1073

UTERINE INERTIA

MR. JEFFCOATE’S BLAIR-BELL LECTURE

AT the British College of Obstetrics and Gynaecologyon Oct. 28th, Mr. T. N. A. JEFFCOATE of Liverpooldelivered the first William Blair-Bell memorial lecture.’His subject, uterine inertia, was, he said, one in whichBlair-Bell had always been particularly interested.His views had been at variance with those of mostobstetricians of his day, but were becoming more andmore accepted, in modified form. Blair-Bell had beenthe first to use posterior-pituitary extract in allstates of uterine atony. He had recognised a physio-logical, protective, reflex type of inertia occurring atthe beginning of labour, and had considered that allother types were caused by deficiency of pressorsubstances in the blood stream.Mr. Jeffcoate then reviewed the physiological

processes concerned in uterine inertia. The physicaldevelopment of the uterus during pregnancy was offirst importance to its behaviour during labour. Thedevelopment was dependent on nutrition, but forthe most part due to the effects of corpus luteumand eestrogenic hormones. As the aestrogenic hormonebecame more and more dominant just before labour,so did uterine sensitivity increase. When thesensitisation was completed, any minor stimulus,such as an emotional change, might be sufficient toinitiate labour. Possibly the oestrogenic hormoneprovoked the onset of expulsive contractions. Theview that the oxytocic principle of the posteriorpituitary caused the onset of labour had still to bedisproved. The factors which brought about theonset might be assumed to be of first importance inmaintaining contractions during labour, but theymight have the assistance of parasympathetic nervousstimuli. The belief that dilatation of the cervix wasbrought about by the pressure of the bag of membraneshad been disproved by the recent widespread use ofartificial rupture to induce labour. The cervix wasby no means purely passive, but actively contractiveand retractive, its action being favoured by an

accurately fitting presenting part. The nature ofuterine contractions and the progress of dilatationlargely depended on the relation between passengerand passages, but endocrine factors were also

important, especially the cestrogenic hormone.

A CLINICAL STUDY

The lecturer then described a series of experimentson the effect of oestrogenic hormone on patientssuffering from uterine inertia in labour. To avertemotional complications, and the confusion of weakbut painful contractions before the. onset of true

labour, only cases of inertia of long standing, withcomplete or almost complete cessation of pains, wereaccepted; ordinary methods of treatment were

always tried first, and the results were assessed byan independent experienced observer. Only 88 casesout of a series of more than 12,000 confinements hadfulfilled the conditions laid down. The duration ofcontractions and the intervals had been chartedbefore, during, and after treatment. The hormonehad been given intramuscularly, usually at intervalsof one hour for 8-10 hours. The dose had been 2 mg.in the case of oestradiol benzoate in oil and oestronebenzoate in oil; 1 mg. of cestrone in oil, and 0-04 or0’05 mg. of cestrone in aqueous solution. Only 16of the 88 patients had been in labour less than 24

hours when treatment was begun ; the averageduration was 45-8 hours. Successful treatment didnot imply delivery by natural forces alone, as theremight be complications such as fcetal distress ; thesuccess of treatment was gauged by its effect on theprogress of labour.The remedy had been successful in 50 cases (57 per

cent.) and labour had been completed spontaneouslyin 27 (54 per cent.) of these. Excluding cases ofCsesarean section, the average duration of labour afterthe beginning of treatment had been 9-5 hours.

