FOURTH SPECIES OF DYSTOCIA.
_Abnormal state of the pelvis.--Equally contracted pelvis.--Unequally
contracted pelvis.--Rickets.--Malacosteon, or mollities ossium.--
Symptoms of deformed pelvis.--Funnel-shaped pelvis.--Obliquely
distorted pelvis.--Exostosis.--Diagnosis of contracted pelvis.--
Effects of difficult labour from deformed pelvis.--Fracture of the
parietal bone.--Treatment.--Prognosis._
This may arise from there being either too much or too little resistance
to the passage of the child; where, in the one case, labour is rendered
difficult or impossible to be completed by the natural powers; in the
other, it is unnaturally rapid. The latter condition belongs to the second
great division of dystocia, where the faulty character of the labour does
not depend upon its progress being deranged, but upon other circumstances:
we shall, therefore, delay speaking of precipitate or too rapid labour
from unusually large pelvis, until then, and devote the present chapter to
the consideration of those cases where the labour is more or less
obstructed by the faulty condition of the mother's pelvis.
The pelvis may obstruct the passage of the child in a variety of ways.
1. It may be merely a diminutive or dwarfish pelvis, viz. well formed but
smaller than usual in every direction--the pelvis simpliciter justo minor
of Continental authors.
2. It may be distorted and deformed.
3. It may be of the natural form and size, but the passage through it more
or less obstructed by exostosis.
_Equally contracted pelvis._ The first species of faulty pelvis (_pelvis
simpliciter justo minor_,) is not of common occurrence, and has received
but little notice in this country. It has been said to resemble the pelvis
of a girl in its general appearance; but this only holds good in point of
size; for, in the relative proportions of its diameter, it presents all
the characters of a well formed adult pelvis. From this circumstance, it
can scarcely be said to be an arrest of development, the necessary changes
in the form of the pelvis having taken place at the time of puberty, as
completely as if it had been of the ordinary size. A pelvis of this sort
may be not more than a quarter of an inch too small in every direction, or
it may be as much as a whole inch: we do not know of any case where the
diminution has exceeded this last degree.
The pelvis equaliter justo minor is not accompanied with a corresponding
diminutiveness in the rest of the skeleton, most of the patients in whom
it has been observed being well formed and of the usual stature.
Fortunately, as before stated, it is of rare occurrence, for even a small
diminution in the size of the bony passages, which is uniform in _every
direction_, presents a most serious obstacle to the passage of the child.
Thus, in three cases of the sort, which have been described by Professor
Busch in his report of the Berlin Lying-in Hospital, the labour terminated
fatally in two. "The first case was a presentation of the breech; the head
was delivered by the forceps; the child was dead; the pelvis measured half
an inch too small in every direction. In the second case, which was a head
presentation, the delivery was effected by the forceps, but not without
the greatest efforts; the child was still-born, and the mother died in a
day or two after from peritoneal inflammation. The third case required
perforation; this also terminated fatally, the forceps having been
previously applied, and considerable efforts made without success. On
examination after death, every diameter of the pelvis was three quarters
of an inch smaller than usual: in appearance it resembled that of a
child." (_Neue Zeitschrift für Geburtskunde_, vol. xv. 1837.)
_Unequally contracted pelvis._ The unequally contracted pelvis (_pelvis
inæqualiter justo minor_) may exist under a variety of forms; the most
common is where the antero-posterior diameter is defective, or, in other
words, where the distance between its anterior and posterior parietes is
less than usual. In a slight degree, it is frequently met with among the
poorer classes, and arises from the patient having been compelled to carry
heavy burdens in early childhood, or otherwise subjected to severe labour.
The practice of entrusting a girl of eight or ten years of age with the
care of a heavy infant, which she carries about in her arms for many hours
every day, is a fruitful source of this species of pelvic deformity; the
young and plastic pelvis is unable to bear the additional pressure which
is thrown upon the sacrum by the overloaded trunk, without having the just
proportions of its growth materially influenced and perverted, especially
at a period of life when the whole form of the pelvis is undergoing
considerable changes. The constant pressure and counter-pressure to which
the pelvis is subjected by the undue weight which is applied to the sacrum
above, and supported by the resistance of the femora against the acetabula
below, must necessarily tend at this age, even in an ordinary state of
health, to impair its symmetry, more or less, and gradually to diminish
the distance between its anterior and posterior parietes. Under no
circumstances has this cause of pelvic deformity acted to such an extent
as in the English manufactories, where young children are compelled to
remain standing for twelve or more hours at the machines: the physical
powers are unequal to the endurance of so much unceasing labour, the
skeleton of the child soon suffers in its growth, and the pelvis almost
certainly becomes contracted.
