Lectures on the theory and practice of midwifery : delivered in the theatre of St. George's Hospital
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I recommended her to lose blood from the arm, or to have leeches and fomentations a))plied to the abdomen ; but no antiphlogistic reme- dies of any kind were employed, and she continued to suffer till the pains of labour commenced. The child was soon expelled, but the midwife in extracting the placenta inverted the uterus, and when I saw the patient about half an hour after, the whole uterus, the entire fundus and body, was hanging out between the thighs like the head of a child ; the uterus had in fact been drawn like a stocking or glove completely inside out. The bed and floor were covered with a great quantity of blood, and the lady was expiring with convulsions. On applying my hand over tlie hypogastrium, the fundus of the uterus could not be felt there in the usual man- ner ; and although the placenta had been entirely detached and removed, there could be no doubt, from the globular shape of the tumour, its peculiar softness and compressibility, its sudden appear- ance along with the placenta after the birth of the child, the red colour of its investing membrane, from which the blood still con- tinued to ooze, that it was the inverted uterus. By grasping the uterus with the hand, and compressing the upper part firmly with the point of the fingers, there was no difficulty in reducing or reinvert- ing it : a sufficient length of time had not elapsed to allow of the cervix and os uteri contracting to prevent- its reduction. The midwife informed me that the placenta was retained, and that little force was employed by her in removing it. This is the only case of complete inversion of the uterus which I have ever seen, and there was no difficulty in the diagnosis, and no doubt about the necessity of immediately replacing the uterus, for if the patient had lived, the reduction of the uterus would have been impossible in a few hours, from the strangulation of the body produced above by the cervix, and inflammation and swelling of the parts. That the uterus, however, has the power of inverting itself, is an opinion which has long been entertained. Astruc says, inver- sion may be produced by certain convulsive contractions of the uterus which occur in some labours, and which push the fundus through the orifice which it enters, as the intestines are sometimes pushed into one another incases of violent colic, or intussusception. To explain the successive increase of inversion in some cases, says Desormeaux, we mi^t admit either that the cause of the displace- ment at first continues to act, or that in the walls of the uterus there is an irregular spasmodic contraction similar to the contractions which produce invagination of the intestinal tube. The following is quoted by Dr. Merriman as a case of spontane- ous inversion of the uterus which occurred in the practice of his uncle. " Mrs. Bishop was so much distorted in the pelvis, that it was found impossible for her to be delivered till the child's head had been lessened by the perforator. Having several times successively undergone this process, she was at last prevailed upon to have premature labour induced when in the eighth month of pregnancy, but the child presenting the nates it was unfortunately dead born. Mrs. Bishop, however, suffered comparatively so little from this labour, and recovered so well and so speedily after it, that in her next pregnancy she was quite impatient for a repetition of the operation. On this occasion the membranes were not pierced, but the connection between the cliorion and the uterus was 412 LABOURS COMPLICATED WITH destroyed by means of the common long flat female catheter care- fully introduced between them. In consequence of this irritation a ranco-saiignineous discharge was produced, and the l.-ibour came on in two or three days. The child was born alive and in health, and the placenta came aioay ivithout any difficulty, and certainly without any ftxispicion of injury to the uterus. The mother reco- vered in the u^ual time, and was enabled to suckle her child, a fiine boy. Between and seven months after her delivery, and while the child was still living upon the breast, upon sotne slight strain she suddenly felt something give way within her, and imme- diately afterwards was sensible of a weight or pressiu-e low down in the vagina, upon which the late Dr. Rowley was in)mediately sent for, who, upon an examination, found the fundus uteri so low down in the vagina as almost to protrude through the osexterum. Dr. Rowley finding matters in this situation sent for Dr. Merriman, and they jointly endeavoured to re-invert the uterus. Dr. Denman, hkewise, and several other accoucheurs, saw the case, but no means that could be used were successful