FIRST SPECIES OF DYSTOCIA.
_Obstructed Labour from a Faulty Condition of the soft Passages._
_Pendulous abdomen.--Rigidity of the os uteri.--Belladonna.--Edges of
the os uteri adherent.--Cicatrices and collosities.--Agglutination of
the os uteri.--Contracted vagina.--Rigidity from age.--Cicatrices in
the vagina.--Hymen.--Fibrous bands.--Perineum.--Varicose and
oedematous swellings of the labia and nymphæ.--Tumours.--Distended or
prolapsed bladder.--Stone in the bladder._
In speaking of the uterus itself as a cause of this species of dystocia,
we only mention it here as one of the soft passages, not as the organ by
the contractions of which the child is expelled; we merely refer to those
faulty conditions of the uterus which produce an impediment to the child's
progress, not to those which interfere with the natural condition of its
expelling powers, as this will be considered under the next division of
dystocia.
We have already stated our disbelief that an oblique position of the
uterus can have any influence in producing malposition of the child. With
the exception of extreme anterior obliquity, or pendulous belly, we
equally doubt that it can have any effect in retarding the labour when the
child presents naturally. The highest authorities in midwifery during the
last hundred years unite in asserting that this celebrated opinion of
Deventer, was a misconception.
_Pendulous abdomen._ Where, from great relaxation of the anterior
abdominal wall, (a frequent result of repeated child-bearing,) the fundus
is inclined so forwards as almost to hang over the symphysis pubis, the
child's head does not readily enter the brim of the pelvis, nor can the
uterine contractions act so favourably in dilating the mouth of the womb;
and in this manner the first part of labour may be considerably retarded.
Pendulous abdomen to this great extent is not very common; and in ordinary
cases the horizontal posture, especially upon the back, is quite
sufficient to allow the head to engage in the pelvis. "We have found more
than once," says Dr. Dewees, "in cases of extreme anterior obliquity, that
it is not sufficient for the restoration of the fundus that the woman be
placed simply upon the back; but we are also obliged to lift up and
support by a properly adjusted towel or napkin, the pendulous belly until
the head shall occupy the inferior strait. To illustrate this, we will
relate one of a number of similar cases in which this plan was
successfully employed. Mrs. O., pregnant with her seventh child, was much
afflicted after the seventh month with pain and the other inconveniences
which almost always accompany this hanging condition of the uterus; was
taken with labour pains in the morning of the 10th of October, 1820. We
were sent for about noon. The pains were frequent and distressing, and,
upon examination per vaginam, the mouth of the uterus was found near the
projection of the sacrum, dilated to about the size of a quarter dollar,
but pliant and soft. During the pain, the membranes were found tense
within the os uteri, but did not protrude beyond it.
As this was the first time we had attended this patient, and from the
history she gave of her former labours, in which she represented her
abdomen being in all equally pendulous, with the exception of the first,
we waited several hours (she being placed upon her side) for the
accomplishment of the labour. During the whole of this period the head did
not advance a single line; nor could it, as the direction of the
parturient efforts carried it against the projection of the sacrum. We had
several times taken occasion to recommend her being placed upon her back,
but to which she constantly objected, until we urged its being absolutely
necessary. She at length reluctantly consented to the change of position;
when upon her back it was found that it did not advance the os uteri
sufficiently towards the centre of the superior strait. The abdomen was
therefore raised, and a long towel placed against it, and kept in the
position we had carried it by the hands, by its extremities being firmly
held by two assistants; at the same time we introduced a finger within the
edge of the os uteri, and drew it towards the symphysis pubis, and then
waited for the effects of a pain. One soon showed itself, and with such
decided efficacy, as to push the head completely into the inferior strait,
and three more delivered it." (_Compendious System of Midwifery_, § 224.)
