiets,"namely,rice,porridge,oatsorrawmeat,thereisfoundarelativelyconstantdeparturefromthenormal.Thetypeofchangeiscommontoallabnormaldiets;itsseverityvaries.Theseverityofthechangesinducedarefoundtobeinproportiontotheagesoftheanimals-atthetimewhentheabnormaldietwasbegun.Thechangesaremostmarkedintheanimalsputonthedietatweaning;theyarelessmarkedthemorematuretheanimalatthetimeofthecommencementoftheabnormaldiet.Inafully-developedanimal,anyabnormaldietmayfailtoFig.2.-Mucosaofadultbreadandmilkfedrat(x600).Fig.3.-Sectionofuterusofyoungrataged10weeks,fedfromweaningonoxflesh(x20).materiallychangeeitherthesizeorstructureoftheuterus.Inregardtothedevelopmentoftheuterus,anabnormaldietappearstoarrestthegrowthoftheuterus;compareFigs.3and4,alsoFigs.5and6.Thisarrestofdevelop-mentismostmarkedinanimalsfedfromweaningonoxflesh,butisalsoverywellseeninanimalsfedonriceoronporridgeoroats.Inregardtostructure,alltheabnormaldietsledtoadiminutionofthenumberofthelargeconnective-tissuetypeofcells,andarelativeincreaseinthesmallcells.Thischange,whichmaybedeecribedasafibrosis(com-pareFig.7withFigs.1and2),wasmostmarkedinanimalsfedfromweaningonanoxfleshdietforperiodsoffromfourtofivemonths;inthisgroupofanWmalsnonebecamepregnant,whilecontrols,fromthesamelitters,fedonbreadandmilk,allhadyoung.Fromtheseobservationsitseemsjustifiabletostate:1.Theuseofanon-physiologicaldiet-forexample,exclusiveflesh,rice,orporridge-inducesinthegreatmajorityofcafesamodificationinthestructureoftheFig.4.-SectionofuterusofyoungratFig.5.-Sectionofaged10weeks,fromsamelitterasFig.3,iiterusofadultratagedfedfromweaningonbreadsoakedin7mnh,fdoamilk(x20).meat(x_20).uterinemucousmembrane.Thismodificationconsistsinadiminutioninthenumberofthelargeconnectivetissuetypeofcells,whichappeartobeimportantconstituentsinaphysiologicallyactivemucosa.Fig.6.-Sectionofuterusofadultrataged7monthsfedonbreadandmilk(x20).2.Thestructuralchangeismostprofoundinanimalsfedfromweaningonanexclusivelyox-fleshdiet.Insuchanimalsthedevelopmentoftheuterusisalsomostinterferedwith.Fig.7.-Mucosaofadultmeat-fedrat,showingmarked'fbrotikchange(x600).3.Thestructuralchangein2isassociatedwithsterilityfChalmersWatson,towhomIamindebtedformuchofthematerialusedinthisinvestigation;pointedout1thiatameatdiet,ifbegunatweaiing,almoetinvariablyled'tosterility.Thepresentinvestigatiln"ShowsthatthbDIETANDT-HEDEVE-WPMENTOFTHE01230TM.BunmIunbi"ZJOVAIU74i[MALY26j** X.25,190YTHEUSE0FTHEBLWNITHOOK.IMZIA,,RA,1231sterilityisprobably,duetothestructuralanddevelop-mentalabnormalitiesintheuterusinducedbytheabnormaldietIthasbeenshown2thattheconsumptionofmeatperheadinthiscountryisto-dayalmostseventeentimesasgreatasitwasin1850.Duringthesameperiodthefallinthebirth-ratehasbeenmostmarked.Whileitwouldbeunwarrantabletoattempttofoundanytheoriesinregardtothefallingbirth-rateontheresultsofthislimitedexperiment,yet,whenweaddtotheabovefactsthefurtherconsiderationthatthediminishedbirth-rateismostmarkedinthebetter-offclassesofsociety-thatis,amongtheveryclasseswhosemeanspermitofanunrestricteduseofthemoreexpen-sivemeatdiet-itisevidentthatthefoodfactorisonewhichisatleastworthyofconsiderationindealingwiththegreatqguestionofthefallingbirth-rate.REFEREqOrS.JouinalofPhypiology,vol.xxxiv.ILancet,July,1905.ACASEOFSUDDENDEATHATTHECLIMACTBRIC.0ByELDONPRATT,M.D.LOND.,M.R.C.S.,HENFIELD,SUSSEX.ONAugust3rd,1906,Iwashastilysummonedtoseeawomanwhowassaidtobeinafit.Iwasonthespotwithinafewminutes,reachingthehouseat,9.10a.m.Ifoundherlyingsupineonasofadead.Shewasahighly-respectablewoman,aged45years