THE daughter of Jonas Pergo had been delivered of four children, having very difficult labours with all of them. While pregnant with the fifth, she suf­fered a considerable degree of uneasi­ness; her pains were much more ur­gent, when in labour, and came on earlier than in her former pregnancies, continuing with violence until the third day before delivery, when they ceased. The midwife could not, by any endea­vours, deliver her. The child, which was supposed to have been dead some [Page 28]days, and which appeared afterwards to have been the case, from the separa­tion of the cuticle, presented with its hands bent behind its neck, and the face obliquely upwards towards the pubis.

The symptoms becoming more and more violent, she being not only faint and feverish, with oppression on the praecor­dia, attended with rigors; but having vomited up some green faeces, which arose, he says, from the foetus pressing upon the rectum, so that they could not find their passage thence, Cornelius Solingius, an experienced surgeon, was sent for with him to her relief. In a short time, he delivered her of a dead child. As he could not easily bring away the after birth, he introduced his hand along the funis, but found that it was in contact with the intestines, before it came to the placenta; which was sound, soon after, hanging down, in three parts, within the abdomen, out [Page 29]of the uterus. From the child having been expelled three days, the uterus was so hard and contracted, that, at first, he supposed it to be a scirrhus. He separated the placenta from the u­terus, to which, he says, it still adher­ed. The cartilage, which connected the bones of the pelvis, was soft, and they were separated from each other nearly the breadth of a finger.

The woman died the same day, and the body was opened on the next, in the presence of Vander Weil and his brother.

The abdomen was much tumified. On making an incision into it, nothing escaped except a quantity of foetid air, and some coagulated blood of a good colour, which came, he says, from the cotyledons, or mouths of the vessels of the uterus, at the time when the pla­centa was detached from it. He passed his hand through the vagina, and again [Page 30]found himself in contact with the intes­tines, the uterus receding above the pubis. A rupture was observed at the inferior and posterior part, just above the os internum, at that place where the common membrane from the peritone­um covers and surrounds the uterus, as well as the rectum; through which rup­ture the whole of the child, except the parts which presented, had passed into the cavity of the abdomen. This he assigns as the cause why the pains ceased, and the mother became easier, a few days before delivery ^*.

In the examination of this case, I shall confine my remarks to the delivery of the placenta, and the appearances upon dissection.

After the child was delivered, Solin­gius, finding that the placenta did not easily follow, introduced his hand along [Page 31]the funis, with an intention to extract it, but found himself in contact with the intestines, the placenta being, ' ex­tra uterum,' in the cavity of the abdo­men. The uterus, from which he sup­poses the child to have escaped some days before, was contracted, and felt so hard, ' ita ut initio scirrhum crederet.' In the next sentence, he speaks of sepa­rating the placenta from the uterus: this cannot be reconciled with what he had before related, of the placenta being ' extra uterum,' otherwise than by sup­posing that the placenta, while in the abdomen, adhered to the external sur­face of the uterus; its adhesion to the surface of the viscera, in some other cases, having been found to be very considerable ^*.

A review of the circumstances, which follow the introduction of his hand, will elucidate the case, when compared [Page 32]with the appearances, which were ob­served on opening the body, after death.

In the first place. No mention is made of any difficulty in introducing the hand through the os internum into the cavity of the uterus, which must have been considerable, from its con­tracted state, if the attempt had been made.

Secondly. As his hand came imme­diately in contact with the intestines, if the placenta had been within the uterus, the intestines must likewise have been within it, which does not by any means appear from the narrative.

And lastly. If his hand had been within the cavity of the uterus, how could he have judged of the degree of its contraction, so as to have thought it, at first, to have been a scirrhus?

If we consider the case as a partial separation of the vagina, from its at­tachment to the cervix uteri, then every one of these objections are surmounted with ease: his hand, on passing along the funis, would have found an easy in­troduction into the cavity of the abdo­men, and he would have been in con­tact with the intestines, before his hand arrived at the placenta. The uterus would have been found on the anterior part, and have felt contracted like a ball, so that, at first, it might have been mistaken for a scirrhus; neither of which could have possibly happened if his hand had been within its cavity: besides, his expression is so clear, in respect to its contraction, 'dure admo­dum compactum atque in se contrac­tum comperit,' as to leave no room to suppose any thing to have been included within it.