This peculiar displacement of the uterus, which has been called by some
anteversion of the gravid womb, has occasionally given rise to the
suspicion that there was no os uteri, from its being tilted upwards and
backwards towards the promontory of the sacrum: it has been said, in some
cases, to have even contracted adhesions with the posterior wall of the
vagina, from the firmness with which it was pressed against it, and thus
tended still farther to increase the deception. "Within our knowledge,"
says Dr. Dewees in the paragraph preceding the one just quoted, "this case
has been mistaken for an occlusion of the os uteri, and where upon
consultation it was determined that the uterus should be cut to make an
artificial opening for the foetus to pass through. They thought themselves
justified in this opinion, first, by no os uteri being discoverable by the
most diligent search for it; and, secondly, by the head being about to
engage under the arch of the pubes covered by the womb. Accordingly, the
labia were separated, and the uterine tumour brought into view. An
incision was now made by a scalpel through the whole length of the exposed
tumour down to the head of the child, the liquor amnii was evacuated, and
in due course of time the artificial opening was dilated sufficiently to
give passage to the child. The woman recovered, and, to the disgrace of
the accoucheurs who attended her, was delivered per vias naturales of
several children afterwards, a damning proof that the operation was most
wantonly performed." Where, in addition to the anteversion, strong
adhesions have taken place between the os uteri and posterior wall of the
vagina, no trace of os uteri will be felt, and the operation
above-mentioned does become sometimes necessary.
_Rigidity of the os uteri._ The chief way in which the uterus can obstruct
the passage of the child, is, by an undilatable state of its mouth: this
may arise from a variety of causes, which may be chiefly brought under the
two heads of functional and mechanical. Under the first head comes
rigidity of the os uteri, either from a spasmodic contraction of its
circular fibres, or from irregularity or deficiency in the contractions of
the longitudinal fibres of the whole organ. In a slight degree this is
frequently met with, especially in first labours, where the patient is
young, delicate, and irritable, and where, in all probability, there is
some source of irritation in the primæ viæ which tends to disturb and
divert the proper and healthy action of the uterus. We see it also in
robust plethoric primiparæ; the os uteri dilates to a certain degree,
perhaps an inch in diameter, and remains tense and firm, with its edge
thin; the contractions of the uterus produce much suffering, and to all
appearances are very violent; but they are chiefly in front, and produce
little or no effect upon its mouth; the vagina is hot and dry, the patient
becomes exhausted with fruitless pains, and fever or inflammation would
quickly follow, if nothing be done to relieve this state. As this subject,
however, belongs rather to the next species of dystocia, viz. that arising
from a faulty condition of the expelling powers, we shall delay the
consideration of the treatment.
_Belladonna._ It has been recommended, and not very judiciously, to apply
belladonna to the os uteri in cases of great rigidity: it was repeatedly
tried by the celebrated Chaussier in the Maternité, at Paris, and,
according to his observations, it produced a considerable effect upon it.
"The knowledge of the extraordinary powers which this drug possesses in
causing dilatation of the iris, led to its employment for the object of
enlarging the aperture of the uterus; but there is certainly no similarity
in the structure and office of the two organs, and no analogy can be drawn
between their functions. It is not likely that this means will produce the
relaxation we require; and if no good results from its use, it must be
injurious; not in consequence of the poisonous quality resident in the
drug itself, but in the friction which is necessary for its efficient
application. The mucus which naturally lubricates the part must be wiped
away, and this irritation must predispose the tender organ to take upon
itself inflammatory action." (_Dr. F. H. Ramsbotham's Lectures, in Med.
Gaz._ May 3, 1834.)
For our own part we must confess, that, although we have seen this
application tried repeatedly, it has never produced the desired effects,
but has invariably brought on very troublesome and distressing symptoms,
such as sickness, faintness, headach, vertigo, &c.
There is a condition of the os uteri which is occasionally met with, and
which presents a degree of rigidity which we have never seen except where
there have been adhesions and callous cicatrices from former injuries. It
has nothing of the thin edge put strongly on the stretch during the pains;
but it is thick and firm, presenting nothing of the elastic cushiony
softness of the os uteri in a favourable state for dilatation; it dilates
to about an inch across, tolerably regularly, and without much apparent
difficulty, but no efforts of the uterus can dilate it farther. We have
already alluded to two extreme cases of this when speaking of ruptured
uterus, and where in each instance the os uteri entirely separated from
the uterus and came away. Whether there is something peculiar in the
structure of the part which renders it thus undilatable, or whether it
required even still more powerful measures than those employed, is not
very easy to decide.
