DYSTOCIA FROM THE SIDE OF THE RETITS.
The causes may be divided into the six following classes: 1. Excess of volume without pathological alteration. 2. Excess of volume through pathological alteration. 3. Abnormal presentations and positions. 4. Prolapse and vicious position of the limbs. 5. Twin pregnancies. 6. Monstrosities. These we proceed to consider separately.
I. Excess in Voltme without Pathological Alteration.
This may be partial, limited to the head, or general.
Excess in Volume of the Head.—This cause of dystocia is rare, and al though Saxtorph, Voigtel, Credo, Hohl, have reported cases of ossification of the sutures, with and without the presence of Wormian bones, Naegel6 and Grenser remark, justly, that there exists no authentic case of labor retarded by this cause alone. The two cases cited by Joulin from Mau riceau and Delamotte, are open to doubt, and, as Cazeaux says, the method of action in such cases is doubtful, seeing that we can only ap proximately estimate the size of the foetus while it•is in the uterine cavity.
Total Excess in Volume.—The majority of the reported cases are apocry phal. Among the recorded cases we cite: Crantz's case where the foetus weighed 23 pounds; Cazeaux's and Riembault's, 18 pounds; Depaul's, 12+; Ramsbotham's, 16; Martin's, 15 pounds. We have seen two. In the one, a boy, the weight was 12+ pounds; in the other, a girl, 10 pounds, 1+ ounces.
The age of the patient and the number of anterior labors combine to increase the weight of the child. This has been proved by the researches of Hecker, Veit, Frankenhauser, Wernich. Clarke and Simpson claim a notable difference in case of boys. Hecker and Schroeder admit this, but with greater reserve. Pfannkuch has shown that, the weights being equal, boys have always larger heads than girls, and Schroeder says that, while in young primiparm it is not exceptional to find a head with the transverse diameter measuring less than 3.7 inches, in old multiparm, if the child is a boy, the same diameter often measures 4 to 4.5 inches.
The researches of Lampe, Hecker, Ahlfeld, Bidder, in regard to the weight of successive infants, allow us to draw the following conclusions: 1. The size of the child is greater in old primiparm than in young. 2. The reverse holds true in case of multipart)). 3. Boys predominate in very young women, and in those who have passed the age of thirty, whether primiparm or multiparm.
It is apparent that when the fcetus weighs as much as in the cases cited above, labor may be prolonged and difficult; but ordinarily it is only where pelvic deformity is associated with increased size that the obstacles to delivery become and then the true cause of dystocia resides, as has been clearly pointed out by Jacquemier, in exaggerated size and ab sence of rotation of the shoulders.
This cause of dystocia has been mentioned, says Jacquemier, by the an cient writers under two varieties: " In the first, it is supposed that, after the spontaneous or artificial birth of the foetal head, the large shoulders may present an obstacle to the birth of the body, which the uterine efforts singly, or aided by artificial means, cannot overcome. In the other, the shoulders are supposedly stopped at the brim or in the excavation. The head does not advance beyond the inferior strait, because the expuhory efforts are wasted on the shoulders, and not transmitted to the head. This constitutes Lavret's imprisonment of the shoulders." When we speak, Jacquemier further adds, of the volume of the shoulders, we really mean the volume of the thorax. Usually the above varieties of dystocia are conjoined.
According to the same authority, arrest of the shoulders may depend: " 1. In four out of five cases exclusively on the exaggerated size of the thorax and the shoulders.
" 2. On lack of proportion between the body of the fcetus and the pelvis.
" 3. On acephalic or anencephalic foetuses.
"4. On absence of rotation of the shoulders, this in turn resulting from inertia uteri.
" The indications for treatment vary, of course, with the cause. If the volume and not the position of the shoulders constitutes the obstacle, then the forceps. If this fails, mutilation of the head, in order to bring down an arm, and by traction on it, to deliver the trunk. If the head has been delivered, either traction on the head, which will often be of no avail, or else the insertion of the fingers in the axillse and traction. A better method is to first disengage one arm, and then the other, for thus the size of the thorax is diminished." This is the method which we advocate, but we must act quickly. We will often fracture an arm, or paralyze it, but both these lesions are re covered from in a short space of time.