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Pathology and Bacteriology:
H. B. ANDERSON, M.D.
H. C. ParsoNS, M.D.
Nose and Throut :
J. MURRAY MCFARLANE, M.D.
D. J. GIBB WISHART, M.D
J. T. FOTHERINGHAM, M.D.
ALLAN BAINES, M.D.
Eye and Ear :
G. STERLING HYERSON, M.D.
C. Trow, M.D.
INERTIA OF THE UTERUS FOLLOWING THE USE OF CHLO
BY J. A. WILLIAMS, M.D., L.R.C.P. LOND., INGERSOLL, ONT.
MR. PRESIDENT AND GENTLEMEN :
The case we bring before you in this paper is one from general practice, such a one as may occur at any time without warning. For emergencies, that are at once dangerous to the patient and to the reputation of the physician, we should have in our minds a well thought out method of procedure, otherwise we may be taken at a serious disadvantage. It is not claimed that there is anything new or original in the methods pursued, or in the thoughts herein given expression to, but it is hoped they will lead to such consideration of the subject, that after your discussions we can settle in our minds a line of treatment in readiness for such cases.
Mrs. A. is a tall, muscular woman, bony and angular, with a broad pelvis and no superabundance of flesh. A woman accustomed to hard work, has raised several children, and is the mother of grown-up daughters. She is approaching forty years of age. She had prepared herself
. for an “easy time” by taking five bottles of a popular remedy called “ Indian Woman's Balm.” We know nothing of its composition. She was taken in labor early in the afternoon on a spring day in 1896. The services of Dr. Rogers were called into requisition. The labor progressed favorably until the head was well engaged in the pelvis, when advance
ment became much less marked, and at times seemed to have ceased, notwithstanding the pains were regular and strong. As she was vigorous and in good health, nature was allowed to put forth her best efforts until well along in the night, when advancement was no longer appreciable. As there was plenty of room in the pelvis the doctor determined upon the use of the forceps. After administering chloroform they were applied; but, notwithstanding the doctor's best efforts, he was unable to complete the accouchment. Recognizing that the case was out of the ordinary, and considering the arduousness and risk of properly managing a difficult forceps case, and at the same time giving the anesthetic to a patient rather obstreperous, the doctor determined upon having assist
At this time, about six in the morning, the writer was called in. The patient's general condition was satisfactory. There was no untoward symptoms, except some indications of fatigue. The head was well down in the pelvis, which was sufficiently roomy that with the aid of forceps we might reasonably expect speedy delivery. The fætus was in the first, or left occipito anterior position. At the request of Dr. Rogers I administered chloroform, and he re-applied the forceps. Strong efforts were made to bring forward the child, and progress was made ; but, in consequence of a tiresome night and hard work, the doctor became fatigued and invited me to a change of occupation. He now administered the anesthetics while I used the instruments. When the head was delivered —no easy task—there was great difficulty with the shoulders, because of their large size relatively to the head. Finally, the body was born, much more slowly than usual, because of its large size. The child weighed fourteen pounds. During the progress of the delivery the doctor followed the fundus, making pressure with his hand, and continued to do so for a short time afterwards. When the infant had been disposed of, and after waiting a few moments, I returned for the placenta, which was found lying in the vagina. It, with a small quantity of clots, was removed.