Similar effects may also be produced by undue pressure on the other parts
of the pelvis. Thus the outlet may become much contracted by sitting many
hours a day on a hard seat, as is frequently the case in schools. The
tubera ischii are pressed together, the pubic arch is thereby contracted,
and the sacrum becomes strongly curved forwards. Much riding on horseback
at an early age is said to be injurious; and it is stated that the females
of those American nations who are constantly on horseback bear but few
children, and are frequently three or four days in severe labour.
_Rickets._ Similar effects, only in a much more aggravated form, are
produced by rickets in early life; the pelvic bones having become soft
from the loss of their earthy matter, gradually give way under the
pressure of the superincumbent trunk, to the support of which they were
unequal. In this way the sacrum is forced downwards and forwards towards
the symphysis pubis, the acetabula are driven upwards and backwards, the
pubic arch becomes distorted; and if the disease continues for a
considerable period of time, the whole pelvis becomes so squeezed together
as entirely to lose its original proportions.
The manner in which the distortion takes place varies exceedingly, and
will be more or less influenced by the circumstances under which the child
has been placed. The most constant change is the shortening of the
antero-posterior diameter at the brim. In severe cases the base of the
sacrum has, as it were, sunk down between the illia, so that its
promontory occupies the cavity of the pelvis, the fourth, or third, or
even the second, lumbar vertebræ occupying its former position. The
gradual yielding of the bones seldom takes place with that degree of
uniformity as to allow the sacrum to approach the symphysis pubis in a
straight line: the more common result of rickets is, that the promontory
is, at the same time, wrung more or less to one side.
"If the superior strait does not constantly present the same figure in
deformed pelvis; if it is sometimes larger on one side than the other; if
one of the acetabula is nearer to the sacrum, while the other approaches
less; if the symphysis of the pubes is removed in many cases from a line
which would divide the body into two equal parts, it is because the
rickets has not equally affected all the bones of the pelvis, nor equally
hurt all their junctions; and because the attitude which the child takes
in walking or sitting may change a little the direction of the compressing
power, which I have just mentioned." (_Baudelocque_, translated by Heath,
vol. i. p. 60.) Nor is it necessary that the degree with which the disease
affects the different parts of the pelvis should vary in order to produce
these inequalities of distortion, for there is no reason to suppose that
the promontory of the sacrum would approach the symphysis pubis in a
straight line, even where the softening of the bones was uniform
throughout; the attitude of the child, as above-mentioned, and the manner
in which it supports itself, will have no inconsiderable influence in
determining the direction in which the distortion takes place.
In those instances where the promontory is forced low down into the pelvic
cavity, the sacrum becomes bent upon itself, the upper part of it forming
a sharp curve backwards, while its lower portion together with the coccyx
being confined by their attachments, and more or less compressed by
sitting, are directed forwards. This is not seen where the projection of
the promontory is but slight; the curve of the sacrum so far from being
increased is rather lessened; the sacrum is straighter and flatter than
usual, so that, although the brim of the pelvis is contracted, we not
unfrequently find the outlet even larger than natural: in other cases,
where the softening of the bones has gone to a considerable extent, the
outlet is diminished, from the tubera ischii having been forced inwards.
The degree to which the promontory projects, of course, varies
considerably. The distortion is occasionally so great as not even to leave
an inch of antero-posterior diameter. This excessive deformity, however,
is more frequently the result of mollities ossium coming on after puberty,
for we seldom find children live through this critical period where it has
been the result of rickets. The brim of a deformed pelvis varies
considerably in shape: "sometimes it has the form of a kidney, or that of
the figure eight ([Symbol: infinity]); sometimes it is triangular or
heart-shaped, the sides being curved inwards, from the acetabula having
been pressed backwards or inwards, the ossa pubis are bent forwards and
outwards, and form at their symphysis a sort of beak-like process, which
is the apex of the heart: in this species of deformed pelvis, which is
usually the result of mollities ossium, the outlet also is usually much
distorted: this arises from the tubera ischii being forced nearer to each
other, thus contracting the pubic arch." (Naegelé's _Lehrbuch_, 2te
Ausgabe, p. 247.)
