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,
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.
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.
Obliquity of the uterus would throw the orifice of the neck to one side of the axis of the pelvis, either too far posteriorly, anteriorly, or yet to the right or to the left lateral. In such cases, the position of the patient should be so changed as to rectify the obliquity. If the os is looking backwards too much, she must lie on her back; if too much forward, even on to the pubis, she must throw her chest and trunk forwards; if to the right, she must lie on her right; if to the left, she must lie on her left. In all these cases, the uterus will right itself very soon, and a speedy delivery will ensue.
Agglutination of the external uterine orifice sometimes occurs, even at the hour of labor. Such a state will be recognized by feeling the outlines of the lips apparently covered over by a thin membrane. At every contraction, the line of demarcation between the lips will become more and more apparent, and allow the thin membrane to sink a little between the lips. Now, during a pain, the thinnest and most yielding spot must be found out, and the finger forced with much violence through the membrane. If the finger is not sufficient, a more potent agent must be used, great care being taken not to wound the child or the mother needlessly.
The swelling and elongation of the anterior lip is a frequent cause of delay in labor. The anterior lip, from some causes, may not dilate. It may swell and become paralyzed, and hang down upon the head of the child; whilst the posterior lip kindly dilates, and the presenting part is ready to pass through, but for the stubbornness of the anterior lip. Great and often immediate relief is obtained by pushing up with the finger this anterior lip, and holding it firmly, and even crowding it up further during a pain. It then slips up, sooner or later, above the head, and the distress of the patient is relieved, and the labor progresses finely to its completion.
Induration and hypertrophy of both lips are found in some cases, when the distress of the patient during labor will furnish the symptoms necessary for the indication of the remedy which will effect the desired dilatation.
A cancerous neck is sometimes an obstacle to easy labor. When the cancerous affection occupies only one-half or so of the neck, dilatation will be effected, and the labor brought to a close. But if two thirds, or quite all of the neck be affected, it will be necessary, in order that dilatation be effected, that an incision be made through the schirrosity, in six or eight places, equidistant from each other.
Complete obliteration of the cervix uteri, it is admitted by all medical writers at the present day, does sometimes occur. Of course no os, in this case, can be found by exploring in any direction, far back towards the promontory of the sacrum, and in other directions; but much care is necessary here, for sometimes it is found at an incredibly distant point towards the promontory of the sacrum. When not the faintest line of demarcation of an os can be discovered, one must be made at the lowest or most pendant point of the uterus by a vaginal Caesarean section.
Hernia of the womb, it is admitted, sometimes takes place, by the inguinal or crural rings becoming so much dilated as to allow the escape of the uterus. Pregnancy may continue to the full term, when a reasonable time should be allowed for spontaneous delivery; but it is most likely that a Caesarean section will be found necessary.
A prolapsed womb may become pregnant; or the womb may prolapse suddenly after conception, and the full term be accomplished there: a slow and difficult labor will result; but it may take place fairly, and the uterus return to its place.
DYSTOCIA FROM RUPTURE OF THE UTERUS.
Rupture of the uterus is one of the most serious complications or accidents which can possibly occur during the puerperal state. It may occur at any time during gestation or labor, but is much more frequent in the latter stage than in the former. Primiparae are much less liable to the accident than multiparae. It may occur in the body or in the neck, when it occurs in the neck, it almost always involves a rupture of the vagina also.
The cause of so unfortunate an accident may be referred to many circumstances: great thinness, a softening, or a diseased condition of the walls; mechanical injuries, or too violent contractions may all be enumerated among the circumstances.
When this accident occurs, a sharp, tearing pain is felt, and that so suddenly and severely as to cause the patient to sacrum out with great force, then a sensation of numbness, paleness, swooning, sinking of the pulse, and finally syncope.
When this accident occurs at an early stage of gestation, before the uterus contains much to be discharged, through the rent, the product of conception may dam up the passage, and cause the contents of the uterus to be retained for some days; so that when a reaction ensues after the first shock, a calm or precedes a more violent set of symptoms after the final escape of the product of conception into the cavity of the abdomen. In the later months of conception, the diagnosis is easier to be made, from the fact that the uterine globe has evidently become dissipated; its contents having escaped and become generally diffused throughout the abdominal cavity. There follows a sense of heat and then a burning sensation, as in cases of peritoneal inflammation.
