Robert T. Frank

A Suggested Test for Functional Cortical Adrenal Tumor

A clinical syndrome characterized by facial and trunk obesity, hirsutism, pig eyes, either persistently high blood pressure or attacks of hypertension, amenorrhea or menstrual irregularity, pinkish skin striae, rarefaction in the bones, polycythemia, acrocyanosis of extremities and susceptibility to infection, has attracted increasing attention, particularly since Cushing described basophilic adenoma as a probable cause. 1 Previously a number of these cases had been found due to cortical adenoma or adrenal tumor. 2 It might readily be conceived, as suggested by Cushing, that a pituitary overfunction, perhaps limited to the basophilic type of cells, might secondarily produce cortical adrenal changes. A typical case, diagnosed as “basophilic adenoma” was under my observation in my clinic and laboratory for 1 1/2 years during which time thorough hormonal studies were performed with extremely striking findings. This patient died suddenly (on the service of Dr. B. S. Oppenheimer) in consequence of an erysipelas secondary to an acute middle ear infection (unoperated), permitting a full autopsy. At autopsy the pituitary was found normal (serial sections, Dr. Joseph Globus), the basophilic elements proving diminished in number. A large carcinoma of the adrenal cortex was found. The case will be described in detail elsewhere. At the moment, the hormonal findings alone will be discussed. Hormonal examination, extending over a period of 4 weeks, showed negative pregnancy tests, no increase in the prepituitary and female sex hormones circulating in the blood. 3 On the other hand, the excretion of female sex hormone in the urine was at times tremendously increased, to a degree seen normally only in pregnancy (13,000 Mouse Units per liter).

Estrogenic Substances in the Blood and Urine After Castration and the Menopause

We noted that the blood cycle persists after hysterectomy. 1 We reported the recovery of estrogenic substances from the blood 2 and urine 3 years after the onset of the physiological menopause. The present report deals mainly with the finding of estrogenic factor in the urine of human castrates. The report is based on the study of 12 female surgical castrates, 5 physiological menopause patients and 3 X-ray castrates. 1. All of the 12 surgical castrates excreted estrogenic factor in the urine. The amount varied between 15-200 M.U.L. In 2 cases, aged 23 and 44 years, studied over a months period, a total of 255 M.U. and 720 M.U. respectively, were excreted. The average normal excretion of a menstruating woman in the same period equals 1500 M.U. 3 Blood studies of these 2 cases failed to show estrogenic factor. 2. No correlation could be demonstrated between the relative amount of estrogenic and prepituitary gonadotropic factor of the urine. Seven patients were studied. With high readings of both luteinizing and follicle stimulating factor as little as 15 M.U.L. of estrogenic factor and as much as 200 M.U.L. were encountered. 3. No difference was noted between castration (2 cases) and castration with removal of the uterus (10 cases). 4. The subjective symptoms (flushes, arthritis) showed no correspondence with the amount of estrogenic factor excreted—6 “mild” cases with from 40 to 200 M.U.L.; 6 “severe” cases with 15 to 200 M.U.L.

Utilization and Excretion of the Female Sex Hormone

Of importance are answers to the question of (1) what happens to the female sex hormone after injection, (2) how is it excreted, (3) can the excretion be stimulated? 1. What happens to the female sex hormone after injection? Half hourly blood samples taken from isolated adult rabbits in whom 2000 M. U. of female sex hormone had been injected intravenously in one dose, showed that only 1 M. U. could be recovered from 4 cc. of serum during the first hour, and none thereafter. After subcutaneous injection, 5 cc. showed this reaction during the first hour. Twenty-four hours later the blood of a rabbit injected with 3000 M. U. and killed 24 hours later by bleeding, showed less than 1 M. U. in 40 cc. of blood, one-half of the total blood volume. From another rabbit given 3000 M. U. and killed 24 hours later, extracts made from the total skeletal musculature, the lungs, brain and liver were assayed. With the exception of the liver, the total extract of the organ proved negative. The extract corresponding to one-half the total liver contained but 1 M. U. This series of experiments shows that large amounts of female sex hormone given intravenously or subcutaneously in the rabbit, rapidly disappear from the circulation and cannot be recovered from the internal organs 24 hours after injection. These results do not show whether the hormone is destroyed or so changed within the body fluids or tissues as to be no longer demonstrable by the Allen and Doisy reaction. 2. How is the female sex hormone excreted? Allen 1 found that female sex hormone was excreted almost quantitatively when injected into monkeys. We injected 2 African green monkeys, a male and female, each with 1500 M. U. of the hormone subcutaneously.

