CONTRIBUTIONS TO THE PRACTICE OF MIDWIFERY. By P. S. Mootoosawmy, g.m.s., f.l.s., Fellow
of
Society of London, Surgeon, Tanjore, Madras.
the Obstetrical
Retired Native
Difficult labour from occlusion of the Os Uteri ; Third pregnancy ; Delivery effected by opening THE Os AND BY THE FORCEPS ; UTERINE INERTIA ; Recovery ; Remarks. On the morning of the 3rd July 1883, about 5 o'clock, I was called to a Guzarati Brahmin female in the western section of the Tanjore town, who had been in labour of her third child I hastened to the since the afternoon of the previous day. spot and found the patient a short, fair, young looking person, of slender build, unmarried, and mother of two children, the first having been prematurely and still-born, and the second a male, surviving, 18 months old. The labour pains on the present occasion were said to have set in about 3 P. M. of the day before : they were strong and frequent at first, but gradually became weaker towards morning. Bowels constipated?no action for three days; bladder distended; urine voided in small quantities. The midwife in attendance, a pupil of mine, reported that the os. to not uteri had commenced dilate, and that the uterine contractions were weak and recurring at distant intervals. I prescribed a dose of castor oil. services My having been.elsewhere emergently required, I was compelled to leave her, and I did not When I arrived I found the woman see her again until 8 p.m. still and quiet, the uterine tumour large, and pains, very Auscultation eliicited weak and coming on at long intervals. The skin was cool;'^features indications of foetal life. anxious; bowels were said to have been moved, five times by the oil; bladder continued very much distendedj the external organs were not swollen; vagina of normal dimensions, but dry and somewhat tender. No os uteri,, could be felt, its site was occupied by a slight depression about the sire of a four-anna piece : the surrounding parts felt thin, like membranous tissue, and the foetal head was found pressing > thereon. , The bladder having been relieved by the intrqdncticjn' of an elastic catheter, 1 divided the occluded portion (cicatrixj with a scalpel by a small crucial incision, and dilated it witfi my finger. The liquor amnii escaped ; I found the head low down in the pelvis arrested from want of uterine action. Delivery was effected by the short forceps. The child, a female, There was no flooding. The placenta having been was alive. removed without any difficulty, three doses of ergot and brandy were given, cold was applied externally, and pressure was maintained at the fundus to secure contraction, but all in vain. The child was put to the breast, the patient made comfortable, and the strictest quiet was enjoined. 2nd day, 7 p.m.?The patient had a quiet night ; lochia free ; complained of pain in uterine region : no uterine tumour could be felt. I ordered an astringent Paginal injection to be used twice a day, and the following three times a day :?
,'tfyp
Ext. Ergotae liquid Brandy Tinct. Opii Aquae. the evening she was ordered
R.
In
Potassii Bromidi Chloratis Hydratis
R.
xx
...
vi
5
...
...
...
Tf]^
xv
?
ss
mst. haust
?
x
grs. grs.
...
...
x
Syrupi Simplicis 511 Aquce 5iss mst. haust, 3rd day.?Passed a good night. A large clot escaped; Uterus contracted this lochia free, urine free, bowels free. morning for the first time. Uterine pains continue. Omit Ergot. Repeat night draught if necessary. \th day.?Slept well. Uterine pain has subsided ; skin hot; pulse quick, thirst. Mammae distended, knotted and painful, Uterus firmly, contracted. ...
R.
Haust. Senme
...
Vin. Ant. Tart.
...
P. haust Stat sum.
Poppy fomentation
to breasts,
? U|^
i xx.
Continue draught at night.
'
.'?v
:
THE
November, 1S83.]
"
ja.'T!
v
.fi< >( ?:;/-?
k> tDQio|>'f nytil^vJf!??>* i gnnn ari l ^th day.?Bowels acted freely; skin warm, dry : pulse quick; secreting freely and continue painful. Mist; Salime Comp., three times a day.
breasts
Continue fomentations.
7//' day.-?Mammary symptotns have subsided; patient doing
wel1-
nthday.?Mother
and
,
infant
1.
doing
r
well.
The
patient
commenced to-day a course of oil bathing which, according to A bath every caste customs, she will continue for some time. alternate day for the first month, and every 3rd and 4th day
subsequently
for several months
Remarks.?This
case
longer.
presents several features of interest,
the first and chief being the rarity of its occurrence. This is the first case of the kind that has come under my observation in a long practice of forty years. 2vdly.~?The cause of the occlusion is not very clear, though it is hitrhly probable that it had its origin in inflammation and possibly ulceration of the os uteri occurring subse-
quently
to
conception.
