There was no previous history to explain it; the muscular structure of the uterus at the anterior part of its cervix was torn, leaving the peritoneum entire. Lastly, we may mention a very singular species of laceration of the uterus, of which we know of but two cases, the one recorded by Mr. P. N. Scott of Norwich (Med. Chir. Trans. vol. xi.), the other which occurred under our own notice, where the whole os uteri separated from the uterus during labour. In both cases the os uteri presented a degree of unnatural rigidity, which was quite peculiar, and which in one case defied repeated and active bleeding, as well as opiates. In Mr. Scott's case the laceration took place during a violent pain, when the patient "felt something snap, the noise of which one of the attendants declared she heard." In the other case the patient was not aware of any thing peculiar having happened: it was a first labour in the eighth month of pregnancy; the os uteri had dilated to nearly the size of half a crown, but would dilate no further; the child had evidently been some time dead; the cranial integuments gave way from putrefaction, the brain escaped, the bones of the skull collapsed, and the bag of scalp protruded so far that we could lay hold of it, although the basis cranii had not passed. We were thus enabled to use more extractive force than we could have ventured upon with the crotchet: after a little effort, but without even a complaint from the patient, the head descended and passed through the os externum. "On the bed lay a disc of fibrous matter with a circular hole in the middle; in fact the os uteri separated from the uterus to the extent of near half an inch, the edge of the laceration being as clean and smooth as if it had been carefully cut off by a knife." In both instances the patient recovered. Whether incisions into the os uteri for the purpose of effecting the necessary degree of dilatation would have been justifiable under circumstances of such unusual rigidity, does not belong to the present subject; for the consideration of this we must refer to the FIFTH SPECIES OF DYSTOCIA. 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 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 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 further 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 endea Mr. Ilot of Bromley, in the seventh volume of the Medical Repository, and quoted by Dr. Merriman, who has also given another at the eighth month by Mr. Glen, p. 268. See also an interesting case in the Brit. and For. Med. Rev. for October, 1838, p. 539. N voured 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 14 lbs., and the late Sir Richard Crofts is said to have delivered one alive which actually weighed 15 lbs. ; 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 From one parietal protuberance to the other Circumference of the thorax over the xiphoid cartilage Extreme length of the child Weight of the child 7 inches. 8 5 15 143 24 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 thereföre 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*: *The late Professor Young of Edinburgh has described a case of this sort in his lectures; he distinctly" heard the head crack, and a large quantity of fluid came away." 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 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. 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 distension 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 tympanitic, 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 15 lbs.; they were 17 inches long. The part by * Observationes Anatomicæ, 52. A similar case has been recorded by Dr. Wrangel, in the Archiv. der Gesellschaft der Correspondirenden Aerzte zu St. Petersburg. When called to the case the forceps had been already applied by a colleague, but could not be locked, owing to the enormous tumour of the head. A doughy swelling was felt between the blades of the forceps, of such a size that he could only just reach the cranial bones. He made pretty strong traction twice, when unluckily the instrument slipped off; it seemed, however, to have brought the head so much lower, that the child was delivered in ten minutes afterwards by the natural efforts: it was dead. A sac filled with serous fluid, and as large as the head itself, was attached to the occiput; it was covered by the cranial integuments, and in ten hours afterwards, as the fluid had found its way through the open sutures into the cranial cavity, the tumour had the appearance of a bydrocephalus. 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. Difficult labour from faulty condition of the parts which belong to the child. - The membranes. - Premature rupture of the membranes.-Liquor amnii.— Umbilical cord.