This series of cases supported Blair-Bell’s view thatthere was no theoretical or practical reason for

regarding primary and secondary inertia as separateclinical entities. In that classification there wouldhave been 67 primary and 21 secondary inertias, theresults of treatment with oestrogenic hormone beingsimilar in both groups. The response to the hormonebore no relation to the time of onset of the inertiaor to the stage in labour at which treatment began.It did, however, vary according to the presence orabsence of mechanical difficulty. Cases complicatedby some form of disproportion or malrotation of thehead reacted badly, only 12 out of 37 (32 per cent.)deriving any benefit. Sometimes there was improve-ment in strength and frequency of the contractions,but the cervix rarely dilated satisfactorily, andlabour did not progress until the fault was corrected.In cases not complicated by mechanical misfits,there had been only 5 complete failures. The incidenceof difficulty in the third stage was unusually low forthe severe types of inertia comprising this series ;there was only 1 case of moderately severe post-partum heamorrhage and 4 cases of slight haemorrhage.Two placentae had had to be removed by hand.There seemed to be no adverse effect on either motheror child. No general or local reaction had ever beenobserved, and there had been no violent or spasmodiccontractions. Of the infants 14 had been born deadand had died in the neonatal period, but there hadbeen no evidence to connect the deaths with thetreatment.

Laboratory experiments suggested that oestrogenichormone only stimulated the uterine muscle somehours after injection. Clinically, however, good andoften brilliant results quickly followed administration,the time of onset of the improvement varying fromten minutes to three hours. It might be that thehuman uterus responded better than the rodentuterus. Only a few cases had been treated withaqueous solutions, but the impression was that theseminute doses were as effective as a larger amountdissolved in oil. Since there was a latent periodbetween the injection and the effect, it was logicalto assume that the hormone had a great prophylacticvalue. It was impossible to forecast inertia, butcestrogenic hormone had been given to 51 womenin whom there was definite reason for expectingprolonged and difficult labour. A dose of 2 mg. hadbeen injected at intervals varying from 1-12 hoursfor periods of 1-21 days before delivery. The bestresults followed administration at 8- or 12-hourlyintervals for four days or longer. In spite of mal-positions, minor degrees of pelvic contraction, atony,and hydramnios, the average duration of labour hadbeen within normal limits, and the incidence ofinstrumental deliveries had been low. In most casesthe rapid and easy evacuation of the uterus had beenquite unexpected. There had been 3 cases of inertia,and these had been in patients who had had very littlehormone and for a period of less than forty-eight hours.

1074

THE VARIOUS FACTORS

Clinical experience did not support the view thatdebilitating disease and under-nourishment causedinertia. Primigravidae over the age of thirty wereparticularly liable to it, as were women of heavybuild, often frankly adipose or masculine. In practiceit was rarely possible to ascribe disordered actionto local disease in the uterine wall. An over-stretchedmuscle lost its power of contraction, yet hydramniosand multiple pregnancy were usually associated withpremature onset and rapid labour. Mechanical errorin the relationship of the passenger to the passageswas of great importance. The nature of the connectinglink might be disputed, but probably the inertia wasreflexly caused by the mechanical obstacles. Nervousexhaustion was more important than muscle-fatigue.A full bladder and rectum reflexly inhibited contrac-tion ; faulty stimulation by the presenting partprobably also produced its effect by a nervous route.Nevertheless, the evidence went to show that hormonicprinciples were much more vital than nervous stimuli.Emotional factors must not be forgotten, fear beingthe most important. The administration of sedativesstill remained the first measure in all cases of inertia.Valuable though the hormone treatment was, it wasonly to be regarded as an accessory measure. Itshould be used in cases where the uterine action wasnot improved by sedatives and antispasmodics. Itnot only enhanced the power of uterine contractionbut also regulated and coordinated it. Informationabout the fate of the hormone after its injection wasneeded.The endocrine aspect of uterine inertia was

intriguing, and investigation into it had only justbegun. Further inquiry would help to solve themystery of uterine inaction.

