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If nausea and languor succeed, with a feeble and irregular pulse, cold sweat, retching, a difficulty of breathing, an inability to lie in a horizontal posture, faintness or convulsions, there is still more reason to suspect the nature of the case. But if the presenting part of the child, which was before plainly to be distinguished, has receded and can be no longer felt, and its form and members can be traced through the parietes of the abdomen, there is evidence sufficient, I believe, to determine that the uterus is ruptured. The labour pain, in consequence of which the rupture is supposed to have happened, is often described by the patient as being similar to cramp, and as if something were tearing and giving way within them. It has been said, likewise, to have produced a noise which could be heard by the people present." (Observations on an extraordinary Case of ruptured Uterus, by Andr. Douglas, M. D., 1785, p. 48.)

Where the peritoneal coat only has been torn, we may have many of the above-mentioned symptoms resulting from laceration of the uterus, without any impediment to the progress of labour. This peculiar species of partial rupture was first noticed by the late Dr. John Clarke, (Trans. for the Improvement of Med. and Surg. Knowledge, vol. iii.) since which cases have been recorded by Mr. Partridge, (Med. Chir. Trans. vol. xix. p. 72,) Dr. Collins, Dr. Ramsbotham, &c. In Dr. Clarke's case the uterus and vagina "were found to have sustained no injury whatever; but on turning down the fundus uteri over the pubes, between forty and fifty transverse lacerations were discovered in the peritoneal covering of its posterior surface, none of which were in depth above the twentieth of an inch, and many were merely fissures in the membrane itself. The edges of the laceration were thinly covered with flakes of coagulated blood; and about an ounce of this fluid was found in the fold of the peritoneum, which dips down between the uterus and the rectum."

Where the uterus has been torn quite through, a frequent result is, that the child passes either wholly, or in part, through the rent into the abdominal cavity: this occurrence will, in great measure, be influenced by the situation and extent of the laceration, and also by the degree of the uterine contractions. It is easily recognised by the presenting part having receded, and in all probability by the members of the child being felt with unusual distinctness through the abdominal parietes.

Treatment. Under such an unfortunate complication nothing remains but to effect the delivery in as speedy and gentle a manner as possible. Where the os uteri is fully dilated, the head presenting, and but little receded, and the pelvis only slightly contracted, the application of the forceps will be justifiable; but in many instances the circumstances of the case will not warrant it, and the attempt must be made to bring down the feet, which has been most usually had recourse to with success, although it occasionally happens that even this is attended with no slight difficulties: the rigid and partially dilated os uteri may be a serious bar to the introduction of the hand; this has been successfully overcome by incisions into its edge; but it is a remedy which no practitioner would use if by any means to be avoided.

• Med. Chir. Trans., case by Dr. Smith, of Maidstone. See also an interesting case by Professor Naegelé, in the British and Foreign Medical Review, where the uterus was ruptured by sudden violence, part of the child was delivered per vaginam, the rest by an abscess through the abdominal parietes. No. x. April, 1838.

Gastrotomy. Where the whole child has passed into the abdominal cavity, and the uterus has evidently contracted, so as to produce a serious, if not insurmountable obstacle to delivering it through the vagina, or at any rate without the risk of increasing the extent of the laceration, the question then remains as to whether we should perform gastrotomy, or leave the fœtus in the abdominal cavity to be gradually discharged, like an extra-uterine pregnancy, by abscess and sloughing. There can be no doubt that the former plan is preferable, nor are there wanting upon record successful cases of gastrotomy after rupture of the uterus; one of which is doubly interesting from the operation having been twice performed with a favourable result in consequence of a repetition of the injury in the patient's succeeding pregnancy. Mr. Ingleby, of Birmingham, gives a similar opinion in favour of the operation: "The result of two cases of Cæsarean operation in which I have been engaged, leads me to view the mere abdominal incision with very different feelings. The operation is not half so dangerous as the Cæsarean, whilst the celerity with which it is done, the absence of hæmorrhage, and the facility with which the intestines are confined within the abdomen, tend to divest it of much of its terror." (Op. cit. p. 201.)

Rupture during the early months of pregnancy. Cases of rupture of the uterus have occasionally been observed at an early period of pregnancy; in many of these the foetus has passed into the abdominal cavity, where it has been enclosed in a species of cyst, and afterwards expelled through the rectum or abdominal parietes by an abscess. It may be doubted whether some of these have not been cases of extra-uterine pregnancy. On the other hand, there is reason to believe that those extraordinary cases of ventral pregnancy, to which we have alluded, where the fœtus has been found in a sac in the abdomen, which communicated with the uterus, and to which the placenta was attached, were the results of rupture at an early period of pregnancy, in all probability the result of ulceration or organic degeneration of the uterine parietes. In some instances it has been produced by violence: and it is by no means impossible that it might take place during a miscarriage, when the uterine contractions are occasionally very violent. Mr. Ingleby remarks that in a case of premature expulsion at the fifth month, the violence of the pains seemed quite equal to produce a breach of surface.

Dr. Collins has recorded a case of ruptured uterus in about the fifth month. The laceration appears to have taken place imperceptibly: the child was very putrid; and as the os uteri was sufficiently dilated, the head was perforated, and "was brought away almost without any assistance. It was nothing more than a soft mass, being so completely broken down by putrefaction." 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.

*Lassus, Pathologie Chirurgicale, tom. ii. p. 237, quoted by Dr. McKeever, op. cit. p. 27. † Collins, op. cit. p. 277. An interesting case of rupture at the sixth month, is recorded by 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.

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 farther; 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.

* [Another case is recorded by Dr. Carmichael, of Dublin. See Amer. Journ. Med. Sc., May 1840, p. 236.-Ev.]

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 FETUS.

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 foetus 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 10 lbs. 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 7 inches.
The occipito-mental

From one parietal protuberance to the other

Circumference of the skull

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Circumference of the thorax over the xiphoid cartilage

Breadth of the shoulders

Extreme length of the child

Weight of the child

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5

15

14/

74

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, 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'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:* 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 ex

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."

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