.Thehistoryofthisfatalattackwasasfollows:Sheroseasusualat5.30&.m.onthemorningofherdeath,andattendedtotherequirementsofthehouse,takingonlyacupofteawithherhusband,wholeftforworkat6a.m.Shewasquitecheerfulandcomplainedofnothing.Hernextdoorneighboursawherat7.20a.m.,andremarkedthatshelooked"faintandratherbad"-latelyanotunusualthingwithher,assheknewthe"changeoflife"wasabouther.Shesaidshebeganto"feelqueer"about7a.m.Herneighbourgavehersomehotteaat7.30a.m.,whichwasquicklyvomited.Smellingsaltswereadministeredasshecontinuedtofeelfaint,andeventuallyherhusbandwassentfor.Althoughsofaintshewascheerful,andquitethoughtshewouldsoonbefeelingbetter;sheretchedtwoorthreetimesbutbroughtnothing.upafterthefirstvomit.At8.45a.m.sheseemedtochangesuddenly;thehandsbecameclenched,thefacesomewhatdusky,andthenailsdiscolouredshesaidshefeltverycoldandshelookedasifa"fit"wereimpending.Afewminuteslater,andquitesud-denlyshechangedagainfortheworse,becameunconscious,gavethreeblowingexpirations,and*thenseemedasdead.WhenquestionedastowhyIwasnotsentforsooner,theneighboursaidshehadseenherinmanypreviousattacksquiteasbad,as,orevenworsethan,thisone,exceptforthesuddenandunlooked-forchangeattheend.Therecenthistoryofthiswomanwasthus:Forthelastyearshehadsufferedfromoccasionalsavereheadache;forthelastsixmonthsshehadbeensubjectto"faintingturns,"withfrequentretching,suchattackslastinghalfanhourtoanhour,whenshewouldbeallrightagaintheattacksalwaysoccurred.ealyinthemorning.Thefrequentflushesandcoldsweatsoftheclimactericwereexperienced,andirregularcatameniaroflateeverytwoweeksorso,notmuchloss,butextendingoveralongerperiodthannormally.Thelastmenstrualperiodwasaweekprevioustothefatalattack.Shewasahealthy,cheerful,bright,andhappywoman.Shehadbornesevenchildren,fivenowliving.Herfatherdiedsuddenlyattheageof60.Theautopsyrevealednothing,allorgansandstructuresbeingnormal,withnosigns.of,internalhaemorrhageorofpoisoning.Thefollowingpointsareespeciallyworthyofnote:(1)Thefatalattackoccurredduringtheclimacteric;(2)attacksofasimilarnature(exceptforthefataltermina-tion)hadoccurredbefore;(3)theattackswerealwaysinthemorning;and(4)absenceofanysignsofdiseasepostmortem.Itisawell-knownfactthatthenervousorganizationofmostwomenisputtoaconsiderablestrainduringtheclimacteric,andattackssimilartotheonerecountedaboveare-commonenough,beingreflexinorigin,andalwaysoccurringearlyinthemorning,inwhichrespecttheattacksareanalogoustothevomitingofpregnancy.Whereasthesymptomsassociatedwiththeclimactericarenotusuallyof,aseriouscharacter,ItakeitasquitewithintheboundsofpossibilityforanattacksuchasI.havede.scribed,andoriginatinginthegenitalorgans,to'so,act*AbstractofapaperreadbeforetheMedico-LegalSociety,'March12thi,1907.reflexly-thatthebalancewouldturntowardsdeathinstead6ftowardsrecovery.Forhavewenotinthiscasetheevidenceoftheneighbourwhosaidthatshehadseenthedeceasedinattacksworsethanthislastfatalone,exceptfortheimmediatechangeattheend?Yetfromthesesufficientlyseriousattacksshehadalwayspreviouslyrecovered.Beitnotedthatthischangeattheendoftheattackwasamatterofafewseconds-itwastrulyacaseofsuddendeath.Thenegativeresultoftheautopsyalsosupportsmeinthissolutionofthecauseofdeath.InmyevidenceattheinquestIgaveasthecauseofdeath"asthenicsyncopeimmediatelydependentupontheclimacteric."Suchacauseofdeath,althoughrare,seemedtometobesoobviousthatsubsequentlyIwasindeedsurprisedtofindnorecordwhateverofanysimilarcase;aftersearchingnumerousauthorities,Ihavefailedentirelytodiscoverthattheclimacterichasbeenheldtoaccountforsuddendeath;hencemypaperwithaviewtoasecertainingtheopinionofothers.ANOTEONTHEUSEOFTHEBLUNTHOOK.ByJ.EDWARDGODSON,M.B.,B.CH.BIRM.THEpointIdesirechieflytoemphasizeinthefollowingreportisthecomparativeeasewithwhichdeliverywaseffectedwiththeblunthookinacasewhichpresentedelementsofgreatdifficulty.Asamatteroffact,Idoubtifanyothermeanscouldhavebeensuccessfullyemployedwithoutrecoursetoanaesthesia,andthis,too,wheretheuseofchloroformwaspracticallyinhibited.Mrs.G.,an8-para.withadvancedmitraldisease,commencedlabouronApril4th,1907,andafterseveralpainsthemembranesrupturedandthewatersescapedinonegush.Thepainsthenabated,butcontinuedatintervalsofaboutanhour.Herlasttwoconfinementshadbeenprolongedandsevere;thesixthashoulderpresentation,theseventhavertexterminatedbyhighforcepsextraction.Inhercasetherewereseveralcausesinevitablytendingtoproducedifficultlabour:constitutionaldebility,uterineinertia,swellingandoedemaofthesoftparts,andaboveallmarkedcontractionoftheA.P.diameteratthebrimproducedbyprojectionofthesacralpromontory.IwascalledtoseeheronApril5th,andfoundtheosuterithesizeofasixpence,thesoftpartsveryoedematous,andabreechpresentation(abdomino-anteriorposition)withthelegsfullyextendedonthetrunk.Aslabourwasprogressingnaturally,Ijudgeditunwisetointerfereatthisstage,andcontentedmyselfwithwatchinghercloselyduringthenextforty-eighthours.Thegeneralconditioncontinuedgood,theuterinepainswerehesitating,long-delayed,andinadequate,thedilatationoftheoswasprogressivebuttardy,andtherewasafreeescapeofmeconium.OnApril7ththepatientwasinmuchthesamecondition,butsufferingfromwantofsleepandinabilitytotakenourishment,whiletheuterinecontrac-tionsstillcameathalf-hourlytohourlyintervals,andtheoedematousoswouldnowadmitthetipsoffourfingers.AftersomehesitationIdeterminedtoleaveheryetawhile,beingchieflyinfluencedbythelong-intervalcharacterofthepains,thedesirabilityoffurthermodellinganddescentofthebreeeh,thedangerofchloroformwiththeheartsofaulty,andthedifficultyofworkingwithoutitinsoconfinedaspace,andwiththepresentationsohighup.Therectumwasemptiedbyenema,thevaginawnshedoutwithantisepticdouches,four5-graindosesofquinineweregiveneveryfourhourstowhiptheuterusintoquickeraction,andliquidfoodwasadminis-teredregularly.Underthistreatmentthepainsbecamemorefrequent,andtheoswasfullydilatedby10p.m.,buttocounter-acttheseadvantagesthepatienthadanalarmingattackofsyncope,andthebreechbecameimpacted.Itriedtobreakupthepresentationandbringdownaleg,butfoundthisevenmoreimpossiblenowthanithadbeenatanearlierstage.Anattempttogetafilletoverthethighwasequallyunsuccessful;whiletheforcepswereeasytoapplyandequallyeasytowith-draw,astheyfailedtoobtainanefficientgrip.Theblunthookremainedasafinalresource,theinstrumenttohandbeingofanobsoletepatternwithaninternaldiameterof1a-in.Asmallhookiseasiertousethanalargeone,butpossessescertaindangersanddisadvantagesofitsown-thedevicebywhichIhaveattemptedtoovercomethesewillbementionedlateron.Iappliedtheinstrumentwithoutdiffi-culty,andextractionofthebreechfollowedwithgreaterreadinessthanmighthavebeenanticipated.Theshoulders-themostmassiveIhaveeverseeninanewbornchild-causedconsiderabledelay,butthisdidnotmattermuchasthe,childhadevidentlybeendeadforseveraldays.Thefinalstageofdeliverywasconeludedwithouttrouble.Thechildwasamale,atfullterm.Ithadanoffensiveodour,andlargesurfacesweredenudedofepidermis.Itwas12lb.inweightand23in.long.Thebonesoftheskullwerestrongandnormallyossified;theoccipito-frontalcircum-ferencewas15in.,theoccipito-mentaldiameterwas6in.whilethebiparietalwas4.50in.Thecircumferenceofth