We find that on dissection, after re­lating the external appearance of the [Page 34]abdomen, and what issued on making an incision into it, he passed his hand, he says, per vulvam, and again felt the intestines; and, what is very material in forming a determination on the na­ture of the case, found the uterus re­ceding above the pubis, ' recedentemque supra os pubis uterum reperit.' To use the expression of Dr. Douglas, in his late, publication, ‘'it fled before the tips of his fingers.'’

I think it must be evident to every one, that the uterus would not have re­ceded before his hand, if its attachment to the vagina had remained entire. It must have resisted the touch.

The place where the rupture is said to have been was at the inferior and posterior part, a little above the os in­ternum, where the common peritoneal membrane is continued from the rectum to the uterus.

Now the same peritoneal coat which surrounds the whole of the abdominal viscera, in its passage from the rectum to become the external coat of the ute­rus, is inflected over that part of the vagina which is attached to the cervix uteri, beginning to form the peritoneal coat of the uterus, at the place where the vagina is joined to the cervix, a little above the os internum. In the same place, on the anterior part, the vagina was lacerated in the case before related; and, I think, on comparing the different parts of Vander Wiel's rela­tion, with each other, it is clear that the injury, in both cases, was nearly similar; the only difference being, that in one the laceration was in the posterior, and in the other in the anterior part of the vagina.

IN the year 1594, a woman of Hage­naw, in Alsace, 40 years of age, who had been the mother of seven children, at the full time, but all of them born dead, died in labour of the eighth, on the third day, without being delivered. The night before, her pains had been violent in the extreme; the women who were present made many efforts to de­liver her, but they were not able to afford her the least help.

On opening the body, they were very cautious in making their incision into the abdomen, that they might have a [Page 37]distinct view of the uterus in situ. The muscles were hardly divided, when the back of the child was wounded. They had no suspicion of what it really was, supposing it, at first, to be the u­terus; but, on continuing the incision, they found it to be a full formed foetus (with signs of putridity from the sepa­ration of the cuticle) without the uterus, in the cavity of the abdomen. It lay with the face to the sacrum, and its body extended at full length. At first, nothing preternatural was observed, there being no appearance of contu­sion, wound, ulceration, or abscess. They wondered much at the singularity of the case; but this was cleared up when they sound the uterus torn, rup­tured, or rather broken off.

The child was still connected by the sunis to the secundines, which were re­tracted, upon the left side, towards the spleen, and adhered so fast that they had some difficulty to separate them. [Page 38]The uterus was so contracted, that it did not exceed the size of the placenta. Near the cervix, directly under the bladder, there was a portion of mem­brane hanging down, about the thick­ness of the dissecting knife, and not exceeding the breadth of half a palm, which was a part of the separated ute­rus, 'uteri abrupti.'

The rest of the uterus, with its pro­per orifice, and the secundines were re­tracted, so that it was totally separated from the cervix, or 'sinus muliebris,' and all the other parts to which it had before been attached. He attributes this accident to the malconformation of the pubis, which was too much flattened in ^*.

The above case requires no comment, as I think it is evident that there was a total separation of the uterus, from its attachment to the vagina.

I remember to have read a case where the same accident happened, from the violent efforts of an accoucheur to in­troduce his hand to deliver.

WE find that the woman, who is the subject of this case, was in her 4th preg­nancy, low in stature, about 30 years of age, and of a weak constitution, but, in general, healthy. When the Doctor was first called to her, the membranes had been ruptured eight hours, and the pains had continued regular from that time: yet though the os tincae was con­siderably [Page 40]dilated, the child did not ad­vance. He found her extremely rest­less, complaining of excessive pain in the region of the pubis. Each return of pain caused her to writhe and twist as if suffering from violent colic, very unlike the urging throes of common la­bour; but her pulse was calm and re­gular, nor did she make any particular complaint, excepting of the pain about the pubis. This being the state of the case, there seemed to be no reason to induce him to precipitate the delivery.

