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MATERNAL INJURIES OF CHILDBIRTH
946 admit
no
A clear
illness,
we
by certain
reasonable doubt as to the nature of their nevertheless confess our complete ignorance as to its cause. Another reason is that minor injuries are so common to all of us and so frequently repeated that most patients can usually remember some such injury which the later development of symptoms makes significant. The general tendency is to discount the effects of any injury as being unlikely to make any contribution to the onset or to the progress of these and similar diseases, and to regard the injury itself as being probably due to some otherwise unnoticed clumsiness or weakness-symptoms of the disease already present. I want therefore to draw your attention to a few cases in which a recent injury would appear either to have precipitated or to have increased the severity of one of these generalised diseases, and also to point out the lines along which an explanation of these effects can possibly be found. These cases differ in no essential way from those which have been already described by Dr. Wilfred Harris in his Savill oration for 1933. (The essential details of six such cases, two of disseminated sclerosis, one of progressive muscular atrophy, one of paralysis agitans, and two of hepato-lenticular degeneration were then given. In each of them the clinical was unusual, in respect either of abnormal picture rapidity of development or of abnormally severe disability in that limb which had previously been injured.) If we are not satisfied with the view that in not all of such cases is the relation between the injury and the unusual features of the subsequent disease a chance coincidence, we are naturally led to look for other similar observations which may throw some light upon the way in which injuries to other parts of the body may be expected to influence the resistance of the central nervous system to the causative agencies of these diseases. In respect of the peripheral nerves it can be demonstrated without doubt that peripheral neurons in which conduction is already slightly impaired, as a result of lead and alcohol poisoning, are less resistant to mechanical injury, in that continued pressure over a nerve trunk containing such neurons leads to paralysis and to sensory loss in their area of distribution much earlier than it does in otherwise healthy persons. We have a priori no reason for assuming that this would be so, since we have none for assuming that the effects of mechanical pressure and of such forms of poisoning would necessarily summate in impairing conduction through the peripheral nervefibre. That they do summate in this way can easily be demonstrated. If damage or destruction of the tissues of a limb is going to produce any change in the cells of the central nervous system, it is in that part of the spinal cord to and from which the nerves of the limb run that we can most reasonably expect to find such changes. They might conceivably result from transmission to the spinal cord of some products of inflammation or of tissue breakdown. Alternatively, since destruction of peripheral neurons is known to give rise to histologically demonstrable changes in their cells of originin this case the spinal root ganglia or the anterior horn cells of the cord-it is possible that the changes underlying these histological appearances may entail a lowering of the resistance of these cells to other pathological influences that are already at work. Whatever may be the mechanism by means of which such a change takes place, we must ask whether there is any evidence that damage of one limb can and does lower the resistance of immediately related segments of the spinal cord to attack by other disease processes.
