The use of a 10-per-cent. solution of co caine is advocated for rigid undilatable os uteri. In five cases, all primiparm, from nineteen to forty years old, it was used with unvarying success, and dila tation was always secured in a very few minutes. The solution is rubbed over the external and internal surfaces of the cervix, and the cotton is alloweu to re main in contact with the os for a few minutes. Farrar (Brit. Med. Jour., Sept.
17, '98).
has been little recognized, and consequently few obstetricians use it in their methods of treatment. In practice the various positions offer most valuable assistance. They are divided into (1) the right and left lateral position, (2) the knee-chest, (3) exaggerated lithotomy, (4) the Walther, and (5) the Trendelenburg.
The lateral postures, right and left, arc of signal service in posterior position of the anatomical head, or in anterior po sitions in which by turning the patient on the side the pains are intensified. Their rationale is not clear, but the sup position is that they overcome the ex treme uterine obliquity present in these cases, causing the fatal spine to be straightened and consequently to be come more rigid. This makes it pos sible to carry the force of the contrac tion directly along practically a straight line, in this way influencing and increas ing flexion or extension of the head, ac cording to whether the vertex or face presents. In these cases the patient is turned on that side corresponding to the position of the presenting part, in R. 0. P. vertex cases on the right side, or, again, L. P. face on the left side. In a majority of these malpositions speedy rotation occurs as a result of these manoeuvres.
The knee - chest position has been recommended by many as a manipula tive position for purposes of operation. It is claimed that versions can be more readily done and that a prolapsed cord will of its own weight fall back into the uterus. This we have never been able to confirm. In performing versions in this position our experience has shown that not alone the foetus, but the whole uterus, is drawn much too far away by force of its own gravity to make the operation easy or satisfactory. In pro lapsus funi a deliberate version is far more preferable to measures such as this or others which at best are uncertain and not reliable.
The exaggerated lithotomy and the Walcher positions are hyperflexions of the lower trunk and legs in the first named, and exaggerated extension of the same in the last named. The lithot omy position is the usual position for delivery in this country. By assuming this decubitus, the pelvic outlet is ma terially enlarged in all its diameters, at the expense of the pelvic inlet. Its ra tionale is the reverse of the Walcher, which will be more fully explained be low. Indications for this position would hold only in contractions at the outlet or for the purpose of increasing the di ameters in normal cases. This would obtain in cases in which the head re mains fixed for many hours at the out let, owing to an apparent or real minor contraction of that part, possibly as a sult of a pseudomasculine type of pelvis.
In the Walcher position we have a really valuable source of assistance. By hyperextension of the trunk, the but tocks overhanging the table and the feet swinging free over the floor, the patient being held in place by roller sheets pass ing under the armpits, there occurs an increase in the size of the diameter of the pelvic inlet of from to $/4 of an inch, at the expense of the pelvic outlet. This increase in the conjugate vera is primarily due to a rotation of the filo femoral joints. This pushes the sacrum at the sacroiliac joint backward, because of the laxity of the posterior ligaments. The axis of the pelvic brim presents downward at an angle of about 40 de grees.
This position is indicated in minor pelvic contractions when the head fails to engage. The patient may be placed in this position and left there for some time till the head engages. In versions for minor contractions as the head passes the pelvic inlet it is of great service. But it must be remembered that the en largement is always at the expense of the outlet, and, as the presenting part passes the obstruction, the patient must be thrown into the exaggerated lithotomy position to enlarge the pelvic outlet. The great value of the Walcher position lies in the fact that it has very materially limited the field for the operation of symphysiotomy, not to mention the positive increase in size obtained at the pelvic inlet.