MENTAL HEALTH IN 19381

OVERCROWDING in public mental hospitals isrecorded by the Board of Control every year. TheBoard anticipated in their last report that over-

crowding would become even more serious in 1937and their prophecy was duly fulfilled, though accom-modation was increased by 1575 beds with the

opening of the new hospital at Runwell and by variousminor extensions at other hospitals. The totalnumber of patients under care in county and boroughmental hospitals throughout the country has increasedby 2201, a figure which is very high in comparisonwith the average for the last five years (1687). The

aggregate number of patients in excess of the author-ised bed space at the end of the year was 3608, thelargest figure ever recorded. Nor are the prospectsat all good. The number of new beds opened in thenext two or three years is bound on the most favourableestimate to fall short of the increase of the numberof persons under care. Assuming that the death-rateremains at or near its present level, the Board expectno improvement in the position until the new mentalhospitals now being built at Laythorn for Lancashireand at Margaretting Hall for Essex are ready to admitpatients.The total number of persons suffering from mental

disorder under care in England and Wales at theend of the year was 157,353, an increase of 1831

during the year. The last quinquennial average

1 Twenty-fourth Annual Report of the Board of Control forthe year 1937. Part I. H.M. Stationery Office. 1938. Pp. 78.1s. 6d.

increase is 1716. The number of direct admissionsto public mental hospitals was 26,892, as against anaverage of 23,597 for the preceding five years.Voluntary admissions totalled 8414 as comparedwith 6904 in 1936 ; they accounted for 31-3 per cent.of the total admissions. Temporary admissionsincreased slightly : from 1361 to 1404. It is probablethat procedure under section 5 of the Mental Treat-ment Act, 1930. will not become popular until thesection is amended in some way. The Board regardthe increase in the number of voluntary admissionsas an encouraging indication that the value of earlytreatment is now more generally recognised. It is,however, singular, in their view, that the certifiedadmissions amount to the same figure as in 1935.The progressive reduction in the number of certifiedadmissions has, for some reason not yet explained,been checked in spite of the rise in voluntaryadmissions.

OUT-PATIENT CLINICS AND THEIR STAFFS

Little progress seems to have been made in theestablishment of out-patient centres under the 1930Act. The number is only 167 as against 165 for theprevious year. Although the number of sessions isincreasing, many centres seem to be mainly diagnostic.Without minimising the value of early diagnosis theBoard think that more might be done in the way ofcontinued treatment of those disorders which do notnecessitate admission to hospital. While the out.

patient centre is a valuable means of attractingvoluntary patients, this is far from being its solefunction. The problem is one, of course, of theenlistment and maintenance of a properly trainedstaff. Psychotherapy demands a great deal of timeand is practically out of the question at a clinic thatonly meets once or twice a month. If centres continueto be staffed inadequately by doctors who have togive up part of their leisure to out-patient work,there is little hope of their development. The Boardadhere to their view that it is important to associatethe mental hospital staffs with the centres, but pointout that to do so does not mean that centres must

necessarily be staffed entirely by whole-time mentalhospital officers. The difficulty might be met to someextent by attaching part-time physicians to thecentres, as is done with outstanding success at theHill End Hospital, St. Albans. The advantages of

: such an arrangement are that it lightens the burdenLon the whole-time staff, not all of whom are sufficientlyexperienced or qualified for out-patient work; andL it gives men and women interested in this work achance to establish themselves in private practiceB in psychiatry. One of the great handicaps to the- fruitful development of out-patient mental work is that to embark on this specialty outside London isj such a hazardous adventure. Part-time posts in centres would at least help to some extent those who contemplate such a career to avoid too great or

r prolonged a drain on their resources. Apart from the3 help they would give the general practitioner, atlarger infusion of private practitioners in psychiatry1 would have a stimulating effect on the developmente of this specialty. It is not a good thing, the Boardt say, for any branch of medicine to be represented

solely by whole-time salaried officers.

e CARDIAZOL AND INSULIN FOR SCHIZOPHRENIA

1 The reported results of Cardiazol treatment ine schizophrenia have been so striking that the Board- considered that they justified a special investigation.Ir They accordingly sent Dr. Rees Thomas and Dr.8. Isabel Wilson to study the treatment at Budapest,