Effect of Administration of Estrogenic Factor upon Hypophyseal Hyperactivity in the Menopause

Summary In 14 menopause cases in which a hyperexcretion of gonadotropic factor was observed, injection of 4,000 to 22,000 R.U. of estrogenic factor was followed by a rapid decrease of gonadotropic factor in the blood and urine. The disappearance of the prepituitary hormone persisted for from 28 to 70 days but was regularly followed by a return to the condition noted before treatment. The amelioration of subjective symptoms roughly paralleled the decrease of the gonadotropic factor in the urine. From these studies it appears that the hypophyseal hyperactivity which follows castration or appears in the spontaneous menopause (Zondek, 4 Fluhman 5 ) can be temporarily ameliorated by the administration of estrogenic factor in high dosage. Graph of a typical case is appended.

Gonadotropic Blood and Urine Cycles in Normal Menstruating Woman

Summary By an improved method increased concentration of the follicle stimulating factor and the presence of luteinizing factor can be demonstrated in the blood of cyclical, menstruating women during the 9th to 12th day of the cycle. 2. In the urine a similar accumulation of both factors was noted between the 10th to the 14th day. 3. The presence of the luteinizing reaction has hitherto been associated with pregnancy and chorionepithelioma.

A Method for Demonstrating Prepituitary Maturity Hormone in the Blood of Non-Pregnant Women.

Since the prepituitary maturity hormone has been shown to produce puberty, follicle ripening and corpus luteum formation 1 , 2 and since this hormone has been demonstrated in the blood serum and urine of pregnant women and female castrates, 2 , 3 , 4 it appeared logical to expect its presence in the blood of women during the menstrual cycle. Aschheim and Zondek 2 have determined 3 types of action exerted by the maturity factor, follicle ripening (A P R I), blood spots (A P R II) and corpus luteum formation (A P R III). They ascribe these results to 2 distinct hormones which they call Prolan A producing A P R I, and Prolan B causing A P R II and III, but have been unable to devise an exact method for separating these factors. We have attempted to devise a method for demonstrating the presence of either or both Prolan A and B in the blood of nonpregnant women. A convenient material for control is supplied by the serum of pregnant women of which 0.2-0.5 cc. contains a M. U. or R. U. The untreated serum could therefore be used and equivalent amounts of the extracts of the same serum compared with this. The following technique was employed: a. Blood serum obtained from women at various phases of the cycle, from 1 to 22 cc. in amount, was injected into immature mice and rats without conclusive results, b. The proteins of the blood serum were precipitated with acid alcohol (one part serum, 3 parts 95% alcohol). After dilution to 50% the supernatant was separated by centrifu-galization and concentrated to a volume of 6-8 cc. by means of an air current at room temperature.

Determination of Luteinizing and Follicle-Stimulating Principles in Castrate and Menopause Urine

Method By the following method it has been possible to demonstrate the presence of luteinizing (in 62.5% of 16 women) as well as follicle-stimulating principle in the urine of both castrates and spontaneous menopause. Two hundred cc. of urine is taken from a fresh 24 hours specimen and acidified with concentrated acetic acid to pH 3.5 (Congo Red). Four volumes of cold acetone are added to the urine, shaken vigorously and allowed to stand overnight in the refrigerator. The supernatant fluid is poured off and the precipitate extracted with weak NaOH. The pH of the mixture is adjusted to between 8 and 8.5, the residual precipitate stirred thoroughly, the mixture centrifuged, and the final precipitate discarded as the supernatant fluid contains the gonadotropic principle. The fluid is then adjusted to pH 7 with dilute acetic acid. The equivalent of 100, 50, and 25 cc. is injected into immature rats weighing 22 to 24 gm. The injections in each rat are divided into 5 doses, given over 3 days. The animals are autopsied at the end of 96 hours. The ovaries are examined in serial section. The same procedure can be performed using alcohol instead of acetone. Acetone is preferable to alcohol as no deterioration or destruction of the hormone occurs on standing, whereas deterioration of the gonadotropic principle occurs when alcohol is used. The opinion is gaining ground that “the principle in castrate or menopause urine seems to be identical with the follicle-stimulating fraction prepared from the pituitary glands.” 1 However, it should be emphasized that Lassen and Brandstrup 2 reported a luteinizing reaction in the urine (diagnosis by gross inspection of the mouse ovaries), and Fluhman 3 in the blood of such patients. Katzman and Doisys benzoic acid precipitation method 4 does not extract the factor found in the menopause or castrate urine. By using our new method, 16 cases, partly surgical castrates, X-ray castrations, and spontaneous menopause were studied.