to this question is, I believe, given of acute anterior poliomyelitis. fracture at the lower end of the radius
answer
cases
In the first, of the right arm
followed two weeks later by of all the muscles in the forearm complete paralysis and slight weakness only of the triceps and deltoid muscles on both sides. Later all symptoms disappeared except for complete and permanent paralysis of the muscles of the forearm. In the second case, severe bruising of the left thigh with pain but no weakness, caused by falling astride a fence, was followed within 48 hours by complete paralysis of the left leg with the exception of some feeble flexor movements of the toes, slight weakness of the right extensors of the knee, and very slight weakness of both triceps muscles in the arm. Two months later all paralysis had cleared up with the exception of that in the left leg, which was still com. pletely paralysed except for slight flexion of the toes. In the third case excessive fatigue of one particular muscle in the arm, the radial extensor of the wrist, which is rarely paralysed in infantile paralysis, was followed within 36 hours by paralysis of this muscle, paralysis of the right deltoid, weakness of the right triceps, and weakness of the right gastrocnemius muscle. Later the gastrocnemius recovered completely, the triceps recovered almost completely, the deltoid remained considerably weakened, but the only muscle which remained completely paralysed and which finally wasted completely was that which had been fatigued to excess in the above way. These three and two other similar but less striking cases have come under my observation in the past two years. The existence of four similar cases was referred to by Abercrombie. They appear to me to prove conclusively that accidental injury of one limb can impair the resistance of immediately connected segments of the spinal cord to attack by the virus of infantile paralysis. That it should impair also their resistance to the pathological changes of progressive muscular atrophy does not necessarily follow, and that the resistance of parts of the central nervous system less directly related to the site of damage can be altered as a result of such accidental injuries is suggested still less. However, I believe that we can no longer with reason maintain that there is no evidence that injuries to a limb can influence in any way the development of diseases confined to the central nervous system, and must allow that when an injury does precede the development of one or another of these conditions, its possible contribution to the course of the disease cannot be summarily denied. was
MATERNAL INJURIES OF CHILDBIRTH
(MR. LESLIE WILLIAMS) MATERNAL injuries during pregnancy and childbirth may be classified as mild or serious. The mild include injuries to the abdominal and other muscles, injuries to the supports of the breasts, and dental caries. So far as the abdominal muscles are concerned, I believe that binders do no good, though they serve a useful purpose in preventing the uterus filling with blood and rising during the first 24 hours after delivery. Instead, the tone of these muscles should be restored by exercises such as sitting up and down at frequent intervals from the very first day. Massage to the limbs may be started on the sixth day, and to the abdomen on the eighth. I feel satisfied that movements and massage do not increase the liability to pulmonary embolus.
947 The breasts should never be pressed downwardsis often done by the nurse-with a binder round the chest. Rather should they be supported by a brassiere during pregnancy and by a similar one of the next larger size as soon as lactation commences. Dental caries may to some extent be limited by taking throughout pregnancy and lactation some preparation of calcium ; but, should it appear, immediate treatment should be undertaken. Apart from wholesale extraction there is no fear of dental treatment causing miscarriage. Among the serious injuries I include the various lacerations. It should be remembered that severe vaginal lacerations may occur while the perineum remains unruptured, and hence are in danger of remaining unrecognised. Their repair must not be performed in any careless manner ; it is useless for example to attempt to repair a complete tear into the rectum unless the circumstances are favourable. For the operation requires a good light, the lithotomy position, an assistant, and an anaesthetist. Lacerations of the cervix, though they sometimes occur in spontaneous natural labour, are, I believe, usually due to the premature application of forceps. It is amazing to note how often full dilatation of the cervix is diagnosed when really this state of affairs is but only half reached. Over and over again cases are sent in to maternity hospitals as " obstructed labour," " failed forceps," &c., and on investigation it is found that the cervix is perhaps one-half or one-third dilated. In such cases treatment by sedatives results in the fullness of time in