in restoring the parts to their natural state, and the patient remained with her uterus inverted till her death, which occurred in about two years." The evidence of spontaneous inversion of the uterus having oc- curred in this case is not satisfactory. There was no pain or he- morrhage after the expulsion of the placenta, or any of the symp- toms present which are usually observed in cases of partial inver- sion of the uterus, and it does not appear that the body was ex- amined after death to demonstrate that it was the uterus which was felt low down in the vagina, and which attempts had been made to replace. On 1st January, 1830, a middle-aged woman, nearly insensil)le, was brought into the Middlesex Hospital with a great globular tumour covered with blood hanging out of the vaeina between the thighs : the patient appeared to suffer great pain when it was touched, and it presented precisely the same appearance which the inverted uterus had done in the case I saw at Odessa. The only difference that I could discover was, the gre;iter density and incompressibility of the mass. Nothing could be ascertained positively respecting the womnn,or whether she had been recently delivered. Dr. H. Ley, Sir Charles Bell, and others, examined the patient, and were of opinion that it was a case of inverted uterus, and repeated unsuccessful attempts were made to reduce it. I saw her the following day, when she was dying with symp- toms of exhaustion from loss of blood and peritoneal inflammation. On examining the body after death, we found that wliat was sup- posed to be an inverted uterus during life was a great fibrous tumour covered with the lining membrane of the uterus, and attached to the cervix by a very thick root. It exactly resembled in size and structure this specimen of large fibrous tumour, growing from the neck of the uterus by a pedimcle as thick as the wrist. From this case, and the following related by Dr. Gooch, yon will perceive that the diagnosis of completely inverted uterus is not always INVERSION OF THE UTERUS. 413 SO simple and easy as some authors would lead us to suppose, or, indeed, can be drawn without a previous knowledge of the history of the patient, and that it is possible the uterus has not been extir- pated in ah the cases in whicli the operation lias been supposed to have been successfully perOirnied, Mr. Borrett, sin-gpon, ai Yarmouth, was called to a lady in labour with her sixth child. On his first examination he found a large fleshy tumour wnhin the vagina. The anterior segment in the os uteri was easily felt, but the posterior was occupied and covered by the altaclmient of the tumour. After liie orifice had dilated, and the membranes had biu'st, the head of the child not descending, Mr. Borrett introduced his hand, brought down the feet, and extracted the ciiild. Tlie placenta was expelled spontaneously. The patient now being delivered, and easy, he left her at 7 in the morning. At 3 in the afternoon he found her in strong pains, as if there was another child, but as the abdomen was flat, and the contracted uterus could be felt in the abdomen, he was satisfied there was not, and gave her an opiate. At 8 o'clock at night he found that the pains continued violent, with a sensation as of a substance coming away, and he discovered a soft round tumour pressing against the outer orifice. What could it be ? He would have thought that it was the uterus inverted, but it was the same tumour which he had felt in the morning before the child was born: there was no he- morrhage; the placenta had been expelled spontaneously, and the uterus was distinct in the hypogastric region. He consulted his medical friends in the town, and sent oft' to Norwich for Mr. Rigby. Tlie pains continued with violent expulsive efforts all night, and the next morning they found her with a languid pulse and pallid countenance: a Iar2;e fleshy livid tumour had been forced out of the vagina, and every pain brought it more and more in sight : she continued to suff'er and to sink through the rest of the day. In the morning Mr. Rigby arrived, but she had expired about half an hour belore. As soon as he arrived he examined the tumour, and was convinced that it was the inverted uterus. On opening the body next morning, the uterus was found contracted, but its ori- fice was dragged down as low as the external orifice by a tumour which grew from it by a thick stalk ; it was attached to the poste- rior part of the orifices, and some way up the neck, was of a livid colour, and weighed three pounds and fifteen ounces. " When the uterus," says Dr. Merriman, " with the placenta attached to it, is drawn in an inverted state without the vagina, no doubt can exist as to the nature of the accident, but if it should happen after the exclusion of the placenta, more difficulty in form- ing an opinion