THEr BRTTTSR 714 APRIL 22, 19331 UTERINE ACTION AND ITS ABNORMALITIES [MEDICAL JOURNAL i natal period, and thus help to annihilate the dread CONGRESS OF OBSTETRICS AND of labour. Professor W. BLAIR-BELL, Dr. M. M. DATNOW, and Dr. T. K. JEFFCOATE presented a paper on the mechanism of uterine action and its disorders. In vivo and The ninth British Congress of Obstetrics and Gynaeco- in vitro experiments on animals were described and graphs of logy was h3ld at the University of Birmingham on April 5th, 6th, and 7th, under the presidency of Professor uterine contractions shown. In woman the anterior pituitary hormone was in excess in the early months, BECKWITH WHITEHOUSE. The foreign visitors were Pro- fessor Oskar Fraenkl of Vienna, Professor Van Rooy of but diminished as pregnancy continued, and by the fourth month the influence of the corpus luteum was on Amsterdam, and Professor Birger Lundqvist of Gothen- the burg. wane. The function of the corpus luteum varied quanti- tatively and qualitatively in different animals. Neither UTERINE ACTION AND ITS ABNORMALITIES oestrin nor " antuitrin S " had any effect on the isolated At the morning session on April 5th, with Professor uterus ; oestrin sensitized the uterus to respond to infun- Whitehouse in the chair, Mr. ALECK BOURNE read the open- dibulin, and it assisted in bringing about hypertrophy ing paper, " The Uterine Action and its Abnormalities." and increased vascularity of the uterine musculature He said that feeble contractions were the cause of many during pregnancy. The hormone of the corpus luteum of the disasters of labour. For the child the long labour inhibited uterine activity ; but after the first two months was a considerable risk. He had searched the clinical it was not essential for the maintenance of pregnancy in histories of over 4,500 consecutive deliveries at Queen the human subject. The view was put forward that the Charlotte's Hospital, and had classified as " long hormones of the anterior lobe of the pituitary assisted, labours " all cases in which the first stage had lasted and might even replace, the corpus luteum in causing for more than forty-eight hours. There were forty-nine inhibition. Primary uterine inertia was due to lack of cL ses of genuine primary uterine inertia ; thirty-six sensitization of the uterus by oestrin, and to insufficiency occurred at full term, and it would appear that inertia of the pressor substances in the maternal blood. The onset was not influenced by maturity. The condition was five of labour and the occurrence of many cases of abortion times more common in primigravidae. Malpresentation were associated with an excess of oestrin in the circula- was not a predisposing factor. In this series there was tion. Uterine inertia was not due to muscle fatigue. In an unduly high number of cases of albuminuria. The abortion oestrin was found in large quantities in the membranes ruptured prematurely in thirty out of the urine, with a disappearance of prolan B. Abortion in its forty-nine cases. Manual removal of the placenta was early stages had been averted by the injection of corpus performed eight times. In less than half the cases luteum and " antuitrin S." Premature labour was delivery was spontaneous. There was no relation between usually due to powerful emotions through sympathetic the weight of the child and the occurrence of inertia. stimulation, as well as to foetal influences. An increased Sedatives had been employed in over half the cases, and amiount of pressor substances was present in the blood in a combination of pituitrin and sedatives in eleven. In tonic contraction, and magnesium sulphate had an only two cases had manual dilatation of the been immediate effect. performed. The maternal mortality was 10 per cent., Dr. J. M. RoBSON dealt with some of the recent and morbidity 40 per cent., three of the maternal deaths hormonic advances underlying uterine activity. He had being due to sepsis. He demonstrated a graph which experimented with strips of human uterus removed at the recorded the intrauterine pressure at the thirty-sixth week time of a . When these were exposed of pregnancy. After an injection of two units of pitocin to the action of oxytocin there was no effect in the early contractions resembling first-stage labour pains were months of pregnancy; but, on the other hand, vaso- registered ; they were not felt by the patient, nor did pressin caused contractions. Strips removed late in preg- the cervix dilate. Normal labour depended on fundal nancy required only a very small amount of oxytocin contraction and cervical -dilatation. -The speaker said to induce a contraction, and those removed durinog labour that FitzGibbon had emphasized the importance of the required a still smaller dose.