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 fœtus 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 fœtus 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 fœtus 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.