_Edges of the os uteri adherent._--_Cicatrices_, &c. A serious impediment
to the passage of the child may be produced by adhesions of the sides of
the os uteri to each other; by hard callous cicatrices resulting from
ulcerations, lacerations, &c. in former labours; by abnormal bands, or
bridles, as they have been called; and by tumours and other morbid
growths. Where the structure of the os uteri has been much injured by
previous injuries of this character, the resistance will probably be so
great as to require artificial dilatation with the knife. Generally
speaking, however, the whole circle of the uterine opening is not
involved, portions still remaining of natural structure, and, therefore,
capable of dilatation. On examination, it feels irregular both in shape
and hardness; a part being soft, cushiony, yielding, and forming the
segment of a well-defined circle, the rest of it uneven, knobby, and hard,
being evidently puckered up by cicatrisation.
In many cases, these callous contractions give way more or less when the
head begins to press powerfully against them; but even where this is not
the case, the healthy portion of the os uteri is so dilatable as to yield
sufficiently. It would be difficult to estimate how far an os uteri in
this state, with perhaps, not more than half, or even a third, of its
circle in a healthy condition is capable of dilating. But from cases which
have come under our own observation, and others which have been recorded
by authors in whom we place the greatest reliance, we are quite confident
that with proper treatment a sufficient degree of dilatation can be
effected without resorting to artificial means.
Bleeding to fainting, the warm bath, laxatives, and enemata, will assist
greatly in promoting our object. Where, however, the contracted portion
shows no disposition to yield to this treatment, or to the pressure of
powerful pains, but forms a hard resisting bridle or band, which
effectually impedes the farther advance of the head, it must be divided by
the knife in order to prevent dangerous laceration of the part on the one
hand, or protraction of labour on the other. The mode of doing this will
be described when these conditions as effecting the vagina are considered.
Artificial dilatation of the os uteri by incision has been practised very
rarely, the chief of these operations having had reference to the vagina.
F. Ould considered that mere contraction of the os uteri from former
lacerations did not require this operation; but that where it was in a
state of schirrus, there would be "no chance for saving either mother or
child but by making an incision through the affected part."
We have quoted, on a former occasion, a case of cicatrised os uteri
recorded by Moscati, and where, in consequence of injury in a former
labour, the opening was nearly closed; fearing the laceration which had
occurred in a similar case under his father's care, in consequence of
making merely one incision, he made a number of small incisions round the
whole of the orifice until a sufficient dilatation was produced.
_Agglutination of the os uteri._ Another condition of the os uteri which
may produce very considerable impediment to the passage of the child, is
that which has been called _agglutination_, where by some adhesive
process, apparently that of inflammation, the lips of the opening adhere
and completely close it. These species of imperforate os uteri may occur
in primiparæ as well as in those who have borne children: the
agglutination of its edges takes place during pregnancy, probably shortly
after conception. Upon examination we find no traces of hardness,
rigidity, or any other morbid condition, either in the os uteri itself, or
the parts immediately surrounding it; the os uteri is closed by a
superficial cohesion of its edges, and which in some cases seem to adhere
by means of an interstitial fibrous substance; this when of a firmer
consistence forms a species of false membrane, which in some cases is
capable of resisting the most powerful uterine contractions, and in others
it appears to cover the os uteri so completely as to conceal it most
effectually, and give rise to the erroneous conclusion that the os uteri
is altogether wanting. Baudelocque describes this condition (_Op. cit._ §
1961;) but from the brief mention which he makes of it, as also from the
treatment recommended, it is plain that he had no very distinct notions
about it, for he advises that "in all cases the orifice must be restored
to its original state, and be opened with a cutting instrument as soon as
the labour shall be certainly begun."
In by far the majority of cases which have been recorded, the pains have
after a time been sufficient to dilate the os uteri. Dr. Campbell has
described two of these cases, where no os uteri could be traced for some
time after the commencement of labour: both were first pregnancies: in the
former, uterine action continued about twelve hours before the os uteri
could be distinguished, when it felt like a minute cicatrix; the other
patient had regular pains for two nights and a day before the os uteri
could be perceived, and she suffered so much as to require three persons
to keep her in bed; both these patients were largely bled, gave birth to
living children, and had a good recovery.