would arise. The following rules, however, would lead to a correct judgment : — If a globular tumour is found soon after delivery in the vagina, or protruded through the os externum, it must be supposed to be either a polypous excrescence, a prolapsed uterus, or an inverted uterus. If it were a polypus, it would be known by its insensibility, its mobility, and its pedicle, which a careful examination could hardly fail to discover ; the edges of the os 414 LABOURS COMPLICATED WITH Uteri surrounding the tumour would likewise be perceptible. A pro- lapsed uterus may always be known by the os uteri being situated at the most depending part of the tumour. The inverted uterus is insensible to the touch, is less moveable than the polypus, has no pedicle, nor a dependent mouth; in a recent state it is entirely covered with a grumous discharge proceeding from numberless bloodvessels upon its whole surface." I have lately seen a case of partial inversion of the uterus mistaken for polypus, and the treatment followed by fatal consequences. All the systematic works on midwifery contain the histories of cases of complete inversion of the uterus. I have selected the fol- lowing from many others to illustrate the effects produced by this dangerous accident, and to impress upon you the necessity of im- mediately detaching the placenta if it adhered, and reducing the uterus. Should you meet with a case in your own practice, it would be a lasting disgrace to you to invert the uterus, whatever the result might be. In 16S4, Mauriceau saw a woman whose uterus had been in- verted eight months before by an ignorant midwife, and who was much exhausted by hemorrhage. He found it impossible to reduce the uterus. He relates another case which occurred in 1693, two days before he saw the patient : the uterus was irreducible, and she ultimately died from the pain and discharge. Giffard's 176th case is entitled, " A delivery where the uterus was inverted and drawn out beyond the labia pudendi, and the pla- centa adhering to the uterus.^' "January the 29th, 1730-31,1 was, about S o'clock in the evening," he says, " sent for to the wife of a brother surgeon in Surrey Street. The child was born about an hour before I came, and the midwife, in attempting to bring away the placenta, had "inverted the uterus, for, upon examination, I found the whole body of the uterus, with the placenta, adhering to the fundus, hanging out beyond the labia; there was a great profusion of blood, and the woman was dead before I came. I rebuked the midwife for not sending sooner, and told her that she, through her ignorance, was tlie inmiediate cause of the poor woman's death, for, by pulling the string too forcibly, she had drawn out and inverted the womb. Before I examined, the mid- wife told me the placenta was partly brought out, being ignorant that she had also pulled out the womb ; but I showed her her error, that the placenta was all brought out, and only adhered to the fundus uteri, which, as the whole womb was inverted, hung out beyond the labia pudendi. This case should be a caution to all practitioners how they attempt to bring away the placenta, and not to pull the string too rudely, lest they invert and draw out the uterus, by which the woman dies a martyr to their temerity and ignorance, as was too plainly the case in the precedent observa- tion." Chapman's 2Sth case is similar : — '-J was, in the greatest haste, sent for to a woman six miles distant from me, to whom I went with all possible speed, but found on my arrival that she had INVERSION OF THE UTERUS. been dead nearly half an hour. I conjectured she had died from flooding, but upon asking the question was answered in the nega- tive. The midwife told me that the after-birth stuck soj'astin one part that she was not able, with all her strength, to take it from her, though she had gained most of it. Upon this I desired the favour of seeing the corpse, which being granted, I found, to my great surprise, that the uterus was inverted, and entirely out of the body, hanging down between the thighs, with the placenta adhe- ring to its fundus, which I separated before the midwife and seve- ral matrons there present, and convinced them all of the dismal accident. This wo:nan, it seems, had a very good and easy de- livery of the child; but, that born, the midwife pulled hard at the string, and so brought down the uterus, which as soon as she could take hold of, she did, and then pulling with fresh violence, and not being deterred by the loudest cries, the poor miserable woman in a few minutes fell into strong convulsions and deliquiums, and so ex- pired. Thus was a young healthy mother cut off in the bloom of life, and cast into the cold arms of death just as she was about to clasp her first-born in her own." Smellie was called to a woman who died before his