[Illustration: _From_ Naegelé.]
[Illustration]
_Malacosteon_, or _mollities ossium_. An arthritic, rheumatic, or gouty
diathesis is a morbid state, in which softening of the bones may take
place at a much later period of life, and to a most extraordinary extent.
In almost all the cases of extreme pelvic deformity which have been
recorded, the distortion has been owing to this disease, and not to
rickets in early life: in a pathological point of view there is a
considerable analogy between these two diseases. From a variety of causes
there is a superabundant formation of acid in the system, which its
excreting organs are unable to throw off. The effects of this condition
will vary according to circumstances; among them the softened state of the
bones from a deficiency of insoluble bone earth is not the least
remarkable. Mollities ossium seldom attacks women who have had no
children: sometimes it begins shortly after delivery, and very frequently
during pregnancy, during the progress of which it continues to increase.
Hence, it occasionally happens, that a woman has given birth to several
healthy living children without any unusual difficulty in her labours, and
where, after this, the pelvis has gradually become so deformed from
mollities ossium, as to render delivery impossible by the natural
passages, and, therefore, to require the Cæsarean operation. Pelves of
this sort, may be easily distinguished from those which have been deformed
in early life by rickets; they have evidently attained their full adult
growth before the process of softening had commenced: the ilia, for
instance, are of the natural size, but bent across, as if they had been
folded like wet pasteboard; whereas, the bones of the ricketty pelvis have
not attained their full development, they are stunted in growth as well as
distorted in shape, the two processes, viz. of growth and distortion,
having evidently, co-existed.
The form of the pelvis in mollities ossium necessarily varies with the
peculiar circumstances under which the individual is placed: thus, if her
strength allows her to sit up, or even to get about, as is generally the
case more or less, the promontory and the pubic bones are gradually
pressed towards each other, so that the antero-posterior diameter is
greatly diminished:[123] if, however, she is confined entirely to bed for
a considerable period, the distortion takes a different and much rarer
form. From her lying first on one side and then on the other, the pelvis
is laterally compressed; the transverse diameter becomes even shorter than
the antero-posterior; and if the disease continues long enough, the pelvis
is at length so altered and mis-shapen, that nearly all its original
configuration is obliterated. The weight of such a pelvis varies
considerably: where the disease has ceased some time before death, and
bone earth has been again deposited, there will be little difference in
this respect from a natural healthy pelvis; but if the patient has died
with the disease in full activity, its weight will be greatly diminished,
amounting sometimes only to a few ounces.
Mollities ossium, to a slight extent, we believe, is not very uncommon,
although cases of extreme deformity from this cause are of rare
occurrence. Mr. Barlow states, that "eight cases of this species of
progressive deformity have fallen under my notice, in one of which the
projection of the last lumbar vertebra at its union with the angle of the
sacrum was so much bent forwards into the cavity of the pelvis, that on
the introduction of the fore-finger up the vagina, a protuberance was
presented to the touch very much resembling the head of the foetus pretty
far advanced into its cavity. On carrying the finger a little anteriorly
past the projection, I could with difficulty ascertain the head of the
child: but on moving it around, the distortion appeared so great, that the
whole circumference did not exceed that of a half-crown piece. This
occurrence was on the 29th of April, 1792, at which time I delivered the
woman with the crotchet, and the bones of the pelvis receded considerably
to the impulsive efforts during the extraction of the head of the foetus;
yet, notwithstanding, the flexibility of the bones of the pelvis, and the
debilitated state of her constitution, she recovered speedily and without
interruption." On the 2d February, 1794, being in the neighbourhood, and
learning that she was still alive, Mr. Barlow visited her and requested an
examination. "I found her unable to walk without assistance, and as she
sat, her breast and knees were almost in contact with each other. The
superior aperture was nearly in the same state as when I delivered her
with the crotchet, but the outlet appeared more contracted, the rami of
the pubes overreached, leaving a small opening under the symphysis barely
sufficient to admit the finger to pass into the vagina by that passage,
and another aperture below, but rather larger, and parallel with the
junction of the tuberosities of the ossa ischii. From what I learned
afterwards respecting this decrepit female, she survived this period about
two years, at which time she was become still more distorted in the spine;
and after her death it was with difficulty she could be put into her
coffin; this woman bore nine children, and died in the thirty-ninth year
of her age." (Barlow's _Essays_, p. 329.)