- Response to either oxytocin engaging head and its pressure upon the cervix as the or vasopressin was absent in menstruation. In pregnant cause of the onset of labour. He was convinced that rahbits a strip of uterine muscle removed during the external stimuli influenced uterine action by way of the puerperium required one hundred times as much nervous system. Non-engagement of the head was often oxytocin to produce the same amount of contraction associated with inertia. He had attempted to induce as that occurring during pregnancy. After injection of labour by injection of tri-hydroxy oestrin in castor oil, oestrin the uterus showed a marked reactivity to the but without success ; the injection did not affect the milk action of oxytocin; corpus luteum had a reverse effect. secretion. He was uncertain of the part played by Mr. WENTWORTH TAYLOR, in a paper on the anomalies oestrin in labour. In an estimation of the oestrin content of uterine action, said that dilatation of the cervix was of the urine in two cases of uterine inertia, the amount not solely a mechanical process, and he described the lower of this hormone had not been found to be definitely uterine segment as the middle segment of the " birth diminished. Pituitary extract did not induce premature sleeve." The walls of the uterus before labour were of labour. By means of hysterograms he demonstrated equal thickness throughout. Incoordinate contraction that adrenaline inhibited fundal contraction during labour might be due to several causes: psychic, hormonic, in the human being. Microscopical slides were shown of mechanical, ante-partum infection of the liquor amnii, portions of the cervix removed at the time of delivery and the administration of oxytocic drugs. Sympathy of from two cases of rigid cervix, which terminated in action between the various parts of the uterus determined circumferential tears. An excess of fibrous tissue was normal labour. A well-fitting dilator caused sympathetic seen. Fear, Mr. Bourne said, played a very great part action between the body of the uterus and the cervix. in causing weak contractions: a contented and care-free Spasm of the uterus was due to obstetrical intervention woman had a spontaneous labour. In the more civilized for this condition he advocated early trial of sedatives. grades of society emotion and anxiety were most impor- in the presence of foetal distress, tenseness of the uterus, tant factors in modifying the course of normal labour. and little or no cervical dilatation Caesarean section was It was essential for the medical attendant to obtain the the method of treatment. In the dystrophic individual confidence of the mother, particularly during the ante- who could not be cured by a course of hormonic extracts, APRIL 22, AND GYNAECOLOGY THE BRITISH 1933] CONGRESS OF OBSTETRI'CS IMEDICAL JOURNAL 715 in occipito-posterior positions, and with a large child in and abnormal phenomena ; the latter were absent in whom flexibility was below normal, anomalies in uterine animals. The importance of the emotional factor in the action were to be expected. human being must never be overlooked. In reply to Mr. Bourne, he said that oestrin in a purely crystalline form increased the reactivity of the uterus to pituitrin AFTERNOON SESSION and was a sensitizing agent. He thought that further At the afternoon session, with Dr. J. P. Hedley in the investigation into the source of the lutein cells was neces- chair, Mrs. BERTRAM LLOYD and Mr. P. J. GANNER sary. If the corpus luteum developed from follicular cells, a case rupture of the uterus in a described of fundal why had it such a different secretion? He was certain premature labour at the thirty- 2-para aged 26, during that polarity of the uterus was a definite entity, and he sixth week. The first labour was normal. Professor thought that during involution of the uterus polarity on a somewhat similar FRAENKL (Vienna) remarked might be replaced by a peristaltic action. He realized case. that calcium was an important prophylactic agent in Mr. W. GILLIATT, in a paper on contraction ring of the uterine inertia. It was essential for uterine tone. uterus in labour, described