FIRST SPECIES OF DYSTOCIA.

We have already stated that the presentations of the full-grown living foetus may be brought under three classes, viz. those of the head, of the nates or lower extremities, and of the arm or shoulder: the former two have already been considered under the head of eutocia or healthy parturition, and may be distinguished from the latter, by the great peculiarity that in them the long axis of the child’s body is parallel with that of the uterus, whereas, in arm or shoulder presentations this cannot be the case, its body lying across the uterus.

Although malposition of the child, strictly speaking, refers to one species of presentation only, viz. to that of the arm or shoulder, yet it has been rendered a matter of great perplexity by the speculations and theoretical notions of authors. No one has propagated more serious errors upon this subject than the celebrated Baudelocque, the more so as the great authority of his name has tended to silence all doubts as to the accuracy of his views upon this subject. Almost every author since his time has contented himself with copying more or less from him, without ascertaining by personal observation how far they corresponded with the actual course of nature. By forcing a stuffed figure into a pelvis in every possible direction, he succeeded in making actually ninety-four presentations of the child, all of which he described as if they had really occurred in nature.

Few have taken so simple a view of this subject as the late Dr. Denman. “The presentations of children at the time of birth,” says this distinguished accoucheur, “may be of three kinds, viz. the head, the breech or inferior extremities, the shoulder or superior extremities; the back, belly, breast or sides, properly speaking, never constitute the presenting part.”

The two greatest Continental authorities of modern times, viz. Madame La Chapelle and Professor NaegelÉ, confirm this opinion: the former points out one of the sources of error which has induced practitioners to suppose that they had met with other species of faulty presentation besides those of the arm or shoulder. “In the greater number of shoulder presentations,” says this experienced authoress, “I have very distinctly touched the chest, in some positions of the nates I have been able to reach the loins, the hips, or lower part of the abdomen; but it would require no slight bias from prejudice and theoretical systems to find presentations of the chest, the back, the abdomen, or the loins, the neck or the ear.”[108]

We would, therefore, limit the term malposition of the child merely to presentations of the arm or shoulder: other presentations, it is true, occur, but not of the full-grown living foetus; they are only where the child is premature, or has been dead in utero some time. Under such circumstances it will follow no rule whatever; for in the first case it is too small, and therefore the passages can have no effect in directing its course through them; and, in the second, a child which has been dead some time becomes so softened by gradual decomposition, that it may be squeezed by the pressure of the uterus into almost any shape: it is by this cause that we occasionally see in still-born children parts in close contact, which in a living child could not have been brought together.

We do not deny that such presentations may be made by ignorant and awkward attempts to deliver, but it is to be hoped that such cases are daily becoming of rarer occurrence.

Malposition of the child is fortunately not of very frequent occurrence: as a general average we would say that it occurs once in 230 cases, as the following results will show:—At the Westminster General Dispensary (1781) it occurred to Dr. Bland once in 210 cases: at the Dublin Lying-in Hospital, to Dr. Joseph Clarke, once in 212: in private practice, to Dr. Merriman, once in 155: “calculated from a great number of cases,” to Professor NaegelÉ, once in 180: at the Dublin Lying-in Hospital, to Dr. Collins, once in 416: at the MaternitÉ, of Paris, to Madame La Chapelle, once in 230.

In arm and shoulder presentations the back of the child is turned towards the anterior part of the uterus more than twice as frequently as it is in the contrary direction, from which circumstance Professor NaegelÉ has called this the first position of the shoulder to distinguish it from the other, which, as being rarer, he calls the second.

In investigating the nature of the causes which produce malposition of the child, which, from the above observations, is evidently a circumstance of rare occurrence, the question naturally suggests itself, by what means is the long diameter of the child in so large a majority of cases kept parallel with that of the uterus? This depends in great measure on the form and size of the uterus. Where the uterus is not unduly distended with the liquor amnii, and where it preserves its natural oval figure, it is scarcely possible that the child should present in any other way than with its cephalic or pelvic extremity foremost. There can be no doubt that the first early contractions of the uterus in the commencement of labour have a great effect in regulating the position of the child; for, by the gentle and equable pressure which they exert upon it, they not only maintain it in the proper direction, but tend materially to correct any slight deviations from the right position. Hence, therefore, we find that where any cause has existed to impair or derange the action of these precursory contractions of the uterus, the child is apt to lie across, or, in other words, to present with the arm or shoulder. Thus, for instance, if the uterus be much distended with liquor amnii, the contractions of its parietes can have little influence upon the child’s position; this will be particularly the case where the accumulation is very considerable, for here the uterus becomes more or less globular, and presents but little variation as to the length of its diameter in any direction.

