FIRST SPECIES OF DYSTOCIA.

Obstructed Labour from a Faulty Condition of the soft Passages.

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.

Œdema 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.

Œdema, 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.