We may suspect that the protraction of labour arises from agglutinated os
uteri, when at an early period of it we can discover no vestige of the
opening in the globular mass formed by the inferior segment of the uterus,
which is forced down deeply into the pelvis, or at any rate, where we can
only detect a small fold or fossa, or merely a concavity, at the bottom of
which, is a slight indentation, and which is usually a considerable
distance from the median line of the pelvis. The pains come on regularly
and powerfully; the lower segment of the uterus is pushed deeper into the
cavity of the pelvis, even to its outlet, and becomes so tense as to
threaten rupture; at the same time it becomes so thin, that a practitioner
who sees such a case for the first time would be induced to suppose the
head was presenting merely covered by the membranes. After a time, by the
increasing severity of the pains, the os uteri at length opens, or it
becomes necessary that this should be effected by art: when once this is
attained, the os uteri goes on to dilate, and the labour proceeds
naturally, unless the patient is too much exhausted by the severity of her
labour. Although the obstacle in some cases is capable of resisting the
most powerful efforts of the uterus, a moderate degree of pressure
against it whilst in a state of strong distention, either by the tip of
the finger, or a female catheter, is quite sufficient to overcome it;
little or no pain is produced, and the appearance of a slight discharge of
blood will show that the structure has given way. Two interesting cases of
this kind have been described by the late W. J. Schmitt, of Vienna, under
the title of two cases of closed os uteri which had resisted the efforts
of labour, and where it was easily dilated by means of the finger.[127]
_Contracted vagina._ The vagina may be naturally very small, or unusually
rigid and unyielding: in the first case serious obstruction to the
progress of labour is rarely produced, the expelling powers being
generally sufficient ultimately to effect the necessary degree of
dilatation; the proper precautions must be taken to avoid every species of
irritation and excitement of the circulation; the bowels must be duly
evacuated; the circulation controlled either by sedatives, or, if
necessary, bleeding, and where it is at hand, a warm bath; if this latter
cannot be easily procured, a common hip bath, or sitting over the steam of
warm water will be of great service; the great object will be to ensure a
soft and cool state of the passage with a plentiful supply of that mucous
secretion which is so essential to the favourable dilatation of the soft
passages.
Nauseating remedies, and even tobacco injections, have been tried to a
considerable extent for the purpose of relaxing the mouth of the uterus;
but they produce little or no good effects, and cause much suffering to
the patient. In Dr. Dewees' second case of obstructed labour from the
above causes, a sufficient trial of this remedy was used to satisfy all
doubts as to its effects. "It produced great sickness, vomiting, and
fainting, but the desired relaxation did not take place: we waited some
time longer and with no better success. In the course of an hour, or an
hour and a half, the more distressing effects of the infusion wore off;
and resolving to give the remedy every chance in our power, we prevailed
on our patient with some difficulty to consent to another trial of it: its
effects were the same as before,--great distress without the smallest
benefit, the soft parts remaining as rigid as before its exhibition."
Bleeding was now proposed; the patient became faint after losing ten
ounces, and the most complete relaxation followed: the forceps were
applied, and a living child delivered.
_Rigidity from age._ In women pregnant for the first time at an advanced
period of life, the vagina and os externum are said to oppose considerable
resistance to the passage of the child from their rigid condition, the
parts having lost the suppleness and elasticity of youth; the vessels also
convey less blood to the mucous membrane and adjacent tissues: hence the
secretion of mucus is more sparing; the cellular tissue is more condensed
and firm; still nevertheless, although it is constantly mentioned by
authors as a cause of this species of dystocia, we cannot help declaring
that it exists to a much less degree than has been generally supposed, and
that primiparæ at a very early age are much more liable to have tedious
and difficult labours than those at an advanced age. Still, however, the
circumstance is well worthy of notice; and in such cases we may produce
much relief by the warm bath, or hip bath, by sitting over the steam of
hot water, by warm water enemata, and great attention to the state of the
intestinal canal and of the circulation. Mucilaginous or oleaginous
injections into the vagina have been recommended; but we have no
experience of their effects: we have frequently used lard, &c. to the
edges of the os externum when the head was beginning to distend it, and we
think with relief; at any rate it produces a feeling of comfort to the
patient, being soft and cooling.