The form of the uterus is no less worthy of attention as a cause of malposition, and is also in a great measure influenced by the character of its early contractions. Thus in a uterus for the first time pregnant, they generally act equally on all sides: hence it is why in primiparÆ the uterus is so exactly oval, and why we so rarely meet with faulty presentations. Sir Fielding Ould, of Dublin, was the first and almost the only practitioner in this country who noticed the influence which the early contractions of the uterus have in determining the position of the child. “The first labour pains, which are very short, continue their repetition for two or three hours, or perhaps for more, before there is the least effect produced upon the os tincÆ, which time must certainly be employed in turning the head towards the orifice.” (Treatise of Midwifery, p. 14.)

Wigand, in reasoning upon the physical impossibility of a child presenting wrong, where the uterus is of the natural configuration, says that “the chief cause of faulty position of the child does not depend so much upon the child itself, as upon the deviation of the uterus from its natural elliptical or pyriform shape.” (Wigand, vol. ii. p. 107.)

The theory at one time so universally entertained, that the obliquity of the uterus was the chief cause of malposition of the child, has long since been disproved, although it continues to find a few adherents to the present day: the uterus, in fact, towards the end of pregnancy, is scarcely ever quite straight; the upright posture of the human female rendering it almost necessary that the fundus should incline somewhat to one side or to the other, or forwards, and yet we find that it has no influence upon the position of the child when labour comes on. The moment a pain commences, the fundus moves towards the median line of the body, so that its axis corresponds nearly with that of the pelvic brim: as the pain goes off, so does it return towards its former oblique position. Even in those cases where it is strongly inclined forwards, and where the abdomen is quite pendulous, the position of the child is unaffected by it.

Where, however, the uterus has been altered in point of form, where from irregular contractions of its fibres it has been pulled down unequally to one side, while it is quite relaxed in the opposite direction, the position of the child may be seriously affected, for it will now present obliquely as regards its long axis, and become a case of malposition.

We may, therefore, state that the causes of arm or shoulder presentations are of two kinds, viz. where the uterus has been distended by an unusual quantity of liquor amnii; or where, from a faulty condition of the early pains of labour, its form has been altered, and with it the position of the child.

It is a well-known fact that cross births, as they have been called, are frequently preceded by severe spasmodic pains in the abdomen, from which the patient suffers for some days or even weeks before labour has commenced: the uterus is more or less the seat of these attacks, which usually come on towards night-time; and, in some instances, it is felt for the time hard and uneven from irregular contraction. It was the circumstance of this symptom having preceded five successive labours of a patient, in all of which the child had presented with the arm or shoulder, which induced Professor NaegelÉ, when attending her in her sixth pregnancy, to endeavour to allay these cramp-like pains, which had begun to show themselves as severely as on former occasions. Having tried opium by itself, and also in combination with ipecacuanha or valerian without effect, he ordered her a starch injection with twelve drops of Tinct. Opii every night as long as she continued to suffer from these attacks: the spasms soon ceased, nor did they appear again during the remainder of her pregnancy, and he had the satisfaction of delivering her at the proper time of a living child, which presented in the natural manner.

Many other causes of malposition have been enumerated by authors, which evidently exist only in theory and not in reality: thus, shortness of the umbilical cord, or its being twisted round the child, insertion of the placenta to one side of the uterus, faulty form or inclination of the pelvis, obliquity of the uterus, as above-mentioned, violent exertions or concussions of the body, plurality of children; of all these, we do not believe that there is one which can exert the slightest influence in determining the position of the child. There is no doubt that several of them will render labour difficult or even dangerous, more especially deformed pelvis; but we constantly meet with it under every degree and variety without at all altering the child’s position. Indeed, if malformation of the pelvis were to be a cause of malposition of the child during labour, what difficulties would it not add to the process of delivery under such circumstances? And yet we find, with very rare exceptions, that in every case requiring artificial assistance on account of contracted pelvis, the head is resting upon the brim which is too narrow to allow it to pass.

We may also mention another circumstance which has occasionally seemed to produce a faulty position of the child. It sometimes happens that the hand, which is frequently felt lying by the side of the face at the beginning of labour, instead of slipping up out of reach as the head descends, which is usually the case, advances more and more, until it not only prevents the head from engaging farther into the pelvis, but pushes it out, so that the head slips up to one side, and lodges in the cavitas iliaca, allowing the shoulder with the rest of the arm to descend.

