Edward Rigby

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:—

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.