SECOND SPECIES OF DYSTOCIA.
_Size and form of the child.--Hydrocephalus.--Cerebral tumours.--
Accumulation of fluid and tumours in the chest or abdomen.--
Monsters.--Anchylosis of the joints of the foetus._
In this case the labour is rendered difficult or impossible to be
completed by the natural powers on account of the faulty size, form, or
condition of the child. In the first instance, it is merely a case of
disproportion between the child and the passages, owing to the unusual
size of the former. Where the child is well formed throughout, but larger
than usual, it rarely happens that the head experiences any serious degree
of difficulty in passing through a well-formed pelvis, the greatest
resistance being observed during the dilatation of the external passages.
Even when the head is born, the shoulders may produce a considerable
obstruction to its farther passage, requiring a good deal of careful
manipulation, in order to disengage the foremost shoulder from under the
pubic arch, and thus diminish the pressure of the child against the
parietes of the pelvic cavity. Where the shoulders have been severely
impacted in this position, it has been in great measure owing to the
practitioner having endeavoured to bring down the wrong shoulder first,
viz. that which is directed more or less backwards.
_Size of the child._ We have already stated that the average weight of the
full grown foetus is between six and seven pounds, and its length about
eighteen inches; but it is frequently found to exceed these proportions
very considerably. Children are not uncommonly observed to weigh 10lbs. at
birth. Dr. Merriman once delivered a still-born child, which weighed
14lbs., and the late Sir Richard Crofts is said to have delivered one
alive which actually weighed 15lbs.; but by far the largest child which we
have yet heard of is recorded by Mr. J. D. Owens, surgeon, at Haymoor near
Ludlow; it was born dead, and the weight and admeasurements ten hours
after birth were as follow:--
The long diameter from the occiput to the root of the nose 7-1/4 inches.
The occipito-mental 8-1/2
From one parietal protuberance to the other 5
Circumference of the skull 15-1/4
Circumference of the thorax over the xiphoid cartilage 14-1/2
Breadth of the shoulders 7-1/4
Extreme length of the child 24
Weight of the child 17 lbs. 12 oz.
(_Lancet_, Dec. 22. 1838.)
We have already pointed out the difficulty of determining the presence of
twins merely from the appearance of the mother's abdomen; the same will
necessarily hold good with regard to one large child. The size of the
patient must rarely have any influence in forming our prognosis: in most
cases she will have many symptoms, which arise either from pressure or
weight in the pelvis, such as difficulty in passing water, oedema of the
feet and legs, varicose veins of the thighs and labia, or from cramps, the
result of pressure upon the absorbents, veins, or nerves; considerable
expansion of the inferior segment of the uterus: all these will give us
reason to suspect the presence of a large child even although the abdomen
may not be remarkably distended.
Where the head is very large, the bones are seldom much ossified; they
therefore yield easily, and the head accommodates itself to the shape of
the passage: sometimes, however, it is unusually hard, the bones are well
ossified and very unyielding, so that even if it be not larger than
common, still, from its hardness, it meets with considerable difficulty in
passing through the pelvis. Cases have been described where the cranial
bones were completely ossified, and the sutures perfect; but this latter
is very doubtful. Perfect mentions an instance where the head was "almost
one entire ossification, and where it passed through the pelvis with great
difficulty." (Perfect's _Cases in Midwifery_, vol. ii. p. 370.) We have
also met with cases requiring perforation on account of deformed pelvis,
and where the cranial bones had almost the feel of a hard nut or shell;
still, however, as already observed, we seldom see any serious impediment
to the passage of a large head, so long as it is naturally formed; and
this applies also to the other parts of the child.
_Form of the child._ On the other hand, where there is an unnatural form
of the child, either from a disproportionate size or anormal configuration
of certain parts, labour may be rendered not only very difficult but
dangerous: thus one of the three great cavities may be distended with an
accumulation of fluid, the most common form of which, is the congenital
hydrocephalus.
_Hydrocephalus._ In many cases it produces much less resistance than might
be expected from the size of the head; this is, in great measure, owing to
the unusual width of the sutures and fontanelles, but chiefly to the
almost entire want of ossification in the cranial parietes, which are
little else than membranous, and so flexible as to allow the head to be
squeezed into almost any shape. In some very rare cases the head has
burst, a large quantity of fluid has come away suddenly, and this has been
followed almost immediately by the birth of the child:[115] but in the
majority the labour has been tedious and severe, and in some instances
attended with dangerous results to the patient; thus, Dr. Merriman has
"known one hydrocephalic foetus pass entire, the circumference of whose
head was 17 inches; another passed alive and lived nearly an hour, whose
head measured in circumference nearly 22 inches; both the above labours
were long and painful." Perfect relates a case of hydrocephalic head, of
which he has given engraved delineations; the labour was attended with
extreme difficulty, and the woman expired in less than two hours after
delivery; the circumference of this head was 24 inches. (_Cases in
Midwifery_, vol. ii. p. 525.) An interesting case of hydrocephalus,
attended with convulsions and laceration of the vagina, has been recorded
by Dr. Collins: "the perforator was used, upon the introduction of which
into the head fully three half pints of water gushed out; the bones then
collapsed, and the delivery was easily completed." (_Practical
Observations_, p. 205.)