About nine o'clock the same evening, the midwife informed him that the pa­tient had had a discharge of blood from the vagina, which, however, did not continue; and that the pains had ceased about half an hour after six o'clock; since which, retching, with an incessant craving for drink, had come on.

He now found her face lengthened, and bedewed with cold sweat; her pulse [Page 41]scarcely to be felt; her breathing short and quick, with great anxiety; but still complaining of no pain, excepting about the pubis. ‘'By examination in the com­mon way,' he says, I could distinguish nothing, excepting a round moveable substance, which I supposed to be the head of the child; but being only able to reach it with my fingers, I could not determine with any certainty what it was. The woman appeared to be in extremis; and my mind was so wholly occupied by her danger, as to preclude all reasoning with respect to the cause.'’ He determined upon immediate delive­ry, as the only chance of relief. ‘'There was no difficulty,' he says, 'in passing my hand; and the substance which I had supposed to be the child, fled before the tips of my fingers: by following it, I at last found my hand in a cavity, which in no sort resembled that of the uterus. I was then forcibly and painfully struck with the nature of the case; and on ex­amining all round, with caution and [Page 42]gentleness, I could with certainty de­termine that my hand was in the cavity of the abdomen: the child being on the fore part; on the back part, the con­tracted uterus like an oblong ball; and the intestines hanging among any fin­gers.'’ There was no obstruction to the turning and extraction of the child, excepting in the passage of the head through the brim of the pelvis. The placenta, which was likewise in the ab­dominal cavity, had so clung to the in­testines, that he was again under the necessity of introducing his hand to de­tach it, which was not difficult. ‘'The uterus seemed,' he says, 'to have been ruptured transversely, on the lower and fore part, some distance above where the vagina is connected with it; and it was more contracted in its size, than I thought possible in the few hours which had elapsed since the accident.'’

After a variety of changes and alarm­ing symptoms arising from peritoneal [Page 43]inflammation, the poor woman fortu­nately recovered; and in about six weeks waited upon the Doctor at his own house, to return thanks; when he persuaded her to permit his neighbour Dr. Osborn to examine per vaginam. He thought the os tinae somewhat more open, ex­ternally, than it usually is; and Dr. Douglas himself fancied he felt rather more fulness than is common about the cervix uteri: but they both agreed, that there was nothing in the touch so dif­ferent from what is observed in the na­tural state, as to have excited any idea of previous disease, had they not known the complaint with which she had been afflicted.

After examining the body of Mrs. Wilkins, and ascertaining the nature of the injury, I began to consider the above case in a different light, from what I did on the first perusal of it. The Doctor represents it as a case of ruptured ute­rus; [Page 44]I now perceive it to be a case of lacerated vagina.

The circumstance which he relates, of a ‘'round moveable substance,'’ which upon introducing his hand, he found to be ‘'the contracted uterus like an ob­long ball,'’ was so similar to what Mr. Waller described, and which every one of us had an opportunity of observing during the dissection, that I have no doubt remaining in my own mind, that there could have been any difference between the two cases. Mr. Waller and the other gentlemen who were present concur likewise with me in the same opinion.

In the preceding pages, I have had occasion, on a review of the case from Vander Weil, to advert to a similar oc­currence, when I expressed my doubts how the degree of contraction can be ascertained, unless the hand of the ac­coucheur [Page 45]has been passed on the outside of the uterus. I cannot suppose that, while the fundus is contracted above the rupture, the os internum will remain for several hours, nay days, dilated, and shew no disposition to contract. The fibres, I should apprehend, which form its texture, will assist its contraction in as great a degree as that of the fundus.

Dr. Douglas, as well as Vander Weil, found that the uterus receded on intro­ducing his hand. Is it possible that the uterus should have receded before his hand, if its attachment had been entire? It must have made some resistance. Yet we find that, when he touched it, it fled, and upon following it, his hand went, not into the uterus, but into a cavity which in no sort resembled it. Can it be supposed from this relation, so point­edly marked, that his fingers ever passed the os internum? The uterus must have been fixed, if he had entered into its cavity; but he says, that he was obliged [Page 46]to follow it, and at length found his hand within the abdomen, the child being on the fore part, on the back part the contracted uterus, like an oblong ball.

