Rupture of the Orrix.—Fatal ruptures are usually spontaneous, and only result when by reason of the contraction of the pelvis, the excessive size of the head, or its failure to engage, delivery is retarded, and the cer vix is greatly distended above the pelvic brim. Rupture takes place when the os internum is situated obliquely above the superior strait, or when it has ascended in such a marked manner that the uterus envelopes the foetus like a hood. (Figs. 145 to 148.) As soon as this condition of affairs exists, the uterus does not tear, as it is extremely difficult for it to rup ture, no matter what operative manoeuvre may be undertaken. At any instant, however, the cervix may rupture in consequence of either a strong contraction or operative interference; but version is especially liable to lead to rupture, an accident that may happen to the most skillful accoucheur, if he fails to recognize the condition of affairs, or interfere in spite of them. In primiparw, as long as the head remains high up, the uterus contracts for many hours without deviating from its normal posi tion. It is only when its force has been exercised for a long time to no purpose, that the abdominal muscles cease to contract, and can not in consequence fix the uterus at the level of the superior strait; all the effect of the contraction then becomes confined to the cervix. The body and fundus of the uterus tend to ascend higher and higher above the head and body of the fcetus; the elastic cervix, consequently, becomes exces sively distended and is impacted between the head and the brim. This condition is rare in primiparte, hence the infrequency of rupture. In multiparte the distension of the cervix will take place sooner, and in con sequence the conditions will also be present that favor rupture. Bandl's theory can really be summarized as follows: Whenever a moderate ob stacle (contracted pelvis, transverse presentation) is opposed to the expul sion of the foetus, the uterine contractions, persisting in the body of the organ, and being no longer counterbalanced by the resistance of the sur rounding parts and abdominal muscles, will act directly on the cervix. The os internum will be drawn above the superior strait, over the fcetal part, and the uterus will be divided into two portions, the upper being formed by the fundus and body, and the lower by the cervix, in which the fcetal part will be more or less engaged. These two portions will be separated by a groove, formed at the level of the os internum, which will become more and more apparent at each contraction. While the body and fundus will tend to become thicker and smaller, the cervix, on the contrary, will become more and more distended, and will become thinner in proportion to this distension. It is evident, then, that the latter por tion may become so thin that at a given time it may rupture, this rupture beginning at the cervix, and extending upwards until it affects the tissue of the corpus uteri. (Figs. 145 to 148.) Symptoms.—Rupture usually takes place suddenly during the expulsive stage, and without any previous warning. Durihg a contraction, or some obstetric manoeuvre, the woman is seized with a sudden agonizing pain, which differs entirely from that which accompanies labor; the pain is accompanied by a sensation of tearing and sometimes by a dull sound, ap preciable to the bystanders, as well as to the patient herself. If the wound is sufficiently large to permit the escape of the child into the abdominal cavity, she has a sensation of displacement. The uterine contractions cease, either at once or quickly, and the intermittent pains are succeeded by a steady pain in the lower part of the abdomen. At the same time the facies is altered, and becomes pale, the skin is bathed in cold perspiration, the pulse becomes small and imperceptible, and attacks of syncope en sue, accompanied by nausea and vomiting. Then appear dyspncea, ring ing in the ears, and convulsions. The shape of the abdomen is changed, the uterus is extremely sensitive on pressure, and, if the child has escaped into the abdomen, the fcetal parts are clearly felt through the abdominal wall. Then the belly becomes tympanitic, blood escapes from the vulva, either pure or sanious, according to the time that has elapsed since the occurrence of the accident. On examination it will be found that the part which presented at the superior strait has either disappeared or has been replaced by another, while on the introduction of the hand, or even the finger alone, the site of the rupture may be detected, and thus the diagnosis may be established directly. Sometimes a deceitful calm suc ceeds this grave condition, while at the same time a mild sensation of heat is diffused throughout the abdomen, but the alarming symptoms soon re appear, and death ensues either rapidly, or more slowly, from consecu tive peritonitis.
According to Jolly, among 580 cases of rupture, the contractions ceased in 256, there was external hemorrhage in 148, collapse in 179, vomiting in 147, retraction of the presenting part in 146, and abdominal pain in 133; the fcetal limbs could be felt through the abdominal wall in 77 cases.
