CHAPTER XVI.

RUPTURE OF THE UTERUS, ETC.

Rupture of the uterus is one of the most dangerous accidents of labor, and until of late years it has been considered almost necessarily fatal and beyond the reach of treatment. Fortunately it is not of very frequent occurrence, although the published statistics vary so much that it is by no means easy to arrive at any conclusion on this point. The explanation is, no doubt, that many of the tables confound partial and comparatively unimportant lacerations of the cervix and vagina with rupture of the body and fundus. It is only in large lying-in institutions, where the results of cases are accurately recorded, that anything like reliable statistics can be gathered, for in private practice the occurrence of so lamentable an accident is likely to remain unpublished. To show the difference between the figures given by authorities, it may be stated that, while Burns calculates the proportion to be 1 in 940 labors, Ingleby fixes it as 1 in 1300 or 1400, Churchill as 1 in 1331, and Lehmann as 1 in 2433. Dr. Jolly, of Paris, has published an excellent thesis containing much valuable information.' He finds that out of 782,741 labors, 230 ruptures, excluding those of the vagina or cervix, occurred-that is, 1 in 3403.

Lacerations may occur in any part of the uterus-the fundus, the body, or the cervix. Those of the cervix are comparatively of small consequence, and occur, to a slight extent, in almost all first labors. Only those which involve the supra-vaginal portion are of really serious import. Ruptures of the upper part of the uterus are much less frequent than of the portion near the cervix; partly, no doubt, because the fundus is beyond the reach of the mechanical causes to which the accident can not unfrequently be traced, and partly because the lower third of the organ is apt to be compressed between the presenting part and the bony pelvis. The site of placental insertion is said by Madame La Chapelle to be rarely involved in the rupture, but it does not always escape, as numerous recorded cases prove. The most frequent seat of rupture is near the junction of the body and neck, either anteriorly or posteriorly, opposite the sacrum, or behind the symphysis pubis; but it may occur at the sides of the lower segment of the uterus. In some cases the entire cervix has been torn away, and separated in the form of a ring.

common.

The laceration may be partial or complete, the latter being the more The muscular tissue alone may be torn, the peritoneal coat remaining intact; or the converse may occur, and then the peritoneum is often fissured in various directions, the muscular coat being unim

1 Rupture Utérine pendant le Travail, Paris, 1873.

plicated. The extent of the injury is very variable, in some cases being only a slight tear, in others forming a large aperture, sufficiently extensive to allow the foetus to pass into the abdominal cavity. The direction of the laceration is as variable as the size, but it is more frequently vertical than transverse or oblique. The edges of the tear are irregular and jagged; probably on account of the contraction of the muscular fibres, which are frequently softened, infiltrated with blood, and even gangrenous. Large quantities of extravasated blood will be found in the peritoneal cavity; such hemorrhage, indeed, being one of the most important sources of danger.

Causes. The causes are divided into predisposing and xciting; and the progress of modern research tends more and more to the conclusion that the cause which leads to the laceration could only have operated because the tissue of the uterus was in a state predisposed to rupture, and that it would have had no such effect on a perfectly healthy organ. What these predisposing changes are, and how they operate, is yet far from being known, and the subject offers a fruitful field for pathological investigation.

It is generally believed that lacerations are more common in multiparæ than in primiparæ. Tyler Smith contended that ruptures are relatively as common in first as in subsequent labors, while Bandl1 found that only 64 cases out of 546 ruptures were in primiparæ. Statistics are not sufficiently accurate or extensive to justify a positive conclusion, but it is reasonable to suppose that the pathological changes presently to be mentioned as predisposing to laceration are more likely to be met with in women whose uteri have frequently undergone the alteration attendant on repeated pregnancies. Age seems to have considerable influence, as a large proportion of cases have occurred in women between thirty and forty years of age.

Alterations in the tissues of the uterus are probably of very great importance in predisposing to the accident, although our information on this point is far from accurate. Among these are morbid states of the muscular fibres, the result of blows and contusions during pregnancy; premature fatty degeneration of the muscular tissues, n anticipation, as it were, of the normal involution after delivery; fibroid tumors or malignant infiltration of the uterine walls, which either produce a morbid state of the tissues, or act as an impediment to the expulsion of the foetus. The importance of such changes has been specially dwelt on by Murphy in England and by Lehmann in Germany, and it is impossible not to concede their probable influence in favoring laceration. However, as yet these views are founded more on reasonable hypothesis than on accurately observed pathological facts. Another and very important class of predisposing causes are those which lead to a want of proper proportion between the pelvis and the fœtus.

Deformity of the pelvis has been very frequently met with in cases in which the uterus has ruptured. Thus out of 19 cases carefully recorded by Radford,' the pelvis was contracted in 11, or more than

1 Ueber Ruptur der Gebärmutter. Wien, 1815.

* Obst. Trans., 1867, vol. viii. p. 150.

one-half. Radford makes the curious observation that ruptures seem more likely to occur when the deformity is only slight, and he explains this by supposing that in slight deformities the lower segment of the uterus engages in the brim, and is, therefore, much subjected to compression; while in extreme deformity the os and cervix uteri remain above the brim, the body and fundus of the uteri hanging down between the thighs of the mother. This explanation is reasonable; but the rarity with which ruptured uterus is associated with extreme pelvic deformity may rather depend on the infrequency of advanced degrees of contraction.

Illustrating the dangerous thinning of the lower segment of the uterus owing to non-descent

of the head in a case of intra-uterine hydrocephalus (After BANDL.)