HE was called to the assistance of a woman, who had been a considerable time in labour, under the care of a mid­wife; she had been seized the day be­fore with a hemorrhage, on which the child, which had before presented with [Page 47]the head, was no longer felt. On exa­mination, his hand entered at once into a cavity, which appeared large; on the fore part, he felt a round substance, of the size, but not the solidity, of a childs head; yet there was not any thing to be felt, which could assure him of a child being there. The woman died soon af­ter, without being further examined. On opening the body, the child and placenta were found in the cavity of the abdomen, entirely out of the uterus, which was of the size of a childs head of five years old, and was the round body which had been felt per vaginam. The rupture was on the posterior and interior part, and then about three or four inches long ^*.

When the easy introduction of his hand into ‘'a cavity which appeared large,' at a time when the 'uterus was contracted to the size of a childs head;'’ [Page 48]his perceiving by the touch, during his attempt to deliver, ‘'a round substance,'’ which afterwards, on dissection, he found to be the contracted uterus, and the state of the rupture, being then about ‘'three or four inches long ^*,'’ are con­sidered, I think that I shall not be too hasty in pronouncing it to have been a separation of the uterus from its poste­rior attachment to the vagina.

AS in ruptures of the uterus, so in la­cerations of the vagina, if the head of the child should be advanced so far in­to [Page 49]the pelvis as to be wedged, before a laceration takes place, it will remain there, and we shall be deprived of one criterion, the retrocession of the pre­senting part, to guide us; the cessation of the true pains must lead us then to judge of the nature of the case, when attended with vomiting and other symp­toms, as described in the relation of the preceding narratives. The following cases is an instance of this kind.

A. B. aged about 30, was taken in labour with her third child, on April 15th, 1785, at four oclock in the morn­ing. [Page 50]The waters soon came away. On examination, the head of the child was found to be low in the pelvis. A con­siderable stricture was observed in the vagina, and the sacrum projected rather forward at its apex. About five hours after she was first taken in labour, she began to complain of pains in her belly, which she distinguished from those of labour. At three oclock in the after­noon, a physician, an eminent teacher of midwifery in London, was called in, at which time, from the degree of stric­ture, the part of the head which pre­sented could not be exactly ascertained. He ordered her an injection, which was given, but without any effect. On en­quiring, it appeared, that since she be­gan to complain of the pain in her belly, the labour pains had ceased. A single blade was introduced with ease, and some endeavours made to deliver, but without success. The Doctor, con­sidering it wrong to struggle against na­ture, or do any thing without the assis­tance [Page 51]of pains, left her, giving directions for an enema to be injected, and four or six ounces of blood to be taken away.

He returned at half past five, when very little alteration could be perceived. She had no labour pains, and the pains continued the same in the abdomen, which she now complained was become tender. Injections were ordered, copious and stimulant; four were given without any return. The forceps were at length applied, and used moderately, with an intent to bring on a return of true pains; but a slight discharge of the glysters was the only effect. A little ground was at length gained, and, by encreasing the force for a considerable time, she was delivered of a dead child: the placenta came away immediately after. She made water frequently during the la­bour, and had it drawn off before the use of the forceps. She was thirsty, and vomited frequently, though little in quantity. By her cries, she did not seem [Page 52]to suffer more pain, than is usually felt in her delivery.

Her pulse were quick after she was in bed; she was disposed to vomit, and passed a restless night; the pain in her belly continued distinct from after pain. She lived until the morning of the 18th, during which time her pulse were gene­rally 130 or more, her skin hot, she com­plained of great pain and tenderness of the abdomen; she vomited frequently, and her urgings to vomit were great.

From no local injury being supposed to have happened, and from the pre­sence of the lochia, and other symp­toms, the case was considered as truly puerperal, and treated as such.

On dissection, the intestines were found to be inflamed, with an exudation of lymph on their surfaces, and the gall bladder was large and distended with bile. The uterus was contracted to the [Page 53]size of double fist, black, and begin­ning to sphacelate. The vagina was found to be lacerated at its connexion to the cervix uteri, anteriorly, no ves­tige of the stricture remaining ⁹.