When it occurs during labor, we have added to the other symptoms, a collapse of the bag of waters, or the retrocession of the presenting part, and a terrible hemorrhage from the ruptured organ, a small portion of which will escape from the vagina, but the remainder passes into the abdominal cavity. Hemorrhage occurs in all cases, it is true, but not from the vagina in so marked a degree as in labor, and after the rupture of the membranes. If this occurs during labor, instruments should be applied as soon as possible, to prevent the escape of the child into the abdominal cavity. Should the child have already escaped, the hand should follow and deliver through the rent, care being taken not to drag out the intestines, or to leave any of them embraced in the rent after the extraction of the child. If the rupture occurs from a hydrocephalic head, apply the trocar at once, and then the forceps, or the crochet. Should this be impracticable from the retraction of the uterine walls, the Caesarean section will be the only remedy.
Should the rupture occur after the seventh month, and previous to labor, the Caesarean section should be resorted to at once, particularly if the child be alive. If it occurs in the earlier months of gestation, it is thought to be the better plan to leave the consequences to nature and to such medication as the symptoms of the case would seem to require.
If, after all, in either of the above cases, the patient, survive the loss of blood we may entertain a reasonable hope to save her life, by combating the symptoms as they occur, by means of the proper medication. Inflammation.
When it occurs during labor, we, have aided to the symptoms, a collapse of the bag of waters, or the retrocession of the presenting part, and a terrible hemorrhage from the ruptured organ, a small portion of which will escape from the vagina, but the remainder passes into the abdominal cavity. Hemorrhage occurs in all cases, it is true, but not from the vagina in so marked a degree as in labor, and after the rupture of the membranes. If this occurs during labor, instruments should be applied as soon as possible, to prevent the escape of the child into the abdominal cavity. Should the child have already escaped, the hand should follow and deliver through the rent, care being taken not to drag out the intestines, or to leave any of them embraced in the rent after the extraction of the child. If the rupture occurs from a hydrocephalic head, apply the trocar at once, and then the forceps, or the crotchet, Should this be impracticable from the retraction of the uterine walls, the Caesarean section will be only remedy.
Should the rupture occur after the seventh month, and previous to labor, the Caesarean section should be restored to at once, particularly if the child be alive, If it occurs in the earlier months of gestation, it is thought to be the better plan to leave the consequence to nature and to such medication as the symptoms of the case would seem to require.
If, after all, in either of the above cases, the patient survive the loss of blood, we may entertain a reasonable hope to save her life, by combating the symptoms as they occur, by means of the proper medication. Inflammation will probably be the first, and the worst symptom to contend with. See the remedies under Peritonitis, Hysteritis, &c.
All foreign substances that remain in the abdominal cavity after rupture in any stage of gestation, become encysted as the patient recovers, and may be carried in the cyst for years, or even during her life time, and she may enjoy, in the meanwhile, a tolerable degree of health.
The vagina sometimes becomes ruptured, in which case a similar condition prevails, in all respects, as in case of ruptures of the uterus; except that the symptoms are not so intense, nor so dangerous. This accident occurs only during labor. A similar course of treatment must be resorted to; instruments must be used immediately, or extraction should be effected through the rent, should occasion require. which is very seldom in cases of this kind. The post-partum treatment, according to the medication above recommended, should be carefully instituted, and with reasonable hope of success.
There are certain diseases which may complicate labor, that require special and particular attention. Of this kind are haemoptysis and haematemesis. In these, cases the remedies must be resorted to which are usually employed in treating such diseases. As a general rule, hemorrhages will be controlled and labor will terminate in a regular hemorrhages will be controlled and labor will terminate in a regular, natural way. But if we are not thus fortunate, the labor must be terminated as soon as possible, by artificial means. In asthmas, palpitations, and other diseases of the heart, we should be governed in our action by the principles stated above. In aneurisms, where there is a great danger of rupture at any pain, immediate resort should be had to artificial means of delivery.
When hernia exists it should be reduced as soon as possible, and when it is utterly impossible to reduce it, the best practice is to resort to artificial means of delivery, in order that the hernial protrusion may not be strangulated longer than necessary, for fear of mortification and consequent sloughing. When the hernia is liable to return after reduction, it may be kept back by constant pressure. Fainting spells and syncopes are all curable by using the proper medicines. See remedies for Labor. When there is great exhaustion from debility, and it cannot be relieved by the proper medicines, resort to artificial means for delivery.