MALFORMATIONS OF THE VULVA AND VAGINA; TUMORS, &C.
Adhesions of the vulva may occur, hindering the expulsion of the child. In a case of this kind, it only necessary to divide the adhering portion with the scalpel at the moment that the presenting part is pressing down upon the adhesion.
The hymen also may be so persistent as to hinder the expulsion; this also should then be divided with the scalpel.
Contractions and rigidity of the vulva quite frequently delay the expulsion very much, but I have never found it necessary to operate in cases of this kind. Aconite, most usually, or some other remedy has aided the dilatation, and a little patience has always sufficed and I believe always will suffice in such cases.
Remarkable cases of resistance on the part of the perineum are met with when the labor has been much delayed. Aconite, or some other remedy, has invariably supported the contractions and aided in the dilatation, and the delivery has been satisfactorily accomplished. In some cases the whole perineum has appeared to fit in such a manner the child’s head, and to sink down so low that it has been found necessary to apply the forceps and simply lift the head directly out of the little sulcus it has seemed to make for itself there.
The vagina may be found malformed, or adherent, or the hymen may be double or triple, and thrown across high up in the vagina; or there may be a complete septum in the vagina. These cases should all be treated with the knife, if necessary; and according to circumstances present; these will indicate the proper treatment.
Inversion of the vagina sometimes takes place during labor, when the protruding portion from prolonged pressure becomes gangrenous, When this is likely to occur, the forceps should be used at once, and the expulsion accomplished. When this condition is apprehended or observed in its incipiency, the accident can be averted by carefully crowding the descending parts back continually as the labor progresses.
Tumors are also liable to obstruct the passage, so as to cause great and even fatal delay. These may be osseous tumors, or they may belong to the soft parts.
Exostoses are likely to exist and to form some of the most formidable obstacles to a safe delivery. These usually arise from the anterior face of the sacrum, sometimes from the ischium and the pubis. This tumor is recognized by its hardness, immobility, roughness, and adherence to the bone. These forms of tumor continue to grow in size from year, and consequently to become more and more formidable at every successive pregnancy, unless cured by the proper Homoeopathic remedies. Compare article on Exostosis. The only plan of treatment is that pursued in deformed pelvis.
Osteo-sarcoma is another type of malformation, quite similar to the one just mentioned. The only difference is that it is somewhat compressible, a mixture of the osseous, fibrous, and cartilaginous matter. Even the osseous crepitation can be felt on pressure. The plan of treatment is the same as that in the last case.
Osseous tumors are sometimes met with in the pelvic cavity. These arise from an improper union of fractures; and, further, from the head of the femur being forced in upon the acetabulum. These affections are of course fixed and incurable. Others may be cured by a proper course of medical treatment. The pain of delivery must be conducted as in similar cases of pelvic deformity.
OEdema of the labia, so far as my experience goes, presents no formidable obstruction to the process of parturition. Patience and the administration of the remedies according to the principles already laid down, will assist the work of nature and no surgical operation will be found necessary.
Sanguineous tumors sometimes form in the soft parts, in the labia, among the muscles of the pelvis, or even in the neck and lips of the uterus. If the size of these tumors increase gradually, the case should be treated by the administration of Aconite, Hamamelis Erigeron, or any other remedy strongly indicated by characteristic symptoms, which will then be sure to arrests the difficulty and facilitate parturition.
Various other tumors are found in and about the track which the child must pursue in its passage to the light of day; many of which need no attention during parturition, if they are not obstacles to the expulsion of the child; if they are, they may need to be punctured, incised, or removed, as the nature of the case may indicate. It is always best to wait and allow nature to do her own work, if possible. Many of these tumors are not discovered until the hour of parturition arrives. And note should be made of them and the proper treatment resorted to, after the lying-in-period has passed.
TUMORS OF THE NECK AND BODY OF THE UTERUS.
These may be Encysted, or Fibrous Tumors, or Cauliflower Excrescences.
If encysted tumors prove an obstruction to delivery, they may be punctured and the fluid which they contain drawn off; or if they contain cheesy matter, an incision will allow it to pass out, especially under the pressure from above during the accession of a pain. But unless their size prevent the expulsion of the child, they need not be interfered with.
Pedunculated fibrous tumors or polypi usually precede the advancing portion of the child as shown in the accompanying cut, Fig. 93. In such cases, we may ligate the neck of the tumor, and remove it, if though best.
Cauliflower tumors, or excrescences. These cancerous or syphilitic growths seldom cause delay, unless their size is very considerable. But where they are large the condition is much serious. Several cases are quoted by Cazeaux from Puchelt: in one, it was necessary to make incisions upon another part of the hard or scirrhous neck, so as to secure the introduction of the hand; and in a second, to remove the tumor that was attached to the anterior lip and occupied all the vagina, by the scissors; gastrotomy was resorted to in a third, on account of a rupture of the womb, and not even the child was saved; in another, the extraction of the child was impossible,
Fig. 93.
This figure, taken from Ramsbotham’s work, shows the situation of the polypus pressed down by the advancing head in parturition.
notwithstanding the perforation of the cranium, and the woman died before delivery. Only a single mother survived. But this great fatality is no doubt in part due to the malignant nature of the disease which supports these excrescences.
Ovarian tumors, and those of the Fallopian tubes, must, if possible, be pushed back above the superior strait. If this should prove impracticable, and they offer serious impediment to delivery, let them protrude still further, then they may be perforated with a trocar, and their fluid contents evacuated. Should these contents prove semi-solid, -cheesy matters, a more free incision may be made, when the downward pressure of the child ‘s head will speedily cause their discharge.
Tumors of the Rectum. Sometimes tumors of this kind seem very formidable, but an injection or two will generally dissipate them. Sometimes, however, they require a scoop. These tumors are composed of an accumulation of feces.
Tumors of the bladder may usually be remedied by the catheter, and when it is prolapsed it must be crowded up to its place. If there is a calculus, it must be elevated above the superior strait, or, if this is impossible, it must be excised. If the bladder be in a cancerous condition, it must be pushed up as high as possible, at the moment the presenting part of the child is descending. In case of calculus, terrestrial gravity will do much for us, if we will place the patient on her knees and face.
Hernia, Intestinal or Omental, Vulva or Perineal. These tumors must be reduced as soon as discovered, and much aid may be derived from placing the patient on her knees and face; then a little manipulation will cause the tumor to ascend. A horizontal position must be insisted on now until the child is born.
Vesical hernia, or cystocele, occurs quite frequently. The male catheter must be introduced at once; and after the urine has been discharged, the bladder must be crowded up to its place. The tumor will be found above in its natural place. See cut 94. The introduction of the catheter makes the case clear and unmistakable.
Fig. 94.
Vaginal cystocele, taken from Ramsbotham.
DYSTOCIA FROM AFFECTIONS OF THE CERVIX AND UTERUS.
Rigidity of the neck of the uterus often causes dystocia. An examination per vaginam results in finding a hard, contracted, unyielding, muscular body, even in the absence of pain. It is not a schirrous, but a muscular hardness. For its relief, see the remarks on labor pains. Belladonna is the remedy most frequently indicated.
In spasmodic contractions of the neck, an examination per vaginam discovers a thin, almost cutting edge of the os tincae. In this state also, labor, is very much retarded until the proper remedy is brought to bear upon the system: Bellad, Sepia, and some others, which may be found among the remedies for labor. The general and the particular characteristic symptoms must determine the proper medical treatment; relief will speedily follow. All these different states arise from some constitutional derangement, and hence the marked success attending the administering of the properly selected medicines in unlocking and setting free the obstruction.