It is to be observed, that the woman had fallen down, a day or two before she was taken in labour, and that the same gentleman had delivered her, two years before, with forceps, on account of the same stricture.

How far the sixth case quoted by Dr. Douglas might be similar to the above, I have some doubts; but the circumstances attending it render it probable.

It appears, that the woman had been in labour the best part of the day, with very strong pains, before the rupture is supposed to have taken place. The head was firmly wedged in the pelvis; but, in attempting to open it, suddenly gave way to the force applied.

Now, let us consider for one moment the nature of the case. If a rupture had taken place in the uterus, as the head was firmly wedged in the pelvis, the feet must have been the part pro­truded; whence, when I recollect the strong contractile power of the uterus ^*, and the length of time intervening be­tween the attempt to open the head, and the time when the rupture is sup­posed [Page 55]to have happened, I cannot per­suade myself that the child would have escaped so easy into the cavity of the abdomen as he found it did.

If the vagina was lacerated, it is easy to account for the sudden retrocession of the child. It is evident, that the ute­rus being only attached in one place, its resistance against the pressure could only be partial; the fundus would be inclined, and the os internum raised in proportion; therefore, when the head was pressed back, it would find an easy admittance, through the laceration, into the cavity of the abdomen; from the endeavours of the uterus to free itself, the body with the placenta would soon follow. The rupture being near the cer­vix is, I think, some support to what I have advanced. I shall likewise endea­vour to shew, in another place, that the placenta being in the cavity of the ab­domen, may be considered as a collate­ral proof.

I AM inclined to believe, that the whole of the child very seldom escapes from a rupture of the uterus. I am, however, very well convinced, that it is always the consequence of a laceration of the vagina, unless it should happen to be as firmly wedged in the pelvis as in the cases I have just noticed.

On a review of fifteen cases quoted by Dr. Douglas, we shall find, that the child escaped into the cavity of the ab­domen in seven; in No. VI. VII. X. XI. XII. XIII. and XIV. I have already endeavoured to shew that No. VI. and XI. were lacerations of the vagina, and I shall draw some inferences from No. XII. when I come to speak of the pla­centa being out of the uterus, tending to show a degree of probability of that being of the same nature. Of No. VII. [Page 57]we have a very uncertain account, as, from motives of delicacy, it is not par­ticularly entered into. No. X. without doubt, must have been a ruptured ute­rus. I think that the two last cannot be considered in point, as they were at an early period of gestation, and the acci­dents happened from external violence.

In the remaining eight, No. I. II. III. IV. V. VIII. IX. and XV. only part of the child had escaped from the rup­ture; indeed, in the two first, it does not appear that any part had escaped. It is therefore evident that, setting aside the two cases from external violence, in only one out of thirteen the child es­caped wholly from a rupture of the uterus.

I am also inclined to believe, that the placenta being in the cavity of the ab­domen, is an occurrence which very sel­dom happens, excepting in those cases where the vagina is lacerated. The [Page 58]size of the rupture, when it happens in the uterus, must be diminished almost immediately after the child has escaped, and the contraction of the uterus must be encreased by its endeavours to pro­pel the placenta; it is therefore almost impossible that the placenta should es­cape into the abdomen: it might indeed sometimes happen, if the funis should be much twisted round the child's neck or body. In almost every case, where we have a certainty that the accident was a rupture of the uterus, we find that the placenta remained behind.

When a laceration takes place in the vagina, the propulsion of the placenta is not different from what happens in common parturition; as every contrac­tion of the uterus forces it towards the os internum, from whence it passes after the child into the cavity of the abdo­men. But when there is a rupture in the uterus, every contraction must be an impediment to its propulsion, by di­minishing [Page 59]the size of the aperture, thro' which it must pass, to be found among the viscera.

In the case of Mrs. Wilkins, where we can entertain no doubt of the nature of the accident, the placenta was found with the child in the cavity of the ab­domen. In that of Mrs. Manning, in those from Vander Weil, Bonetus, and Pouteau, and in the sixth case quoted by Dr. Douglas, all of which I have en­deavoured to shew were of the same na­ture, the placenta was likewise found among the viscera.

There are two more instances, among the cases quoted by Dr. Douglas, where the same occurrence is said to have hap­pened; in No. X. and XII.

