LECTURE XXI.

RUPTURE OF THE UTERUS, VAGINA, AND PERINÆUM-DEFINITION OF LACERATION, RUPTURE, AND PERFORATION-PREMONITORY SIGNS AND PROPHYLAXIS THE CONDITIONS UNDER WHICH RUPTURE OCCURS IN NON-PREGNANT UTERUS; DURING PREGNANCY; DURING LABOUR-LACERATIONS FROM OBSTRUCTION TO LABOUR-LACERATION OF THE VAGINA-TRAUMATIC LACERATIONS - THE SYMPTOMS AND COURSE OF CASES OF LACERATION-THE TREATMENT-DIFFICULTIES FROM DIFFICULTIES IN DIAGNOSIS ILLUSTRATIONS OF SOURCES OF ERROR-DESCENT OF INTESTINE,

RUPTURE of the uterus has this affinity to the Cæsarian section, in that it is sometimes produced by conditions similar to those which determine us to perform the Cæsarian section. Indeed, a great motive for this operation is to avoid rupture. And when rupture has occurred, it is often necessary to open the abdomen in order to remove the foetus. There are, in fact, cases of dystocia where Nature, unable to effect delivery per vias naturales, seems, by rending open the uterus and extruding the child into the abdominal cavity, to endeavour to accomplish that which the surgeon accomplishes by cutting open the uterus after laying open the abdomen. It rests with the surgeon in these cases to meet Nature half way, by performing abdominal section, to get at the child cast out into the abdominal cavity.

There are few subjects in obstetric practice more interesting, or possessing a wider range of relations, than rupture of the uterus. A full knowledge of the conditions under which the accident may arise, of the symptoms and terminations, is of the highest importance in medical and in medico-legal relations.

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The accident rarely or never happens without some imputation or suspicion of malapraxis falling upon the medical practitioner. It is of the last importance to know what to do, and what not to do, not alone in the interest of the patient, but also, reflecting on the fearful penalties under which we practise, in our own. It is of the very nature of the accident that it commonly happens suddenly, without warning, and therefore precludes the medical attendant from using means to obviate it. I have been more frequently consulted in criminal charges connected with rupture of the uterus than with any other obstetric casualty. In almost every instance the conclusion that the accident arose from unavoidable causes proved to be the best founded.

The following general propositions may be affirmed :— 1. The non-pregnant uterus may burst.

2. The uterus may burst at any period of gestation independently of labour proper.

3. Any part of the parturient canal may be lacerated during labour.

4. By far the greater number of cases occur during labour at term.

5. The uterus will not burst unless it be in a certain degree of tension, from containing something in its cavity.

6. The uterus may burst in child-bearing women of all ages; in women pregnant for the first time, or in women who have borne one or more children; the greater risk being in primiparæ and in women who have borne many children.

It is desirable to attach definite meanings to certain terms. By so doing, we shall at once effect a natural classification of cases that will much simplify our inquiry.

1. Rent, or laceration, occurs when a breach begins at the edge of the os uteri, or perinæum, and extends, under the action of labour; or when the structures are torn by the hand or instruments.

2. Rupture, or bursting, occurs in the body of the uterus, or at the junction of the vagina and uterus, or in the middle of the perinæum. Rupture of the uterus may occur at any period of pregnancy or labour. This is generally the result of spontaneous uterine action.

3. Perforation, or boring-through, occurs when the tissues give way from change of structure, as from disease, or long-continued

compression of one part, or continued attrition. In these cases the wearing of tissue is the first stage; but the same forces may act as in "rent" or "rupture," and cause extension of the lesion. Rent and rupture are generally produced suddenly, although they may subsequently be extended gradually. Perforation is a slow, gradual process. It may occur from disease in the nonpregnant uterus. Ruptures, then, may be instantaneous or progressive. They may also be spontaneous or traumatic.

Before discussing particularly the causes of rupture, we may here conveniently dispose of the important questions: 1. What are the premonitory symptoms? 2. What is the prophylactic treatment? Since, in a large proportion of cases, the injury occurs without warning, there is no opportunity of preventing it. And, although, starting from the general fact that the uterus may give way if there be impediment to the progress of labour, we may, in some cases, hope by removing recognised impediments, to obviate rupture, there will still remain other cases in which it will not be possible to discover impediments, or even, if discovered, to remove them. As Denman well observes, "Some of the causes are unavoidable, for it is not within the sphere of human abilities to give to some part the principle by which it has the disposition or power to perform any function." The tissues, for example, may be diseased or degenerated.