To facilitate the use of the forceps, the patient had been placed transversely on the bed, with the hips close to the edge, the legs supported. This position enabled me to notice that the delivery was being followed by an unusual amount of hæmorrhage. Proceeding to ascertain the cause, the hand was passed to examine the condition of the os and the uterus. No os or uterus was recognizable, but in place of these a pelvis filled with fresh clots and blood. On a more careful examination the os was found to have been dilated by the passage of the fætus and to have remained so, while at the same time the fundus had completely collapsed. The uterus was without tonicity. The doctor's hand, which had been removed from the uterine globe, was now returned to the lower abdominal region, but the tumor was gone. Hot water was at once called for, and fortunately, thanks to the forethought of the doctor, a goodly supply was immediately available. While the nurse was procuring it a hypodermic injection of the fluid extract of ergot was administered, and immediately after one of strychnine. A Davidson's syringe, the only one available, was brought into requisition. The nozzle was carried boldly to the top of the uterus, and the collapsed portion, still flaccid, carried back to its place. The hot water, so hot it could scarcely be borne by the hand, was then pumped in, and at the same tiine friction was made with the one hand in the interior and massage with the other on the exterior of the uterus. After about a quart of water had been forced in and a correspondingly large place had been cleaned of clots and blood at the fundus, for the bleeding ceased in that part with which the water came in contact, and contractions commenced. As the hand and water cleared and cleaned down to the cervix the contractions followed, leaving a firmly closed, clean uterus. The passages were then washed out, and the danger was over. There was no return of the inertia. The patient progressed favorably, and on the tenth day was in the street. Very shortly afterwards, however, she had an attack of pelvic cellulitis, from which she was in bed for some weeks.
On following this case, the first question that forces itself upon us is, why did this uterus fail to contract, why this inertia ? When there is a marked pre-disposing cause, such as the weakness resulting from albuminuria, from frequent recurring pregnancies; from over-distensions, as from pluriparity or from polyhydramnios; or from the effect of chronic diseases, there are usually premonitory warnings, by weak contractions through the first anů second stages of the labor, heralding insufficient uterine action in the third stage. In this case none of these conditions existed, and there were no such premonitory warnings. The pains were strong and vigorous through both stages.
In the absence of these predisposing causes, we look for something more immediate. The too rapid eniptying of the uterus is considered among these. This cause had no existence in this case, for the very significant reason that we were not able to make a rapid delivery had we been so disposed. Second, when the uterus is rapidly emptied, and care is not taken to follow down with the hands upon the abdomen, lessening the organ as the contents are removed. Here, again, we were not at fault. The rapid delivery did not occur, and Doctor Rogers carefully followed down the uterus during its descent, and held it for some time.
Other than the time the labor lasted, about eighteen hours, and its severity, there were none of the usually assigned causes of inertia present, and neither of these was sufficiently marked to lead to an expectation of this kind.
In the absence of other causes, we are forced to look upon the administration of chloroform as being the most potent influence, probably aided by the effect of eighteen hours' severe labor.
Opinions of leading obstetricians do not harmonize as to the effect of this anesthetic on uterine contractions. While some regard it as being without effect, others, whose opinions are no less deserving of weight, believe its influence so great that it can be used only with the utmost care in obstetric practice. We will make no attempt to follow writers, but will make bold to say, our experience leads to the belief that the truth is between these extremes. Much depends on the extent to which the anesthesia is carried. The more profound, the greater the extent to which it influences uterine action, and the less its anesthetic influence, the less disturbance of the normal contractions.
It will be within the experience of most practitioners, that immediately it is given the pains become less frequent and have less strength. This influence continues during its administration. Because of this, when the contents of the womb have escaped, there is an absence of or a diminution of, that contraction that is very necessary and usually follows a normal case. Post-partum hemorrhages are consequently more frequent after its administration, unless precautions are taken to prevent them. Fortunately, in obstetric cases the full benefit may be obtained from the anesthetic without the anesthesia being carried to the extent that is necessary for major operations; by taking care to limit the effect and at the same time to use such measures as will stimulate uterine contractions, we may secure all the advantages with comparatively little risk of the dangers. In this case, partially perhaps from a somewhat lengthened administration, our patient was too profoundly anesthetised at the time the contents were removed. While the contractions were sufficiently strong to aid in the final expulsion of the child, and in the detachment and expulsion of the placenta, yet when the internal irritation of these substances was gone, the period of rest which is usual in normal cases became prolonged into a dangerous inertia. In the period of rest following natural birth there is not an entire absence of tonicity. While the organ is passive it still retains form, and may by slight irritation be called into activity. In this complete inertia all form is gone, the uterus is in a flaccid condition.