Where, however, the pelvis is large or the head small, the arm will not always force it to one side, but the two will come down together and be born in this position. (See case in our Midwifery Reports, Med. Gaz. April 19, 1834.)

Sometimes the two hands present (La Motte, book iii. ch. 26.,) or a hand and foot: this, however, does not long continue so, for when the membranes have ruptured, the liquor amnii flowed away, and the uterus contracted upon the child, one shoulder and arm descend before the rest, and remain in this position.

The complication of two arms presenting with the head we disbelieve entirely, except where it has been made during some awkward and ignorant attempts at delivery.

Although the symptoms of malposition of the child during the last few days before, or at the commencement of labour, are far from being distinct, still, however, when taken collectively, they will be sufficient to excite our suspicion. The abdomen is irregularly distended, and marked with unequal prominences; anteriorly, it is more or less pointed. It is usually much increased in breadth, and this is generally in an oblique direction, forming a globular protuberance at the upper part on one side, and at the lower part on the other: the former is the pelvic extremity of the child; the other, from its size, form, and hardness, may easily be recognised as the head.

“The movements of the child feel differently to what they did before; they are no longer exclusively confined either to one side or the other. Sometimes, as before-mentioned, cramp-like pains are felt in the abdomen, during which it is more or less distorted with violent movements, apparently of the child, as if it were trying to force its way through the abdominal parietes at this spot.” (NaegelÉ, Lehrbuch, p. 223.)

Upon examination per vaginam, either no presentation is to be reached at all, or only small parts can be indistinctly felt, such as the hand, the arm, or the shoulder. The not being able to feel a presenting part in a primipara shortly before or at the commencement of labour, is an unfavourable symptom; for the head at this time ought to be deep in the cavity of the pelvis; still, however, it does not necessarily prove that the child is presenting wrong, for it may be a presentation of the nates, which, as we have before shown, do not descend so low into the pelvis just before labour, as the head does; or it may arise from the unusual size of the child’s head, especially in cases of congenital hydrocephalus. It may arise from a large quantity of liquor amnii, and where the head is nevertheless presenting; it may be a case of twins, or lastly of dystocia pelvica, where the head is presenting, but unable to pass through the contracted brim.

In women who have had several children, it is frequently impossible to reach the presentation during the early part of the labour: this arises either from the abdomen in these cases being generally more or less pendulous, or from the circumstance of the uterus having been distended in so many previous pregnancies: its lower part does not become so fully developed as before, but continues more or less funnel-shaped, a considerable portion of the cervix still remaining. Where this is the case, the head will not descend so low as usual at first, but remains out of reach, or nearly so, until the os uteri is fully dilated and the membranes have given way.

“If, upon such an examination, it should be ascertained that the os uteri is considerably dilated, and the child cannot be felt, this affords reason to suspect that the presentation is preternatural. Should the liquor amnii be discharged and the child be out of reach of the finger, the probability of a preternatural position is greater. Should the membranes be found hanging down in the vagina not of the usual globular form, but rather conical and small in diameter, this likewise is a presumptive proof of a cross-birth; especially if there be any part presenting through the membranes which is smaller, feels lighter, or gives less resistance when touched than the bulky heavy head.”[109]The diagnosis of the shoulder is by no means easy: it offers no distinctive marks, and may readily be mistaken for the nates, or even for the head. It feels round, but is smaller and softer than the head. The scapula and clavicle, the neck, the armpit, the arm itself, and the ribs, assist us in our diagnosis. From the direction of these parts, we shall be able to ascertain the position of the rest of the body, and which shoulder presents. If the hand has prolapsed, the direction of the palm and of the thumb will soon show the position of the child.

Labours with malposition are always dangerous; when left without assistance, they are almost always fatal to the child, and generally so to the mother.

When a full-grown child has presented with the arm or shoulder, and nothing has been done to assist the delivery of it, the results are usually as follow:—After the membranes have burst, and discharged more liquor amnii than in general where the head or nates presents, the uterus contracts tighter around the child, and the shoulder is gradually pressed deeper into the pelvis, while the pains increased considerably in violence, from the child being unable, from its faulty position, to yield to the expulsive efforts of nature. Drained of its liquor amnii, the uterus remains in a state of contraction even during the intervals of the pains; the consequence of this general and continued pressure is, that the child is destroyed from the circulation in the placenta being interrupted, the mother becomes exhausted, and inflammation or rupture of the uterus or vagina are almost the unavoidable results.