The first, communicated by Dr. Garth­shore, is against the opinion I have form­ed, that being, as I have before observed, evidently a rupture of the uterus. In the [Page 60]other, from Saviard, it appears, that the child presented favourably, with every appearance that the labour would be soon finished; yet the pains ceased at once, after two days continuance; the presenting part receded, and only the placenta was to be felt. She died un­delivered; and when the body was opened, the child and secundines were in the abdomen among the viscera, the feet of the child touching the stomach of the mother. The intestines were all fretted, and the omentum rotten and stinking, but the uterus was of the na­tural appearance. I have not Saviard's book to refer to; but I think, from a re­view of this account, I shall be able to draw some inferences in my favour.

From the manner in which he ex­presses himself, that the uterus was of its natural appearance, we may be led to suppose that no injury had happened to it. When we recollect the circum­stance, that, after the presenting part [Page 61]had receded, the placenta alone was to be felt, I apprehend but a small degree of doubt concerning the nature of the case will remain.

After the body was opened, the se­cundines as well as the child were found in the abdomen. As the placenta was to be felt on examination, after the rupture had taken place, how can it be supposed that the rupture was in the uterus? The uterus must have been at that time considerably contracted, and the aperture so much diminished, as to have rendered the escape of the pla­centa impossible.

Hence I am clearly of opinion, that the placenta being felt on examination, after the rupture had taken place, and being afterwards found in the abdomen, is a great proof that the accident was not in the uterus, but in the vagina.

Out of eight cases, therefore, where the placenta was found with the child in the cavity of the abdomen, there is the greatest probability to suppose that seven of them were lacerations of the vagina.

THE difficulty attending delivery, when the vagina is lacerated, must be very trifling, when compared to that which will occur if the accident hap­pens in the uterus. In the case of Mrs. Wilkins, the only resistance was in bringing down the breech, which all the gentlemen present agreed arose from the protuberance of the child's belly projecting over the fundus of the contracted uterus; which, as the extrac­tion went on, was brought lower down, and, of consequence, pressed the breech of the child over the pubis: after this was overcome, not the least difficulty [Page 63]whatever occurred. In the case of Mrs. Manning, it does not appear that there was any resistance to the delivery of the breech; but we find there was a consi­derable obstruction in the passage of the head through the pelvis. I am some­what inclined to believe that this might have arisen from the same cause, al­though Dr. Douglas supposes it to have proceeded from the narrowness of the pelvis.

In those cases, where the uterus has been ruptured, the difficulty will be en­creased or diminished, in proportion as more or less of the child has escaped into the cavity of the abdomen.

If the rupture should be so extensive as to admit the child to escape entirely out of the uterus, from the natural dis­position of its fibres, the uterus will al­most immediately contract, and the size of the rupture will become less, of con­sequence, in proportion to the degree [Page 64]of contraction which takes place. If the rupture should be so small as to ad­mit the protrusion of part of the child only, a stricture will be formed upon such part as has escaped, which will re­quire a considerable degree of force to overcome, as, from its endeavours to expel the part which remains, the ute­rus will still continue to contract. In performing the caesarean operation, M. Soumain found that the edges of the in­cision made in the uterus pressed so close upon the foetus, that he could hardly get his fingers in to extract it ^*. Hence we may account for the alternate though ineffectual pains, which, in some cases, have been observed to continue for some time after the rupture has taken place; and I believe we may be led to form a probable opinion that, when this hap­pens, some part of the child still re­mains within the uterus.

The hand of the accoucheur, when he sits down to deliver, must be passed through the os internum into the cavity of the uterus, and from thence through the rupture. The difficulty attending the passage of the hand will be in pro­portion to the degree of contraction; but, unfortunately, it is very seldom that the nature of the case is known so early, as to induce us to make any at­tempt to deliver before the uterus is considerably contracted. After the re­sistance from the diminished state of the rupture is overcome, and the hand pas­sed into the abdomen, the feet, in gene­ral, may be soon found, and brought down with some ease; but as the ope­rator proceeds, and the legs come for­ward, every inch of the child, as the extraction takes place, will create a fresh resistance from its increasing bulk. The irritation which must be given to the uterus, by the introduction of the hand, will increase its endeavours to contract, and make considerable addition to the [Page 66]difficulty. Caldani, of Bologna, in a letter to Haller, relates some experi­ments made on the uterus of a bitch, which show the great degree of contrac­tion that takes place even after death, on any stimulus being applied to it ^*.

