Finally, pathological changes in the vaginal walls themselves may give rise to spontaneous ruptures sub partu. Hugenberger found two such among his forty cases; there being in one case stenosis and in another case large cicatrices from antecedent and successfully operated upon fistula ves. vag.
Ruptures of the vaginal vault are frequently penetrating. Hugenberger found thirty-four of them so; while in two cases the peritoneum was preserved and only elevated by extravasations.
The symptoms are very like those of cervical ruptures of the uterus. There is sudden pain, distinctly localized hypogastric tenderness on pres sure, increasing abdominal distension, collapse even with but slight ex ternal hemorrhage, sometimes cessation of the pains, change of shape of the lower abdomen from partial or complete extrusion of the fcetus through the rent, and the occasional formation of a hcematoma. These are the symptoms which are common to both affections. Vaginal ruptures can often be directly reached with the fingers; if they affect the anterior wall, the entrance of air will occasionally cause emphysematous crepita tion above the symphysis. (M'Clintock, Hugenberger.) Protrusion of the presenting part of the child does not follow vaginal as frequently as it does,utorine ruptures. Thus Hugenberger's cases the head remained seventeen times and the breech once in the pelvic canal, even when, as sometimes occurred, other parts of the child were already within the ab dominal cavity. Hence it happens that the external hemorrhage is some times very slight, the parts of the child preventing outflow. Nevertheless, all these signs are not 'sufficient to enable us to make a diagnosis of vagi nal rupture before the child is born. Feeling the lower border of the rupture will only enable us to decide that the vagina is involved. We can only ascertain the facts after the uterus is empty.
As regards their course and termination, vaginal ruptures occurring high up sub partu in most cases terminate fatally from hemorrhage, shock, or peritonitis septica, like similar ruptures of the neck of the uterus. It is usually not in our power to control the conditions necessary for an aseptic course. Yet the prognosis is better than that of uterine
rupture. Hugenberger calculates from the reports of the large Euro pean lying-in institutions, that the mortality of the latter class of cases is 95 per cent., while in 40 cases of kolpoporrhexis 11 recovered, althbugh 9 of them were penetrating ruptures.
Deep ruptures during labor of the median segment of the vag,ina proba bly only occur spontaneously when stenosis is present. 'Traumatic rup tures, also, are rare, though a,s elsewhere they may occur from the use of instruments or from pieces of bone in difficult extractions. Spiegelberg mentions a case in which a large fold of the anterior vaginal wall was seized with the part, and an opening torn into the vesico-vaginal septum..
As to ruptures at the introitus, the passage of the child's head is most likely to cause it at the tensest part, the posterior wall. They regularly begin at the narrowest part, where the hymen is inserted, and run to the entrance of the vagina. (Kiwisch.) They therefore occur most com monly in primiparEe. The mucous membrane first gives way, on account of the excessive circular distension, in a longitudinal direction. The tear then continues, boring into the deeper strata, either upwards as a. longitudinal fissure, or, combined with a transverse rupture, it attains a, Y or W-shape, depending upon whether it is continued in the direction of the raphe perin. or not. As a rule longitudinal ruptures at the vaginal entrance do not run exactly in the median line; they always go to one or the other side, since the columna rugarum post. is always more resistant than other parts. The columna also limits the transverse rup tures of the introitus. But apart from these features, due to the anatomi cal peculiarities of the parts, the ruptures may vary much in shape, es pecially when the tissues have been contused and are sugillated. We then often find the ruptures continued into the perineum. Transverse fissures of the introitus may also be continued into the depths of the perinea' tissue, without there being any longitudinal rupture of that structure.