Another although much rarer consequence of malposition of the child, is that peculiar mode of expulsion which was first noticed by Dr. Denman in 1772. From the supposition that the shoulder receded and the nates came down into the pelvis, in which position the child was born, he called it “the spontaneous evolution of the foetus;” but the term spontaneous expulsion, as proposed by Dr. Douglas in 1811, is much better adapted, it having been shown by that gentleman that the explanation of this process as given by Dr. Denman was not correct. (An Explanation of the real Process of the spontaneous Evolution of the Foetus, by J. C. Douglas, M. D. 2nd ed. 1819, p. 28.,) but that whilst the shoulder rested against the pubes, the side of the thorax and abdomen, followed by the nates, passed in one enormous sweep over the perineum, leaving the head and other arm still to be extricated.

The shoulder and thorax thus low and impacted, instead of receding into the uterus, are at each successive pain forced still lower, until the ribs of that side, corresponding with the protruded arm, press on the perineum, and cause it to assume the same form as it would by the pressure of the forehead in a natural labour. At this period, not only the entire of the arm but the shoulder can be perceived externally, with the clavicle lying under the arch of the pubes. By farther uterine contractions the ribs are forced more forwards, appearing at the os externum, as the vertex would in a natural labour, the clavicle having been by degrees forced round on the anterior part of the pubes with the acromion looking towards the mons Veneris. “The arm and shoulder are entirely protruded with one side of the thorax, not only appearing at the os externum, but partly without it: the lower part of the same side of the trunk presses on the perineum, with the breech either in the hollow of the sacrum or at the brim of the pelvis, ready to descend into it, and, by a few farther uterine efforts, the remainder of the trunk, with the lower extremities, is expelled.” (Douglas, op. cit. p. 28. 2nd ed.)

Farther experience has confirmed the correctness of Dr. Douglas’s views (Med. Trans. of the Royal Coll. of Physicians, vol. vi. 1820;) and, indeed, the original case as related by Dr. Denman himself tends to prove that nothing like an “evolution” of the foetus takes place. I found the arm much swelled, and pushed through the external parts in such a manner that the shoulder nearly reached the perineum. The woman struggled vehemently with her pains, and during their continuance I perceived the shoulder of the child to descend.

Some years afterwards, the late Dr. Gooch had the opportunity of observing a case of spontaneous expulsion with great accuracy, and came to the same conclusion as Dr. Douglas had done. “Resolved to know what became of the arm, if this (the spontaneous expulsion) should happen, and thus fit myself for a witness on this disputed point, I laid hold of it with a napkin and watched its movements: so far from going up into the uterus when a pain came on, it advanced, as well as the shoulder, still forwarder under the arch of the pubes, the side of the thorax pressing more on the perineum and appearing still more externally; it advanced so rapidly that in two pains, with a good deal of muscular exertion on the part of the patient, but apparently with less suffering than attends the birth of the head in a common first labour, did the side of the chest, of the abdomen, and of the breech, pass one after the other in an enormous sweep over the perineum till the nates and legs were completely expelled.” (Ibid.)

The celebrated Boer, has, however, detailed a case where the arm had prolapsed into the vagina, the hand appearing externally; and on introducing his hand for the purpose of turning, he felt the hand distinctly receding, and the breech beginning to occupy the cavity of the pelvis. This is very different to a case of spontaneous expulsion: “the child lay completely across, with its abdomen towards the back of the mother;”[110] it had, in fact, not yet begun to press against the brim, or to assume any definite position, there having been as yet but little uterine contraction, and both rectum and bladder being considerably distended. When these were evacuated the pains increased: the breech being nearest to the brim, descended, and the arm in consequence receded. Dr. Gooch considers it most probable that “it was only a breech presentation, the hand having accidentally slipt down into the vagina.”

Although in cases of malposition where turning has become excessively difficult and dangerous, the spontaneous expulsion must be looked upon as a most fortunate process by which nature effects delivery, still, however, we must never venture to wait for it without making such attempts to turn the child as the state of the patient may justify. It is always more or less dangerous to the mother, and almost certainly fatal to the child. Indeed, it is our opinion, that the spontaneous expulsion can rarely, if ever take place, except where the child has been already dead some time, or where it is premature. “Nor can any event,” says Dr. Douglas, “ever be calculated upon than that of a still-born infant. If the arm of the foetus should be almost entirely protruded with the shoulder pressing on the perineum, if a considerable portion of its thorax be in the hollow of the sacrum with the axilla low in the pelvis, if with this disposition the uterine efforts be still powerful, and if the thorax be forced sensibly lower, during the presence of each successive pain, the evolution may with great confidence be expected.” (Op. cit. p. 42.)

