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The question of the effect on labor of ovarian tumor which does not obstruct the pelvic canal is one of some interest, but there are not a sufficient number of cases recorded to throw much light on it. I am disposed to think that labor generally goes on favorably. What delay there is depends on the inefficient action of the accessory muscles engaged in parturition, on account of the extreme distention of the abdomen.

There are a few other conditions connected with the maternal structures which may impede delivery, but which are of comparatively rare

occurrence.

Vaginal Cystocele.-Amongst them is vaginal cystocele, consisting of a prolapse of the distended bladder in front of the presentation, where it forms a tense fluctuating pouch which has been mistaken for a hydrocephalic head, or for the bag of membranes. This complication is only likely to arise when the bladder has been allowed to become unduly distended from want of attention to the voiding of urine during labor. The diagnosis should not offer any difficulty, for the finger will be able to pass behind, but not in front of, the swelling, and reach the presenting part; while the pain and tenesmus will further put the practitioner on his guard. The treatment consists in emptying the bladder; but there may be some difficulty in passing the catheter, in consequence of the urethra being dragged out of its natural direction. A long elastic male catheter will almost always pass, if used with care and gentleness. Should it be found impossible to draw off the water -and this is said to have sometimes happened-the tense pouch might be punctured without danger by the fine needle of an aspirator trocar, and its contents withdrawn. When once the viscus is emptied, it can easily be pushed above the presenting part in the intervals between the pains.

Vesical Calculus.-In some few cases difficulties have arisen from the existence of a vesical calculus. Should this be pushed down in front of the head, it can readily be understood that the maternal structures would run the risk of being seriously bruised and injured. Should we make out the existence of a calculus-and, if the presence of one be suspected, the diagnosis could easily be made by means of a sound-an endeavor should be made to push it above the brim of the pelvis. If that be found to be impossible, no resource is left but its removal, either by crushing, or by rapid dilatation of the urethra, followed by extraction. Should we be aware of the existence of a calculus during pregnancy, its removal should certainly be undertaken before labor sets in.

Hernial protrusion in Douglas's space may sometimes give rise to anxiety, from the pressure and contusion to which it is necessarily subjected. An endeavor must be made to replace it, and to moderate the straining efforts of the patient; and it may even be advisable to apply the forceps so as to relieve the mass from pressure as soon as possible. It is, however, of great rarity. Fordyce Barker, in an interesting paper on the subject,' records several examples, and states

1 Amer. Journ. of Obst., 1876, vol. ix. p. 177.

that he has met with no instance in which it has led to a fatal result, either to mother or child, although it cannot but be considered a serious complication.

Scybalous masses in the intestines may be so hard and impacted as to form an obstruction. The necessity of attending to the state of the rectum has already been pointed out. Should it be found impossible to empty the bowel by large enemata, the mass must be mechanically broken down and removed by the scoop.

[Our Southern readers are aware of the fact that their lowest class of women living in the country sometimes eat clay as a remedy for heartburn, and occasionally in excessive quantities, during the pregnant state. Impacted clay in the lower bowels has on two occasions proved such an obstacle to delivery that the Cæsarean operation was performed, one case occurring in Louisiana and the other in Georgia, in the years 1866 and 1882 respectively, after labors of sixty hours and three days. The first case recovered, the clay being removed by an attack of diarrhoea on the sixth day. The second died of convulsions in twenty days after the uterine and abdominal wounds had healed. Under chloroform about two and a half pounds of sand and marl were removed three days after the operation.-ED.]

Edema of the Vulva.-Excessive ædematous infiltration of the vulva may sometimes cause obstruction, and require diminution in size, which can easily be effected by numerous small punctures.

Hæmatic effusions into the cellular tissue of the vulva or vagina form a grave complication of labor. Such blood-swellings are most usually met with in one or both labia, or under the vaginal wall; in the gravest forms, the blood may extend into the tissues for a considerable distance, as in the case recorded by Cazeaux, where it reached upward as far as the umbilicus in front, and as far as the attachment of the diaphragm behind.

The conditions associated with pregnancy, the distention and engorgement to which the vessels are subjected, the interference with the return of the blood by the pressure of the head during labor, and the violent efforts of the patient, afford a ready explanation of the reason why a vessel may be predisposed to rupture and admit the extravasation of blood.

The accident is fortunately far from a common one, although a sufficient number of cases are recorded to make us familiar with its symptoms and risks. The dangers attending such effusions would seem to be great, if the statistics given by those who have written on the subject are to be trusted. Thus, out of one hundred and twentyfour cases collected by various French authors, forty-four proved fatal. Fordyce Barker points out that, since the nature and appropriate treatment of the accident have been more thoroughly understood, the mortality has been much lessened; for out of fifteen cases reported by Scanzoni only one died, and out of twenty-two cases he had himself seen, two died, and all these three deaths were from puerperal fever, and not the direct result of the accident.1

1 The Puerperal Diseases, p. 60.

The blood may be effused into any part of the pelvic cellular tissue, or into the labia. The accident most often happens during labor when the head is low down in the pelvis, not unfrequently just as it is about to escape from the vulva. Hence the extravasation is more often met with low down in the vagina, and more frequently in one of the labia than in any other situation. I have met with a case in which I had every reason to believe that an extravasation of blood had occurred within the tissues immediately surrounding the cervix. It is natural to suppose that a varicose condition of the veins about the vulva would predispose to the accident, but in most of the recorded examples this is not stated to have been the case. Still, if varicose veins exist to any marked degree, some anxiety on this point cannot but be felt.