The nearer likewise the rupture hap­pens to the fundus or cervis, the greater degree of ease or difficulty will ensue. In the first instance, the extraction will be made nearly in a direct line. In the other, and which most commonly hap­pens, that part of the child which re­mains in the abdomen must form an angle with the feet and legs, while they are passing through the vagina, and the degrees of such angle will be decreased or increased, in proportion as the rup­ture may happen to be, either near the cervix, or further towards the fundus.

Very little more exertion will be re­quired than what is obliged to be made [Page 67]use of in a common case, where the child is turned, when the feet are the only parts that have escaped. When the legs have protruded as far as the knee, the resistance will be considera­bly more powerful; as, in such case, the hand must be passed to a greater distance through the rupture in search of the feet: but how much more must the difficulty be increased, if the aper­ture should be large enough to admit the child to pass out of the uterus as far as the hips? Indeed I apprehend this situation to be worse than when the whole of the child has escaped; as, in that case, there may be some hope that the resistance might be overcome, and the child extracted by the feet; but when the child has escaped as far as the hips, such a very considerable distension, if not further laceration of the rupture, must take place, and so great a degree of force must be made use of to over­come the contraction, in order to gain sufficient room to bring the feet back, as [Page 68]leave little room to hope for success. In fact, when I reflect on the very great difficulties that must arise when any considerable part of the child has es­caped, I do not at all wonder that au­thors have concurred in pronouncing the accident mortal, and giving no en­couragement for attempting relief, ex­cept by having recourse to the caesarean operation.

In addition to Mrs. Manning's case, of which we have had occasion to speak so often, eight others are adduced by Dr. Douglas, to evince the ease with which delivery may be performed in cases of ruptured uterus. No. I. IV. V. VI. VII. VIII. IX. and XV. On read­ing them over with attention, I have observed that the situation of the child, in most of them, was such as to create the smaller degree of resistance, accord­ing to the opinion I have entertained in respect to the difficulty attending de­livery.

In the first, which was related to Heis­ter by Rungius, it does not appear that the child, or any part of it, had ever been in the cavity of the abdomen. Indeed Dr. Douglas is of the same opi­nion himself, as he says, ‘'the recovery of the patients, No. I. and II. may have been in a great measure owing to the viscera having sustained little or no in­jury, as there is no reason to suppose that the child in either case had been in the cavity of the abdomen ^*.'’ This may give us some idea of the prospect we have of recovery when a rupture takes place, but cannot be brought to show the ease with which delivery may be performed, when the whole or part of the child has escaped from the uterus.

In No. IV. which is taken from La Motte, observation 317, the feet were the only parts out of the uterus, and the rupture was at the fundus; whence [Page 70]the extraction was not attended with much difficulty, for two reasons: the endeavours made use of were in a di­rect line, in the first instance, and in the second, the feet being the only parts that had escaped, the hand of the accou­cheur was introduced until it came to the knees, so as to bring them down and disengage the feet; after which, no more difficulty would arise than what happens in a common case of turning.

In No. V. likewise from La Motte, observation 318, it appears that the child had escaped out of the uterus as far as the hips, or even further, part of the body being in the cavity of the abdo­men. The child was turned, he says, and extracted with considerable ease; en moins d'un miserere, as he expresses it himself. I cannot think, with Dr. Douglas, that La Motte's observations are related with such plainness and can­dour, as to claim our most perfect con­fidence. In this instance, we have a [Page 71]case the most difficult that can possibly happen, and yet the delivery was per­formed with the greatest ease imagi­nable. I really am of opinion, that the relation is not founded in fact: I ap­prehend that he has either magnified the proportion of the child which was out of the uterus, or that he has con­cealed the difficulty he must have met with, in case such a considerable part of the child had been in the abdomen.