This inertia allowed “Spontaneous Passive Uterine Inversion to take place.” Duncan recognizes four kinds of inversion as to methods of occurrence. These are: First, Spontaneous Passive Uterine Inversion ; second, Artificial Passive Uterine Inversion; third, Spontaneous Active Uterine Inversion ; and, fourth, Artificial Active Uterine Inversion. For any of these to take place there must be partial inertia. For the first ano second there must be complete inertia, as we had in this case. In the active form, the endeavor in treatment, and the chief difficulty, is in the restoration of the organ to its natural position--its reposition. This being fully accomplished, the contracti will maintain it so long as that contraction is continued in full natural force. In the passive forms the difficulty is not in the reposition, but in overcoming the inertia which allowed the inversion to take place. In either case the consequence may be serious, if prompt steps are not taken, or if these are not crowned with success. Our case being one of passive inversion, the endeavor was to overcome the inertia.
As the chloroform was the main cause, the first step must be to get from under its influence. To this end we discontinue to administer it, and by an abundant supply of fresh air we facilitate the escape of what is in the system. We had in our favor the very important fact, nicely expressed by a recent writer, “ That chloroform produces no permanent paralysis, only anesthesia, and if elimination, and excitation can be obtained, the temporary condition will soon be overcome.” Betore, however, this inertia is overcome, it is of the first, importance that the organ shall have been reposited, otherwise there may be great difficulty in doing sn. Hence the necessity of early recognition and prompt action.
Though the cause is largely removed, we would not be justined in waiting for nature unaided to resume her wonted functions and restore the tonicity. Could time be allowed without danger, there is no doubt she would do so. But each moment permits of great loss of blood, which impairs, if it does not endanger, vitality. We must, therefore, take steps to call her from slumber to her accustomed activity.
In our case we gave ergot and strychnine hypodermatically. quite aware some good therapeutists tell us these remedies neither severally nor jointly can initiate uterine pain. Yet, admittedly, they have the power of stimulating into activity the nervous system, and this arousing of the vital energies plays no unimportant part in this case, and is practically what we are after. It is admitted, too, that when uterine contractions do exist, these remedies have the effect of stimulating them into greater activity. But, say some, no reliance can be placed upon
their producing any effect in less than about two hours after administration, and the case will be terminated before that time. If, for the sake of argument, we concede this to be true, they still come into play to prevent subsequent relaxation which is liable to recur. When adininistered hypodermatically, we do not believe the action is nearly so long delayed. Fifteen minutes would be more nearly correct, and in many instances evidence of the effects are appreciable in even less time. Were the administration by the stomach we could quite understand the long time, for chloroform anesthesia will much diminish, if it does not entirely arrest, absorption from this organ. I hen again, there may be material in the stomach with which our potion becomes intermingled. Absorption of the whole mass must take place before the effect of the dose is secured. All things considered, we are strongly of the opinion that hypodermatic administration is best suited for emergencies.
Our duty is not completed by the removal of the cause and the administration of medicine. Experience has brought into use expedients even more prompt in their action than these. What we used in this case was friction and hot water. The former is an old expedient that has stood the test of time, and is not likely to be superseded. It requires no instrument other than a pair of clean hands, and while the one is in the interior of the uterus making friction on its surface, the other is on the exterior after the manner of bimanual manipulation, using massage. This method is always available, and could the facts be known there is no doubt the saving of many lives would go to its credit. The hot water, while it has not received from the profession the same lengthened recognition, is still a most valuable expedient. Used conjointly, they are a most prompt means of arousing uterine energy and arresting hemorrhage. In our case they did not fail us.
From this case we may draw several important lessons. First, when we use chloroform we should make it a rule to use the least possible amount that will secure the object desired, to have the anesthesia as light and as short as possible. Second, we should make preparation in advance to counteract the effects, which way possibly come without warning. Among the preparations made we may mention the administration of some oxytocic sufficiently early, that its period of activity may be reached by the time