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.