On the other hand, if either from the rigidity, &c. of the child or of the passages, but little material advance is made in the manner above-mentioned, if the soft parts are become swollen and inflamed, and the powers of the patient are beginning to flag, and exhaustion coming on, if turning has been attempted as far as could be done with safety, and still without success, we have no choice left but that of embryotomy; the chest and abdomen must be evacuated of their contents as already directed under the head of Perforation, and in this manner the child delivered.

Malposition with deformed pelvis, or rigidity of the uterus.—Where the pelvis is deformed, or the uterus (from the early escape of the liquor amnii) spasmodically contracted upon the child, and the os uteri in a state of rigidity, the difficulties and danger of the case are greatly multiplied: in the former complication the embryotomy must be carried much farther, in the latter we must have recourse to bleeding, opium, warm-bath, &c. as recommended under the head of Turning.

The prolapsed arm is not to be put back or amputated.—Where the arm has been some time prolapsed, and, from the pressure of the soft parts, much swollen, it fills up the vagina so completely that it would seem almost impossible to introduce the hand, unless we push up the arm first: experience however confirms the valuable rule of La Motte, viz. that we must slide our hand along the arm into the uterus; we shall rarely find, where the passages are in a proper state for undertaking the operation, that the prolapsed arm presents any serious obstruction to the passage of the hand. “An arm presenting,” says Chapman, “and advanced as far as the armpit, is not to be returned, but the hand is to be introduced (which, as Deventer justly observes, is often found to penetrate with much more ease when the arm hangs down than when it is thrust back again) and the feet to be sought for, which, when found, the arm will prove no great hindrance in turning the child.” (Chapman’s Midwifery, p. 46. 2nd. ed., 1735.)

In no case is it necessary to separate the arm at the shoulder, “for I have found it,” says Dr. Denman, “a great inconvenience, there being much difficulty in distinguishing between the lacerated skin of the child and the parts appertaining to the mother.” (Essay on Preternat. Labours, p. 32.)

Dr. Meigs, of Philadelphia, has added another powerful argument against this practice, viz. that cases have occurred where the arm had been cut off and where the child was nevertheless born alive.

As to how far it is possible or advisable so to alter the position of the child as to make it present with the nates or head, this has already been considered in the chapter upon Turning.

The presentation of the arm with the head is of very rare occurrence, so much so that some have doubted if it really existed: two cases of this kind have come under our own notice, in both of which the child was born in this position, although with some difficulty.

“Independent of the awkwardness of position which the head may assume, from the circumstance of the hand or arm descending with it into the pelvis, there will be so much increase in the bulk of the part as to render its passage slow and difficult; yet if the case be not interrupted by mismanagement, it will terminate favourably, for this complication of presentation seldom happens but in a wide pelvis.” (Merriman’s Synopsis, p. 48, last ed.)

It is by no means uncommon to feel the hand lying upon the side of the head or on the cheek; but this produces no impediment to the labour, for as the head descends through the brim of the pelvis the hand usually slips up: in the other case we have felt the arm bent over the head, and pressing the ear on the opposite side.

Presentation of the hand and feet. We sometimes also meet with cases where the hand presents with one or two feet; but these complications merely exist at the commencement of labour, where the uterus has been greatly distended with liquor amnii, and where its contractions have not yet begun to press the child into the brim. Cases of this nature sooner or later are sure to terminate in presentations of the nates or shoulder, unless the process of labour has been interfered with.

Presentation of the head and feet. Presentations of the head and one or both feet have also been described: these, however, have only occurred during the operation of turning, when the feet have been brought down into the pelvis before the head had left it, and, therefore, must be considered as having been made by unskilfulness on the part of the practitioner. Where this is the case it may be necessary to premise blood-letting, &c., on account of the inflamed condition of the parts from the previous unsuccessful attempts to turn: after this, a fillet should be passed round the feet in order to secure them, and then the head may be safely pushed out of the pelvis.