- Knots upon the cord. Placenta. IN describing this species of dystocia, according to the arrangement of Professor Naegelé which we have adopted, it will be necessary to observe that serious obstruction to the passage of the child is seldom produced by it, although at the same time many slight derangements in the progress of labour are liable to result which demand the care of the practitioner. The membranes when too thick or tough (Merriman's Synopsis, p. 217.) may retard labour occasionally, especially during the second stage, when instead of bursting and allowing the uterus to contract more powerfully upon the child by the evacuation of the liquor amnii, they are pushed down into the vagina, forming a large conical sac, which may even protrude externally. We doubt much, however, if the non-rupture of the membranes at the proper time during labour is of itself sufficient to retard its progress, for it is frequently observed that the head will nevertheless advance rapidly and even be born covered by the protruded membranes. Where labour is rendered tedious by the unusual strength of the membranes, it is generally connected with considerable distension of the uterus from liquor amnii; in which case the bag of waters is so spherical that it will not descend readily into the vagina, even although the os uteri is fully dilated, and therefore prevents the advance of the head to this we shall recur immediately. So long as there is no undue accumulation of liquor amnii, we may safely allow the membranes to descend to the os externum before we rupture them. In former times a variety of instruments were employed for this purpose, many of which were dangerous, and all unnecessary, the finger being in most cases sufficient. The most effectual way of doing this is to press the thumb and middle finger upon the membranes during a pain and thus increase their tension, whilst the point of the forefinger is pushed against them: scratching them with the nail during a pain will be sufficient when they are higher up the vagina. Premature rupture of the membranes. More frequently the membranes rupture too soon, that is, before the os uteri is fully dilated: this may arise from their being too thin, a condition however which it is not very easy to prove: in most instances it is observed where the uterus is but moderately distended, and where it has that oval or pyriform shape which we have already pointed out as being best adapted for acting efficiently upon the os uteri. This perhaps is one reason why too early rupture of the membranes so frequently occurs in primiparæ; and this may be one cause, among many others, why first labours are generally so much more tedious and severe. The membranes may also be prematurely ruptured by violent exertions, coughing, sneezing, vomiting, &c. by straining immoderately and too soon, by rough and awkward examination, &c. Where this is the case, the patient should preserve the horizontal posture, and keep as quiet as she can until the os uteri has dilated sufficiently and allowed the head to advance. Liquor amnii. Where the uterus is distended by an unusual quantity of liquor amnii, its contractile power is necessarily much impaired; and until the quantity of its contents be somewhat diminished, the progress of the labour will be more or less retarded. The average quantity of liquor amnii at the full period of pregnancy is about eight ounces; but it frequently exceeds this very considerably, occasionally amounting to several pints or even quarts. The causes of this extraordinary accumulation are still but little known. "M. Mercier has, in some cases, attributed it to an inflammatory condition of the amnion, the fœtal surface of this membrane being stated to have been partially coated with false membrane, and the amnion itself crowded with blood vessels of a rose colour:" in another case "about a quarter of the fœtal surface of the amnion was inflamed, being of a deep red colour and double the natural thickness."* The results of Dr. R. Lee's observations, after having paid a good deal of attention to the subject, do not tend to confirm this view: he has described six cases of unusual accumulation of the liquor amnii, in one amounting actually to sixteen pints. In five of them "there existed with dropsy of the amnion some malformed or diseased condition of the fœtus or its involucra, which rendered it incapable of supporting life subsequent to birth." In two only of the preceding cases was the formation of an excessive quantity of liquor amnii accompanied with inflammatory and dropsical symptoms in the mother; and in none did the amnion, where an opportu nity occurred for making an examination, exhibit those morbid appearances produced by inflammation which M. Mercier has described, and which led him to infer that inflammation of the amnion is the essential cause of the disease." (Lee, op. cit.) Dr. Merriman has given a similar opinion, and states, that "when the embryo or fœtus is diseased, the liquor amnii is sometimes immense in quantity. I once saw at least two gallons evacuated from the uterus: the child was monstrously formed and much diseased."† * Quoted by Dr. Lee in the Med. Gazette, Dec. 25. 1830, from the Journ. Gén. de Méd. tom. xliii. xlv. + Merriman's Synopsis, p. 216.; also Dr. J. Y. Simpson's fifth case of fatal peritonitis, in Edin. Med. and Surg. Journ. No. cxxxvii. The patient had suffered under four different attacks of venereal disease. Some interesting cases have been published in the Neue Zeitschrift |