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treme 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 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 Geburtshilfe, 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

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 hydrocephalus.

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 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 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 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 foetal 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 foetal 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 opportunity 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 foetus 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."+

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

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*Quoted by Dr. Lee in the Med. Gazette, Dec. 25, 1830, from the Journ. Gen. 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 dif ferent attacks of venereal disease. Some interesting cases have been published in the Neue Zeitschrift für Geburtskunde, band vii. heft 1, by Dr. Bunsen of Frankfort and Dr. Kyll of Cologne. In almost every case of great accumulation of liquor amnii, the child was dead, hydrocephalic, or with ascites, and in many the placenta was diseased.

in the groins and pelvis, the oedema 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.

*

The umbilical cord may obstruct labour, by either being too short, or rendered so from being twisted round some part of the child. Its length varies very considerably. Although we have stated it to average about eighteen or twenty inches, 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's Lond. 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's Transl. vol. i. § 516.) Mauriceau

[Dr. Churchill has given a table of the length of the umbilical cord in 500 cases. In 127 of these, the cord was 18 inches long, in 77 cases 24 inches, and in 45 cases 20 inches long. The extremes were 12 and 54 inches. Op. Cit. ED.]

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