arrival. He found the uterus inverted, pulled quite without the external parts, and the placenta adhered firmly to the fundus. This misfortune was occasioned by the midwife pulling at the placenta with too great force. Mr. Lucas, of Pontefract, sent the following account of a case of inverted uterus to Smellie, which occurred in 1759: — "In April last I was called to a woman just delivered of a live healthy child, and to my surprise found the uterus totally inverted, lying between her thighs, of the size of a large foot-ball. The woman's pulse was weak and unequal, and there was a continued pouring forth of blood from the vessels of the uterus. I apprised the friends of the great danger of so deplorable a case. Nevertheless, with the approbation of a judicious physician, her neighbour, I undertook and succeeded in the reduction, and after gave her gentle anodyne and cordial medicines, and left her, in appearance, better, and tolerably easy. Finding, alter some further time, that it did not descend, he at- tempted to^ introduce his hand into the uterus; hut in this attempt he was foiled. Wailing a little longer, a strong after-pain came on, when he made another irial by the funis; and finding an ad- vance, as he thought, continued to extract, when, to his surprise and alarm, the uterus came out of the parts as large as a child's head, with the placenta adherent to it. Previous to this unfortu- nate occurrence there had not heen much discharge of hlood, but now the woman beg;ui to flood violently, and soon became faint. He now entieavoured to separate the placenta with liis liand, but the violence of the flooding deterred him, and he desisted. Fright- ened beyond measiu'e at the dilemma into which he had brought himself, and not knowing how to proceed, he sent for a medical friend, at the distance of about a mile, and wailed his arrival ; the poor woman all the time becoming worse and worse. His friend peeled oft'ihe placenta while the uterus was inverted, and during the operation there was an increase of loss. The woman was now in articulo tnortis, and the uterus was passed into the vagina, but not reverted. I first passed my finger into the vagina, and found it completely filled up by the inverted uterus, which had now become flaccid ; during life it had been firm and resistant." Nothing fiirtlier was ascertained respecting the relative state of parts in this case. Dr. Ramsbotham has " never seen a case im- mediately after inversion; but I was desired," he says, "some months ago, to visit a poor woman in Shoreditch parish, three weeks after delivery, to whom the accident had happened at the time of labour, hut it had not been detected. The inverted uterus was then about the size of a goose's egg, and regularly contracting. The woman had sufl'ered much from flooding and its consequences, but was recovering." But inversion of the uterus may be partial or incomplete, so that the fundus and body are retained within the vagina, or protrude very slightly through the os uteri. On the 17ih February, 1843, I saw, in consultation, a case of partial inversion of the uterus, fourteen hours after the accident had occurred ; and this is the only case of inverted lUerus I have seen in London. The patient had been delivered of her first child after an easy labour ; but the um- bilical cord was not only twisted firmly aromid the neck, but was remarkably short. The placenta was not expelled for half an hour, and then Mr. found it protruding through the external parts with the uterus, to which it still adhered. The placenta was detached from the uterus and removed, and an unsuccessful effort made to reduce the uterus. The discharge of blood which took place was not very profuse, and an opiate having been adminis- tered, the patient, though considerably exhausted, suffered little pain during the interval between the delivery and the time I was called to see her. On passing my hand into the vagina, I found its upper part completely occupied with the fundus, and a portion RUPTURE OF THE UTERUS. 417 of the body of the uterus, Hke a soft cricket-ball. So firmly was the neck of the uterus contracted above, that all my efforts, which were long continued, to reduce or push up the inverted uterus, were unavailing, and the uterus remains now, I believe, in the same condition, and the patient suffers continually from pain, pro- fuse menorrhagia, and leucorrhcea, and will continue to suffer from these symptoms from the inverted uterus during the remain- der of her life. There is the greatest probability that if the same efforts to reduce the uterus had been made within a few hours after the displacement occurred, they would have been perfectly successful. Remember, that if the attempt fails, the evil speedily becomes irre- mediable. If the placenta still adheres, some recommend that it should not be