Rupture of the uterus. Of the injurious results arising from protracted or neglected cases of arm or shoulder presentation none can compare in point of danger with those where the uterus has given way or burst. This state may also be produced by deformity of the pelvis, tumours, and other causes of obstruction to the passage of the child, by which the uterus is excited to unusually violent efforts in order to overcome the impediment during which the laceration is effected. It may also arise from injuries to the uterine tissue without undue exertions, as from exostosis of the pelvis, sharp projecting edges of the promontory or brim, and also from organic disease: thus, “when the rent speedily follows the accession of labour, before the pains have become severe, or the uterus has scarcely begun to dilate, its structures will probably be found diseased.” (Facts and Cases in Obstetric Medicine, by I. T. Ingleby, p. 176.)

Usual seat of the laceration. The part of the uterus in which laceration is most frequently observed to occur is near to or at the junction of the uterus with the vagina: this happens rather more frequently behind than before, but the difference in this respect is very trifling. Thus in 36 cases which were collected by Mr. Roberton, of Manchester, “in 1 the cervix was separated from the vagina except by a thread: in 11 the laceration was posterior, in 8 it was anterior, in 5 lateral, in 3 anterior-lateral, and in 3 posterior-lateral.” (Edin. Med. and Surg. Journal, vol. xlii. 1834, p. 60.) In 34 cases which occurred at the Dublin Lying-in Hospital, “in 13 the injury was at the posterior part; in 12 anteriorly; in 2 laterally; in 1 the mouth of the womb was torn, and in 6 the particular seat of the laceration was not described.” (A Practical Treatise on Midwifery, &c., by Robert Collins, M. D., 1835, p. 244.)

The nature and extent of the laceration varies a good deal: in the worst cases the uterus is torn completely through, and the child escapes either partly or wholly into the abdominal cavity; whereas, in many, the peritoneum has not given way, the laceration being confined entirely to the tissue of the uterus itself. Thus, in 9 of the 34 cases recorded by Dr. Collins, “the peritoneal coat of the uterus was uninjured, although the muscular substance of the cervix was extensively ruptured.” In other instances the peritoneum has been cracked or torn in numerous places without any injury to the subjacent tissue.

From the greater degree of resistance to the passage of the child, in cases of first labour, we might naturally suppose that rupture of the uterus would be more frequently seen among primiparÆ: this, however, is not the case, for of 29 cases mentioned by Mr. Roberton, only one of them was a primipara; a larger (and as an average probably more correct) proportion, viz. 7 in 34, has been given by Dr. Collins: of the multiparÆ, 5 were in their sixth pregnancy, 2 in their tenth, and 2 also in their eleventh pregnancy.

Experience also shows that in a large proportion of these cases, the duration of the labour has been very far from being longer than usual; indeed, in a considerable majority, the mischief has taken place very few hours after the commencement of active labour. Thus, the average duration of it in the 36 cases recorded by Mr. Roberton, was 15 hours: in 24 of those by Dr. Collins, it was 17 hours: but if we take merely the majority of them we shall have a much smaller average: thus, in 20 of Mr. Roberton’s cases it was 9 hours, and in 15 of Dr. Collins’s it was only 6 hours.

Causes. A large proportion of cases where the uterus gives way during labour, are connected with more or less deformity of the pelvis, and where, from previous severe and difficult labours, its structure has been injured, and rendered incapable of bearing that degree of tension, which even the ordinary exertions of the uterine fibres would require. In many others, the impediment produced by the contracted pelvis, or malposition of the child, has roused the uterus to those violent efforts which have produced the laceration. Organic diseases of the uterus, or cicatrisations of the soft passages from extensive injuries in former labours, either render its powers of resistance defective, or, by increasing the resistance, excite it to unusual violence. “The operation of turning is not unfrequently a cause of laceration of the vagina or mouth of the uterus, particularly, where it is performed previous to the soft parts being sufficiently dilated to admit the easy passage of the hand, or where great haste is employed. The same consequences may ensue from rash or violent attempts to remove a retained placenta. I have also known the mouth of the womb to be torn by the imprudent use of the forceps when not sufficiently dilated.” (Dr. Collins, op. cit. p. 242.) “The sex of the infant, it would appear, may also have some share in occasioning this very distressing occurrence.” (Practical Remarks on Lacerations of the Uterus and Vagina, by Thomas M’Keever, M. D., p. 4.) Thus, of 20 cases reported by Dr. M’Keever, 15 were delivered of boys and 5 of girls; of the 34 cases described by Dr. Collins, “23 of the children were males. This is satisfactorily accounted for by the greater size of the male head, as proved by accurate measurement made by Dr. Joseph Clarke.”

