One striking factor marks hydrocephalus, and this is the association of presentation of the pelvic extremity.
While, where the pelvis and fcetus are of normal size, the vertex pre sents in 19 cases out of 20, and the pelvic extremity once out of 70 or 80, in the 28 cases of hydrocephalus collected by Chassinat, there were seven presentations other than that of the vertex. Scanzoni, in 152 cases of hydrocephalus, found 30 other than the vertex. Poullet in 106 cases, found vertex in 65, face in 6, breech in 30, shoulder in 8, and in three cases, although not the vertex, not stated. There seems ground for error in these figures, for it is difficult to understand how the face can present at all when we consider the shape of the bead in hydrocephalus.
Presentation of the Vertex before Labor.—Sometimes increased size of the abdomen will be noted; again considerable edema of the lower limbs. Again supra-pubic edema, which is also found in case of hydramnion and twin pregnancy. Palpation will often give us the most precise informa tion. If the uterus does not contain much fluid, if it is soft and com pressible, we may determine the disproportion existing between the large head and the breech. In two cases Blot made the diagnosis by ausculta tion from the unusual height of the point where the foetal heart-sounds were heard.
During Labor.—While the membranes are still intact, the diagnosis is often difficult, but when once ruptured, it becomes easy. The bead rep resents a fluctuating pouch, which might be mistaken for a second bag of waters, but the skin of the head is always thicker, and the hair may be felt. While the sutures and the fontanelles are scarcely recognizable, owing to their exaggerated dimensions, one or another bone of the skull may always be reached, and this will frequently feel like parchment. The cases are not rare where, in the belief that there was a second bag of waters, the brain has been perforated. The caput succedaneum is a further source of error. Further still, where the foetus is dead and his been retained for some time, the changes determined by prolonged macer ation might at first deceive us. The absence of the foetal heart and of
the movements, for some time, and the character of the amniotic fluid, which is like wine-lees, will, however, in this instance, make the differen tial diagnosis.
As a general thing, labor progresses slowly, and uterine inertia often follows on energetic contractions. The influence of hydrocephalus on labor is, however, variable, and Spiegelberg makes three divisions: Labor is only slightly prolonged, the affection not very marked, and delivery occurs spontaneously. Delivery is still spontaneous, but it is prolonged and painful. Delivery is impossible, and it is here that rupture of the uterus may occur.
In certain instances, where the distension was great, spontaneous deliv ery has occurred, owing to the formation of a pouch containing the fluid, which enables the head to be compressed, and to pass through the pelvic canal. Sometimes, instead of forming a pouch, the fluid infiltrates the neck and thorax of the foetus, and even the abdomen, giving rise to a generalized edema, and enabling the bones of the skull to collapse. These cases are exceptional and usually accompany pelvic presentations. Finally where delivery is impossible, the uterus may, as we have stated, rupture. In ?4 cases of hydrocephalus, this occurred 16 times. (Keith.) Presentation of the Pelvic Extremity before Labor.—The diagnosis has never been made.
During Labor.—The progress of labor is characteristic. Everything is normal until the body has been delivered, and then the head does not engage, but is stopped above the superior strait, projecting above the symphysis. Traction is useless, and delivery is only possible through evacuation of the fluid, either artificially or spontaneously.
Prognosis.—This is grave both for the mother and the infant.
Chassinat, in 60 cases, noted the death of the foetus 41 times before or during labor, and of the 19 remaining, 8 lived less than four months, 5 one year, 2 less than two years, and only 4 over two years. Further, it was only in the instances where delivery was spontaneous that the infants survived. Intervention is absolutely fatal.