_Cerebral tumours._ The bulk of the head is sometimes increased by tumours
or sacs of fluid, which arise from a suture or fontanelle: they are of the
same nature as the spina bifida, being formed by a protrusion of the
integuments and cerebral membranes from an accumulation of fluid beneath:
these are of very rare occurrence, and appear to have retarded labour but
little, even although of considerable size. The largest cases on record
are those which have been described by Ruysch, where one was as big as the
head itself, and another where it was nearly as large as the child's
body.[116] A case of fluctuating tumour upon a child's head has been
described by Mauriceau, (Case 544,) but the precise nature of it is not
very apparent.
_Accumulations of fluid, and tumours in the chest or abdomen._ It is very
rare that the chest is distended by any accumulation of fluid or morbid
growth, although this is not unfrequently met with in the abdomen. La
Motte has given three cases of ascites which, by the distention of the
abdomen, produced considerable obstruction to the delivery of the child.
(Cases 331, 332, and 333.) In other cases the liver or the kidneys have
been enormously enlarged. A case is described by Dr. Hemmer, where the
child was born as far as the shoulders, and there stuck; finding it
impossible to extract the child, he perforated the abdomen in two places,
but could not extract it; in a few minutes after it came away of itself.
The abdomen had been distended with small hydatids; these gradually
escaped, and thus diminished the size of the abdomen. (_Neue Zeitschrift
für Geburtshülfe_, band iv. heft 1, 1836.) Where the child has been dead
some time in the uterus, the abdomen is frequently tympanic, and thus
retards its expulsion.
_Monsters._ Certain cases of monstrous formation may produce very serious
obstacles to the progress of labour: the most considerable is of twins
united by the breast. It is difficult to conceive how so large a mass can
be forced through the pelvis: we can only suppose it possible where the
children have been dead some time before birth, or where they were
premature: to this latter circumstance only we can attribute the fact of
their having been born alive, as in the celebrated case of the Siamese
twins. Where the children have been united by one pelvis, &c., the chances
here of the foetus being dead before birth would be even still greater. M.
Rath, of Zetterfeld, has lately described a case of extremely difficult
labour, in consequence of twins united by the breast. "The children (two
girls) weighed 15lbs.; they were 17 inches long. The part by which they
were united was 9 inches broad and 3 long, and extended from the upper
extremity of the sternum to the navel, into which one umbilical cord,
which was common to both, entered. The diameter of the two children when
laid together was between 7 and 8 inches from one back to the other. One
child had two thumbs on the right hand. The cord was 19 inches long, and
unusually thick. After suffering some time from peritonitis, &c., the
patient recovered." (Siebold's _Journal_, band xvii. heft 2. 1833.)
_Anchylosis of the joints of the foetus._ Lastly, we may mention a very
rare cause of this species of dystocia, which has been observed by
Professor Busch, where the obstruction to the passage of the child arose
from anchylosis of its joints. "The head had been delivered by the
forceps, but the body would not follow. As no cause of obstruction could
be discovered, a gentle and then more powerful traction was used: this
was followed by a cracking sound, and the upper part of the trunk passed
through the os externum: here again it stopped, but still, as no cause of
obstruction could be discovered, and as the child was dead, another
traction was made, with a repetition of the cracking sound, and the child
was delivered. On examination it was found that all the joints of the
extremities were anchylosed in the usual position of the foetus in utero,
so that the ossa humeri and then the ossa femoris had given way. The child
had been dead some time." (_Neue Zeitschrift für Geburtskunde_, vol. xv.
1837; and _British and Foreign Med. Rev._ April 1838, p. 579.)
No precise rules can be given for the treatment of these cases of
malformation of the child; it must be modified according to the
peculiarities of each individual case. Whenever a part has undergone
considerable increase of size from accumulation of fluid, this can be in
most cases removed without much difficulty by perforation, whether it be
of the head or abdomen. With monstrous growths the accoucheur must depend
upon his own resources, ingenuity and knowledge of the mechanism of
parturition. The more careful and correct his diagnosis is, the more
efficient will be the means he adopts for delivering the child. In such
cases the examination can scarcely be made effectually by the finger
alone, but the hand will be required for this purpose.