spontaneous delivery. Such a failure to realise the absence of full dilatation of the cervix is due to the examination being conducted too rapidly and in too cursory a In the intervals between pains the soft manner. cervix may often be pushed aside by the examining finger and so give the impression of complete dilatation. If, however, a pain is awaited, the margin of the os will become tense and the real state of the opening can be appreciated. If this were regularly done there would be many fewer cases of forceps application through or outside the undilated cervix, and many fewer cases of cervical laceration. When the forceps are applied inside an incompletely dilated cervix, and when traction is applied, the cervix, the upper part of the vaginal wall, and the subjacent bladder are dragged down, and it is probable that some dislocation of the structures surrounding the internal urethral orifice takes place. I believe that it is in this way that that most distressing symptom " stress incontinence is brought about. It is also presumably caused after proper application of forceps if the operator neglects to make sure that the bladder is not being pulled down. At the time such maternal injuries are apt to be overlooked, but the patient’s discomfort subsequently is a very serious matter. I have tried various operations to relieve these symptoms, for it must be realised that anterior colporrhaphy does not succeed in more than about half the cases. In some cases passing a catheter, exposing the urethra through the anterior vaginal wall, and tying an unabsorbable suture outside the urethra in the region of sphincter may succeed. Perhaps the injury with the most distressing results for the mother is vesico-vaginal fistula.. This is sometimes due to prolonged pressure on the bladder base, nipped between a large foetal head and the back of the symphysis. But undoubtedly it sometimes results from forceps application without catheterisation of the patient immediately beforehand. I always teach students that when they go into practice and buy a pair of obstetric forceps, they should at the as
"
time buy a catheter and tie it to the forceps. In this way this most essential precaution of catheterisation is not apt to be omitted. Finally retroversion may be mentioned, though it must be stressed that only a small proportion of retroversions need such drastic treatment as ventrosuspension. The woman who had a congenital retroversion prior to her pregnancy is almost certain to develop retroversion again in the puerperium, but not only such patients, but all puerperal women, must be examined on the tenth day and the retroversion, if found, corrected. A pessary should then be fitted and this can be done at as early a date as this without any danger. All puerperal cases should again be examined six weeks after labour. It is often found then that the uterus previously anteverted has become retroverted. Its position can still be easily corrected and the organ remains soft enough to permit itself to be moulded into a good shape, as well as manipulated into a good position. A pessary is again fitted ; and in this case, as in the one previously mentioned, it is changed three months later, and removed six months later. same
THE SERVICES ROYAL NAVAL MEDICAL SERVICE Lt. J. W. L. Crosfill promoted to rank of Surg. Surg. Lt.-Comdr. Surg. Lts. (D.) R. W. Stevens to Ganges and F. A. Pearse to
Victory for R.N.B. ROYAL NAVAL VOLUNTEER RESERVE
Surg. Lts. R. M. Buchanan and A. R. Thomas to Surg. Lt.-Comdrs. Proby. Surg. Lt. W. F. Jones to be Surg. Lt.
promoted
ARMY MEDICAL SERVICES Col. J. D. Richmond, D.S.O., O.B.E., late R.A.M.C., having attained the age for retirement, is placed on ret. pay. The undermentioned Lt.-Col. to be Col.:H. L. Howell, O.B.E., M.C., from R.A.M.C. ROYAL ARMY MEDICAL CORPS R. G. Shaw, M.C., to be Lt.-Col. Short Serv. Oommn.-F. J. O’Dowd to be Lt.
Maj.
ARMY DENTAL CORPS
Lt.
(on prob.)
R. H. Green is confirmed in his rank. TERRITORIAL ARMY
A. M. Cooke to be Maj. Lts. T. F. Briggs and J. G. Lawson to be
Capt.
TERRITORIAL ARMY RESERVE
Capts.
OF OFFICERS
Maj. F. Hauxwell having attained the age limit, retires and retains his rank, with permission to wear the prescribed uniform. ROYAL AIR FORCE Lt. A. Flight Harvey is promoted to the rank of Squadron Leader. Group Capt. A. E. Panter to R.A.F. General Hospital, Hinaidi, Iraq, for duty as commanding officer. Squadron Leader A. Briscoe to R.A.F. General Hospital, Hinaidi, Iraq, for duty as medical officer. Flight Lts. J. F. McGovern to R.A.F. General Hospital, Hinaidi, Iraq; C. G. J. Nicholls to R.A.F. Hospital, Aden. Flying Offs. H. S. Barber to Aircraft Park, India, Lahore, V. D’A. Blackburn to No. 28 (Army Cooperation) Squadron, Ambala, India. AUXILIARY AIR FORCE
No. 601 (County of London) (Fighter) Squadron : J. H. Williams is granted a commission as Flying Officer.
INDIAN MEDICAL SERVICE C. V. Falvey to be Maj. Lt. (on prob.) J. J. Barton to be Capt. (on prob.). Capts. S. D. Dalal and A. Ahmed relinquish their temp.