A Dosage Response Equation for Androgen Assay by the Chick Comb Method.

In previous reports on the relation between dosage of crystalline androsterone (A)† and mean comb weight (W) of white leghorn chicks, we described experiments involving 582 chicks in 5 monthly series. Each series consisted of 6 “gamma-groups” of chicks; 1 , 2 i.e., each bird received a total dose of 0, 10, 20, 30, 40 or 50γ androsterone in 0.35 cc of sesame oil, 0.05 cc being applied to the comb daily from the 3rd to the 9th day after hatching. The comb was excised and weighed on the 10th day. In the work now reported the number of series was increased to 10 (1439 chicks) over a period of 12 months, but in addition to W, A, Nm, and Nf, we recorded Bo and B. We also continued to run a control (zero γ) group of chicks with each series, as a measure of variations in spontaneous comb growth activity associated with season and batch of chicks. Using these combined data, we investigated graphically and statistically the desirability of applying to W for any series and sex a simple correction for mean comb weight of the corresponding controls (Wc ). Apart from sex difference, the improvement in the dose-response relation effected by this correction (W — Wc) was very small and probably negligible in the presence of corrections for B and Bo. Analysis of the data was therefore continued without such corrections. Graphs of W for each gamma-group (sexes separate) against A (Fig. 1) show that the data conform roughly to parallel straight lines, but a curvilinear fit may be closer. However, the graph for W against log A (Fig. 2) fits no better than the linear relation; this is confirmed by the identity of the corresponding correlation coefficients.

The treatment of cystocele, rectocele and uterine prolapse

Abstract If the anatomy of the pelvic outlet is understood, if cases are judiciously selected, and if the technic described is followed, the results are fully as satisfactory as those obtained in the radical cure of inguinal hernia. A certain number of recurrences may be expected, especially in patients with flaccid tissues and general enteroptosis. It should be emphasized that patients, whose complaints and pains did not arise from the minor lacerations of the cervix, the small cystocele, the negligible rectocele present, will not be benefited by unnecessary plastic repair.

Significance of Female Sex Hormone Reaction in the Male Blood.

In 1925, simultaneously and independently, Loewe of Dorpat 1 and one of us with collaborators 2 demonstrated the presence of the female hormone in the circulating blood of females by means of the rodent vaginal spread test. 3 Since then, in numerous publications we have attempted to simplify and standardize the method of extracting and testing human blood for the female sex hormone. 4 Among other applications we advocated the use of this test to determine the sex of pseudo-hermaphroditic individuals in whom we regarded a positive reaction, appearing cyclically, as a proof of the presence of functioning ovaries and feminine sex. 5 Our preliminary work had shown that large quantities of bulls blood (150-100 cc.) gave a negative reaction when extracted by our method. The same applied to concentrated lipoid, HCl, saline and watery extracts of bulls testes, as well as extracts of the hypophysis, thyroid and adrenal, liver, muscle, various proteins, etc. 6 The work of Dohrn, 7 who claimed to have obtained a positive reaction with male urine first called our attention to the possible non-specificity of the Allen and Doisy reaction. After our investigation on male bloods had been completed, the short article of Hirsch, 8 who used our method, appeared. In the 4 male bloods which he examined, he has found a positive reaction. To date we have obtained 70 bloods from 55 males. Of these, 10 had to be discarded because the injected mice died early. The technic was that mentioned iii our last article, 4 in which 40 cc. of blood were dried with sodium sulphate, extracted with ether, the dry ethereal cxtract taken up in 2 cc. of water and injected. Our readings are : 0 to −2 =no reaction; 2 to 2+ =weak reaction; −3 to 3 =threshold reaction; 3 to 4 = strong reaction.