A System of Midwifery Part 9

(_Medical Obs. and Inquiries_, vol. ii. p. 369.)

A case of ventral pregnancy has recently come under our care, a short account of which will enable the reader to understand the subject better than a mere enumeration of symptoms; the more so as we believe it to have been the first case of extra-uterine pregnancy in which the stethoscope has been used.

The patient, aet. 32, and the mother of four children, was admitted, May 26, 1837, into St. Bartholomew's Hospital, under Dr. Latham, who kindly consigned her to our charge. She considers herself to be six months advanced in pregnancy; is continually suffering from attacks of acute pain in the lower part of the abdomen, both at the sides and front, causing her to moan from its great severity; this is accompanied with a constant dragging pain on the right side, and in the loins: the attacks of abdominal pain go off at intervals, leaving her comparatively easy. She is pale, with an anxious expression of face. Pulse 120, and firm. Tongue moist. Bowels very constipated.

The abdomen is as large as in common pregnancy at the sixth month, but does not present the same uniform distension, being irregularly shaped. At the left hypogastrium is a soft tympanitic prominence of considerable extent, and appears, from its feel and also from auscultation, to consist of a large portion of the intestines pushed over to that side: at the inner edge of this tumour a solid ma.s.s, as large as the head of a six months' foetus, can be felt. Between this and the median line of the abdomen, and half way between the p.u.b.es and umbilicus, a small hard k.n.o.b-like and moveable prominence is felt immediately beneath the abdominal parietes, and intensely painful to the touch. From this point, quite to the right side, the abdomen has a solid irregular feel; below this to the symphysis pubis, a very loud souffle is heard, synchronous with the mother's pulse, having all the characters of the uterine souffle in common pregnancy except its extraordinary loudness. Its limits, superiorly, are remarkably defined; below a transverse line, drawn half way between the umbilicus and p.u.b.es, it is heard in full strength, whereas, immediately above it the sound ceases: it is also heard some way to the right side. At the upper part of the right iliac region two ridge-like prominences, like the extremities of a child, may be felt close beneath the abdominal parietes. No trace of foetal pulsation can be heard over any part of the abdomen, although it has been carefully ausculted round to the loins: it was however distinctly heard the day before we saw her, by two gentlemen who are proficients in the use of the stethoscope, and whom we consider fully capable of judging in such a case.

On examining per v.a.g.i.n.am, the os uteri is found high up and backwards, barely within reach. Its edges are thick, soft, and closed; the cervix is short, and seems less than half an inch. The anterior portion of the inferior segment of the uterus feels somewhat firm and full, as if there was something in the uterus. We were confirmed in this respect by our friend, Dr. Nebel, jun., of Heidelberg, who was on a visit to this country at the time, and who examined the case with us. He was at first induced to suppose that it was the head. We considered that it was the uterus more or less anteverted, the fundus being pressed forwards and downwards, and the os uteri backwards, by the extra-uterine cyst above; farther examinations tended to confirm this view.

She states that the catamenia appeared last in November, during the middle of which month she was attacked with inflammation of the bowels, for which she was treated, and soon afterwards began to have the violent attacks of pain of which she now complains. She felt the child move at the usual time; it evidently formed the ma.s.s which occupies the lower part of the abdomen, and its movements appeared unusually close to the surface. During the last few days they have ceased altogether. The above-mentioned attacks of pain have continued to recur ever since at short intervals and with increasing severity.

As leeches had been applied without relief, and as the pulse was quick and hard, she was ordered to be bled to eight ounces, and to take half a grain of morphia immediately.

_June 2._--Has been in constant suffering, in spite of leeches and morphia; bowels obstinately constipated, but moved at length by repeated injections and doses of house medicine. Has not felt the motions of the child since the intestines have become tympanitic: still, however, the ma.s.s can be felt lying across the abdomen, half-way between the p.u.b.es and umbilicus, commencing from about three inches to the left of the median line, and extending to about four inches on the opposite side. On the left side it feels firm and rounded, and so superficial, that it can almost be grasped through the abdominal integuments. Face very pale and anxious.