Bandl, who has made the most important of modern contributions to our knowledge of the subject, points out that rupture nearly always begins in the lower segment of the uterus, which becomes abnormally stretched and distended when from any cause the expulsion of the foetus is delayed. The upper portion of the uterus becomes, at the same time, retracted and much thickened (see Fig. 154). As the pains continue, the stretching of the lower segment, called by Spiegelberg the "obstetrical cervix," becomes more and more marked, until at last its fibres separate and a laceration is established. The line of demarcation between the thickened body and the distended lower segment, known as the ring of Bandl, can, in such cases, be occasionally made out by palpation above the pubes.

Amongst the causes of disproportion depending on the foetus are either malpresentation, in which the pains cannot effect expulsion, or undue size of the presenting part. In the latter way may be explained the observation that rupture is more frequently met with in the delivery of male than of female children, on account, no doubt, of the larger size of the head in the former. The influence of intra-uterine hydrocephalus was first prominently pointed out by Sir James Simpson,' who states that out of seventy-four cases of intra-uterine hydrocephalus the uterus ruptured in sixteen. In all such cases of disproportion, whether referable to the pelvis or foetus, rupture is produced in a twofold manner-either by the excessive and fruitless uterine contractions, which are induced by the efforts of the organ to overcome the obstacle; or by the compression of the uterine tissue between the presenting part and the bony pelvis, leading to inflammation, softening, and even

gangrene.

The proximate cause of rupture may be classed under two headsmechanical injury and excessive uterine contraction. Under the former are placed those uncommon cases in which the uterus lacerates as the result of some injury in the latter months of pregnancy, such as blows, falls, and the like. Not so rare, unfortunately, are lacerations produced by unskilled attempts at delivery on the part of the medical attendant, such as by the hand during turning, or by the blades of the forceps. Many such cases are on record, in which the accoucheur has used force and violence, rather than skill, in his attempts to overcome an obstacle. That such unhappy results of ignorance are not so uncommon as they ought to be is proved by the figures of Jolly, who has collected seventy-one cases of rupture during podalic version, thirtyseven caused by the forceps, ten by the cephalotribe, and thirty during other operations the precise nature of which is not stated. The modus operandi of protracted and ineffectual uterine contractions, as a proximate cause of rupture, is sufficiently evident, and need not be dwelt on. It is necessary to allude, however, to the effect of ergot, incautiously administered, as a producing cause. producing cause. There is abundant evidence that the injudicious exhibition of this drug has often been followed by laceration of the unduly stimulated uterine fibres. Thus, Trask, talking of the subject, says that Meigs had seen three cases, and Bedford four, distinctly traceable to this cause. Jolly found that ergot had been administered largely in thirty-three cases in which rupture

occurred.

Premonitory Symptoms.-Some have believed that the impending occurrence of rupture could frequently be ascertained by peculiar premonitory symptoms, such as excessive and acute crampy pains about the lower part of the abdomen, due to the compression of part of the uterine walls. These are far too indefinite to be relied on, and it is certain that the rupture generally takes place without any symptoms that would have afforded reasonable grounds for suspicion.

General Symptoms.-The symptoms are often so distinct and alarming as to leave no doubt as to the nature of the case. Not infre

1 Selected Obst. Works, p. 385.

Op. cit., p. 38.

quently, however, especially if the laceration be partial, they are by no means so well marked, and the practitioner may be uncertain as to what has taken place. In the former class of cases a sudden excruciating pain is experienced in the abdomen, generally during the uterine contractions, accompanied by a feeling, on the part of the patient, of something having given way. In some cases this has been accompanied by an audible sound, which has been noticed by the bystanders. At the same time there is generally a considerable escape of blood from the vagina, and a prominent symptom is the sudden cessation of the previously strong pains. Alarming general symptoms soon develop, partly due to shock, partly to loss of blood, both external and internal. The face exhibits the greatest suffering, the skin becomes deadly cold and covered with a clammy sweat, and fainting, collapse, rapid feeble pulse, hurried breathing, vomiting, and all the usual signs of extreme exhaustion quickly follow.

Abdominal palpation and vaginal examination both afford characteristic indications in well-marked cases. If the child, as often happens, has escaped entirely, or in great part, into the abdominal cavity, it may be readily felt through the abdominal walls; while in the former case, the partially contracted uterus may be found separate from it in the form of a globular tumor, resembling the uterus after delivery. Per vaginam it may generally be ascertained that the presenting part has suddenly receded, and can no longer be made out, or some other part of the foetus may be found in its place. If the rupture be extensive, it may be appreciable on vaginal examination, and, sometimes, a loop of intestine may be found protruding through the tear. Other occasional signs have been recorded, such as an emphysematous state of the lower part of the abdomen, resulting from the entrance of air into the cellular tissue; or the formation of a sanguineous tumor in the hypogastrium or vagina. These are too uncommon and too vague to be of much diagnostic value.

Unfortunately, the symptoms are by no means always so distinct, and cases occur in which most of the reliable indications, such as the sudden cessation of the pains, the external hemorrhage, and the retrocession of the presenting part, may be absent. In some cases, indeed, the symptoms have been so obscure that the real nature of the case has only been detected after death. It is rarely, however, that the occurrence of shock and prostration is not sufficiently distinct to arouse suspicion, even in the absence of the usual marked signs. In not a few cases distinct and regular contractions have gone on after laceration, and the child has even been born in the usual way. Of course, in such a case mistake is very possible. So curious a circumstance is difficult of explanation. The most probable way of accounting for it is, that the laceration has not implicated the fundus of the uterus, which contracted sufficiently energetically to expel the foetus. Hence it will be seen that the symptoms are occasionally obscure, and the practitioner must be careful not to overlook the occurrence of so serious an accident because of the absence of the usual and characteristic symptoms.

Prognosis. The prognosis is necessarily of the gravest possible