A CASE

OF

RUPTURE OF THE UTERUS,

SUCCESSFULLY TREATED BY

DR. SMITH,

OF MAIDSTONE.

COMMUNICATED BY

DR. LOCOCK.

Read April 25, 1827.

ON Saturday morning, July 16, 1825, I was requested to visit Mrs. H. a stout, healthy, well-made woman, about forty years of age, the mother of nine children. Her last labour, two years since, was severe and tedious; she was however delivered without instrumental assistance. Considerable constitutional irritation followed, with some sloughing of the vagina and bladder, and she has since been unable to retain her urine, which passes per vagi

nam.

I was informed that Mrs. H. was about seven months gone with child; she was taken in labour early in the morning; the membranes broke about five, and Mr. Whatman, her medical attendant,

was called immediately. He found the pains sharp, and regular in their recurrence, and the presentation natural. I met Mr. Whatman in consultation about ten o'clock; the pains were then extremely acute, short, and frequent, and Mrs. H. complained very much of her back. On examination I found the os uteri dilated nearly to the size of a crown piece, but rigid; the head of the child could readily be felt at the brim of the pelvis, the vagina was rather swollen and hot, countenance distressed, tongue moist and clean, pulse about a hundred, not hard nor particularly full. It was agreed that eight or ten ounces of blood should be taken from the arm, that a common Enema should be given directly, and a draught, containing twenty minims of Tincture of Opium.

5,

On my return from the country in about three hours, Mr. Whatman informed me that the veins in the arm were so covered with fat that he had not been able to bleed our patient, but the glyster had been administered, and the anodyne draught taken.

The head, when Mr. W. last made an examination, appeared to have advanced a little, since which Mrs. H. had experienced a most severe pain in "her back and through her belly", to use her own expressions, "as if a sword had been thrust through her", immediately followed by a considerable discharge of blood from the vagina (according

to the nurse's account a pint or more), faintness, cold extremities, and sickness. This occurred about an hour before my return. The labour pains, which immediately before were frequent and strong, had now entirely ceased. Mrs. H. complained of no pain in the back, but of great soreness and continued pain in the abdomen, the countenance was sunk, and had a peculiarly anxious expression. Pulse 130, and extremely feeble, skin cool; the abdomen had become more irregular in shape, and very tender on pressure. I named my suspicion to Mr. Whatman that a rupture of the uterus had taken place, and on examination this opinion was confirmed, for no part of the foetus could be distinguished either by Mr. W. or myself, and in a subsequent examination, I distinctly felt a rent about two inches from the os uteri, across the posterior part of the uterus, nearly three inches in length, through which two fingers readily passed. The edges of the rupture were extremely thin.

We agreed that it would be adviseable to deliver immediately by turning the child; but prior to performing that operation, we informed Mrs. H.'s husband of her desperate situation, and as there seemed, every reason to believe the case would speedily terminate fatally, we suggested for his further satisfaction, and also to lessen our own responsibility, that the assistance of Mr. Charles should be requested. Mr. C. was from home, and the state of our patient becoming rapidly more critical, it

was determined that delivery should be immediately attempted. Mrs. H. had already taken fifty drops of Tincture of Opium. Mr. W. now endeavoured to pass his hand into the uterus, but found a resistance he could not overcome, and requested I would make the attempt; neither of us, however, nor Mr. Charles, who had just arrived, were able to pass the hand farther than the knuckles, in consequence of a contraction, which at first appeared to be formed by the vagina, but on more accurate examination, was ascertained to arise from part of the os uteri adhering to the vagina under the pubis, and presenting a hard sharp edge, which firmly resisted the passage of the hand; the effect, probably, of the inflammation and mischief which had followed the former labour. The opiate was repeated, and every effort, consistent with the safety of the patient, was made to dilate the os uteri, but without effect; the same obstruction to the passage of the hand still continued. The symptoms were rapidly becoming more urgent; constant nausea, with frequent efforts to retch, although little was rejected from the stomach, violent abdominal pain, great restlessness, quick breathing, faintness, feeble running pulse, which could not be counted, and cadaverous countenance; under these circumstances we deemed it imperative to deliver as soon as possible, for it appeared evident, unless this was speedily accomplished, our patient would die undelivered.

It was agreed, therefore, on consultation, to dilate the os uteri by a slight incision through the hardened and unyielding part, so as to allow the hand to pass. This operation was performed with great nicety and dexterity by Mr. Whatman; and after some little trouble the hand was passed into the uterus, the feet brought down, and the body of the child delivered; but there was so much obstruction to the passage of the head, that it was deemed adviseable to perforate through the lambdoidal suture, which I accomplished with little difficulty; and having lessened the head, the delivery was speedily completed, and the placenta soon followed. There were slight uterine efforts during the delivery, and very little hæmorrhage.

We were several times seriously alarmed lest our patient should sink during the operation, and were obliged frequently to urge her to take wine, brandy and water, ammonia, &c. A draught, containing an hundred drops of Tincture of Opium, was given immediately, and very soon rejected; a second draught, with fifty drops, was then taken and retained. Mrs. H. continued in the most alarming state for about two hours; great nausea, unconquerable restlessness, pulse running, and at times not to be felt, quick breathing, sighing, cold extremities, and Hippocratic countenance. The feet were directed to be fomented, and brandy and water, or brandy and milk, to be given frequently.