A CASE OF COMPLETE OCCLUSION OF THE OS UTERI
I THINK that the following case is worth recording because of the recent correspondence on this subject and the almost immediate relief after the birth of the child. On March 4th, 1899, I was called to a woman whom I found to be suffering from a well-marked eclamptic seizure. I learned from the friends that she was eight months pregnant with her first child and that her age was 25 years. There was no family history of convulsions and the patient had never had a "fit" before. On the previous day
... On the previous day she had suffered from epigastric and lumbar pain ; there had been no eye symptoms, headache, or vomiting. At 9 P M. she was suddenly seized with a convulsion which was followed by unconsciousness. Between 9 P.M. and 4 A.M. on March 5th she had four " I fits " and was insensible the whole time. On examination I found the temperature to be 103° F. The tongue was nearly bitten through and there were profuse frothy discharge from the mouth, great cyanosis, sweating, cedema of the legs, and a good deal of pulmonary oedema. I immediately administered chloroform and continued for half an hour during which time she had three convulsions and an involuntary discharge of urine and faeces. The pulse was 120, small, very feeble, irregular, and compressible. 10 minims of tincture of veratrum viride were given hypodermically and the pulse-rate dropped to 110 per minute. After consultation with Mr. Pooler, deeming delay dangerous, we decided to empty the uterus as quickly as possible under chloroform. The os was tightly closed. The position was right occipito-anterior. The pelvic diameters, though no pelvimeter was used, were considered to be normal. We decided upon manual dilatation. In 65 minutes we had dilated sufficiently to introduce the hand. Version was performed and delivery was rapidly effected, this method being quicker than extraction by forceps, time being allimportant. The child, a male with one testicle descended, was stillborn and weighed five and a half pounds. There was very little liquor amnii. Th gr. of citrate of ergotinin was now given hypodermically and the placenta was expressed by Crede's method. The uterus was washed out with one in 60 carbolic solution and contraction was well maintained. There was very slight post-partum hoemorrhage, the blood being dark-coloured and slow to coagulate. The condition of the patient was now somewhat improved. The temperature was 103° and the pulse was 100, regular, not so compressible, but still small and weak. The cyanosis was not so marked and there was no recurrence of the convulsions but the insensibility was profound. A quarter of a minim of croton oil in sugar of milk was administered on the tongue. By 9 A.M., or two hours after the birth of the child, the cyanosis had entirely disappeared. The pulse was 96, of better quality, and we considered it safe to leave the patient. At 3 P M. there had been no more convulsions. The pulse was 96 and the temperature was 99°. The patient was still unconscious. There was no post-partum hoemorrhage. At 8 P.M. there was a slight return of consciousness. A voluntary discharge of urine took place, being eight ounces in quantity and dirty white in colour; its specific gravity was 1030 and it contained 3 per cent. of urea, 12 parts per 1000 of dried albumin measured by Esbach's albuminometer, no sugar, but blood-cells, epithelium, epithelial and hyaline casts, and urates. A mixture containing 10 minims of tincture of veratrum viride and five grains of hydrate of chloral was given hourly. During the following 24 hours the patient gradually recovered consciousness but had no memory of events later than eight days before the onset of the convulsions. She had no convulsions. She passed 20 ounces of urine of specific gravity 1030 and containing urea (2 per cent.), urates, and dried albumin (two parts per 1000) ; no casts or cells were seen. A saline aperient was given and continued every four hours. A strictly milk diet was ordered. The progress since has been steady; there have been no more convulsions, the albumin has gradually disappeared, the quantity of urine has gradually increased, and the memory has returned. The patient left her bed on the fourteenth day and the convalescence has been uninterrupted. This is a comparatively frequent complication of pregnancy. Statistics vary from Auvard'sl three in 1000 to those 1 Traité Pratique d'Accouchements. of the Philadelphia Board of Health, one in 170, but the affection is of such a serious nature that every case seems. worthy of record. The percentage of deaths is estimated at between 50 (Pajot) and 30 (Kaltenbach). All observers agree that the primipara is much more liable to this condition,2' and plural births especially predispose to it, the above case being an exception. The extreme rigidity of the os in this case under profound ansestbesia was remarkable, remembering that the tendency of eclampsia is to expel the uterine contents. With a group of symptoms including high temperature, great cyanosis, profuse discharge from the mouth, profound stupor, and pulmonary oedema authorities 3 tell us to expect a fatal termination, and the rapid improvement after emptying the uterus was most gratifying, though Duhrssen 4 says that in 93'75 per cent. the convulsions cease after this has been done. The tincture of veratrum viride introduced by Dr. Baker of Eufaula, Alabama, and revived by Dr.! Squibb 6 is of undoubted use because of its effect on the circulation and it, is well to remember that it takes half an hour to act. ON May 2nd, 1899, I attended a woman, aged 43 years, primipara, who had been in labour about six hours when I arrived. The pains were almost constant, not permitting of any uterine relaxation the whole time during which l remained with her. She complained very much of & tearing pain in the region of the bladder. Upon examination I found the vulva to be a good deal swollen" the vagina hard and dry, and the perineum very thick and rigid. I found the head presenting but entirely covered by the distended cervix. I could nnA no os uteri, but this did not surprise me as I concluded' that it was too high to reach. I was very much struck,. however, by the dryness of all the parts and by the head, being so low without dilatation of the os uteri. In threehours I returned and found the bulging head lower but no os uteri. The pain in the lower part of the anterior abdominal wall was now unbearable. Under chloroform I made a thorough examination and found complete occlusion of the o& uteri with just the smallest of dimples to indicate its position. I relaxed the chloroform and permitted the pains to. begin again and as soon as the cervix became tense over the presenting part I forced my finger with a sharp nail through the cervix and afterwards through the membranes. Thewater escaped and the pain stopped for half an hour. There was a good deal of bleeding. The rupture through the cervis took a somewhat triangular shape. As soon as the pains. began again the artificial os uteri dilated rapidly and 1 delivered with forceps as the patient was much exhausted. She made a good recovery and is now quite well. Brechin.