fourteen cases he had seen. Premature rupture of the membranes and intervention predisposed to it, but uterine inertia was not a definite MISCELLANEOUS PAPERS contributing factor. Sedative treatment was disappoint- On April 6th, when Dr. James Young presided at the ing, but amyl nitrite in a dose of three minims relieved morning session, Professor OSKAR FRAENKL (Vienna) the contraction in one case. He advised Caesarean section described the isthmus uteri. He concluded that the when the cervix was undilated and when there was little isthmus was a well-characterized part of the uterus which risk of sepsis. The maternal death rate was 14.2 per cent. " grossly " belonged to the cervix, but with regard to its and the foetal 20 per cent. Mr. L. C. RIVETT thought mucous membrane it resembled the body, and might be that differences in the thickness of the uterine wall was recognized and limited nearly always by naked eye, and the cause of irregular uterine action, and the endocrine always microscopically. Premenstrual changes were slight system had a very definite role in influencing uterine or even absent. Correspondingly, in pregnancy there was action. In one case of rigidity of the os he had made no true decidua. He discussed the various pathological small multiple incisions in the cervix, and was thus able conditions which might be associated with this region. to extract the child in half an hour. In another case, Adenomyomata rarely transgressed the anatomical internal in which the os was " half a crown " dilated, he incised os. The isthmus mucosa seemed to have an immunity the cervix, applied forceps, and attached a weight to against cancer of the body of the uterus. them ; delivery took place twenty-three hours later. Dr. Mr. VICTOR BONNEY described a method of performing 1J. READE emphasized the importance of the mental aspect the lower uterine segment Caesarean section by means of of the patient and the function of the sympathetic a cervical compressor. He extracted the foetal head by nervous system in labour. Most women suffered from the application of Willett's forceps. an anxiety state before labour began. By a mathematical Professor GILBERT STRACHAN presented a paper on the explanation he was able to demonstrate the effect of main pathological conditions of the cervix. After the relaxation of the circular muscle of the external os. The menopaus*e the cervix atrophied, due to reduction of circu- sympathetic acted on this muscle, and its action could lation. Trauma could not be prevented at normal labour. be inhibited when there was complete mental and physical Absence of healing in a cervical wound was due to con- relaxation on the part of the patient. Labour was facili- stant reinfection. Cervical carcinoma was rarely asso- tated when the influence of the sympathetic system was ciated with procidentia. excluded. Professor MILES PHILLIPS agreed with Mr. MIr. L. C. RIVETT gave an account of ten cases of Bourne about the part played by fear. Disillusionment hydramnios in which he had performed paracentesis. He during the ante-natal period was necessary. In cases had endeavoured to ascertain whether the liquor amnii in which the uterus was flabby during the ante-partum was absorbed into the mother's system, but he had failed. period he had found that calcium increased uterine tone. He advised this method of paracentesis as there was little He regretted the confusion which existed in textbooks on danger in it. Professor MUNRO KERR said that he had this subject. He differentiated between the sluggish and injected uroselectan into the amniotic sac and had then the colicky uterus. In the latter the pain was of an taken x-ray photographs. By this means placenta praevia excruciating nature. could be diagnosed. Unfortunately, this method was asso- Mr. CHASSAR MOIR demonstrated graphs of uterine con- ciated with the risk of premature labour. tractions on the seventh day of the puerperium. He had With Professor Leyland Robinson presiding at the inserted a small bag into the body of the uterus and afternoon session, Professor VAN RooY (Amsterdam) read another in the cervix. The contraction of the cervix a paper on the obstetrical significance of transverse con- occurred fifteen to seventeen seconds after that of the traction of the pelvis. He had investigated cases in which uterus. It would appear that a wave of peristalsis passed the head had been well flexed but floating, dilatation had over the uterus. In another