Pulse 120.

_June 10._--Was easy and free from pain when we first saw her: the souffle is heard over a smaller extent; in the centre of the s.p.a.ce where it is heard it is as remarkably loud as ever, but it gradually becomes indistinct towards the circ.u.mference. As she was able to rise we examined her standing: the os uteri is exceedingly high up to the left sacro-iliac symphysis, so that it can scarcely be reached; the cervix is short, the lips somewhat larger than usual, and the whole very firm and immoveable.

The anterior portion of the uterus, to be felt through the v.a.g.i.n.al parietes, is somewhat firmer and larger than usual: on pressing the tumour in the left hypogastrium, this appeared to lie altogether anterior to the uterus. Little motion is communicated to the os uteri when this is moved.

_June 20._--Has been in much suffering since last report; much emaciated; complains of a fetid taste in the mouth; bowels inclined to be purged; stools of a whitish purulent appearance; tongue clean; pulse tolerably natural; has continued to pa.s.s portions of fibrinous matter from the v.a.g.i.n.a, mixed with b.l.o.o.d.y mucus, since last report. The hard globular swelling at the left side of the abdomen is more distinct at times: the hand can almost pa.s.s round it: it has the precise feeling of the head; the ma.s.s which lies across the abdomen is also more distinct: the souffle is heard over a much smaller s.p.a.ce and is diminished in strength.

_June 27._--Much the same, except that, after severe bearing down and tenesmus, she has pa.s.sed a considerable quant.i.ty of blood from the r.e.c.t.u.m and v.a.g.i.n.a. The little prominences on the right side, presumed to be the extremities, are remarkably distinct, like two heels or knees.

_July 18._--No material change has taken place since last report; she has suffered from irregular attacks of pain, and has had repeated discharges of blood from the v.a.g.i.n.a, which always give relief; is weaker than usual, and feels exhausted from the continued character of the pain; abdomen less swollen; the globular ma.s.s on the left side is lower and much nearer to the median line; the little prominences on the right are also lower, and nearer the median line; the whole ma.s.s appears much more compressed together and nearer to the p.u.b.es; it is extremely painful on the left side, and at the most painful spot the skin is red and inflamed; the bowels, appet.i.te, &c. are natural; pulse feeble, but regular; scarcely any trace of souffle to be heard.

Shortly after this she left the hospital, and for some time continued to enjoy tolerable health, occasionally suffering from severe paroxysms of abdominal pain; the abdomen diminished considerably in size, and the various prominences became indistinct.

In _May, 1839_, she was again admitted in a state of great exhaustion from constant severe pain. The abdomen had diminished still more, and a portion of the ma.s.s had descended between the uterus and r.e.c.t.u.m; the constipated bowels were moved with great difficulty, but with much relief. The symptoms gradually diminished, and she was discharged in the first week of the following _August_.

In _January, 1840_, she returned to the hospital, all her former sufferings being greatly aggravated. The abdomen had subsided still farther; early in _February_ she pa.s.sed a quant.i.ty of putrid purulent matter from the r.e.c.t.u.m, after which the abdomen diminished considerably.

The pain appeared to be chiefly situated in the upper part of the r.e.c.t.u.m, accompanied with severe bearing down, and on examining per v.a.g.i.n.am the ma.s.s was felt deep at the posterior part of the pelvic brim: the debility and emaciation increased, and she died early in _February_. Our notes of the post mortem examination were as follows:--

Much emaciated, abdomen concave, but on pressing it the tumour can be felt at the brim of the pelvis. On opening the abdominal cavity, the ma.s.s was found adhering firmly to the neighbouring intestines, and on the right side to the soft linings of the pelvis: it was of an irregular form, with spots of livid vascularity in different parts: on the upper and left side of it, fetid purulent matter was seen exuding from a small orifice. The uterus was below, its fundus pushed over to the left side. On separating its adhesions, and attempting to raise the sac from the pelvis, the half-softened parietes gave way, and the decomposed putty-like ma.s.s of the foetus became visible; the cranial bones were at the left side; the feet were still distinct on the right side; the whole was immersed in a quant.i.ty of thick fetid pus, and there were no traces either of umbilical cord or placenta.