Capt.
commns.
no
A clear
illness,
we
by certain
reasonable doubt as to the nature of their nevertheless confess our complete ignorance as to its cause. Another reason is that minor injuries are so common to all of us and so frequently repeated that most patients can usually remember some such injury which the later development of symptoms makes significant. The general tendency is to discount the effects of any injury as being unlikely to make any contribution to the onset or to the progress of these and similar diseases, and to regard the injury itself as being probably due to some otherwise unnoticed clumsiness or weakness-symptoms of the disease already present. I want therefore to draw your attention to a few cases in which a recent injury would appear either to have precipitated or to have increased the severity of one of these generalised diseases, and also to point out the lines along which an explanation of these effects can possibly be found. These cases differ in no essential way from those which have been already described by Dr. Wilfred Harris in his Savill oration for 1933. (The essential details of six such cases, two of disseminated sclerosis, one of progressive muscular atrophy, one of paralysis agitans, and two of hepato-lenticular degeneration were then given. In each of them the clinical was unusual, in respect either of abnormal picture rapidity of development or of abnormally severe disability in that limb which had previously been injured.) If we are not satisfied with the view that in not all of such cases is the relation between the injury and the unusual features of the subsequent disease a chance coincidence, we are naturally led to look for other similar observations which may throw some light upon the way in which injuries to other parts of the body may be expected to influence the resistance of the central nervous system to the causative agencies of these diseases. In respect of the peripheral nerves it can be demonstrated without doubt that peripheral neurons in which conduction is already slightly impaired, as a result of lead and alcohol poisoning, are less resistant to mechanical injury, in that continued pressure over a nerve trunk containing such neurons leads to paralysis and to sensory loss in their area of distribution much earlier than it does in otherwise healthy persons. We have a priori no reason for assuming that this would be so, since we have none for assuming that the effects of mechanical pressure and of such forms of poisoning would necessarily summate in impairing conduction through the peripheral nervefibre. That they do summate in this way can easily be demonstrated. If damage or destruction of the tissues of a limb is going to produce any change in the cells of the central nervous system, it is in that part of the spinal cord to and from which the nerves of the limb run that we can most reasonably expect to find such changes. They might conceivably result from transmission to the spinal cord of some products of inflammation or of tissue breakdown. Alternatively, since destruction of peripheral neurons is known to give rise to histologically demonstrable changes in their cells of originin this case the spinal root ganglia or the anterior horn cells of the cord-it is possible that the changes underlying these histological appearances may entail a lowering of the resistance of these cells to other pathological influences that are already at work. Whatever may be the mechanism by means of which such a change takes place, we must ask whether there is any evidence that damage of one limb can and does lower the resistance of immediately related segments of the spinal cord to attack by other disease processes.