removed till we have reduced the uterus; but it is difficult to conceive what benefit can result from pushing back the mass of the placenta into the uterus, and afterwards extracting it. Partial inversion of the uterus, though sometimes immediately fatal by hemorrhage, does not always produce death. In a patient whose case has been related by Dr. Cleghorn, menstruation was performed by the inverted uterus, and she enjoyed tolerable health for twenty years after the accident. When the inverted uterus is irreducible, we ought to palliate the symptoms, of which pain, hemorrhage, and leucorrhcea, are the most distressing, by appro- priate remedies. If the life of the patient is greatly endangered by the irritation and discharge, it is justifiable, though it be attended with great danger, to attempt her relief by removing the inverted uterus with a ligature. Numerous cases have been re- corded since the days of Ambrose Pare, in which this operation was successfully performed, and there are many others in which attempts to extirpate the inverted uterus have been followed by fatal consequences. It should never be had recourse to if the patient's life can be preserved by any other means. It is unne- cessary to detain you by reading any of these cases, fortunate or unfortunate ; and the operation, which is nearly the same as tying a polypus of the uterus, will be described hereafter. ON RUPTURE OP THE UTERUS. This may take place in any part of the walls of the uterus, but it is most frequently observed in the cervix and towards the sides, or behind in the part corresponding with the promontory of the sacrum. The rent may have a longitudinal direction, or it may take a transverse, or oblique, or curved course. When the cervix 53 418 LABOUKS COMPLICATED WITH Uteri is torn, the vagina is most frequently involved in the mischief. The edges of the laceration are usually thin and ragged, and of a red livid colour, as if gangrenous. Where the rupture is extensive, and is situated in the lower part of the uterus, the fcetus, with the placenta and membranes, are sometimes forced out of the cavity of the uterus, through the rent, into the sac of the peritoneum ; and if the hand be applied to the abdomen, the different parts of the child can be distinctly felt through the parietes. In all cases of difFicult%nd protracted labour, where an obstacle is presented to the progress of the child, which the uterus has not power to overcome, the occurrence of fatal rupture of its coats is the accident we have most to dread. It is of no importance whether the disproportion between the child and pelvis depends upon an unfavourable position of the child itself, as in arm and shoulder presentations, hydrocephalus or ascites, distortion of the bones of the pelvis, or tumours of the ovaria, and uterus, malig- nant disease of the os uteri, or cicatrices of the vagina. The effect produced is the same, whatever the cause of the disproportion may be ; and the upper part of the uterus often goes on contract- ing, until it forces the head of the child, or the whole body and placenta, through its walls into the abdominal cavity among the intestines. The reason why the lower part of the uterus is most frequently lacerated is obvious. In labour it is the fundus and body only which contract ; the os and cervix uteri are relaxed. The lower part is in a state of relaxation ; and when the head of the child here meets with a resistance from the distorted pelvis, which cannot be overcome, it is forced laterally or posteriorly, by the pressure above, through the walls of the uterus; the coats burst over the head as a small soft glove does when drawn hastily upon the hand, or the hand is roughly pushed into it. " There is one fact," observes Dr. Collins, " which clearly shows disproportion to be a frequent cause, namely, its being oftener met with in the expulsion of male children; thus, of thirty-four cases which I am about to state, twenty-three of the children were males ; and of about twenty mentioned by Dr. M'Keever, fifteen were males. This is satisfactorily accounted for by the greater size of the male head, as proved by accurate measurements made by Dr. Joseph Clarke, which may be seen in his second letter to Dr. Price. Of sixty male and sixty female children born at the full time. Dr. Clarke found that the average circumference in the males was fourteen inches, and in the females thirteen inches and five-eighths ; the arch from ear to ear over the crown was seven and a quarter inches in the males, and only seven one-fifth inches in the females. Of the one hundred and twenty examined, there were only six where the circumference of the head exceeded four- teen and a half inches, all of which were males. This difference may appear trifling, but in a practical point of view it is of vast im- portance, especially where any diminution in the size of the pelvis exists." " The part that most usually gives way is at the junc- RUPTURE OF THE UTERUS. 