CHAPTER II.
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 fœtus.
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 fœtus 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 | 7¼ | inches. |
| The occipito-mental | 8½ | — |
| From one parietal protuberance to the other | 5 | — |
| Circumference of the skull | 15¼ | — |
| Circumference of the thorax over the xiphoid cartilage | 14½ | — |
| Breadth of the shoulders | 7¼ | — |
| 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, œdema 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.