Another circumstance which influences to a certain extent the frequency of rupture of the uterus, is the rank of the patient: in private practice, especially among the better classes of society, it is an extremely rare occurrence; but in the lower grades of life several causes concur to render it more frequent. They are “much more exposed to falls, bruises, and other accidental injuries during pregnancy, in consequence of which the uterus may be either ruptured at the time they have sustained the violence, or may be so weakened in structure at some particular point, as readily to give way during its efforts to accomplish delivery. Lastly, they are more liable to fall into the hands of ignorant inexperienced midwives, who not unfrequently, with a view of expediting the process of delivery, rupture the membranes at an early period of the labour; in consequence of which, the firm unyielding head of the child is prematurely brought in contact with the passages, exciting by its pressure, swelling, inflammation, and an interrupted state of the circulation in the uterus and adjacent parts. In such a case should there unfortunately exist any disproportion between the parts of the mother and the head of the infant, or should proper measures not be employed to obviate distressing symptoms, and that the labour pains continue to recur with extreme violence, there is great risk of the uterus giving way, the laceration being of course most likely to occur at that part where the greatest pressure has been sustained.” (M’Keever, op. cit. p. 3.)

The premonitory symptoms of rupture of the uterus are not always sufficient to warn us of the impending danger, for in many cases nothing unusual has occurred until the actual injury has been produced, and it has then been inferred by the alarming change observed in the patient’s appearance. In many cases, especially where the muscular substance only of the uterus was torn, the pains have continued with a sufficient degree of power to expel the child; in others the mischief has been attended with so little suffering at the moment, and for the time with so little constitutional derangement, as to excite no suspicion, either on the part of the patient, or her attendant. “Farther, as on some occasions, the uterus has been known to give way during the very pain which effected the delivery of the child, instances of which may be found in the works of Crantz and Guillimeau.” (Ibid. p. 15.)

Symptoms. “When a rupture of the uterus has really happened, it is generally marked by symptoms which are decisive; but it being a case which occurs so very rarely, they do not immediately create suspicions. When labour has continued violent a considerable time, if a pain expressive of peculiar agony is followed by a discharge of blood, and an immediate cessation of the throes, there is reason to apprehend this mischief. If nausea and languor succeed, with a feeble and irregular pulse, cold sweat, retching, a difficulty of breathing, an inability to lie in a horizontal posture, faintness or convulsions, there is still more reason to suspect the nature of the case. But if the presenting part of the child, which was before plainly to be distinguished, has receded and can be no longer felt, and its form and members can be traced through the parietes of the abdomen, there is evidence sufficient, I believe, to determine that the uterus is ruptured. The labour pain, in consequence of which the rupture is supposed to have happened, is often described by the patient, as being similar to cramp, and as if something was tearing and giving way within them. It has been said likewise, to have produced a noise which could be heard by the people present.” (Observations on an extraordinary Case of ruptured Uterus, by Andr. Douglas, M. D., 1785, p. 48.)

Where the peritoneal coat only has been torn, we may have many of the above-mentioned symptoms resulting from laceration of the uterus, without any impediment to the progress of labour. This peculiar species of partial rupture was first noticed by the late Dr. John Clarke, (Trans. for the Improvement of Med. and Surg. Knowledge, vol. iii.,) since which cases have been recorded by Mr. Partridge (Med. Chir. Trans. vol. xix. p. 72.,) Dr. Collins, Dr. Ramsbotham, &c. In Dr. Clarke’s case the uterus and vagina “were found to have sustained no injury whatever; but on turning down the fundus uteri over the pubes, between forty and fifty transverse lacerations were discovered in the peritoneal covering of its posterior surface, none of which were in depth above the twentieth of an inch, and many were merely fissures in the membrane itself. The edges of the lacerations were thinly covered with flakes of coagulated blood; and about an ounce of this fluid was found in the fold of the peritoneum, which dips down between the uterus and the rectum.”

Where the uterus has been torn quite through, a frequent result is, that the child passes either wholly, or in part, through the rent into the abdominal cavity: this occurrence will, in great measure, be influenced by the situation and extent of the laceration, and also by the degree of the uterine contractions. It is easily recognised by the presenting part having receded, and in all probability by the members of the child being felt with unusual distinctness through the abdominal parietes.