419 tion of the cervix uteri with the vagina, either anteriorly or poste- riorly; and, according to my experience, equally in both situa- tions. Of thirty-four cases that occurred in the hospital, in thir- teen the injury was in the posterior part; in twelve, anteriorly or posteriorly ; in two laterally ; in one the mouth of tlie womb was torn ; and in six the particular seat of the laceration was not described. In nine of the thirty-four cases the peritoneal coat of the uterus was uninjured, although the muscular substance of the cervix was extensively ruptured. One singular case occurred in the hospital, precisely similar to that recorded by Dr. J. Clarke, in the Transactions of a Society for the Improvement of Medical and Surgical Knowledge, vol. iii., where the patient died with all the symptoms of ruptured uterus. These are the symptoms by which you will recognise laceration of the uterus during labour, and which sometimes takes place with- out any precursory signs. The pains are not so violent as to lead to any suspicion of what is about to occur ; the uterus may be tora extensively before the patient has been twenty-four hours in labour, and where there has been nothing peculiar observed in the charac- ter of the pains, and nothing like irregular violent spasmodic con- tractions of the uterus around the body of the child ; the accident may happen without the patient feeling any peculiar pain or sen- sation of the tearing of the parts within, and where no sound is heard either by herself or by those around her. But if rupture of the uterus has taken place in some cases without any premoni- tory symptoms, there is reason to believe that it has happened in many where it might have been foreseen and prevented. What can be expected to occur but rupture of the uterus, where tlie hand is rudely forced up into the cavity of the uterus to turn the child, when the organ is firmly contracted around its body, and the liquor amnii has been long discharged ? What else can be looked for but laceration of the uterus and vagina, where the blades of the forceps are pushed up between the head and a deformed pelvis, before the OS uteri is more than half dilated ? In cases of distorted pelvis. 420 LABOURS COMPLICATED WITH where the head of the child has been allowed to remain many hours jammed in the brim, where the promontory of the sacrum projects in the form of a sharp angle, and the sacro-pubic diameter is much reduced, fatal laceration of the posterior part of the uterus is what we have just reason to apprehend, if we do not, in proper time, relieve the patient by the operation of craniotomy. In a deformed pelvis, where the head has long remained in the same position, and the abdomen is tense, and the different parts of the child can be felt remarkably distinct, and the labour-pains occur at short inter- vals and with unusual intensity, and produce more suffering than labour-pains usually do, making the patient exclaim that she is about to burst, rupture of the uterus will probably take place, if the labour is allowed to proceed, and no treatment is employed. It was supposed by La Motte, Levret, and Cranz, that the vio- lent movements of the child could rupture the uterus; but the child is entirely passive when this occurs. Softening of the uterus, by chronic inflammation or some other morbid process, appears occasionally to take place in the latter months of pregnancy, which renders it liable to spontaneous rup- ture when labour commences. A rent has sometimes occurred, with fatal internal hemorrhage probably from the same cause, as early as the period of quickening, before the uterus had begun to contract. This preparation now upon the table was taken from the body of a woman who died from spontaneous rupture of the uterus, who had been delivered with the forceps in a former labour. The presentation was natural ; there was no distortion of the pelvis; but towards the end of the first stage of labour the pains ceased, the presenting part receded beyond the reach of the finger, considerable hemorrhage followed, and dark-coloured vomiting took place, and she died undelivered. This was the history of the case which I received from the midwife. I ex- amined the body, and found the whole contents af the uterus in the peritoneal sac, with very little blood. There was an immense rent in the lower part of the uterus and vagina on the left side, the edge of which was of a dark red colour, and as soft as jelly. This softening had affected a considerable part of the uterus, and was not the result of decomposition. Dr. Merriman has related a similar case; and the uterus which I saw in the recent state had undergone a process of softening in the muscular coat at the part where the laceration existed. The uterus has been torn by various kinds of external violence applied to the abdomen, and it is reported to have occurred from a violent fit of passion. " A woman," says M. Desormeaux, " has the abdomen strongly pressed between the wall and a carriage, another is thrown down by a horse upon an angular stone or body which is directed against the umbilicus, a third falls with violence upon the abdomen ; in all these cases the uterus is ruptured, and the foetus passes partially or completely into the peritoneal sac. The contusion, in these cases, has sometimes not led to immediate TREATMENT OF RUPTURE OF THE UTERUS. 