DYSTOCIA THROUGH CIRCULAR CONTRACTION OF UPPER UTERINE SEGMENT. BY C. H. LEWIS, A.M., M.D., MORBID Contractility in the transverse muscular fibres of the cervical segment as a retarding agent in the first stage of parturition is so frequent as to excite no comment, and we all know with what strength and persistence it will often, in primiparous cases, resist both the natural dilating forces and all artificial promoters of cervical relaxation; and, in rare cases, similar action in the transverse bands near the ring of Bandl, due to irregular retraction or adherent placenta, resulting in the condition known as hour-glass contraction, seriously delays labor in its third stage. The case recorded below is the first in my experience in which such a state of affairs in the body of the uterus, seriously complicating the second stage of labor, has been positively demonstrated. This tendeney to irregular action may exist in delayed labors more frequently than we know, because, the combination of conditions favorable to its full development seldom co-existing, its partial operation may be overcome by the expellent forces, and the true cause of the delay be, at most, only suspected. At no other point on the fetal ovoid, except the neck, is there space for the formation of a diaphragm by circular contraction, nor there while the ovisac is distended by fluid; and in head presentations, without fluid, the attempt to form a midriff around the neck could not long resist the stronger expellent power above, concentrated on the child's body as a wedge, and acting in the line of gravitation. Few cases combine the three conditions favoring such an accident, viz., breech presentation, excessive circular contraction, and absence of amniotic fluid. On September 4th, 1885, at 9 A. M., I was called to Mrs. F. G., in her first confinement, at full term. She was 26 years of age, under medium size, but symmetrically built, and healthy. Her pains had been regular since 1 A. M., yet the os barely admitted. the end of the index finger, its rim was thick and rigid, contracting with every pain, and continued so nearly all day, in spite of the usual means for hastening dilatation. As soon as sufficient opening for diagnosis was secured, the breech was found presenting in the right dorso-posterior position. The membranes could not be felt, and their previous rupture was proven by a free dischargeof meconium after every pain, yet at no time during labor or after it was there any perceptible escape of water. At about 6 P.M. the second stage was fairly inaugurated with complete dilatation and pretty good expulsive pains. For an hour or more all went well, and the presenting part came rapidly down, nearly to the pelvic outlet, but there its progress ceased and thenceforward the only effect of the expulsive efforts was to canse swelling of the buttocks until the pelvis was crammed with a soft elastic mass, giving to the finger an impression like that of the membranes full of water. The strongest traction which could safely be made, with the finger in the flexure of the thigh, failed to either advance the breech or bring down a limb. With no contraction of the pelvic diameters, no obstruction of any kind within reach of the fingers, and no lack in the "vis a tergo," an hour spent in fruitless efforts convinced me that some obstacle existed above, the nature of which was not apparent. True labor pains were now beginning to flag, while there was a constant agonizing pain which allowed the patient no rest; she was becoming discouraged, and I could not cheer her with a promise of speedy relief. I felt reluctant to interfere in a case, where, seemingly, natural forces should be sufficient to terminate the labor, but manifestly they were not likely to prove so, and it seemed to me better to render aid promptly than to wait until there should be danger of exhaustion coming in to further complicate the situation. Two methods of giving assistance were open to me, between which a choice must be made-viz., application of forceps to the breech, and introduction of a hand into the uterus. The amount of force which I had already vainly expended, with the finger as a tractor, made me doubtful of getting a hold sufficiently secure with forceps applied in conformity with the pelvic curve; and, moreover, being ignorant whether the hindrance to delivery was of a nature to be overcome by traction alone, I should with forceps be working in the dark, while the hand in the uterus would impart to me an intelligent idea of the cause of delay. Realizing, in a measure, the difficult nature of the proposed undertaking, I requested counsel, and at 9 P. M., my friend, Dr. Cyrus Smith, came to my assistance. He administered chloroform to complete anesthesia, then we waited in the hope that this alone might remove the obstruction if it were simply spasmodic, but, though the regular pains improved under its influence, they effected no more than before. With Dr. Smith's concurrence, I then proceeded to introduce the hand, we both supposing that under chloroform a foot could readily be brought down. With the patient on the back, the hips to the edge of the bed in the position for applying forceps, I gently pushed my right hand through the blockaded pelvis, into the uterus, and upward toward the fundus, passing the palm over the posterior aspect of the limbs, which were stretched upward at full length-thighs flexed, and legs extended; the feet reaching to the chin. With the patient snoring in profound unconsciousness, and complete relaxation existing everywhere else, the uterus was in strong tonic contraction, offering great resistance to the passage of the hand, and compelling me to proceed with caution lest I should injure its rigid tissues. Toward the fundus of the womb my fingers encountered a constricted band of circular fibres embracing the child's neck and ankles, and dividing the uterus into two compartments, the upper and smaller one containing the head and feet, the lower and larger one the body and limbs. The cincture was not so close but that my fingers passed easily through it, yet was so narrow, that, drawing tighter with every pain, it prevented descent of the head and feet, thus frustrating all expulsive efforts. Circular contraction predominated throughout the lower compartment, which seemed to exert no expelling power, but held my hand and wrist in a grasp so vise-like that the fingers, passed over the feet, could not close upon them. In momentary expectation of a little relaxation, I kept