Accidental rupture occurs from the ac tion of the uterus being violent while the hand of the practitioner is within, or the same thing may happen from pressure of the knee or some other part of the child, which last is frequently the cause.
The manner in which the uterus gives way in this instance is exactly a fibre conteacting over a pulley, which being a disadvantageous position, is liable to be ruptured if the contraction be strong. Certain symptoms take place which are evidences of its having happened ; one is, a sensation of a sudden and most excru ciating pain, which always conies on at the moment of the rupture. A lady, when in labour, was attended by a most respectable practitioner, and a man in years; this case is an example of the manner in which it may come on. The labour went on perfectly well, and it be ing late at night, he proposed that the husband should go to bed, as his wife would be delivered in three or four hours more. The gentleman then sat down by the bedside of his patient, and in about three quarters of an hour she began to scream suddenly: he supposed the head was in the vagina, as the labour had gone on so well, when, to his astonishment, he found the head was not to be felt, it had entirely receded. She would get up, and he in vain prayed and begged her to lie still. This state of pain and restlessness was succeeded by faintness from two causes, hemorrhage and pain. These are attended with another, which is the sudden loss of labour pains. There is a faint inclination in the uterus to keep them up, but they are sure to sink. The organ is destroyed and its functions must necessarily be destroyed too. There is great restlessness, accompanied with a sense of pain different from that lately felt: there will be faintness, but without loss of blood externally, for it generally passes into the abdomen; there will be vomiting of a tenaceous chocolate colour ed fluid; the head or other presenting part recedes usually, and the child can be no longer felt.
All these symptoms, combined, become a proof of ruptured uterus ; but any one of the symptoms may occur alone ; the patient may be in violent pain without rupturing the uterus ; she may faint, but it does not follow that her uterus is torn : there must be all these things in com mon ; excruciating pain, a fainting, sick ness, and vomiting of that singular kind, and the retiring of the presenting part ; these in the aggregate will determine our opinion. If in a case of this kind we find
the head bas only entered the upper aperture of the pelvis ; we cannot get the forceps applied : here it has been said we might turn and bring down the feet : but this should never be attempted ; it only occasions more mischief; the on change is to open the head of the child. If, however, from the head being high up, aad loose, we think that we can embrace it with the forceps, we may try, for we by this mean give another chance for the delivery of a living child, which is a great object at all times.
Suppose a case where the child has actually retired from the cavity of the uterus into the cavity of the abdomen what is to be done ? there have been dif opinions; some say it is best to bring the child back, while others leave it to nature. It should always be return ed and delivered by the feet. The chance is something in favour of the mother, whose cue cannot be worse, and largely in favour of the child.
Uterine Hemorrhage. Flooding cases belong naturally to this section, hemor rhage being one of the constant atten dants on the last mentioned accident. We have already considered the history and management of trifling floodings occur ing in the six first months of pregnancy, when speaking of the management of abortion : what we are now going to treat of relates to the three last months, the commencement of labour,dering the pro gress of labour, or after the delivery of the child, and before that of the placenta; and each of these divisions, as regards time, will run into the rest.
Theproximate cause of puerperal flood ings is in all cases the same thing, consist ing of a partial separation of the surface of the placenta from that of the uterus. The difference existing in structure, be tween the human placenta and that of brutes, accounts for it happening less frequently in them than in us. In quad rupeds, the fatal part separates from the maternal portion, as was before ex plained; while in us the whole placenta comes away entire, leaving vessels with open mouths; so that when any portion of the placenta is separated by any mis chance, a consequent hemorrhage at tends, which is proportioned in violence and duration to the extent of the part so exposed. The vessels are largest towards the middle of the placenta; and some of them are very large indeed on the inner surface of the uterus.