421 laceration : this has taken place afterwards, on making an effort or raising a weight. In a case of contraction of the cervix uteri, with retention of the placenta, the hand of the practitioner was forced throush the coats of the uterus, and the woman soon died." TREATMENT OF RUPTURE OF THE UTERUS. Where the head of the child presents, and rupture of the uterus h takes place, the best plan is without delay to deliver with the per- | forator and crotchet ; and to prevent the child, during the opera- f tion, from passing through the rent into thePperitoneal sac, pressure should be made over the fundus uteri, and the opening made in the head in the most gentle manner. I have seen no case | of ruptured uterus in which it was possible to deliver with the I forceps; and I am not aware that any case of ruptured uterus has .? been recorded in which a living child was delivered with the for- ceps. " Efforts have frequently been made to deliver with the forceps in such cases," says Dr. Collins, " but this instrument is seldom applicable, as the introduction of the blades generally forces the head out of our reach ; besides, but little would be thus gained, for the child dies shortly after rupture takes place ; the dimensions, too, of the pelvis are in such cases for the most part defective ; all which circumstances would seem strongly opposed to this mode of delivery. In three of the thirty -four cases above alluded to, attempts were carefully made to deliver with the forceps, but without success." Dr. Burns is of a different opinion. He says the child may live for hours, after rupture of the uterus, if the placenta be not detached, or the hemorrhage great. If the head have entered the pelvis, and be within reach of the forceps, we must cautiously introduce the blades, taking great care not to press up the head or make it recede. From this hazard, and from ob- serving that in such cases the child is generally dead, it has been advised, by good authorities, to perforate the head; but if we have no other inducement to use the perforator, I should consider that, unless the head be high, the forceps would be as safe in this respect. If the child has passed entirely from the cavity of the uterus into the peritoneal sac, an attempt should be made without delay to extract it, by introducing the hand into the cavity and through the rent in the uterus, grasping the feet and drawing the child back into the uterus, and delivering as in the common operation of turning. In the following case, related by Dr. Blundell, recovery took place under these circumstances. " A woman in this neigh- bourhood," he says, " had a contraction of the pelvis. It was a case that occurred to one of yourselves, but no blame attached to its management. I was called in, in consequence of collapse of the strength ; and when I examined I found the child lying in the peritoneal sac, distinct from the uterus, the aperture of which was contracted, and I found further a large transverse rent opposite to 422 TREATMENT OF RUPTUUE OF THE UTERUS. the bladder. Well, in this case, agreeably to the rule, I determined to turn, and for this purpose introduced my hand into the perito- neal sac: I perceived the intestines, felt the beat of the large abdo- minal arteries, touched the edge of the liver, and ultimately reach- ing the feet of the child, I withdrew it by the operation of turning, subsequently abstracting the placenta and membranes, the woman recovering in a few weeks afterwards. About five years after the recovery I saw her, not so vigorous as before the accident, but nevertheless tolerably well. On very careful examination at this time the os uteri was found to present the natural characters, and not a vestige of i|cicatrix was discoverable in the vagina any where above or below. The rupture, therefore, had been above, in the uterus itself When, in this case, my hand was introduced to turn the foetus, the womb, large as a child's head, was felt lying upon the promontory of the sacrum, above and behind the rent." If a considerable period has elapsed after the accident, and the uterus has contracted so closely that the hand cannot be passed through the orifice