The woman denies ever having suffered from any ailment connected with the uterus, and it is likely that her statement is correct; for writers on uterine diseases assure us that organic changes of structure resulting from disease may take place without giving rise to any marked symptoms. It is therefore possible that the woman's attention had not been specially attracted to the uterine organs by any symptoms In confirmation of this statement I may of consequence. here quote an extract from Dr. Churchill's work "On the Diseases of Women, Sixth Edition, page 169." "Dr. Ashwell agrees with Dr. Naegele that complete obliteration may be easily produced by an amount of local inwhich would not seriously flammation following conception, interfere with the health of the individual." Moreover females of the class to which my patient belongs would prefer silently to endure suffering rather than consult medical men for uterine ailments ; and only that they considered the patient's life in danger did her friends seek my assistance. In many instances it would seem as if they preferred the sacrifice of their lives to the relinquishment of their prejudices. 3rd. The absolute imperviousness of the os is another feature which renders this case interesting ; and associated with this is the fact that there wis no extension of the induration induced by the cicatrix. The finger impinged on a depression to which the hardness was limited; the surrounding parts giving the feel of thin membranous tissue on which the foetal head was
pressing.-
"17(11!'
BLACK DISEASE" OF THE GARO HILLS.
i,th. Tbe uterine inertia In the case is a point worthy of notice, The persistence of since it is difficult to assign a cause for it. this inert condition until the morning of the third day after delivery is also remarkable. The inertia was not due to any of the causes to which it is usual to ascribe this deficiency of uterine power: It s'rikes. me thatj though I could see nothing abnormal in the tone of her general nervous and muscular systems, there may possibly have been some defect in .he uterine structures themselves, and which caused the parts surrounding the cicatrix to feel like paper. I have mentioned the fagt of the patient's having had recourse to oi' baths every alternate day from the eleventh day of her It appears to be the This need* some explanation. delivery recognized practice of the particular caste to which this woman belonged to adopt this system of bathing, not from any therapeutical properties it may be supposed to possess, but simply as a religious observance. The patient is first freely anointed with gingely oil, and then bathed in tepid water.
321
of
Society of London, Surgeon, Tanjore, Madras.
the Obstetrical
Retired Native
Difficult labour from occlusion of the Os Uteri ; Third pregnancy ; Delivery effected by opening THE Os AND BY THE FORCEPS ; UTERINE INERTIA ; Recovery ; Remarks. On the morning of the 3rd July 1883, about 5 o'clock, I was called to a Guzarati Brahmin female in the western section of the Tanjore town, who had been in labour of her third child I hastened to the since the afternoon of the previous day. spot and found the patient a short, fair, young looking person, of slender build, unmarried, and mother of two children, the first having been prematurely and still-born, and the second a male, surviving, 18 months old. The labour pains on the present occasion were said to have set in about 3 P. M. of the day before : they were strong and frequent at first, but gradually became weaker towards morning. Bowels constipated?no action for three days; bladder distended; urine voided in small quantities. The midwife in attendance, a pupil of mine, reported that the os. to not uteri had commenced dilate, and that the uterine contractions were weak and recurring at distant intervals. I prescribed a dose of castor oil. services My having been.elsewhere emergently required, I was compelled to leave her, and I did not When I arrived I found the woman see her again until 8 p.m. still and quiet, the uterine tumour large, and pains, very Auscultation eliicited weak and coming on at long intervals. The skin was cool;'^features indications of foetal life. anxious; bowels were said to have been moved, five times by the oil; bladder continued very much distendedj the external organs were not swollen; vagina of normal dimensions, but dry and somewhat tender. No os uteri,, could be felt, its site was occupied by a slight depression about the sire of a four-anna piece : the surrounding parts felt thin, like membranous tissue, and the foetal head was found pressing > thereon. , The bladder having been relieved by the intrqdncticjn' of an elastic catheter, 1 divided the occluded portion (cicatrixj with a scalpel by a small crucial incision, and dilated it witfi my finger. The liquor amnii escaped ; I found the head low down in the pelvis arrested from want of uterine action. Delivery was effected by the short forceps. The child, a female, There was no flooding. The placenta having been was alive. removed without any difficulty, three doses of ergot and brandy were given, cold was applied externally, and pressure was maintained at the fundus to secure contraction, but all in vain. The child was put to the breast, the patient made comfortable, and the strictest quiet was enjoined. 2nd day, 7 p.m.?The patient had a quiet night ; lochia free ; complained of pain in uterine region : no uterine tumour could be felt. I ordered an astringent Paginal injection to be used twice a day, and the following three times a day :?