Cases of ventral pregnancy have been recorded where the child has remained in the mother's abdomen without producing any dangerous symptoms, and where she has again become pregnant in the natural way. The earliest instance of this sort was recorded so long ago as by Albucasis. A very interesting case of this nature is described by Dr. Bard of New York.

(_Med. Obs. and Inquiries_, vol. ii. p. 369.) It was the patient's second pregnancy; at the end of nine months she had pains, which after a time went off; the tumour gradually diminished somewhat, and in about five months after she conceived again, and in due time was delivered, after an easy labour, of a healthy child. "Five days after delivery she was seized with a violent fever, a purging, suppression, pain in the tumour, and _profuse fetid sweats_:" an abscess formed in the abdomen, which was opened, and a vast quant.i.ty of extremely fetid matter was discharged; the opening was enlarged, and a foetus of the full size was extracted. Dr.

Bard "imagined the placenta and funis umbilicalis were dissolved in the pus, of which there was a great quant.i.ty."

It becomes a question of deep interest whether it be really possible to save the patient and the child in cases of ventral pregnancy, by performing gastrotomy. The separation of the placenta from the walls of the cyst can only be effected with much difficulty and hazard; indeed, we are at a loss to conceive how it can be removed with any degree of safety, where the child has been found alive. The attachment in these cases was more than usually firm, and it has been left to undergo that process of solution which has been described in Dr. Bard's case. In all the cases where gastrotomy has been performed some time after the child's death, little or no trace of the placenta has been found, but in its place a quant.i.ty of ill-conditioned purulent matter, which was excessively fetid.

The fourth species of extra-uterine pregnancy, which M. Breschet has described as taking place in the substance of the uterus, is of very rare occurrence, four cases only having been recorded by him. (_Med. Chir.

Trans._ vol. xiii.) M. Breschet has attempted a variety of explanations of this singular anomaly, but without success; and from the circ.u.mstance of the cyst having always been found situated in the fundus to one side, the Fallopian tube of which was closed at its uterine extremity, we think that there can be little doubt of its having been a modification of tubarian pregnancy, where the ovum had been obstructed at that portion of the Fallopian tube where it pa.s.ses obliquely through the wall of the uterus: in one case the tube appears to have given way at this part, and the ovum to have insinuated itself between the uterus and peritoneum. In these cases the sac ruptured at about the same period as in tubarian pregnancy, except in one instance, where she went five months. A rather inexplicable case of extra-uterine pregnancy has been recorded by Mr. Hay, of Leeds (_Med. Obs. and Inquiries_, vol. iii.,) where a full grown foetus was found enclosed in a large sac, which filled the abdominal cavity, and which communicated inferiorly with the uterus. On tracing the umbilical cord, "we were led," says Mr. Hay, "to a large aperture in the right side of the inferior globular sac already mentioned, from which that which contained the foetus seemed to have its origin. This inferior sac we now found to be the uterus, containing a very thick placenta, which adhered very firmly to about three-fourths of its internal surface, having the navel string attached to its centre, and this centre corresponded nearly with the centre of the fundus uteri. The placenta filled up the greatest part of the aperture of communication between the uterus and sac. The Fallopian tube on the left side was very small; the place of that on the right was occupied by the beginning or orifice of the sac." (_Op. cit._)

This would seem to have been a case of pregnancy in the substance of the uterus, and where a portion of the ovum had burst its way into the cavity of the uterus lined with decidua, to which it adhered; the other portion, containing the embryo, distended the uterine parietes in a contrary direction, and thus formed the large sac which communicated with the cavity of the uterus.