and the rent, the best practice would be to leave tiie case to nature. Some have recommended gastrotomy under these circumstances ; but the child is already dead, and the mother could hardly be expected to survive after such an operation. But I had nearly forgotten to mention that the Csesarean section was actually proposed by Cranz, where, from the size of the head and dimensions of the pelvis, there were symptoms merely threatening rupture of the uterus, and before rupture had positively taken place ; and that he considered it a great honour to have been the first to make this barbarous proposal. " J'aurais encore ici la gloire," he says, "d'avoir propose le premier I'usaged'unmoyendont personne avant moi n'avoit eu I'idee pour le cas dont il s'agit." If the foetus has escaped into the peritoneal cavity, and is allowed to remain there, the patient may recover without gastrotomy, and the foetus be afterwards discharged through an ulcerated opening in the parietes of the abdomen. It is probable that the greater number of cases recorded by authors, in wliich this event took place, were cases of extra-uterine gestation, and that the foetus had never been within the cavity of the uterus. The foetus remained many years in the abdomen, and became co- vered with a layer of calcareous matter. In 1814, Dr. M'Keever published an interesting case of reco- very after lacerated uterus, which shows the power which nature possesses in some individuals to repair the most dreadful injuries. A stout young woman had the uterus ruptured during labour which continued nearly thirty-hours, and nearly four feet of in- testine protruded into the vagina, and sloughed off on the 16th day after the accident. For about two years the patient voided all the faeces through the breech of the uterus. At the conclusion EXTRAVASATION OF BLOOD INTO THE LABIA. 423 of that period the faeces took their natural course. Eighteen months afterwards the woman conceived, and has since at the full time been safely delivered of a small feeble child. I have already related to you the history of a case of rupture of the uterus from hydrocephalus in the fostus, similar iti some respects to the pre- ceding case, which fell under my observation on the 22d of June, 1S42. If the patient is delivered after rupture of the uterus, and survives the immediate shock of the accident, it should be re- membered that she is liable to perish from an attack of perito- neal inflammation and suppuration in the neighbourhood of the uterus. EXTRAVASATION OF BLOOD INTO THE LABIA. One of the labia pudendi sometimes becomes suddenly and ex- cessively distended with blood during labour, or soon after the birth of the child, from rupture of varicose veins or other vessels. The labium becomes of a dark livid colour, and as large as the head of a child, in a very short time, and a great quantity of blood is sometimes lost, from the inner surface of the labium be- coming lacerated. Its situation on one side, and its dark colour, will prevent you from supposing that it is the foetal membranes protruding, or a hernial tumour. Dr. Dewees states, that if the bursting of the inner surface of the labium does not take place, in the first instance, the tumour is sure to yield in a short time from gangrene. When the parts sloughs, he says, it exposes a large surface of coagulated blood, which quickly becomes decomposed and foetid. If the parts do not give way the pain is agonising: fever of an active kind is excited, delirium takes place, and the patient's life is greatly endangered. Her sufferings are augmented by the retention of urine, and nothing gives relief but a free in- cision into the tumour to give vent to the extravasated blood. This should be done, he thinks, before the process of ulceration has commenced, or the chance of bursting. The urine should then be drawn off by pressing the enlarged labium to one side, and introducing the catheter, and warm fomentations to the hands and feet ; but the progress of the symptoms is sometimes so rapid as scarcely to allow time for the administration of remedies. In the Archives Generales de JNIedecine, August, 1834, several cases are related. A woman, aged 41, pregnant with her fifth child, was seized with labour pains, which gradually abated after the liquor amnii was discharged. In a short time, however, a violent pain was experienced, and the left labium became enormously swollen and discoloured. The tumour soon burst, and a great quantity of dark-coloured blood was disharged. She became exhausted, and soon died in convulsions. There was a laceration on the inner surface of the labium an inch and a half in length, through which the finger could be passed mto a large cavity containing coagu- lated blood. On the right labium and inner surface of both thighs 434 EXTRAVASATION OF BLOOD INTO THE UTERUS. 