_Cicatrices in the vagina._ The most serious impediments to the progress
of labour connected with the vagina are the contractions of this canal
from callous cicatrices, the results of sloughing and other injuries in
former labours. The vagina may be contracted throughout its whole length,
its parietes hard, gristly, and uneven, and so small as not to admit even
the tip of the little finger; the course of the canal from the
irregularity of the contractions and adhesions is frequently much
distorted; in other cases it is obstructed in different places by bands or
septa, which have been produced by similar causes.
Where the condition of the vagina has been ascertained before labour, much
may be done to ameliorate the condition of the parts, not only by the
treatment already mentioned for rigidity of the vagina under other
circumstances, but also by the judicious application of tents, bougies,
and other means for dilating the passage. A case of this kind came under
our notice some years ago; the patient had been married many years without
being pregnant, and was considerably beyond the age of forty. The deranged
health and enlargement of the abdomen which took place excited no
suspicions of pregnancy either in her mind or that of her medical
attendant: the case was suspected to be ovarian dropsy, and a variety of
medicines under this supposition were administered, both internally and
externally: the commencement of actual labour appears to have been equally
mistaken; nor was it until labour had advanced considerably that the real
nature of the case was discovered; from its length and severity, violent
inflammation and sloughing of the vagina was the result, the canal became
much contracted, and was rendered still farther impervious by the
formation of strong bands or septa which were stretched across it, and
which effectually prevented the os uteri from being reached; sponge tents,
and oval gum elastic pessaries of different sizes were introduced, and by
degrees such a state of dilatation was produced as not only permitted the
os uteri to be reached, but restored the vagina in great measure to its
natural size.
The action of labour forcing the head of the child against these
contractions and adhesions is frequently sufficient ultimately, to effect
the necessary degree of dilatation; where, however, this is not the case,
they require to be divided by the knife. The proper moment for doing this
is during a pain, when the parts are put strongly on the stretch: we can
now feel exactly where there is the greatest resistance, and where an
incision will produce the most effect. In this state also the incision can
be effected with most ease, for the stricture being firmly distended, the
knife will more readily divide it than where it is relaxed; the patient
also at this moment is not sensible to the cutting of the knife. The lower
part of the blade well armed with lint or tow should be cautiously
introduced along the side of the finger during an interval of the pains:
in this way the necessary number of incisions may be made: this is usually
followed by a good deal of bleeding, which tends still farther to relax
the parts; and when the head has advanced low enough, a cautious attempt
may be made with the forceps to deliver it.
In recommending dilatation by means of the knife, it must be distinctly
understood, that a sufficient time should be allowed in order to see how
much can be effected by the uterine efforts, for in many of these cases
the stricture has at length yielded after severe and protracted
suffering.[128] In cases of this kind, also, the effects of bleeding are
by no means inconsiderable, and must not be neglected.
The _unruptured hymen_ has been said to be capable of impeding the
progress of the head, but this can only be where the membrane is of
unnatural strength and thickness. It has more than once occurred to us at
the commencement of labour, to find the hymen uninjured; but it has broken
down under the finger, even during examination, and we are convinced would
have produced no obstacle whatever to the child. Where its structure is
abnormal, and the advance of the labour is evidently retarded by it,
division is the simplest and easiest remedy.
Bands of firm fibrous or almost ligamentous tissue are sometimes found
stretched across the vagina or os externum. We described a remarkable case
of this sort in the _Medical Gazette_, Sep. 26, 1835, where it extended
from the symphysis pubis backwards to the perineum; it had resisted the
pressure of the child's head so powerfully as to produce a deep
indentation along the cranial bones; it was divided by a bistouri, and the
head was immediately expelled.
