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 fœtus 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 fœtus 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 fœtus. 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 fœtus 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.
CHAPTER III.
THIRD SPECIES OF DYSTOCIA.