Prognosis. —This is, thus, serious enough, although, even in these cases, a cure may be effected and the disease end in anchylosis. Gener ally, these inflammations cease after a time.
Treatuumt.—This embraces local revulsives and venesections, vrith ab solute repose and opiates.
Rupture of the Symphyses.
Sudden relaxation of the symphyses may occur and constitute rup ture of the symphyse& As Bach said, in 1832, "In order that the separation of the sym physes may occur, there must be a great expansibility of the articulations. If this expansibility does not exist, and if the force e,ausing the relatively large foetal body to pass through the pelvis is sufficient to separate the pelvic bones, rupture will occur. In ordinary cases, the pelvis resists longer than the head, but often, the overlapping of the cranial bones does not suffice, and we meet with many more e,ases of rupture of the symphysis in labor than of fractures of the skull. The symphysis pubes is less susceptible to rupture than the posterior articulation& We meet many more examples of rupture of the sacro-iliac articula tions than of the symphysis pubes, while relaxation of the latter is oftener seen." In rare cases, spontaneous rupture may occur (Duverney, An siaux), but generally, rupture follows the use of the forceps. De Lamotte quotes a case of rupture from version, and Chaussier has cited a similar one. Bach does not believe that rupture can occur without predisposition, and it is also necessary that relative narrowness exist without which only separation would take place. Among the predisposing causes, he cites failure in the cohesion of the ligaments of the symphyses, found in cachectic persons and in rickets, osteomalacia, scrofula, scorbutus, gout and syphilis. Most frequently, the rupture takes place on the descent of the head into the pelvis, but it may occur at the time of the extraction or expulsion of the head from the inferior strait. When rupture occurs in the posterior symphyses, it is due to backward displacement of the sacrum. Hence the tendency of the pubic bones to approach each other in front, and to separate behind. When the rupture is at the symphysis pubes, the surfaces are separated, leaving an interval between them, and there is, also, always a separation of the saero-iliac joints at their anterior part.
The sudden stretching of the ligaments of the posterior symphyses, by the separation of their articular surfaces, the retrocession of the saerum, the separation of the ilia, cause a rupture of the ligaments maintaining these bones in contact. The anterior ligament is raised and made tense, but does not tsar. A part of the posterior ligaments is torn or loosened, when the separation is sufficient.
When the symphysis pubes is involved, the inter-articular fibro-cartilage and the anterior ligament are tom, the posterior ligament is elongated; sometimes the cartilage of incrustation is separated from one of the bones, or is torn off. Bach, who has seen this arrangement at the symphysis pubes, does not consider it possible at the sacro-iliac joints.
Signs and Diagnosis.—If rupture occurs, the woman feels an acute pain, a sense of laceration, at the moment when the head passes through the inlet or outlet of the pelvis. Often, there is a cracking sound, per ceptible to the assistants, and louder when the symphysis pubes is rup tured. This is not a pathognomonic sign, however, for this cracking sound is often heard without rupture, when the head passes a contrac tion of the pelvis. The obstetrician then, has an articular sense of re sistance overcome, which is noticed when forceps are applied at the inlet, in pelvic contractions. It is then due to the depression of a parietal bone by the promontory. In rupture, there is always acute pain, which is lacking in the other cases. The separation is never so marked in the posterior articulations as at the pubic symphysis, but the pain is more severe. At the latter joint, the separation is often considerable. The pain is intensified by pressure and by movements of the legs. Some times there is a real crepitation. After from twenty-four t,o forty-eight hours, sometimes later, inflammatory reaction ensues, and the symptoms of inflammation of the symphyses, with their sequehe, make their ap pearance.