the hand in place an hour and a half, then was forced very reluctantly to withdraw it, because under the long pressure it had lost both the power of motion and the sense of feeling. After a brief respite, I again carried the same hand into the same position, and after some time, succeeded in liberating both feet and bringing the right one down to the mother's pubes. The grasp of the uterus was yet so close that I could not bring the left one with it, and in spite of great care the right foot came under the left limb, whence it required a long time to release it. Then my tired and numb fingers could not draw it under the pubic body. Dr. Smith, relieving me, accomplished the delivery of the right foot, but so constricted was the space in which to work that he could not bring down the knee before his fingers cramped so that he, too, "lost his grip." At length, turning the patient on the right side, and drawing the foot directly backward over the relaxed perineum, thus extending the leg and straightening the knee, I with difficulty brought it through. Having thus gained a little room, the left limb was brought down with less trouble. The delivery of the body was accomplished slowly and by strong traction, as if the stricture above held the head as long as possible, yielding only when tired out. The right shoulder coming to the front and the occiput also under the pubes, the head was easily turned out, and our tedious task completed with the birth of a dead male child weighing ten pounds. Had the head been liberated at the same time with the feet, then, after flexing the knees, the further expulsion might have been left to nature without the long and toilsome efforts to deliver both feet, but the difficulty with which the body was extracted satisfied us that nothing short of what was done would have sufficed. Post-partum retraction was complete, and the placenta promptly expelled. The whole hand being within strong muscular walls, and the distance from the os to the fingers' ends being fully nine inches, proved that the constriction was far above the ring of Bandl, and their regular action seemed to be, not retraction due to obstructed labor, but rather, exaggerated circular contraction, itself constituting the obstruction, beginning early in the second stage of labor, involving nearly the entire organ, and, in the absence of distended membranes, becoming nearly complete at the point of least resistance, that is, around the child's neck. This condition lasted about three hours under full anesthesia. In how far it may have been perpetuated by the stimulus of the hand in the uterus is not clear; but it certainly existed prior to its introduction. The life of the child was destroyed by the long arrest of the utero-placental circulation. Ordinarily, I would not continue the use of chloroform so long, but no such protracted anesthesia having been contemplated, I was not provided with ether; however, the pulse and respiration never faltered, and consciousness returned soon after the chloroform was withheld. Ergot, which is with me only a post-partum agent, had not been used, and quinine only in tonic, not in oxytocic quantity. The latter, in ten to fifteen grain doses, is my favorite parturient, the use of which, I believe, has lost me many opportunities to enlarge my experience with the forceps. The next day I found the patient somewhat depressed, with pulse slow, temperature a little below normal, slight nausea, and decidedly cool extremities. On the third day, the pulse was 48, mouth temperature below 94° F., nausea increased, tongue heavily coated, countenance anxious, skin of a sickly yellow hue, and the urine (drawn with catheter) very dark and scanty, while the uterus reached above the umbilicus, and was very tender; the abdomen was quite tympanitic, and the lochia were entirely replaced by a thin, yellow, and very offensive discharge. There was at no time more than a slight attempt toward secretion of milk. These local symptoms were accompanied by great weakness and profuse perspiration. Under stimulants and tonics, attention to the secretions, turpentine externally, and thorough local disinfection, aided by good nursing, by the seventh day the pulse and temperature had reached 60 and 98 respectively, with corresponding abatement in all the bad symptoms, and from this time convalescence was slowly established. FARADIC ELECTRICITY IN RIGIDITY OF OS UTERI BY MARY PUTNAM JACOBI, M.D. A PRIMIPARA was brought during a premature labor, occurring at seven months of pregnancy, to the N. Y. Infirmary in a state of considerable exhaustion resulting from the prolonged laborpains. The external os was tetanically rigid. I did not see the patient until after she had been for some time in the hospital, and the physicians in charge, Drs. Blackwell and Cushier, had used all the most usual and approved means of relaxing the rigidity of the os, but without the slightest effect. Even chloroform had failed, and the increasing exhaustion of the patient rendered this method hazardous to be persisted in. It seemed to me that the tetanized condition of the os, which would barely admit the tip of a finger, and resisted manual dilatation to an extraordinary degree, was precisely due to the exhaustion of the nerve force destined to the uterine fibre. The tetanus would then be analogous to the intestinal cramps of lead colic; to those induced in both the rectum and the genital canal by compression of the aorta (in rabbits), or, on an even more general scale, to the universal muscular contractions of rigor mortis. If this were true, -and surely the clinical history of cases of rigid os uteri tends to support the hypothesis-local stimulation of the exhausted nerve fibres was indicated as the remedy. A small electrode was applied to the os, and connected with a faradic battery; the other electrode being held in the patient's hand. It was considered desirable to avoid passing the current through the body of the uterus, lest new contractions should be excited and struggle in vain against an impassable resistance. The application was continued for fifteen minutes. Immediately afterwards, and for the first time, Dr. Cushier succeeded in inserting a finger into the cervical canal, and after some further effort, in gradually effecting manual dilatation and delivering the patient by the forceps. Stimulus to the nerve fibres thus seemed to have succceded in inhibiting the spasm into which the muscular fibre had been thrown, as is habitual when left to its own irritability. |