Mollities ossium may be feared when, in addition to the general breaking
up of the health and strength, the patient suffers from arthritic pains
and swellings of the limbs, the urine is generally loaded with lithic
secretion: and most of all, where distinct shortening and gradual
distortion of the skeleton is taking place. Where the deformity has been
the result of rickets in early life, a little careful observation of the
patient's external appearance will quickly lead the experienced eye to
suspect the nature of the case.
_Symptoms of deformed pelvis._ Among the external appearances which would
lead us to suspect a deformed pelvis, are "the lower jaw projecting beyond
the upper; the chin very prominent; the teeth grooved transversely;
unhealthy appearance; pale ashy colour of the face; diminutive statue;
unsteady gait; when the woman walks the chest is held back, the abdomen
projects, and the arms hang behind; there is deformity of the spine and
breast, one hip higher than the other, the joints of the hands and feet
are remarkably thick; curvature of the extremities, especially the
inferior, even without distortion of the spine is a very important sign;
wherever the lower extremities are curved, the pelvis is mostly deformed:
it is well to ascertain also if, when a child, it was a long time before
she could walk alone; whether she had any fall on the sacrum; whether as a
girl she was made to carry heavy weights, or to work in manufactories."
(Naegelé's _Lehrbuch_. § 444.)
_Funnel-shaped pelvis._ Besides the above-mentioned species of pelvic
deformity, others are occasionally met with, the origin of which is but
little understood. The funnel-shaped pelvis is of this character, where
the brim is perfectly well formed, but where it gradually contracts
towards the inferior aperture. There are no evidences of its having been
produced by any disease; nor in fact can we assign any satisfactory cause
for this peculiar configuration: it appears to have been a congenital
formation.
[Illustration]
_Obliquely distorted pelvis._ A still more remarkable species of pelvic
deformity is the _pelvis obliqué ovata_, which, of late years, has been
pointed out by Professor Naegelé. In this case the pelvis appears awry,
the symphysis pubis being pushed over to one side; and the sacrum to the
other; one side of the pelvis is more or less flattened, the other bulges
out, so that one oblique diameter is shorter, the other longer than
natural; and this applies not only to the brim, but to the cavity and
outlet of the pelvis. In most cases the sacro-iliac symphysis on that side
which is flattened, and to which the sacrum is inclined, is completely
anchylosed, not a trace of the division between the ilium and sacrum to be
detected, the two bones being completely united into one. In many, the
sacrum on this side is smaller than on the other, as if a portion of it
had been removed by absorption during the process of anchylosis, or at
least not properly developed. When we consider the form of the pelvis, and
the appearances which the sacro-iliac symphysis and the sacrum present, we
are almost led to conclude that ulcerative absorption must at one time
have existed between the sacrum and ilium at this point, probably at an
earlier period, by which means more or less bone had been destroyed before
the termination of the disease in anchylosis; indeed, we can to a certain
extent imitate this peculiar species of pelvic deformity by sawing off the
surfaces of the sacrum and ilium which had formed the symphysis, and then
putting the bones together again. Still, however, in the various cases
which have been collected by Professor Naegelé, no proofs could be
obtained of disease having existed in the pelvis during early life.
"In none of the cases, the particulars of which have come to my knowledge,
has there been any trace of rachitis; nor have any of the symptoms,
appearances, and morbid changes been observed which characterize mollities
ossium coming on after puberty. None of these cases have been traced to
the effects of external violence, as falls, blows, &c.; nor has there been
any complaint of pain in the region of the pelvis, inferior extremities,
&c." (_Das Schräg Verengte Becken_, p. 12.) "With respect to the
strength, colour, structure, &c. of the bones of this species of deformed
pelvis, no difference could be observed between them and the bones of
young and perfectly healthy subjects; not a trace either in form or other
respects could be detected of those changes which usually result from
rachitis or mollities ossium; and but for this distortion and some other
slight irregularities, which required close inspection to detect, these
pelves would have been looked upon as well-shaped, and of sufficient
capacity." (Naegelé, _op. cit._ p. 11.) In some specimens no trace of
anchylosis at the sacro-iliac symphysis has been observed; but whether
this was the case throughout the union of the two bones we cannot say.