The _perineum_ can rarely, if ever, prove a serious hindrance to the
labour in primiparæ so long as its structure is healthy, even although it
may be unusually broad. With patience and due management the necessary
degree of dilatation may be obtained by the pressure of the head; and
proposals to dilate it artificially, or even to make a slight incision
into it, do not deserve a moment's consideration. Where, however, it has
been extensively lacerated in a previous labour, and has healed again
throughout its entire length (by no means a common occurrence) or when
there has been much sloughing, the cicatrix thus formed may render it
incapable of relaxation, and thus produce much resistance to the passage
of the head. Even here we may do a great deal by warm hip baths,
fomentations, and especially by bleeding; an incision through the callous
portion is by no means desirable where it can be possibly avoided, as it
only endangers a farther laceration during the expulsion of the head.
Cases nevertheless, occur where the contracted ring of the os externum is
so unyielding and gristly as to make this operation necessary.[129] In all
these cases, where, either the adhesion and contractions have given away,
or have been divided during labour, great care should be taken to prevent
them forming again during the process of healing, by using sponge tents
well greased, and other appropriate means.
_Varicose and oedematous swellings of the labia and nymphæ_ also deserve
mention, although they rarely interfere with the progress of labour to any
great extent. Varicose labia seldom annoy the patient during her
pregnancy; the veins of the part may have become somewhat dilated and the
labium swollen; but it is generally not until the commencement of labour,
that they become hard and knotty: at first they feel like a bunch of
currants imbedded in the cellular tissue of the labium, and as labour
advances, and the return of blood from the part is still more impeded, the
swelling continues to increase in size, and frequently obstructs the os
externum very considerably. The danger here is not so much from its acting
as an obstacle to the passage of the child, as from its bursting during
labour and causing loss of blood and other serious consequences. The
tumour seldom bursts directly externally, but first gives way beneath the
skin, producing extravasation, after which, in consequence of still
farther distention, the labium itself ruptures. In some cases the
hæmorrhage is not very profuse externally, while the extravasation
internally, amounts to some pounds, extending not only to the vagina and
perineum, but also to the groin; and instances have occurred where it has
spread to a great distance over the glutæus muscles.
"The extravasation," says Mr. Ingleby, "usually happens during the pain
which expels the child; but sometimes at an early period of labour, as in
the example of severe hæmorrhage here annexed. I had just left a patient
to whom I had been called, in consequence of the difficult transmission of
the child's head through a distorted pelvis, in connexion with an
inordinate varicose enlargement of the labia pudendi (especially the
left,) when a messenger overtook me urging my immediate return. It
appeared that during the violence of the straining, the tumour on the left
side had suddenly burst at the edge of the vagina posteriorly. The patient
lay in a little lake of blood; and as the bleeding recurred in gushes with
the return of every pain, it became essential to complete delivery, and a
child weighing fifteen pounds was extracted with the forceps. A large
slough separated at the end of the third week." p. 109.
Where no laceration has taken place externally, it is seldom that an
opening for the purpose of removing the effused blood will be of use; on
the contrary, the access of external air cannot but be prejudicial in many
cases. The action of the absorbents is generally sufficient for this
purpose, and may be increased by friction with stimulating liniments, and
most remarkably of all by the application of electricity. Where the
extravasation extends beneath the lining membrane of the vagina, so much
swelling may be produced as nearly to close the passage; this, however,
generally takes place after the birth of the child, the rupture of the
varicose vessel having occurred whilst it was passing.
On perceiving, at the commencement of a labour, that there are varicose
veins in the labium, which are beginning to increase in size and hardness
as the head advances, it will be as well to compress them as much as
possible during the intervals of the pains, when there is less impediment
to the blood returning from them: we can, by thus squeezing out their
contents to a certain degree, lessen the size of the swelling, and thus
prevent it from gaining that extent which might endanger laceration. We
may instantly know when this injury has taken place, by the livid
tumefaction of the parts, and our being no longer able to feel the knotty
portions of the varix. In order to check the effusion of blood as much as
possible, we must apply cold, and thus favour its speedy coagulation
beneath the skin. Where the distention is very great, it may become
necessary to evacuate the effused fluid; but, generally speaking, it is
deeper beneath the surface than might, at first sight, be expected. "It
has been proposed," says Mr. Ingleby, "that the swelling should be
punctured, provided there has been no delay, and the puncture is made
whilst the blood is still liquid. On one occasion I promptly carried this
suggestion into effect, but without success; and, considering the
structure of the labium, it is probable that the greater part of the blood
will coagulate almost as rapidly as it is effused." (Ingleby, _op. cit._
p. 109.)
