[Dr. Malcolm McLean, of New York, has recently reported a case of partial rupture of the uterus, where he was able to perform podalic version. All of the child had escaped from the uterus except the head and one arm. The mother recovered, notwithstanding the formation of a large kematocele to the right of the uterus.
McLean lays stress on the fact that in the above case the fcetal envel opes remained unruptured and thus protected the peritoneum from con tact with liquor amnii, etc.—Ed.] XII. Ruptures and Lacerations of the Vagina.
The vagina, as well as the uterus, may rupture spontaneously, or may be torn by the introduction of the hand, or by splinters and fragments of bone; the tears may be situated at the upper, middle, or lower part of the vagina. Those affecting the fornix, when very extensive, are often asso ciated with rupture of the uterus, give rise to the same symptoms and call for the same treatment. Ruptures of the fomix, especially when spontaneous, are usually transverse, and the vagina may be entirely de tached from the uterus. As in ruptures of the uterus, these tears may allow the complete or partial escape of the foetus into the abdominal cav ity, but they are more frequently accompanied by prolapse of the intes tine. When the tears occur at the middle or lower part of the canal, they often escape notice during labor, and are only recognized after the expulsion of the foetus. Although frequently fatal, they may, however, result favorably, even when the foetus has escaped into the abdomen. If not immediately fatal, they may cause para. and perimetritis, suppuration, more or less extensive gangrene, and consequent fistula'. Filially, lesions of the vagina not infrequently result in consequence of prolonged pres sure, whence vesico- and recto-vaginal fistulas.
The child may usually be extracted per vias naturales, and hemorrhage becomes the accident that demands immediate attention. Injections and tamponing being naturally contra-indicated in these cases, we must be content with cold applications. In rare cases gastrotomy is advisable, as a last resort. Tears of the mucous membrane are usually of little impor tance, and only require astringent and antiseptic injections.
Ruptures of the vagina, although grave, are not by any means always fatal. l)anyau records 4 recoveries in 17 cases, and McClintock in 51 cases, 13 recoveries.
XIII. Puerperal Hemorrhages.Xiii. Puerperal Hemorrhages.
Under this head are included all hemorrhages that may occur in the pregnant woman, from the cessation of the menses to their reappearance— in short, hemorrhages during pregnancy, labor, delivery, and the puer peral state. The following varieties are to be distinguished: 1. Hemorrhages during the first six months of pregnancy, or before the Rana is viable, which lead to abortion.
2. Hemorrhages during the last three months, including those that occur during labor, which are invariably due to placenta prievia. They often compromise not only the existence of the pregnancy, but that of the mother and child.
3. Hemorrhages during the third stage of labor.
4. Secondary hemorrhages, occurring several hours, or days, after de livery, and sometimes representing a return of the menses with too pro fuse flow.
1. Hemorrhages auring the first Six Months.
We shall consider these briefly, referring the reader to the chapter on " A bortion. " Causes.—The primary cause is pregnancy itself, which leads to general pelvic congestion, as well as to the various disturbances already mentioned at length. Two distinct conditions may exist, anaemia and plethora, both of which may lead to practically the same result; the former is really a serous plethora, while the latter, which is rare, is so to speak an active plethora. We must also bear in mind the peculiar alteration in the blood that occurs during pregnancy. Under these different influences conges tion may be produced, which leads to hemorrhage. But the menstrual congestion is also an active factor, especially during the early months of pregnancy; conception causes suppression of the monthly flow, but slight losses of blood are sometimes observed, especially during the first three months, which, on account of their coincidence with the usual time at which menstruation appears, seem to be related to that function. Nu merous cases are on record in which women have menstruated through out pregnancy; Els:maser alone has collected 50 examples. This is not true menstruation, since the hemorrhage differs in quantity or quality, and would not be connected with the normal flow except for the coinci dence in its appearance.