Professor Naegelé is inclined to look upon them as modifications of the
_pelvis obliqué ovata_, and certainly in the majority of known cases
anchylosis has been found present.
It is scarcely necessary to do more than enumerate other varieties in the
form of the pelvis, which are occasionally met with: it is sometimes
round, the transverse and antero-posterior diameters being of the same
length; in other cases it possesses many of the characters which
distinguish the male pelvis, being more or less triangular, deep, and with
a contracted angular pubic arch.
_Exostosis._ Lastly, the pelvis may be perfectly well formed, but the
passage through it more or less interrupted by the exostosis: this is,
perhaps, the rarest species of dystocia pelvica. It may arise from wounds
of the periosteum, from fracture of the bones, callus, &c. and may vary in
size from a small protuberance to a large mass, which completely fills up
the pelvis.
_Diagnosis of contracted pelvis._ The difficulty of detecting an abnormal
configuration of the pelvis, will depend, in great measure, upon its
extent: where it is but slight, it may easily be passed over unobserved by
a young practitioner, although it may, nevertheless, be quite sufficient
to render labour both difficult and dangerous. In the ordinary form of
contracted pelvis, where the antero-posterior diameter is shorter than
natural, the being able to reach the projecting promontory of the sacrum
with the finger is of itself a sufficient evidence: but the converse of
this is not true, for we frequently meet with cases of contracted pelvis,
without being able to reach the promontory. The numerous instruments which
have been invented at different times for measuring the pelvis are of such
doubtful accuracy, as to be nearly useless; the experienced finger is the
best pelvimeter; and the power of correctly estimating the dimensions of
the pelvis during examination, can only be acquired by constant practice,
based on a thorough knowledge of them in the healthy pelvis.
The manner in which labour commences is frequently sufficient to make us
suspect the presence of a contracted pelvis. Besides, the general
appearance of the patient, we frequently find that the uterine
contractions are very irregular; that they have but little effect in
dilating the os uteri; the head does not descend against it, but remains
high up; it shows no disposition to enter the pelvic cavity, and rests
upon the symphysis pubis, against which it presses very forcibly, being
pushed forwards by the promontory of the sacrum. It is probably from this
circumstance that the os uteri, more especially its anterior lip, shows so
little disposition to dilate in these cases, for the lower portion of the
uterus being jammed between the head and symphysis pubis in front, and
promontory behind, the contractions of the longitudinal fibres can have
little effect upon the os uteri. Hence we find, that in cases of
diminished antero-posterior diameter requiring perforation, and where the
os uteri in spite of violent pains, bleeding, &c. has refused to dilate
beyond a certain point, on lessening the head, and thus removing its
pressure from the symphysis pubis, it has quickly attained its full degree
of dilatation.
Where the pains have been active, and a portion of the head has forced
itself through the brim, and now projects to a certain extent into the
cavity of the pelvis, it will be still more difficult to reach the
promontory before delivery; and if, as is frequently the case, the sacrum
is bent strongly backwards, so as to render the cavity and outlet very
spacious, the real cause of impediment to the progress of labour may be
entirely overlooked. It is here that the position of the head upon the
symphysis pubis will prove a valuable means of diagnosis. The straightness
of the sacrum will also be a guide in other cases.
In that form of the pelvis which has been called the funnel-shaped pelvis,
and where the brim and upper portion of the cavity are of the natural
dimensions, but where it gradually diminishes towards the outlet, the
appearances are frequently very deceptive, the head advances without
impediment, and descends as far as the inferior aperture, with every
promise of speedy delivery; but here its progress is arrested, and even in
the very last stage may require perforation.
It occasionally happens, also, where the deformity is very considerable,
that the promonotory projects to such an extent as to be even capable of
being mistaken for the head itself; and cases have actually occurred
where, under this impression, the bone has been perforated instead of the
child's head. So gross an error as this may easily be avoided by care in
making the examination; by ascertaining that the projecting mass is
immoveable; that the patient is sensible to the pressure of our finger;
and that the promontory can be traced to be continuous with the adjacent
parts of the pelvis.
