Rigidity of the Os Uteri.

Selected writings of John King.

This article is selected from Dr. King's work on Obstetrics and represents at that date advanced views upon the treatment of rigidity of the os uteri. Of the use of lobelia Dr. King was thoroughly familiar by reason of long experience with it. Gelsemium was just coming into prominence among Eclectic practitioners, for the treatment of this same form of difficult labor. Dr. King had used it sufficiently to test its worth, but for neither of these agents, perhaps the two best drugs for rigid os, were the exact conditions in which one was superior to the other then recognized. Now the specific medicationist knows that lobelia is specifically indicated by the thick, doughy, and unyielding os, and gelsemium when the os is thin and tense, with the parchment-like edge and the patient's condition is one of great excitation and painful apprehension. Both agents are safer than chloroform.—Ed. Gleaner.

RIGIDITY OF THE OS UTERI, during the first stage of labor, is a frequent cause of its protractedness. This may occur in any case, but is more frequently met with in primiparae, in females of an advanced age, and in instances where the membranes are prematurely ruptured. It may be occasioned by repeated and unnecessary examinations, the use of stimulants, mental excitement, constipation, or retained urine. It may also be owing to dysmenorrhea, or a diseased condition of the os itself, either natural, or effected by the improper use of pessaries or other mechanical aids to support the uterus, as well as the imprudent application of escharotics to the os, for the removal of some real or imaginary affection.

Rigidity of the os uteri may be suspected in cases where the head presents and the pains are regular and normal, but dilatation proceeds very slowly, if at all; the pains gradually lose their force, and the patient becomes exhausted; in addition to which. Madam La Chapelle refers to another symptom, viz.: pains in the loins. On examination, the os uteri will be found thin, resisting, hot, dry, and painful to the touch, or soft, oedematous, semi-pulpy, and un-dilatable, and which must be carefully distinguished from the soft and flabby condition into which the thin and rigid cervix must pass before it will dilate. Sometimes the rigidity is excessive, the os being unusually dense, feeling like cartilage, with a stubbornly unyielding edge; or if this be thin, the same resistance will be met with, and a sensation is conveyed to the touch, similar to that produced by a hole made in thin, extended parchment.

Very frequently the rigidity will not be confined to the os uteri, but will extend into the vagina and soft parts; they will be found hot, dry, swollen, and extremely sensitive to the touch, and if this condition be not overcome, the patient becomes restless and feverish, the pulse rises to 100 or 110, and finally exhaustion of the vital forces manifests itself. Occasionally the os uteri will be found to contract during a pain, remaining rigid in the interval; and in such instances a rupture of the uterus may occur. Instances are recorded in which the rigidity was so obstinate that the os uteri has been torn off and expelled in the form of a ring.

TREATMENT.—Among many writers, venesection, ad deliquum animi, is considered the most successful and potent remedy in this difficulty, and is the one on which the utmost reliance is placed by the major part of the profession. I admit that bleeding will overcome rigidity of the os uteri, as a general rule, but then I by no means admit it to be a proper or safe remedy. A female in labor requires all the strength natural to her system, not only to sustain her during its progress, but also to enable her to withstand and quickly recover from the nervous shock. By the loss of an amount of blood sufficient to cause syncope, a debility of the nervous and circulatory systems must ensue, producing a condition unfavorable to either of these requirements; and I have frequently witnessed a tedious second stage, with subsequent hemorrhage or other evils, following a bleeding practiced in the first stage, and which I had every reason to believe were augmented, if not actually produced, by the venesection. Debility of the system, and more especially when sudden, persistent, and at the period of parturition, is incompatible with a safe or energetic labor. Besides the weakening influence of venesection upon the constitution, we have an increased prostration of nervous and muscular force, produced by the shock imparted to the brain and nervous system, as well as by the loss of blood which necessarily follows the birth of every child. Indeed, it is impossible for any practitioner to determine what amount of blood may be lost from the labor itself, independent of any artificial discharge; and who can tell how many precious lives have been lost from uterine hemorrhage, or other fatal symptoms, in the practice of believers in this treatment, which might have been preserved had the lancet been cast aside? Indeed, so well are the adherents of this practice satisfied of its danger to the parturient woman that they especially caution us not to resort to it until the parts become swollen and tender, the pulse increased, with febrile symptoms, or a tendency to cerebral congestion; and even then we are advised to use it with care. The injurious tendencies of bleeding do not cease with the completion of delivery, for whether it be artificially effected by the lancet or naturally by uterine hemorrhage, not only is the puerperal month one of slow, tedious convalescence, if this term can justly be applied to it, but very frequently a lifetime of irremediable suffering and disease is the inevitable consequence.

In the treatment of this difficulty, we have no occasion to wait for the appearance of the above symptoms before attempting relief, because we have means to subdue it without the infliction of any immediate or permanent injury to the system, and as soon as the evil manifests itself, we at once apply the remedy, saving the patient a great amount of suffering, and the friends and ourselves much anxiety and alarm. And hence we believe our practice has a vast advantage over that which dare not attempt certain relief until after a lengthened period of pain and distress, and when exhaustion of the vital forces is about to commence. Promptness in combating this system, as well as many others, is the only method by which to insure certainty of success.