There are certain other signs that deserve attention, viz.: a tearing sound, heard by the patient and bystanders, violent movements of the foetus, followed by sudden cessation of the heart-sounds, and change in the shape of the abdomen, the uterus and the escaped fcrtus each forming a tumor, with a furrow between them. Several writers have called atten
tion to the development of fluctuation and emphysema. Hemorrhage is constant, and may be internal, external, or mixed; if it is purely inter nal, it sometimes escapes recognition. At other times the blood collects at one point, and forms a hypogastric tumor. According to Hervieux, the loss of blood will be slight when the distension is confined to the cer vix and its vicinity, where there are few vessels, when the fcetal part is so engaged in the wound as to compress the vessels, and when the entire contents of the uterus has escaped into the abdomen, thus allowing the organ to retract completely. The hemorrhage will be profuse if the rup ture occurs at the placental site, so that the placenta is stripped off, and if the uterus is in a state of inertia. In some instances, symptoms are absent, and the rupture may not be recognized, as in 37 cases collected by Jolly. But there are unusual phenomena which awaken suspicion, such as fixed pain, vomiting, recession of the presenting part, and sud den or gradual cessation of the contractions, that are not explained either by the course of the labor or by the general condition of the patient. But there are many cases in which the presentation is not altered, and the uterine contractions continue. Labor has sometimes proceeded, in spite of the rupture, until the child was expelled spontaneously. The persist ence of the contractions has been explained in various ways, some believ ing that the pressure of the foetus continues to irritate the uterus until it is expelled, after which the organ lapses into a condition of inertia, others affirming that the wound is the determining cause of the contraction, as long as it is not too extensive, while Tyler Smith thinks that the child is expelled by the same contraction that ruptures the uterus. The latter theory may apply to tears of the vagina and perineum, but not to those of the uterus. Baudl has given the true explanation of the mechanism in most cases, that is, where the rupture begins at the cervix and extends to the body.
Prognosis.—This is extremely grave for both the mother and the child, especially so for the latter, when it escapes into the abdomen. Franqu reports 26 foetal deaths in 26 cases, Ramsbotham 217 deaths in 237 cases. Scanzoni explains the fatal result as due to the loss of blood, as well as to the severe nervous shock experienced by the mother, and by the strangu lation of the cord or important parts of the fcetus, in the retracting wound. The prognosis for the mother is less grave. 100 women recov ered out of 580 cases collected by Jolly, 63 being saved out of 88 in which the child had escaped into the abdominal cavity.
Treatment. —Three courses are presented to the obstetrician, expectation, extraction per vias naturales, and gastrotomy.
1. Expectant Treatment.—This has been almost entirely abandoned at the present day, except in the case of rupture occurring during the early months of pregnancy; but, as soon as the pregnancy has advanced to the sixth month, the extraction of the fcetus is positively indicated, especially if it is living. Out of 144 cases left to nature alone, 142 died, while out of 154 women who were delivered by artificial means, 57 were saved.
2. Extraction per vias naturales.—This is the usual procedure, and almost the only one adopted in France. If the child remains within the uterus, with the head presenting, delivery should be effected with the forceps or cephalotribe, according as the pelvis is normal or contracted; if these fail, version should be practised. In 75 forceps deliveries, with or without previous crushing of the head, 13 mothers were saved, in 85 versions 15 were saved. If the child is partly or wholly outside of the uterus, Baudelocque advises the use of the forceps, if the wound is large and the pelvis normal; he reports 1 cure in 12 cases. Ramsbotham ad vises version, and reports 45 cases with 33 deaths. If the wound is large and the pelvis narrow, we may resort to the forceps or to cephalotripsy; it is better to perform version and to puncture the head after it has been fixed. If the child is alive, gastrotomy is indicated; also when the child. is partly outside of the uterus, and the wound has retracted, and extrac tion can not be effected without employing great violence or enlarging the wound with a blunt-pointed bistoury. Gastrotomy is the only resource where the entire fcetus has escaped into the abdominal cavity, and it is impossible to extract it per vias naturales, by reason of the contraction of the pelvis, the retraction of the wound, or uterus, or the resistance of the cervix; the fcetus must first be extracted, then the clots and placenta. But if the extraction presents too many difficulties, it is better to leave the placenta to be detached spontaneously later. The statistics presented by Trask and Jolly appear to indicate that gastrotomy is the operation that gives the most successful results, the mortality, according to the former, being 24 per cent. as compared with 68 per cent, after version, and 38 per cent. after natural delivery. Jolly estimates the cures by gas trotomy at 68.4 per cent., by version at 23 per cent., and after the use of the forceps 12 per cent. The time to interfere is as soon after the acci dent as the condition of the woman permits, and we must afterward guard against peritonitis, by keeping the woman for some time under the influ ence of opium, administered in full doses.