The effects which may result from labour protracted by pelvic deformity
are very various, both as regards the mother and her child. The most
common form of injury which is produced by this cause, is the contusion
and consequent inflammation and sloughing of the soft tissues which line
the pelvis from the long continued pressure of the head against the
symphysis pubis in front, and against the promontory of the sacrum behind.
Not only may sloughing of the vagina and lower part of the uterus be the
result, but the mischief may extend through the posterior wall of the
bladder, and thus render the patient incapable of retaining her urine, and
an object of great, and, generally speaking, incurable suffering.
The danger from rupture of the uterus will chiefly depend on the degree of
pressure with which the uterine contractions force the head against the
brim. Where the pains are violent, and yet insufficient to overcome the
obstacle which the contracted pelvis presents to the advance of the head,
there is not safety for a minute, and perforation must be immediately had
recourse to. Where the edge of the promontory is very projecting and
sharp, the structure of the uterus may be seriously injured by the
pressure and contusion. In some cases it has evidently been the cause of
ruptures, the fibres having given way first at this spot.
The constant severe pressure upon the head will be not less injurious to
the child's life; it must inevitably produce a considerable impediment to
the cerebral circulation; and where the liquor amnii has escaped, the
pressure of the uterus upon the body of the child will scarcely be less
prejudicial. The cranial bones frequently become remarkably distorted, so
that after a difficult labour a deep furrow is found on that part of the
head which corresponded to the projecting promontory.
_Fracture of the parietal bone_ may even be produced, a fact of which
practitioners, till lately, have not been sufficiently aware; and cases
have occurred where children have been born dead, with the head greatly
distorted, and one of the bones fractured, from which circumstances the
mothers have been suspected of infanticide. Dr. Michaelis, of Kiel, has
lately reported an interesting case of this kind, where the fracture seems
to have resulted from the great immobility of the coccyx. The head was
much disfigured, and on examining it the frontal bones were uninjured, but
so flattened that the frontal and parietal portions of the sagittal suture
lay nearly in the same place; the fontanelle and anterior two-thirds of
the sagittal suture projected high up, and the sagittal borders of the
parietal bones were firm and well formed. In the posterior third of the
sagittal suture, where the parietal bones were firm and well formed, and
the suture only two lines in width, were seen small livid portions of the
longitudinal sinus forced between the bones. The occipital bone was
flattened and forced deep under the parietal bones, but not otherwise
injured. The right parietal bone, which during birth had been turned
towards the promontory of the sacrum, was covered anteriorly and
superiorly with effused blood, and on removing the periosteum, was found
fractured in five places. (_Neue Zeitschrift für Geburtskunde_, vol. iv.
part 3. 1836.[124])
Where the action of the uterus is not very violent, and the bones
yielding, the head gradually adapts itself to the form of the passage
without destroying the foetus; it elongates itself more and more until it
is enabled to pass, so that after a tedious labour of this sort, we
sometimes find the configuration of the head remarkably altered.
Baudelocque, has mentioned a case recorded by Solayres de Renhac, where
the head was so elongated that the long diameter measured eight inches all
but two lines, the transverse being only two inches and five or six lines.
_Treatment._ Where the pelvic deformity is very considerable, there can be
little difficulty in deciding upon the line of conduct to be adopted. It
is in those cases where the obstruction is but slight that the indications
for treatment are less distinctly marked: nor must we be satisfied with
merely ascertaining the relative proportions of the head and pelvis; for
the hardness or softness of the cranial bones, the disposition which they
manifest to yield to the pressure of the uterus and surrounding parts, the
state of the cranial integuments, and though last not least, of the soft
tissues which line the pelvis, must all be carefully ascertained before a
correct opinion as to the precise mode of treatment can be formed. Nor, if
the woman has already had children, can we altogether be guided by the
history of her previous labours; for where the above-mentioned
circumstances have been favourable, a slight diminution of the pelvis will
scarcely be attended with any perceptible delay or increase of difficulty
beyond the natural degree; whereas, if the head happens this time to be a
little larger, its bones more ossified, the fontanelles smaller, the scalp
and soft linings of the pelvis more swollen, &c. a serious obstruction to
the progress of labour will be the result. Thus it is that we not
unfrequently meet with patients in whom the first labour has been
tolerably easy, the second has been attended with much difficulty and
required the forceps, in the third, the difficulty was so much increased
as to require perforation, and the fourth where the labour was, like the
first, perfectly easy and natural.
