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.
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:—
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’sCases 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 andfontanelles, 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 tumourupon 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’sJournal, 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: thiswas 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; andBritish 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.
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.
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 obstructions 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’sSynopsis, p. 217,) may retard the 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 distention 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 fore-finger is pushed against them: scratching them with thenail 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.”[117]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 opportunity occurred for making an examination, exhibit those morbidappearances 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.”[118]
In these cases the size and globular form of the uterus, the tenseness of its parietes, the more or less distinct feel of fluctuation, the absence of the child’s movements and of any prominences arising from the projecting portions of its body, the rapid increase which has been observed in the size of the abdomen, the pain in different parts of the uterus, especially in the groins and pelvis, the œdema or anasarca of the lower extremities, serve to mark this condition. On examination per vaginam we also feel the inferior segment of the uterus much expanded, the cervix probably shorter than might be expected for the period of pregnancy; the ballottement is unusually free and distinct. In some instances the patient has suffered so much, either from the effects of the retarded circulation in the lower extremities, or from the impeded respiration as to require the membranes to be punctured in order to reduce the size of the uterus. The child is usually born dead where the accumulation has gone to so great an extent: in the three cases recorded by La Motte, it was dead before birth in the first two, and died immediately after birth in the third. Many of these cases, which have been complicated with disease or malformation of the fœtus, have appeared to arise from a syphilitic taint; but in others, of more common occurrence, where there was merely an unusually large quantity of liquor amnii without any disease either of the mother or her child, the cause must still remain a matter of uncertainty. This latter condition is mostly seen in women who have been frequently pregnant; the os uteri in them is generally yielding, and when once it has attained its full degree of dilatation, we may safely rupture the membranes and thus expedite labour considerably.
There being an unusually small quantity of liquor amnii can scarcely operate as an obstruction to labour, except where the membranes have been prematurely ruptured.
Theumbilical cordmay obstruct labour, by either being too short, or rendered so from being twisted round some part of thechild. Its length varies very considerably. Although we have stated it to average about eighteen or twenty inches,[119]we have met with extreme deviations both within as well as beyond this medium length. The shortest cord which we know of occurred some years ago at the General Lying-in Hospital, “where, after two or three violent pains, the child was suddenly and forcibly expelled the cord was found ruptured at about two inches from the navel of the child, which cried stoutly. After removing the child the matron sought for the other end of the funis, but could not find it; she examined per vaginam but could not feel it; and on introducing her hand into the uterus, found the placenta with the remains of the cord ruptured at its very insertion; so that in this case the cord could not have been much more than two inches long.” (Printed Lectures in Renshaw’sLond. Med. and Surg. Journ.May 1835, p. 426.)
We quite agree with Professor Naegelé, that unusual shortness of the cord can rarely if ever retard labour; and that where the cord really produces an impediment to its progress, it is from being twisted round the neck, or some other part of the child. (Lehrbuch, 2d ed. p. 289.) This generally arises from its unusual length, and from its having formed several coils around the child: we have met with it forty-eight inches long, and twisted four times round the child’s neck; but Baudelocque mentions a case where it actually measured fifty-seven inches, “forming seven turns round the child’s neck.” (Heath’sTransl.vol. i. § 516.) Mauriceau has given an instance (Obs.401.,) where the cord had “longueur d’une aune et un tiers de notre mesure de Paris:” which, converted into English measure, amounts to somewhat more than sixty-one inches.
Although nothing is of more common occurrence than the cord being twisted once or twice round the child, it nevertheless, happens, but very rarely, that its advance is thereby obstructed. In a case of this sort, the labour usually commences quite favourably; the os uteri dilates, and the head advances to a certain extent, beyond which it makes no other farther progress; the uterine contractions are attended with much pain in the fundus, during which the head advances somewhat, but retires again during the intervals. Where the head is already near the os externum, this may be easily attributed to the elasticity of the soft parts, until the delay which takes place to the farther progress of the labour warns the practitioner that something more than ordinary is the cause. But where this takes place, and the head is still in the pelvic cavity; where at the same time, although it refuses to advance, it is quite moveable, and allows the finger to be passed freely round it; where any attempt to extract it with the forcepshas not only met with great opposition, but has greatly aggravated the sense of painful dragging in the upper parts of the uterus there will be pretty certain evidence of the cord being either too short, or, what is most probable, of its being twisted round the child. In each of the three cases recorded by La Motte, the head had descended to the os externum; whereas, in two others described by Burton, it was evidently much higher up: he ruptured the cord in both instances; La Motte succeeded in cutting the cord with a pair of scissors in one case, in another he appears to have separated the placenta, and in the other to have delivered by little else than force. Where upon introducing the hand we find it impossible to undo the coil of the funis, we should endeavour to slip it first over one and then the other shoulder, as we have recommended under the more ordinary circumstances: should this fail, we must try to cut it through either by a finger nail slightly notched for the purpose, or by the introduction of a Smellie perforator well guarded.
The cord being twisted round the child’s neck may not only retard labour, it may destroy the child itself by preventing the free return of blood from the head: this may take place some little time before birth, or during the actual process of labour. That suffocation cannot possibly be the cause of death under these circumstances is sufficiently evident.
Knots upon the cordhave been mentioned by some authors as a cause of danger to the child shortly before and especially during labour; for the circulation in the umbilical vessels being more or less compressed, the child would either be born dead or in a very weakly state. Experience has, however, shown that these effects have been much over-rated, and that these knots are seldom injurious to the child.[120]Baudelocque has not only met with single, but even triple and very complicated knots tied tightly upon the cord, and yet the child was not only born alive, but remarkably robust and healthy. Circumstances, however, may occur by which the knot is gradually drawn so tight as to destroy the child. Smellie has given a case of this kind; but it is to the late Matthew Saxtorph, of Copenhagen, that we are indebted for an admirable essay on this subject. The result of his observations coincides with those of Baudelocque, viz. that it rarely proves fatal to the child.[121]The manner in which these knots are formedmay be easily imagined; when by chance the cord lies in the form of a ring, and the fœtus happens to float through it, a noose is made, which, when drawn tight by accident, forms a knot.
The most favourable time for the formation of such knots is in the earlier months of pregnancy, when the quantity of liquor amnii, in proportion to the bulk of the fœtus, is so much greater than at an after period, and when its movements are consequently less impeded. The circulation in the knot will be obstructed in proportion as the knot is drawn closer: if it be merely somewhat impeded, the vessels on each side of the knot will be distended and varicose, and the cord itself, where it forms the knot, from the constant gradual pressure of one fold against the other, will become more or less flattened.[122]We believe that in every case the cord has been of unusual length.
Theplacentacannot easily obstruct the birth of the child, although it may render the labour exceedingly dangerous in a great variety of ways: these circumstances will be considered under their respective heads.
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.
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, ascompletely 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 inevery 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 itssymmetry, 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 theirjunctions; 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 (∞); 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’sLehrbuch, 2te Ausgabe, p. 247.)
FromNaegelé.
Malacosteon, ormollities 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 apathological 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 fœtus 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 fœtus; yet, notwithstanding, the flexibility of the bones of the pelvis, and the debilitated state of her constitution, she recoveredspeedily 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’sEssays, 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’sLehrbuch. § 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 anydisease; nor in fact can we assign any satisfactory cause for this peculiar configuration: it appears to have been a congenital formation.
Obliquely distorted pelvis.A still more remarkable species of pelvic deformity is thepelvis 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 tothe 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 thepelvis 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 littleeffect 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 sloughingof 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 bonemay 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 onremoving 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 fœtus; 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 conditionof 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.
Inexostosisof 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, ineach 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.