to this question is, I believe, given of acute anterior poliomyelitis. fracture at the lower end of the radius
answer
cases
In the first, of the right arm
followed two weeks later by of all the muscles in the forearm complete paralysis and slight weakness only of the triceps and deltoid muscles on both sides. Later all symptoms disappeared except for complete and permanent paralysis of the muscles of the forearm. In the second case, severe bruising of the left thigh with pain but no weakness, caused by falling astride a fence, was followed within 48 hours by complete paralysis of the left leg with the exception of some feeble flexor movements of the toes, slight weakness of the right extensors of the knee, and very slight weakness of both triceps muscles in the arm. Two months later all paralysis had cleared up with the exception of that in the left leg, which was still com. pletely paralysed except for slight flexion of the toes. In the third case excessive fatigue of one particular muscle in the arm, the radial extensor of the wrist, which is rarely paralysed in infantile paralysis, was followed within 36 hours by paralysis of this muscle, paralysis of the right deltoid, weakness of the right triceps, and weakness of the right gastrocnemius muscle. Later the gastrocnemius recovered completely, the triceps recovered almost completely, the deltoid remained considerably weakened, but the only muscle which remained completely paralysed and which finally wasted completely was that which had been fatigued to excess in the above way. These three and two other similar but less striking cases have come under my observation in the past two years. The existence of four similar cases was referred to by Abercrombie. They appear to me to prove conclusively that accidental injury of one limb can impair the resistance of immediately connected segments of the spinal cord to attack by the virus of infantile paralysis. That it should impair also their resistance to the pathological changes of progressive muscular atrophy does not necessarily follow, and that the resistance of parts of the central nervous system less directly related to the site of damage can be altered as a result of such accidental injuries is suggested still less. However, I believe that we can no longer with reason maintain that there is no evidence that injuries to a limb can influence in any way the development of diseases confined to the central nervous system, and must allow that when an injury does precede the development of one or another of these conditions, its possible contribution to the course of the disease cannot be summarily denied. was
MATERNAL INJURIES OF CHILDBIRTH
(MR. LESLIE WILLIAMS) MATERNAL injuries during pregnancy and childbirth may be classified as mild or serious. The mild include injuries to the abdominal and other muscles, injuries to the supports of the breasts, and dental caries. So far as the abdominal muscles are concerned, I believe that binders do no good, though they serve a useful purpose in preventing the uterus filling with blood and rising during the first 24 hours after delivery. Instead, the tone of these muscles should be restored by exercises such as sitting up and down at frequent intervals from the very first day. Massage to the limbs may be started on the sixth day, and to the abdomen on the eighth. I feel satisfied that movements and massage do not increase the liability to pulmonary embolus.
947 The breasts should never be pressed downwardsis often done by the nurse-with a binder round the chest. Rather should they be supported by a brassiere during pregnancy and by a similar one of the next larger size as soon as lactation commences. Dental caries may to some extent be limited by taking throughout pregnancy and lactation some preparation of calcium ; but, should it appear, immediate treatment should be undertaken. Apart from wholesale extraction there is no fear of dental treatment causing miscarriage. Among the serious injuries I include the various lacerations. It should be remembered that severe vaginal lacerations may occur while the perineum remains unruptured, and hence are in danger of remaining unrecognised. Their repair must not be performed in any careless manner ; it is useless for example to attempt to repair a complete tear into the rectum unless the circumstances are favourable. For the operation requires a good light, the lithotomy position, an assistant, and an anaesthetist. Lacerations of the cervix, though they sometimes occur in spontaneous natural labour, are, I believe, usually due to the premature application of forceps. It is amazing to note how often full dilatation of the cervix is diagnosed when really this state of affairs is but only half reached. Over and over again cases are sent in to maternity hospitals as " obstructed labour," " failed forceps," &c., and on investigation it is found that the cervix is perhaps one-half or one-third dilated. In such cases treatment by sedatives results in the fullness of time in spontaneous