It is impossible for the head to remain long in the pelvis (except under
unusually favourable circumstances) without more or less obstruction to
the circulation, both in the scalp itself and in the surrounding soft
tissues. The necessary consequence of this is swelling, by which the head
increases while the passage diminishes in size; and this must still be
more remarkably the case where the pelvis is at all contracted. It is in
these cases that we frequently see such relief produced by venesection;
and it is also as a topical depletion to the overloaded vessels, that we
can explain why a free secretion of mucus is so favourable a symptom.[125]
_Prognosis._ Where the pains are moderate and equable, the os uteri nearly
or quite dilated, the head not large, its bones yielding and overlapping
at the sutures; where the greater portion of it has evidently passed
through the brim, and, although slowly, advances perceptibly with the
pains; where the passages are cool and moist, the pulse good, and the
patient not exhausted, we may safely wait awhile and trust to the efforts
of nature. On the other hand, where the pains are violent, the os uteri
thin and undilatable, the head forced forwards upon the symphysis pubis by
the projecting serum, if the greater part of its bulk has not yet passed
the brim, if the soft parts are much swelled, the vagina hot and dry, the
pulse has become irritable, the abdomen tender, the patient exhausted and
much depressed both in mind and body, the powers of nature are evidently
incompetent to the struggle, and require the assistance of art.
Such cases seldom permit the application of the forceps; the head is
already pressing too firmly against the brim, and its greatest bulk having
not yet passed, a still farther increase of pressure will be required to
effect this object, which therefore cannot be attained without producing
serious mischief. Where, however, the head has fairly engaged in the
cavity of the pelvis, and the case is rather becoming one of deficient
power, the forceps will be justifiable, and generally quite sufficient to
effect the delivery safely.
The young practitioner must be cautious not to mistake an increase in the
swelling of the scalp for an actual advance of the head itself--an error
which may very easily be committed if he merely touches the middle of the
presenting portion: he must carefully examine the circumference of the
presenting part, where the head is pressing against the pelvis, and where
there is little or no swelling, and he will frequently find to his
disappointment, that although the cranial swelling may have even nearly
approached the perineum since his last examination, the head itself has
remained unmoved.
Where the forceps has been determined upon, we should endeavour to render
its action as favourable as possible, viz. by bleeding, by the warm bath,
and by evacuating the bladder and rectum before proceeding to the
operation: we thus improve the condition of the soft parts, and diminish
the chances of its acting injuriously.
From what has now been stated respecting the various circumstances which
may tend to aggravate or alleviate the existing degree of pelvic
deformity, it will be seen how incorrect and unpractical must be the
attempt to classify the means of treatment merely according to the
dimensions of the pelvis. To assert that within certain limits of pelvic
contraction the child can be delivered by the natural powers, and that
beyond these limits the forceps must be used; and that where it proceeds
to a certain extent farther, it can only be delivered by perforation, &c.
is evidently objectionable: for there are no two cases alike, even
supposing that the degree of pelvic contraction is exactly similar; hence,
on the one hand, we might (under such fallacious guidance) be induced to
trust to the natural powers when they are wholly incompetent to the task,
and on the other, to have recourse to art when the real condition of the
case justified no such interference.[126]
With regard to the diagnosis and treatment in the case of obliquely
distorted pelvis (pelvis obliqué ovata,) our data are still too scanty to
enable us to give any decided rules: the immobility of the head, although
the antero-posterior diameter appears of its full length, the shortness of
one oblique diameter, and consequent undue pressure upon the head in this
direction, and the unusual length of the other, are the characteristics
which we have observed in the only case of the kind which has come under
our notice during life. In all the cases of labour rendered difficult by
this condition of the pelvis, which have been collected by Professor
Naegelé, the perforation has been strongly indicated; and where the
forceps has been used, it has either failed, as with us, or if the
delivery has been effected by this means, it has been attended with fatal
consequences.