The explanation commonly given of rupture of the uterus is that it is produced by obstruction to labour. The histories of the great majority of reported cases prove that obstruction to labour was the immediate antecedent. But this explanation can scarcely apply to those cases where the uterus suddenly bursts during pregnancy when there was no labour. The immediate cause is, I think, more comprehensively stated in the following proposition:-The uterus ruptures because there is a loss of balance and of due relation between the expelling power of the body of the uterus and the resisting power of the parturient canal, the resisting power being in excess.

Trask, discussing the 417 cases he had collected, says: "Inordinate voluntary exertion deserves to be enumerated among the causes of rupture. We believe no case of rupture has yet (1856) been published in which chloroform was used, which may be due to the fact that voluntary effort is greatly suspended

under its influence." Tyler Smith says: "In ordinary labour, some amount of voluntary or instinctive action of the muscular system, and particularly of the expiratory muscles, is quite natural during the stages of propulsion and expulsion. In acute or severe labour, these voluntary exertions are productive of great mischief, as lacerations of the uterus, and perinæum and exhaustion.

In many cases no decisive symptoms precede. This uncertainty is a cogent reason for watching closely in every case for the signs of obstructed labour, and for removing any cause of obstruction that may be detected. Obstruction, allowed to persist, leads either to exhaustion or to rupture. In a case of occlusion of the cervix uteri, the pulse rose to 140; crampy, painful contractions of the uterus set in; rupture seemed imminent. Incision of the cervix, allowing expulsion of the fœtus, almost immediately brought relief. This rule must especially be observed in weakly, exhausted subjects. The case is well stated by Dr. Ewing Whittle. When we are attending a patient from whose antecedents and constitution, and from the slow and unsatisfactory progress of whose labour we have reason to fear that we have a feeble, flabby uterus to deal with, our first care should be to soothe the patient, and keep her quiet until the os is fully relaxed. Opiates will here be of service. This sedative treatment should, however, not be trusted too long. The cervix should be dilated by the hydrostatic bags. In these subjects avoid ergot. There is serious danger in goading an exhausted system to put out strength it cannot spare. When the os is dilated, rupture the membranes, and, if labour does not proceed satisfactorily, deliver with the long forceps. Since Roberton has shown that when rupture occurs from faulty pelvis, it generally does so within twelve hours, the indication is clear to watch closely, and to act betimes where the signs of obstruction are present.

Commonly, when the resisting power is in excess, the uterus becomes exhausted, or from other causes ceases to struggle against the resistance. In this way rupture is averted. We may then look upon obstructed or retarded labour, or the signs of it, as summed up in Lecture I., as the premonitory signs of rupture. We shall rarely get anything more precise. But the following summary by Crantz is valuable: "When a

woman is threatened with rupture of the womb in difficult labour, the abdomen is very high and tense, the vagina is retracted, and the os uteri very high; the pains are strong, leave but short intervals, and are without effect."

We might, then, in cases where we see the uterus struggling impotently against an obstacle, avert rupture by one of two ways. First, we may endeavour to restore the proper preponderance of the uterine force, by lessening the resistance; or, secondly, we may avert or postpone danger by subduing the excessive action of the uterus.

We will dispose of the latter alternative first. Can we persuade the uterus to be passive for a time? If we can command temporary quiescence, we may gain time and opportunity for the diminution or removal of the resistance. We possess in ergot a great, a dangerous, power of augmenting the force of the uterus. Indeed, this agent has too frequently, by goading the uterus beyond measure, caused it to burst itself. We want an agent endowed with the opposite effect, that will control and suppress uterine action. An agent that could be depended upon to do this would extend, and-if considered in association with the powers we now possess of accelerating labour, namely, the means of provoking labour, the uterine dilator, the forceps, turning, ergot-complete our command over the course of pregnancy and labour. I consulted Dr. Richardson on this point. He tells me the desired power exists in the nitrite of amyle. Three minims of this added to one drachm of ether taken by inhalation is the form he recommends. It does not produce unconsciousness, but it is an anesthetic as well as a sedative of muscular action. It is the antidote or opposite force to ergot. In it we have the desiderated "epechontocic agent."

We have long been accustomed to give opium with the view of allaying muscular action and postponing labour. Its use in this way is often valuable in gaining time. Chloroform has of late years been frequently resorted to. But it has the disadvantageous property, derived from the chlorine in its composition, of exciting vomiting and muscular spasm. It is only when pushed to extreme anesthesia that muscular resolution is obtained. I think, therefore, that the nitrite of amyle should have a fair trial.

A most interesting narrative of a cure of tetanus by the