Sitz, or full baths, emollient injections, fumigation with aromatics, venesection till syncope ensues, laudanum-enemata, and applications of belladonna to the cervix, have been recommended in turn. We have had some results from the application to the cervix of the watery extract of belladonna, but it often fails. Chloroform, pushed to the degree of complete anaesthesia, has been recommended, but in order to affect 'the uterine muscle it must be administered to a dangerous extent. Its prin cipal action seems to be that of a nervous sedative; chloral accomplishes the same result without danger, and to it we give the preference. If chloral fails, and it becomes necessary to terminate the labor, we must resort to incision of the cervix. A long, blunt-pointed bistouri is passed along the left forefinger, and a small lateral incision is made at the sharp, rigid border of the os; one or two cuts are usually sufficient and dilatation then proceeds rapidly. Blot was once obliged to make eight incisions before the os would dilate. Such incisions are to be preferred to forced dilatation, after other remedies have failed. If the spasm is confined to the os internum, incision is absolutely contra-indicated, and we must . try forced dilatation, although the latter should be regarded as an ex treme measure, because it exposes the woman to extreme danger, and often leads to rupture of the uterus. If the spasm occurs after the birth of the head or trunk of the foetus, we must act quickly, and either incise or dilate forcibly, according as the contraction is at the external or in ternal os.
C.—Pathological Rigidity.—This may be due to bands or cicatrices, tumors, or cancer of the cervix. It is to be distinguished from the other two varieties by the shape and peculiar character of the cervix.
II. Obliteration of the Cel When limited to the os cxternum, this has been termed by Naegel( adhesion of the os externum. In this case the obstacle consists of a fi brous tissue similar to peritoneal adhesions. The entire cervical canal may be affected, a condition called by Depaul complete obliteration of the cervix; this is much rarer than the partial forms.
Causes.—Injuries during parturition, especially from the use of instru ments and cauterization of the cervix are among the causes. In closure of the os externum the finger seems to enter a cul-de-sac at the upper part of the vagina, no orifice being felt; or the cervix may be felt, but there is only a slight central depression. How shall we recognize complete oblit eration ? 1. Obliteration of the Os Internum.—A suspicion of the existence of this condition will be aroused when the uterine contractions have con tinued for some time without producing the usual results. The finger passes through the os externum and meets at the level of the os internum, a complete septum without any opening. Through the speculum the condition will be recognized at once.
2. Obliteration of the Os Externum.—On examination a smooth,
rounded tumor will be felt at the upper part of the vagina, having a firm consistence (if the head presents), but without any projection, orifice, or depression, suggesting the cervix. The adhesion in this instance is be tween the lips; sometimes a slight prominence may be felt, or a small de pression, without any orifice, which indicates beyond doubt the site of the obliterated os. The vagina is dry, there being neither mucus, nor amniotic fluid. The uterine contractions produce no change in this con dition.
This alteration is not to be mistaken for deviation of the os, a malfor mation of the portio vaginalis, atresia of the cervix, or cicatricial bands or septa in the vagina.
Prognosis.—This is graver than would at first appear. When the ci catricial tissue is old and dense, surgical interference may be necessary.
Treatment.—Wait till you are sure that nature cannot overcome the obstacle, then try to dilate with the finger, and finally resort to incision, because eclampsia and rupture of the uterus may result from too long delay. We must always operate at the point of obliteration, which can easily be found when it is situated at the os internum, because the canal is a guide to it; when the os externum is closed, we must determine the point of least resistance, and then introduce the bistoury, dividing each layer of tissue in turn, and not by a single cut. The finger glides be tween the uterine wall and the fcetal part, and the opening is then en larged by multiple incisions. Before operating, be sure that there is really an obliteration of the orifice and not merely a deviation of the same, because a fatal error has been made in this way. We should not confine ourselves to an examination by the finger and speculum, but should chlo roform the patient, and introduce the whole hand into the vagina, if nec essary, before proceeding to make an incision. Hecker has reported a unique case of agglutination of the os uteri produced by its union with the membranes.
III. Deviations of the 08.
These follow displacements of the uterus, the cervix being carried back wards or forwards, according as the organ is ante- or retroverted; the former is most common. As labor proceeds, the cervix will be carried so much farther backwards, according as the lower uterine segment projects farther into the vagina. The cervix dilates very slowly in these cases, since the contracting force is exercised upon its anterior and upper part.
It is sufficient to draw the cervix forwards into the pelvic axis during the pain, and to keep the woman on her back, reversing the former ma noeuvre if the cervix point forwards. In some cases this deviation of the cervix may be due to what Depaul has called " sacciform dilatation" of the uterus; the cervix is pushed up above the symphysis, so that it is ex tremely difficult to reach it. This may become a very serious cause of dystocia.