,'tfyp
Ext. Ergotae liquid Brandy Tinct. Opii Aquae. the evening she was ordered
R.
In
Potassii Bromidi Chloratis Hydratis
R.
xx
...
vi
5
...
...
...
Tf]^
xv
?
ss
mst. haust
?
x
grs. grs.
...
...
x
Syrupi Simplicis 511 Aquce 5iss mst. haust, 3rd day.?Passed a good night. A large clot escaped; Uterus contracted this lochia free, urine free, bowels free. morning for the first time. Uterine pains continue. Omit Ergot. Repeat night draught if necessary. \th day.?Slept well. Uterine pain has subsided ; skin hot; pulse quick, thirst. Mammae distended, knotted and painful, Uterus firmly, contracted. ...
R.
Haust. Senme
...
Vin. Ant. Tart.
...
P. haust Stat sum.
Poppy fomentation
to breasts,
? U|^
i xx.
Continue draught at night.
'
.'?v
:
THE
November, 1S83.]
"
ja.'T!
v
.fi< >( ?:;/-?
k> tDQio|>'f nytil^vJf!??>* i gnnn ari l ^th day.?Bowels acted freely; skin warm, dry : pulse quick; secreting freely and continue painful. Mist; Salime Comp., three times a day.
breasts
Continue fomentations.
7//' day.-?Mammary symptotns have subsided; patient doing
wel1-
nthday.?Mother
and
,
infant
1.
doing
r
well.
The
patient
commenced to-day a course of oil bathing which, according to A bath every caste customs, she will continue for some time. alternate day for the first month, and every 3rd and 4th day
subsequently
for several months
Remarks.?This
case
longer.
presents several features of interest,
the first and chief being the rarity of its occurrence. This is the first case of the kind that has come under my observation in a long practice of forty years. 2vdly.~?The cause of the occlusion is not very clear, though it is hitrhly probable that it had its origin in inflammation and possibly ulceration of the os uteri occurring subse-
quently
to
conception.
The woman denies ever having suffered from any ailment connected with the uterus, and it is likely that her statement is correct; for writers on uterine diseases assure us that organic changes of structure resulting from disease may take place without giving rise to any marked symptoms. It is therefore possible that the woman's attention had not been specially attracted to the uterine organs by any symptoms In confirmation of this statement I may of consequence. here quote an extract from Dr. Churchill's work "On the Diseases of Women, Sixth Edition, page 169." "Dr. Ashwell agrees with Dr. Naegele that complete obliteration may be easily produced by an amount of local inwhich would not seriously flammation following conception, interfere with the health of the individual." Moreover females of the class to which my patient belongs would prefer silently to endure suffering rather than consult medical men for uterine ailments ; and only that they considered the patient's life in danger did her friends seek my assistance. In many instances it would seem as if they preferred the sacrifice of their lives to the relinquishment of their prejudices. 3rd. The absolute imperviousness of the os is another feature which renders this case interesting ; and associated with this is the fact that there wis no extension of the induration induced by the cicatrix. The finger impinged on a depression to which the hardness was limited; the surrounding parts giving the feel of thin membranous tissue on which the foetal head was
pressing.-
"17(11!'
BLACK DISEASE" OF THE GARO HILLS.
i,th. Tbe uterine inertia In the case is a point worthy of notice, The persistence of since it is difficult to assign a cause for it. this inert condition until the morning of the third day after delivery is also remarkable. The inertia was not due to any of the causes to which it is usual to ascribe this deficiency of uterine power: It s'rikes. me thatj though I could see nothing abnormal in the tone of her general nervous and muscular systems, there may possibly have been some defect in .he uterine structures themselves, and which caused the parts surrounding the cicatrix to feel like paper. I have mentioned the fagt of the patient's having had recourse to oi' baths every alternate day from the eleventh day of her It appears to be the This need* some explanation. delivery recognized practice of the particular caste to which this woman belonged to adopt this system of bathing, not from any therapeutical properties it may be supposed to possess, but simply as a religious observance. The patient is first freely anointed with gingely oil, and then bathed in tepid water.
321