In _exostosis_ of the pelvis we must be guided by our knowledge of the
healthy pelvis, and by our carefully ascertaining the form and size of the
bony growth, and in what degree it is likely to impede the passage of the
child. As in cases of simple projection of the promontory, the head may be
capable of passing, but in doing so becomes more or less distorted: thus
Dr. Burns quotes a case from Dr. Campbell, where from exostosis within the
pelvis, the left frontal bone was so greatly sunk in, as to make the eye
protrude. Professor Otto, of Breslau, mentions a woman who had pelvic
exostosis being the mother of four children, in each of whom a small
portion of the cranium was depressed and not ossified.
An interesting case has been described by Dr. Kyll, of Cologne, where the
patient was the mother of seven children; her former labours had been
perfectly natural, except that in the last there had been preternatural
adhesion of the placenta, which had required to be removed by the hand; in
six days after she was seized with feverish symptoms and violent pain at
the spot where the placenta had been attached. The attack yielded to
proper treatment, but she continued feverish at night with perspirations,
frequently deranged bowels, difficulty in passing water, and severe pain
in the abdomen, especially when she tried to stand on the right leg. An
abscess formed in the right groin, which was opened and discharged a large
quantity of pus, from which her recovery was very slow, and in three years
afterwards she became again pregnant. When labour came on, no presenting
part could be reached; after a long time the feet came down one after the
other, but the nates would not advance. Dr. Kyll found the child resting
with the hips on the brim of the pelvis, and completely wedged fast by a
hard immoveable tumour as large as a hen's egg, springing from the upper
part of the right sacro-iliac symphysis, and apparently having been a
result of the pelvic abscess; the child was delivered with great
difficulty by embryotomy.
[Illustration: Exostosis of the pelvis.]
Perhaps the most remarkable case of pelvic exostosis is that which has
been described by Dr. Haber of Carlsruhe, and where also the cause was
ascertained to have arisen from a violent fall on the ice when carrying a
heavy load upon the head; on coming to herself the woman found that she
was unable to move, and in this state was conveyed home; she recovered to
all appearances in a few weeks, married, and soon became pregnant. When
labour came on it was found impossible to deliver her, from the pelvis
being entirely filled with a huge exostosis: the Cæsarean section was
performed, but she died, and on examination after death an immense mass of
bony growth was found springing from the sacrum, which had been apparently
fractured, not only filling up the whole cavity of the pelvis, but arising
to a considerable extent above the brim.
In those cases of funnel-shaped pelvis which we have had the opportunity
of observing, perforation has been ultimately required, although the head
had passed easily through the brim and entered the cavity; in one of
these we have subsequently used the artificial premature labour with
success.
We have already stated the doubtful utility of arranging cases of deformed
pelvis according to their degree of contraction, and of classifying the
different modes of treatment by such a scale; still, however, there must
be certain limits beyond which it will be impossible to make the child
pass, even when diminished by embryotomy. To draw the precise line of
demarcation, however, will be nearly if not quite impossible; and, as in
cases of slighter deformity, we must take many other circumstances into
consideration which we have already mentioned. An inch and a half from
pubes to sacrum has been mentioned by many as the extreme degree of
contraction through which a full grown child can be delivered by
embryulcia; generally, however, in these cases of unusually deformed
pelvis, there is much more space on each of the sacrum; and on this, in
great measure, will depend the possibility of effecting the delivery. The
celebrated case of Elizabeth Sherwood, which Dr. Osborn has recorded, and
where he succeeded in delivering the child, although the antero-posterior
diameter "could not exceed three-quarters of an inch," has been looked
upon as being of doubtful accuracy, and that Dr. Osborn had
unintentionally deceived himself. When, however, we learn that on the
right side of the sacrum the antero-posterior diameter was an inch and
three-quarters, the incredible nature of the case diminishes considerably,
the more as the patient was examined by Dr. Denman and others who fully
coincided with Dr. Osborn's statements. To assert that in this case the
antero-posterior diameter was only three-quarters of an inch, as many have
done, is evidently incorrect, and tends to throw doubt upon it: the case
was evidently the closest possible approach to the limits requiring the
Cæsarean operation; its success was mainly attributable to the gradual
manner in which it was performed; the child had become completely soft and
flaccid from putrefaction, and was thus more capable of being moulded to
the contracted passage.