case he found that the cervix been normal, but intervention of some sort had been contracted quite independently of the body of the uterus. necessary in order to complete delivery. He found con- Mr. A. C. BELL thought it was dangerous to conclude that traction of the transverse diameter of the brim in this a woman would react in the same way as an animal. type of case. This contraction should be suspected if the He said that adrenaline inhibited the uterus in labour, ilio-pectineal ridges were prominent and the external and that the oxytocic principle did augment uterine con- measurements were diminished. Only by x-ray pelvimetry traction. A mechanical factor played a definite part in could the superior strait be measured satisfactorily. He causing anomalous uterine action,. Mr. BOURNE asked gave details of forty-three cases. In these labour had whether oestrin, purely crystalline, did increase the reac- lasted for forty hours with good uterine contractions; there tivity of the uterus to pituitrin. He had used adrenaline in had been delay in engagement of the head, instruments two cases of tonic contraction: in one it had had no were applied, the true conjugate was greater than 11 cm., effect. He was of the opinion that tonic contraction was and the weight of the foetus had been less than 3,500 a myogenic spasm, whereas rhythmic contraction depended grams. Pelvimetry had shown in 44 per cent. of these or, a neuro-muscular mechanism. Professor BLAIR-BELL cases a diminution of the- transverse diameter of 1 cm.: said that there were enormous differences between normal the sacral wings were denser. He was uncertain whether 716 APRIL 22, 1933] CONGRESS OF OBSTETRICS AND GYNAECOLOGY r THE BRITISH the condition was due to abnormal congenital ossification or to osteo-arthritis of the sacro-iliac joints. It was only by x-ray examination that the condition could be France diagnosed. He referred to the importance of collaboration [FROM OUR CORRESPONDENT IN PARIS] between the radiological and ante-natal departments. Professor MUNRO KERR said that alteration of the flexion Conjugal Tuberculosis of the head by transverse diameter contraction might The subject of conjugal tuberculosis was discussed on necessitate Caesarean section. Professor MILES PHILLIPS, March 5th at a meeting in Paris of the Assemblee Mrs. R. H. B. ADAMSON, Professors DOUGAL, FLETCHER Frangaise de Miedecine Generale, a body which, though SHAW, and LEYLAND ROBINSON contributed to the dis- only a year old, promises to become a powerful institu- cussion. tion, rallying the general practitioners throughout France In Dr. E. L. Fahmy's absence, Professor R. W. into a scientific organization for the advancement of JOHNSTON read a paper on an analysis of 1,000 cases of medicine. The subjects chosen for research and dis- post-menopausal haemorrhage. Carcinoma of the cervix cussion a year or so in advance of a general meeting are accounted for one-quarter of the total; ovarian dysfunc- first thrashed out by local branches, whose members pool tion was the next most frequent cause. High blood their experiences, gained, in many instances, in country pressure rarely caused bleeding from the uterus, and practices which have been! handed down from father to malignancy should be suspected if haemorrhage had been son for several generations. It might be thought that constant over many weeks. conjugal tuberculosis was a subject par excellence On1 Professor LEONARD PARSONS and Dr. R. J. GITTINS read which a gathering of general practitioners could throw papers on the anaemia of pregnancy and its effect upon the much useful light. But is it? Your correspondent has foetus. They had administered vitamin B (in the form of unearthed a reprint of a paper by William Bulloch and sterilized wheat-germ " yestamin "), iron, and a com- Major Greenwood read before the Royal Society of bination of these, before and after parturition. By Medicine in May, 1911. An extract reads: excessive restriction of diet during the ante-natal period " It may be pointed out, however, that in the period there was a real danger of causing an anaemia. Particu- immediately following Koch's discovery, great activity was larly was this likely to happen in toxaemia of pregnancy, manifested in civilized countries to settle the question of the which was always treated by vigorous dietetic measures. contagiosity of phthisis. Collective investigations, so called, were instituted in America, Germany, France, Italy, and