The thrombus occasionally, though rarely, forms before delivery. Most commonly it first forms toward the end of labor, or after the birth of the child. In the latter case it is probable that the laceration in the vessels occurred before the birth of the child, and that the pressure of the presenting part prevented the escape of any quantity of blood at the time of laceration.

The symptoms are not by any means characteristic. Pain of a tearing character, occasionally very intense, and extending to the back and down the thighs, is very generally associated with the formation of the thrombus. If a careful physical examination be made, the nature of the case can readily be detected. When the blood escapes into the labium, a firm, hard swelling is felt which has even been mistaken for the foetal head. If the effusion implicate the internal parts only, the diagnosis may not at first be so evident. But even then a little care should prevent any mistake, for the swelling may be felt in the vagina, and may even form an obstacle to the passage of the child. Cazeaux mentions cases in which it was so extensive as to compress the rectum and urethra, and even to prevent the exit of the lochia. In some cases the distention of the tissues is so great that they lacerate, and then hemorrhage, sometimes so profuse as directly to imperil the life of the patient, may occur. The bursting of the skin may take place some time subsequent to the formation of the thrombus. Constitutional symptoms will be in proportion to the amount of blood lost, either by extravasation or externally, after the rupture of the superficial tissues. Occasionally they are considerable, and are the same as those of hemorrhage from any cause.

The terminations of thrombus are either spontaneous absorption, which may occur if the amount of blood extravasated be small; or the tumor may burst, and then there is external hemorrhage; or it may suppurate, the contained coagula being discharged from the cavity of the cyst; or, finally, sloughing of the superficial tissues has occurred.

The treatment must naturally vary with the size of the thrombus, and the time at which it forms. If it be met with during labor, unless it be extremely small, it will be very apt to form an obstruction to the passage of the child. Under such circumstances it is clearly advisable to terminate the labor as soon as possible, so as to remove the obstacle to the circulation in the vessels. For this purpose the

forceps should be applied as soon as the head can be easily reached. If the tumor itself obstruct the passage of the head, or if it be of any considerable size, it will be necessary to incise it freely at its most prominent point and turn out the coagula, controlling the hemorrhage at once by filling the cavity with cotton wadding saturated in a solution of perchloride of iron, while at the same time digital compression with the tips of the fingers is kept up. By this means pressure is applied directly to the bleeding-point, and the hemorrhage can be controlled without difficulty. This is all the more necessary if spontaneous rupture has taken place, for then the loss of blood is often profuse, and it is of the utmost importance to reach the site of the hemorrhage as nearly as possible.

If the thrombus be not so large as to obstruct delivery, or if it be not detected until after the birth of the child, the question arises whether the case should not be left alone, in the hope that absorption may occur, as in most cases of pelvic hæmatocele. This expectant treatment is advised by Cazeaux, and it seems to be the most rational plan we can adopt. True, it may take a longer time for the patient to convalesce completely than if the coagula were removed at once, and the hemorrhage restrained by pressure on the bleeding-point; but this disadvantage is more than counterbalanced by the absence of risk from hemorrhage, and of septicemia from the suppuration that must necessarily follow. Softening and suppuration may in many cases occur in a few days, necessitating operation, but the vessels will then be probably occluded, and the risk of hemorrhage be much lessened. The late Dr. Fordyce Barker, however, held the opposite opinion, and thought that the proper plan was to open the thrombus early, controlling the hemorrhage in the manner already indicated, unless the thrombus is situated high in the vaginal canal.

Whenever the cavity of a thrombus has been opened, either by incision or by spontaneous softening at some time subsequent to its formation, it must not be forgotten that there is considerable risk of septic absorption. To avoid this, care must be taken to use antiseptic dressings freely, such as iodoform powder or wool, applied directly to the part, and frequent vaginal injections of diluted Condy's fluid. Barker laid special stress upon the importance of not removing prematurely the coagula formed by the styptic applications, for fear of secondary hemorrhage, but of allowing them to come away spontaneously.

[Polypus.-Large uterine polypi may act as serious obstacles to delivery. When sufficiently long in pedicle, a polypus may be extruded before the head of the foetus. The tumor may also be detached in its expulsion, or may be removed by an écraseur if recognized in time; it may also be pushed up out of the way and secured by bringing down the child. I once replaced a large polypus that was extruded before the head, and the woman carried it two years longer; by which time, being much wasted by the discharge, she made up her mind to have it removed.-ED.]

CHAPTER XI.

DIFFICULT LABOR DEPENDING ON SOME UNUSUAL
CONDITION OF THE FETUS.

Plural Births.-The subject of multiple pregnancy in general having already been fully considered, we have now only to discuss its practical bearing as regards labor. Fortunately, the existence of twins rarely gives rise to any serious difficulty. In the large proportion of cases the presence of a second foetus is not suspected until the birth of the first, when the nature of the case is at once apparent from the fact of the uterus remaining as large, or nearly as large, as it was before.

There may possibly be some delay in the birth of the first child, inasmuch as the extreme distention of the uterus may interfere with

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its thoroughly efficient action; while, in addition, the uterine pressure is not directly conveyed to the ovum as in single births, but indirectly through the amniotic sac of the second child (Fig. 130). Such delay is especially apt to arise when the first child presents by the breech, for, even if the body be expelled spontaneously, difficulty is likely to occur with the head, since the uterus does not contract upon

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