delivery. Such a failure to realise the absence of full dilatation of the cervix is due to the examination being conducted too rapidly and in too cursory a In the intervals between pains the soft manner. cervix may often be pushed aside by the examining finger and so give the impression of complete dilatation. If, however, a pain is awaited, the margin of the os will become tense and the real state of the opening can be appreciated. If this were regularly done there would be many fewer cases of forceps application through or outside the undilated cervix, and many fewer cases of cervical laceration. When the forceps are applied inside an incompletely dilated cervix, and when traction is applied, the cervix, the upper part of the vaginal wall, and the subjacent bladder are dragged down, and it is probable that some dislocation of the structures surrounding the internal urethral orifice takes place. I believe that it is in this way that that most distressing symptom " stress incontinence is brought about. It is also presumably caused after proper application of forceps if the operator neglects to make sure that the bladder is not being pulled down. At the time such maternal injuries are apt to be overlooked, but the patient’s discomfort subsequently is a very serious matter. I have tried various operations to relieve these symptoms, for it must be realised that anterior colporrhaphy does not succeed in more than about half the cases. In some cases passing a catheter, exposing the urethra through the anterior vaginal wall, and tying an unabsorbable suture outside the urethra in the region of sphincter may succeed. Perhaps the injury with the most distressing results for the mother is vesico-vaginal fistula.. This is sometimes due to prolonged pressure on the bladder base, nipped between a large foetal head and the back of the symphysis. But undoubtedly it sometimes results from forceps application without catheterisation of the patient immediately beforehand. I always teach students that when they go into practice and buy a pair of obstetric forceps, they should at the as
"
time buy a catheter and tie it to the forceps. In this way this most essential precaution of catheterisation is not apt to be omitted. Finally retroversion may be mentioned, though it must be stressed that only a small proportion of retroversions need such drastic treatment as ventrosuspension. The woman who had a congenital retroversion prior to her pregnancy is almost certain to develop retroversion again in the puerperium, but not only such patients, but all puerperal women, must be examined on the tenth day and the retroversion, if found, corrected. A pessary should then be fitted and this can be done at as early a date as this without any danger. All puerperal cases should again be examined six weeks after labour. It is often found then that the uterus previously anteverted has become retroverted. Its position can still be easily corrected and the organ remains soft enough to permit itself to be moulded into a good shape, as well as manipulated into a good position. A pessary is again fitted ; and in this case, as in the one previously mentioned, it is changed three months later, and removed six months later. same
THE SERVICES ROYAL NAVAL MEDICAL SERVICE Lt. J. W. L. Crosfill promoted to rank of Surg. Surg. Lt.-Comdr. Surg. Lts. (D.) R. W. Stevens to Ganges and F. A. Pearse to
Victory for R.N.B. ROYAL NAVAL VOLUNTEER RESERVE
Surg. Lts. R. M. Buchanan and A. R. Thomas to Surg. Lt.-Comdrs. Proby. Surg. Lt. W. F. Jones to be Surg. Lt.
promoted
ARMY MEDICAL SERVICES Col. J. D. Richmond, D.S.O., O.B.E., late R.A.M.C., having attained the age for retirement, is placed on ret. pay. The undermentioned Lt.-Col. to be Col.:H. L. Howell, O.B.E., M.C., from R.A.M.C. ROYAL ARMY MEDICAL CORPS R. G. Shaw, M.C., to be Lt.-Col. Short Serv. Oommn.-F. J. O’Dowd to be Lt.
Maj.
ARMY DENTAL CORPS
Lt.
(on prob.)
R. H. Green is confirmed in his rank. TERRITORIAL ARMY
A. M. Cooke to be Maj. Lts. T. F. Briggs and J. G. Lawson to be
Capt.
TERRITORIAL ARMY RESERVE
Capts.
OF OFFICERS
Maj. F. Hauxwell having attained the age limit, retires and retains his rank, with permission to wear the prescribed uniform. ROYAL AIR FORCE Lt. A. Flight Harvey is promoted to the rank of Squadron Leader. Group Capt. A. E. Panter to R.A.F. General Hospital, Hinaidi, Iraq, for duty as commanding officer. Squadron Leader A. Briscoe to R.A.F. General Hospital, Hinaidi, Iraq, for duty as medical officer. Flight Lts. J. F. McGovern to R.A.F. General Hospital, Hinaidi, Iraq; C. G. J. Nicholls to R.A.F. Hospital, Aden. Flying Offs. H. S. Barber to Aircraft Park, India, Lahore, V. D’A. Blackburn to No. 28 (Army Cooperation) Squadron, Ambala, India. AUXILIARY AIR FORCE
No. 601 (County of London) (Fighter) Squadron : J. H. Williams is granted a commission as Flying Officer.
INDIAN MEDICAL SERVICE C. V. Falvey to be Maj. Lt. (on prob.) J. J. Barton to be Capt. (on prob.). Capts. S. D. Dalal and A. Ahmed relinquish their temp.
Capt.
commns.