CONCLUDING SESSION England. The results of the opinions of some 50,000 doctors With Professor James Hendry presiding at the final who participated in this gigantic undertaking have been session on April 7th, Mr. R. G. MALIPHANT read a paper described by Cornet as ' mehr als bescheiden.' " on the histological classification of cancers of the uterine It is perhaps idle to ask now if those who were respon- cervix, and the relation between cellular structure and sible for the choice of conjugal tuberculosis for study prognosis after radium treatment. He had examined and discussion would have selected it had the " mehr als 236 cases of cancer of the uterine cervix treated with -bescheiden " harvest of earlier efforts at collective mass radium. He adopted Martzloff's method of histological research been prominent in their minds. Be this as it classification, which was based on the microscopical ap- may, the discussion at the Hotel-Dieu on March 5th pearance of the individual cell. Ten of the 236 growths was quite brisk and, now and again, illuminating. It (4.2 per cent.) were adenocarcinomata, and of the remain- was reported that in one area conjugal tuberculosis ing 226 solid cancers 30.9 per cent. belonged to the highly affected barely 10 per cent. of those exposed to it ; in differentiated spinal-cell group and 13.3 per cent. to another this ratio was reduced to 2 per cent. In one the spindle-cell group, while there was a large inter- locality it had been noticed that there were many more mediate group, comprising 55.8 per cent. of the cases, in widows than widowers surviving tuberculous partners in which the tumour was mainly composed of transitional matrimony, while in another women were found to cells. The three-year survival rate had been studied in suffer more than men. The meeting, which was attended a group of 151 cases treated more than three years ago. by between 100 and 200 doctors, unanimously adopted The differences in the three-year survival rates in the a resolution which, while not dismissing conjugal tubercu- various structural groups were examined, but the differ- losis as a figment of the imagination, emphasized the ences shown were too small to be of much significance. much greater danger of infection in childhood. The spindle-cell cancers, though apparently the most malignant type, gave at least as good results with radium as those given by the more benign spinal- Cobra Venom as an Analgesic in Cancer cell growths. They were the most radio-sensitive. The Early in 1929 Dr. Monaelesser of New York had his conclusion reached was that microscopical examination attention drawn to the case of a Cuban leper whose pain, was of no assistance in arriving at the ultimate prognosis. due to neuritis, was greatly relieved after he had been Dr. E. BULMER made a small communication on osteo- bitten by a tarantula. This was the starting-point of malacia. Dr. DUGALD BAIRD described a method of study- investigations which brought Dr. Monaelesser to the ing the tone of the human during pregnancy. The Pasteur Institute in October, 1929. Here he secured the patients were also examined by intravenous pyelegraphy co-operation of Professor Calmette, whose earliest work and dye methods. In this way stasis could be determined. on cobra venom dates back many years. In October, In albuminuria of pregnancy there was good ureteric tone. 1930, Dr. Monaelesser and a Parisian colleague, Dr. He had never seen a case of albuminuria of pregnancy Taguet, approached Professor Gosset of the Salpetriere and pyelitis coexisting in the same patient. Mr. A. A. with the request that he would co-operate with them in DAVIS described the innervation of the uterus, his paper studying the influence of cobra venom on certain cases being illustrated by lantern slides of dissections. of cancer under his care. On March 14th, 1933, Pro- At the conclusion of this session Mr. T. G. STEVENS fessor Gosset presented to the French Academy of Medi- recorded a vote of thanks to the University of Birming- cine a report by Dr. Monaelesser and Dr. Taguet on 115 ham. Professor DOUGAL thanked the Midland Obstetrical cases, including fifteen of cancer of the stomach and Society, and the chairman, Professor HENDRY, congratu- twenty-five of cancer of the breast. They were con- lated Professor Beckwith Whitehouse on the success of secutive and not selected in any sense. There were the meeting. sevrere cases which had been operated on, with or without