During labor, we should also be guided by the same rule, to temporize as long as there is no immediate danger. But there is a method which we should always try, because it is very simple, and is generally free from danger—that is, the displacement of the tumor, especially when it is solid, to the side of the abdomen. If this does not succeed, we should try puncture through the vagina, or the rectum, the former being preferred. Ovariotomy during labor is not practicable, and the removal of the tumor through the vagina, as advised by Merrimann, would not give any better results; we must then resort to dilatation of the cervix, and interference with the forceps, version, cephalotripsy, and embryotomy, according to the cases, or the Ciesarean operation. Olshausen rejects the forceps, on account of the danger of rupturing the cyst, and prefers version to it, as being a little less dangerous. Litzmann reports 56 deliveries, 32 mothers and 7 children saved; in 10 cases, in which delivery was spontaneous, 5 mothers, and one child lived; in 7 in which the tumor was displaced, 6 mothers and 2 children survived. 13 out of 17 mothers were saved by embryotomy. Playfair has also collected 57 cases, in 13 of which delivery was spontaneous, resulting in the death of 6 mothers and 5 children; in all of the cases (9) in which puncture was resorted to, all of the mothers and two-thirds of the children were saved. 8 out of 15 women survived after embryotomy, 1 out of 5 after version, and 1 out of 2 in forceps de liveries.
IX. Tumors of Various Kinds.
Carcinomata, fibromata, and ovarian tumors are not the only ones that may become causes of dystocia, and there are a certain number of other growths that have opposed serious obstacles to delivery by obstructing, more or less, the pelvi-genital canal. Among these are carcinoma of the vagina, tumors of the Fallopian tube,(hydro-salphinx), fibroma, carcinoma, etc., of the pelvic cellular tissue, luematocele, hydatids, pelvic abscess, lithopfedia, enchondroma, vaginal cysts and tumors of the rectum. With regard to these different varieties of tumors, Naegel6 and Grenser remark, " these tumors have exactly the same influence on labor as ovarian cysts; their location is invariably the same, i.e., between the vagina and rectum, and it is often difficult, or even impossible, to distinguish between the two kinds of tumors. However, the differential diagnosis is of no practical impor tance, except in so far as regards the question of extirpation, because the other indications are precisely the' same. We empty the cysts by punc ture or incision, according to the consistency of the contents, then leave the delivery to nature, or, if necessary, terminate it artificially. Large solid tumors sometimes leave no choice between extirpation, embryotomy, or Caesarean section. Extirpation, although it is one of the gravest and most difficult of operations, is sometimes successful.
X. Rupture of the Uterus.
Rupture during pregnancy, and especially at the beginning, is rare; after the fourth month the uterus is exposed to injury through the ab dominal wall, and rupture then becomes more frequent. Sometimes
rupture occurs spontaneously, under the influence of recent and acute uterine lesions; the affected regions sometimes become so soft that they are less resistant than healthy tissue, and yield to the least muscular effort, or to external pressure exerted upon the uterus through the abdominal wall; cicatrices from former lesions may yield in like manner. Blows, falls, etc., or even compression by mitre-coup, are among the direct causes. Among recorded cases, we would note Corigne's case of wound of the uterus at the eighth month, Dionis at 6 months, Saxtorph at 7, Hohl at 5, Pigne at 8, Gueniot at 8, Geissler at 9. In 1868, Trask collected 12 cases of rupture of the uterus during the first six months with recov ery, and 26 after the sixth month with death in many of the instances. [Since Trask's report, the instances have multiplied to such an extent that it is impossible as well as unnecessary to cite them.—Ed.] The symptoms of rupture vary somewhat according as the accident takes place during the first four months of pregnancy, or after that time. In the former case the woman has a severe shooting pain in the lower part of the abdomen; at the same time a tearing sound is heard within the belly, the, face becomes pale and is bathed in cold perspiration, the pulse is rapid and feeble; hiccough, vomiting, convulsions and syncope appear, the ab domen becomes distended, hard and tender, the cervix is hard, and there is usually no external hemorrhage. The woman usually dies soon after the occurrence of the rupture, or she may succumb to subsequent peri tonitis. From the fifth month on, the first symptoms after the accident are the same as in the former case, but, as the child often escapes into the abdominal cavity, special symptoms result. Aside from the fact that there is always hemorrhage in these cases, the shape of the abdomen be comes altered, the foetal parts are felt, and the movements are often seen; by the touch changes are noted in the condition of the cervix and in the shape of the uterus. Finally, in wounds of the uterus, we find escaping from the wound blood and amniotic fluid, and in some instances the rent has been large enough to permit the escape of the entire foetus. Trask has only collected 12 cases of recovery.
II. Ruptures during Labor.
These may be complete or incomplete, according as they involve the entire thickness of the organ, or only extend to the peritoneal covering; they may extend to the vagina. It is only when they extend beyond the os internum that they become serious. They may be spontaneous or in consequence of obstetrical manipulations; the former are of most interest to the obstetrician, because the latter are nearly always preventable. Opinions vary regarding the frequency of this accident. The average percentage, as estimated from the statistics of upwards of 30 different writers, and representing over 3,000,000 cases of labor, was 1 in from 2000 to 4000. In 573 cases of rupture, Jolly found that 376 were spon taneous, and 197 traumatic.