In cases of rigidity, during the early part of labor, it will be necessary to evacuate the contents of the rectum as well as of the bladder; if, after having waited for ten or fifteen minutes subsequently, the rigidity still remains, it may readily be overcome by one of the following means: The compound tincture of Lobelia and Capsicum may be given in a dose of one, two, or four fluidrachms, according to the urgency of the case, and repeated in ten or fifteen minutes should it be required, and in the generality of cases this will effect a speedy and safe relaxation. I have sometimes met with cases in which it became necessary to administer, in conjunction with the above, an injection of the same tincture, employing it in the quantity of half a fluidrachm, or a fluidrachm diluted with a similar amount of water, and requesting the patient to retain it as long as possible. Indeed, in many instances this enema will be found sufficient to overcome the rigidity, without the administration of any medicine by mouth; and in a few instances, where rigidity had existed for a long time, and was rather intractable, I have subdued it by aiding the above conjoined means with fomentations of Stramonium leaves applied over the abdomen and genital parts. In the first stage of labor this fomentation may be employed with safety. Lobelia, or some of its compounds, has been used by various practitioners in a manner similar to the above, and with almost universal success. The emetic influence of this agent, in whatever combination it may be given, is not necessary to produce the required result, nor indeed is it always desirable that emesis should follow; much more salutary and immediate results will ensue from nauseating and relaxing doses—and when vomiting has once occurred from its use, without relaxation, it will frequently be found that smaller doses will not be retained sufficiently long upon the stomach to exert any relaxing influence. Lobelia has been combined with some preparation of Opium and administered by mouth and in enema with success by several physicians, but I have never employed it in this form, although I have no doubt of its efficacy.

The tincture of Gelseminum has within the last few years been recommended to overcome this difficulty, and I have administered it in a considerable number of cases with benefit. It possesses an advantage over Lobelia in not causing nausea or vomiting; but, as a general rule, its influence is not so readily experienced as with that drug, and when once effected it is of a more permanent character. Some cases will be met. with, however, whose susceptibility to its action is so great that half a fluidrachm will produce powerful relaxation, while others again may take several fluidrachms with but little effect; these latter instances are found only occasionally, but sufficiently often for the practitioner to keep the fact constantly before him. The dose of the tincture is from half a fluidrachm to a fluidrachm, which may be repeated every fifteen or thirty minutes, according to the peculiar nature and urgency of the case. An overdose will not produce any evil effects, further than an increase of relaxation and its greater persistency, unless the remedy be improperly continued after a full manifestation of its influence; the antidotes to its overaction are stimulants internally, aqua ammonia to the nostrils, and, if required, electro-magnetism.

In those cases where inflammation of the os uteri is caused by unequal pressure of the child's head upon it, the Gelseminum will be found a valuable remedy.

The induction of copious perspiration by the spirit vapor-baths or otherwise has been advised, and will, probably, be found effectual in some cases. But on account of the trouble attending its application during parturition, and the danger of chill subsequently, it is better to employ it only when imperatively required.

Inhalation of Chloroform, the direct application of extract of Belladonna to the os uteri, artificial dilatation, etc., have all been recommended by various writers, but I have never used them; the above means having proved successful in my own practice, as well as in that of others presented to my notice. I have, however, known Chloroform to be a very efficacious remedy in the hands of other practitioners.

Rigidity depending on disease of the os uteri, may be removed by the above plan, but it can not always be expected to answer. Incising the cervix has been advised as a successful measure in those cases which prove very obstinate and protracted; but I have never had occasion to attempt the operation, probably from never having had a case of this nature.

When the various means recommended to subdue the rigidity fail to accomplish this result, and artificial delivery becomes necessary, it is recommended to complete the labor with the forceps, provided the os is fully dilated, and the fetal head has descended so low into the pelvic cavity that an ear can be felt. But if the os is not fully dilated, and the greater part of the fetal head remains above the superior strait, and circumstances present, demanding prompt delivery in order to save the mother's life, the perforator and crotchet must be employed, for in such instances the attempt to deliver by forceps would be rash and unjustifiable; however, it will seldom happen, unless in cases of diseased os, that the treatment above named will fail in overcoming the rigidity.

The tendency to this cause of difficult labor, as well as of inefficient uterine contractions, may generally be obviated by a proper course of management through the gestating period, or at least during its latter months, in all cases where the physician is aware of his selection as the accoucheur. For a few months previous to the expected labor he should explain and impress upon his patient's mind the necessity and advantages to be derived from a proper preparatory course, especially if any circumstances exist which might lead him to anticipate a difficult parturition. The course to be pursued at this time, and which has proved generally successful, is to keep the bowels in a normal condition by diet, if possible, otherwise by mild laxatives, as Rheum and Bicarbonate of Potassa; avoid fatigue, overstimulus, and improper food, and administer once or twice daily a dose of the compound syrup of Partridgeberry, which exerts a healthy tonic influence over the uterus, disposing it to act with proper energy at the time of labor.—JOHN KING, American Eclectic Obstetrics.

The Biographies of King, Howe, and Scudder, 1912, was written by Harvey Wickes Felter, M. D.