A considerable degree of suffering and annoyance to the patient may arise
from oedematous swelling of the labia and nymphæ, both previous to and
during her labour. The labia are occasionally so distended as not only to
close the os externum, but to require that the legs should be kept as wide
asunder as possible, to prevent the swollen parts being crushed: the
patient is thus rendered very unwieldy and helpless, if she were not
already so previously by an anasarcous state of the lower extremities,
which frequently accompanies this condition.
Oedema of the labia is of less consequence where the patient has had
several children than where she is a primipara, and seldom either retards
labour to any serious extent, or is attended with any troublesome
consequences afterwards: where, however, it is her first labour, and the
swelling is very considerable, laceration may be produced, the results of
which may be sloughing and gangrene: a fatal case of this kind has been
described by Burton.
Where the labia are much swollen, they not only render the patient
incapable of moving, but are apt to become inflamed and excoriated, from
being in such close contact, and constantly moistened by the trickling of
the urine over them. By preserving the horizontal posture, and thus taking
off the pressure of the child from the soft parts of the pelvis, by
keeping the bowels open by saline laxatives, and by using saturnine and
evaporating lotions to the part, a good deal may be done for the patient's
relief. Where there is no disposition to inflammation, and the parts
appear somewhat flabby, warm and gently stimulating applications will be
preferable. Mr. Ingleby remarks that, "if the swollen parts are punctured
(and a particularly fine curved needle answers best,) a load of serum is
drained off, and relief is rapidly obtained. I have not observed any of
the reported bad effects (sloughing and gangrene for instance) succeed
this little operation; nor are they likely to occur in an unimpaired
constitution." The celebrated Wigand of Hamburgh, who strongly opposed
making incisions into the dropsical structure, does not appear to have
tried the plan recommended above. He considered that, as these swellings
are the result of pressure, the less we do with them the better, merely
taking care to keep up the action of the skin.
Oedema, or rather dropsy, of the nymphæ, is not of common occurrence, and,
when it takes place to a considerable extent, produces a singular
alteration in the appearance of the external organs. The nymphæ protrude
beyond the labia, and depend so much as to rest upon the bed on which the
patient lies, forming a soft membranous bag, fluctuating with the fluid
which it contains. If labour has not actually commenced, we would prefer
endeavouring to excite the absorbents of the part, and thus remove the
effused fluid, to its evacuation by puncture: we have perfectly succeeded,
by the use of warm aromatic stimulating fomentations. The "_species
aromaticæ_" of the Continental pharmacopeiæ may be used with much
advantage in these cases: the mode of its application is, to tie some up
in a loose muslin bag, and soak it in hot wine; this forms an excellent
warm stimulating application, and appears to excite the absorbents very
briskly. A very good imitation of this, is to scald some chamomile
flowers, and having squeezed them tolerably dry, to sprinkle some port
wine over, and then apply them as a poultice. A swelling of this sort can
offer but little obstruction to the passage of the head; and if labour
commence before we have been able to reduce its size sufficiently, we may
at the last let off the fluid by puncture, should the pressure of the head
be such as to threaten laceration.
_Tumours_ of different sorts may obstruct the passage of the child, and,
in some cases, produce an impediment of the most serious character.
Fibrous polypi and hard tubercles of the subcartilaginous character
(commonly called the fleshy tubercle) are those which may present the
greatest resistance, while fungoid growths of malignant disease, whether
cephaloma (brain-like tumour,) hæmatoma (fungus hæmatodes,) or carcinoma,
rarely oppose much obstruction. Their structure is soft and spongy, they
therefore yield to the gradual pressure of the head, become more or less
flattened, and thus allow it to pass. But fibrous or chondromatous tumours
are of too firm a structure to admit of this, and are capable of rendering
the labour not only difficult, but very dangerous. The mass being situated
at the lower part of the uterus, or attached to it by means of a pedicle,
is perhaps forced down into the cavity of the pelvis, beyond which its
attachments do not allow it to advance; if it be a fleshy tubercle
imbedded in the structure of the uterus, it will not be able to advance so
far, but will obstruct the brim of the pelvis, and thus prevent the head
descending into it. In many cases, these tumours are merely covered by the
lining membrane of the uterus, which sometimes forms a species of pedicle.