I have advanced some reasons, in a former part of these observations, when speaking of the head of the child being wedged in the pelvis, at the time when a laceration happens, tending to show that No. VI. was a laceration of the vagina.

We have a very defective account of No. VII. as from motives of delicacy to the gentleman who attended the pa­tient, Dr. Douglas does not think him­self at liberty to enter more particular­ly into it.

In No. VIII. from Peu, the time elap­sed between the accident and the deli­very is not related; but I am inclined to believe that it was done very soon after, from the apparent facility with which it was accomplished. There ap­pears likewise some deficiency in the contractile power of the uterus, by the excessive hemorrhage that followed. We find however that he ‘'delivered with great caution to avoid doing further in­jury to the uterus.'’ This seems to inti­mate some degree of resistance, altho' none is mentioned.

Dr. Douglas observes, that the great contractile power of the uterus is fa­vourable to the process of healing, by bringing the divided parts more into contact; ‘'but,' he says, 'the presence of any considerable extraneous sub­stance, even in the abdomen, seems, in some degree to counteract this power of contraction ^*.'’ If the uterus after the expul­sion [Page 73]of its contents, does not con­tract as in common parturition, we must expect a considerable flooding. In the above case, we are told that it was ex­cessive. In the cases of Mrs. Wilkins, and the others which I have related as lacerations of the vagina, the hemorrhage was not very great ^*, and the uterus was found contracted to the usual size it would have been, in the same space of time, if no extraneous body had been in the cavity of the abdomen.

In No. IX. from Steidele, it appears that the head had escaped from the rupture, he brought down the feet with ease, but found some difficulty in ex­tracing [Page 74]the rest of the foetus. This dif­faculty must evidently have arisen from the stricture formed by the edges of the rupture round the child's neck; whence I think it cannot be considered as much support, to evince the ease with which delivery is performed, any more than the last case, where the patient expired while the accoucheur was endeavouring to bring the head through the pelvis.

LACERATIONS of the vagina, I have before observed, have been taken notice of by authors, yet it does not appear that they have had any idea of the child's escaping by such means into the cavity of the abdomen. If the case which gave rise to these observations, in which the nature of the accident could not be mistaken, and my reasoning on the dif­ferent cases I have adduced, are allow­ed [Page 75]to have any weight, I think I may venture to draw the following conclu­sions.

First, that the whole of the child es­capes, into the cavity of the abdomen, much oftener from a laceration of the va­gina than from a rupture of the uterus.

Secondly, That, from the little diffi­culty with which delivery is accomplish­ed in lacerations of the vagina, there is a greater prospect of recovery in such accidents, than when the uterus is the seat of the injury.

It is evident that the gloomy idea of inevitable death has not only been the means of checking such endeavours as might have been sometimes successful, but that it has likewise been often the means of preventing us from knowing the real nature of the injury. I hope practitioners in future will, from the for­tunate event of the case of Mrs. Man­ning, [Page 76]related by Dr. Douglas, and the new light thrown on the subject by the case I have related of Mrs. Wilkins, entertain a more favourable opinion of the success likely to attend their endea­vours, in a situation where nothing but immediate delivery can afford the least prospect of recovery.

When first I made my private remarks on Mrs. Wilkins's case, I did not intend to enter further into the subject, than to draw the case up sair, and send it to some periodical publication, as worthy the attention of the medical world. But the similarity between it and that of Mrs. Manning was so striking, that the more I considered it, the more reasons I saw to induce me to publish it in the pre­sent form.

The nature of the subjct has obliged me to enter very fully into the merits of Dr. Douglas's case. That he should be liable to cr [...] in forming an opinion [Page 77]on the nature of the accident, is not to be wondered at, when we consider how silent authors have been upon it, and how seldom accidents of this nature oc­cur. I have not the honour of being known to him; but I am confident, from the liberality of his sentiments as a gentleman, that he will not consider the liberty I have taken as personal, or in any other light than as a discharge of the duty every man in the profession owes to the world. It has a claim upon us to elucidate any occult part of the science, and every man is bound by the laws of humanity to comply with it, whenever an opportunity offers. Ex­empla rara non reticenda, etiam causa incognita; ita enim scitu digna infinita praeteribuntur.