Treatment. Under such an unfortunate complication nothing remains but to effect the delivery in as speedy and gentle a manner as possible. Where the os uteri is fully dilated, the head presenting and but little receded, and the pelvis only slightly contracted, the application of the forceps will be justifiable; but in many instances the circumstances of the case will not warrant it, and the attempt must be made to bring down the feet, which has been most usually had recourse to with success although it occasionally happens that even this is attended with no slight difficulties: the rigid and partially dilated os uteri may be a serious bar to the introduction of the hand; this has been successfully overcome by incisions into its edge;[111] but it is a remedy which no practitioner would use if by any means to be avoided.

Gastrotomy. Where the whole child has passed into the abdominal cavity, and the uterus has evidently contracted, so as to produce a serious, if not insurmountable obstacle to delivering it through the vagina, or at any rate without the risk of increasing the extent of the laceration, the question then remains as to whether we should perform gastrotomy, or leave the foetus in the abdominal cavity to be gradually discharged, like an extra-uterine pregnancy, by abscess and sloughing. There can be no doubt that the former plan is preferable, nor are there wanting upon record successful cases of gastrotomy after rupture of the uterus; one of which is doubly interesting from the operation having been twice performed with a favourable result in consequence of a repetition of the injury in the patient’s succeeding pregnancy.[112] Mr. Ingleby, of Birmingham, gives a similar opinion in favour of the operation: “The result of two cases of CÆsarean operation in which I have been engaged, leads me to view the mere abdominal incision with very different feelings. The operation is not half so dangerous as the CÆsarean, whilst the celerity with which it is done, the absence of hÆmorrhage, and the facility with which the intestines are confined within the abdomen, tend to divest it of much of its terror.” (Op. cit. p. 201.)

Rupture during the early months of pregnancy. Cases of rupture of the uterus have occasionally been observed at an early period of pregnancy; in many of these the foetus has passed into the abdominal cavity, where it has been enclosed in a species of cyst, and afterwards expelled through the rectum or abdominal parietes by an abscess. It may be doubted whether some of these have not been cases of extra-uterine pregnancy. On the other hand, there is reason to believe that those extraordinary cases of ventral pregnancy, to which we have alluded, where the foetus has been found in a sac in the abdomen, which communicated with the uterus, and to which the placenta was attached, were the results of rupture at an early period of pregnancy, in all probability the result of ulceration or organic degeneration of the uterine parietes. In some instances it has been produced by violence: and it is by no means impossible that it might take place during a miscarriage, when the uterine contractions are occasionally very violent. Mr. Ingleby remarks that in a case of premature expulsion at the fifth month, the violence of the pains seemed quite equal to produce a breech of surface.

Dr. Collins has recorded a case of ruptured uterus in about the fifth month. The laceration appears to have taken place imperceptibly: the child was very putrid; and as the os uteri was sufficiently dilated, the head was perforated, and “was brought away almost without any assistance. It was nothing more than a soft mass, being so completely broken down by putrefaction.”[113] There was no previous history to explain it; the muscular structure of the uterus at the anterior part of its cervix was torn, leaving the peritoneum entire.

Lastly, we may mention a very singular species of laceration of the uterus, of which we know of but two cases, the one recorded by Mr. P. N. Scott, of Norwich, (Med. Chir. Trans. vol. xi.) the other which occurred under our own notice, where the whole os uteri separated from the uterus during labour.[114] In both cases, the os uteri presented a degree of unnatural rigidity, which was quite peculiar, and which in one case, defied repeated and active bleeding, as well as opiates. In Mr. Scott’s case, the laceration took place during a violent pain, when the patient “felt something snap, the noise of which one of the attendants declared she heard.” In the other case, the patient was not aware of any thing peculiar having happened: it was a first labour in the eighth month of pregnancy; the os uteri had dilated to nearly the size of half a crown, but would dilate no farther; the child had evidently been some time dead; the cranial integuments gave way from putrefaction, the brain escaped, the bones of the skull collapsed, and the bag of scalp protruded so far that we could lay hold of it, although the basis cranii had not passed. We were thus enabled to use more extractive force than we could have ventured upon with the crotchet: after a little effort, but without even a complaint from the patient, the head descended and passed through the os externum. “On the bed lay a disc of fibrous matter with a circular hole in the middle; in fact, the os uteri separated from the uterus to the extent of near half an inch, the edge of the laceration being as clean and smooth as if it had been carefully cut off by a knife.” In both instances the patient recovered. Whether incisions into the os uteri for the purpose of effecting the necessary degree of dilatation would have been justifiable under circumstances of such unusual rigidity, does not belong to the present subject; for the consideration of this, we must refer to the Fifth Species of Dystocia.