In either case, an early diagnosis is of great importance, as we may thus
have the opportunity of removing the mass either by the scissors or
ligature.
Dr. Merriman has recorded an interesting case of this kind, where the
polypus which arose from the inner surface of the right lip of the os
uteri was tied, and removed rather more than three weeks before labour
came on. A fatal case, communicated to him by the late Dr. Gooch, is
equally valuable, inasmuch as it shows the results of a contrary
practice.[130]
"The class of tumours which most frequently obstruct labour comprise
follicular enlargements and the prolapsed ovarium. The former disease
originates in the vagina, and has been shown by Mr. Heming to consist in a
dilated state of one of the mucous follicles, which acquires a cyst, and
secretes a fluid of varying colour and consistence, from a dark to a
straw-coloured serum, or a deposition purely gelatinous. Owing to the
density of its walls, and its general tension, the fluid contents of the
tumour are not easily distinguished; but the flaccidity which succeeds a
free puncture is very striking."
"There are two forms of ovarian tumour which obstruct the passage of the
child; in the one, a small cyst in connexion with a very bulky cyst; or
else a portion of a large cyst passes into the recto-vaginal septum, and
bulges through the posterior part of the vagina: in the other, and that
which occurs by far the most frequently, the whole ovary, moderately
enlarged, prolapses within the septum. The descent is peculiarly liable to
happen at two periods; the first near the end of gestation, the second
during labour, the prolapsus being promoted by the relaxation of the soft
parts. The changes which the ovary undergoes when long detained in the
septum, will chiefly depend upon the capacity and yielding state of the
parts. If the woman has not previously borne children, it may remain
small, and scarcely retard delivery; but under contrary circumstances, it
acquires a large size, and nearly fills the vagina. In rare instances, the
bulging is said to have appeared at the anterior part of the pelvis."
(Ingleby, _op. cit._ p. 118.)
The contents of these tumours vary a good deal; the hard ones are usually
lipomatous or fatty tumours, not unfrequently containing hair and
rudiments of teeth. Numerous cases have been recorded where ovarian
tumours, which had been pushed down before the child, have at length
burst, discharging their contents, and thus ceasing to act as an obstacle
to the labour. We quite agree with Mr. Ingleby in recommending puncture
under such circumstances; for, independent of pregnancy, it is a
well-known fact, that there is a much better chance of successfully
tapping an ovarian dropsy per vaginam, than through the abdominal
parietes. The same holds good in operating through the rectum; and he has
described two highly interesting cases where this mode of treatment was
completely successful; one in his own practice, the other in that of our
friend Mr. W. Birch.
_Distended or prolapsed bladder_, &c. Lastly, the urinary bladder may
obstruct the passage of the child, from being prolapsed and distended with
water, or from containing a calculus which is forced down below the head.
In the first case, a prolapsus of the distended bladder can scarcely take
place without much inattention on the part of the practitioner, not having
ascertained whether the bladder had been lately evacuated. In case we
find, upon examination, that there is a disposition to this displacement,
the elastic catheter will enable the tumour of the prolapsed bladder to
collapse, and thus remove all farther trouble. The examination in these
cases must be conducted with care; for an elastic fluctuating tumour of
this kind may be mistaken for the distended membranes, or a hydrocephalic
head; and Dr. Merriman has given a melancholy case where, in consequence
of such an error, the bladder was punctured.
_A stone in the bladder_ is sometimes more difficult to manage. If the
head is only just beginning to enter the brim, the stone may be pushed up
above it; but if it has already engaged completely in the pelvic cavity,
it becomes a question whether it will not be necessary to cut down upon
it, and thus remove it. These cases are, however, of very rare occurrence,
and we must be entirely guided by circumstances, it being impossible to
lay down any precise rules for their treatment.