CHAPTER VI.

RETROVERSION OF THE UTERUS.

_History.--Causes.--Symptoms.--Diagnosis.--Treatment.--Spontaneous terminations._

During the earlier months of pregnancy the uterus is liable, although rarely, to a peculiar species of displacement, called _retroversion_, in which the fundus is forced downwards and backwards into the hollow of the sacrum, between the r.e.c.t.u.m and posterior wall of the v.a.g.i.n.a, and its os and cervix are carried forwards and upwards behind the symphysis pubis.

[Ill.u.s.tration: _a a_ Half the bladder on each side turned over the spine of the os ilium. _b_ Anterior extremity of the vertical incision by which the bladder was opened. _c_ One turn of the r.e.c.t.u.m, which was seen at the posterior end of the same incision. _W. Hunter._]

Retroversion of the uterus appears to have been known to the ancients, as we find it alluded to by Hippocrates (_De Nat. Mulieb._ sect. 5.) and Philumenus (_Histoire de la Chirurg._ par Dujardin and Peyrhille, t. ii.

p. 280.) Oetius, who has quoted the works of the celebrated Aspasia, describes this displacement of the uterus very exactly, and gives rules for introducing two fingers into the r.e.c.t.u.m, in order to remedy it. Rod. a Castro, who wrote in the sixteenth century, in his work on the diseases of women, quotes what Hippocrates had written on the subject of this displacement; and it is astonis.h.i.+ng that no farther notice was taken of it until the eighteenth century, when it excited considerable attention among accoucheurs. (_Martin le Jeune_, p. 137.) Gregoire appears to have been the first who gave a good description of it; his pupil, Mr. W. Wall, on his return to England, met with what he considered to be a case of this displacement, and not being able to restore the uterus to its natural position, requested the advice of Dr. W. Hunter. On pa.s.sing his finger between the os uteri and symphysis pubis, and thus removing, in some degree, the pressure upon the neck of the bladder, a considerable quant.i.ty of urine was discharged, but he was unable to return the uterus to its natural situation, and the patient gradually sunk. The bladder was found immensely distended; the lower part of it, "which is united with the v.a.g.i.n.a and cervix uteri, and into which the ureters are inserted, was raised up as high as the brim of the pelvis by a large round tumour, (viz.

the uterus,) which entirely filled up the whole cavity of the pelvis. The os uteri made the summit of the tumour upon which the bladder rested, and the fundus uteri was turned down towards the os coccygis and a.n.u.s."

(_Medical Obs. and Inquiries_, vol. iv. 404.)

_Causes._ This displacement may also occur in the unimpregnated state, either from the fundus being pushed into that position by some morbid growth, or where this effect has been produced by the violent pressure of the abdominal muscles in lifting heavy weights, under circ.u.mstances where the uterus has been larger and heavier than usual;[51] but it is in the early months of pregnancy that it is most likely to happen, because now the fundus is both larger and heavier than before, and, therefore, more liable to be affected by the pressure of the intestines and abdominal muscles, and has not yet attained a sufficient size to prevent its undergoing this displacement in the pelvis: this period is about the third or fourth month, often before it, but never after it. (Burns's _Anatomy of the Gravid Uterus_, p. 17.)

It has been supposed by many authors, especially Dr. Burns, that distension of the bladder is, in many instances, the immediate cause of retroversion, owing to the intimate connexion which exists between the lower part of the uterus and this organ, inasmuch, "that whenever the bladder rises by distension, the uterus must rise also." In the later editions of his work on the principles of midwifery, he has considerably modified this opinion, and from careful examination of the parts in situ, in the third month, is not disposed to consider the distension of the bladder as the cause, but the effect of retroversion. In every case which has come under our own observation, the bladder has not been distended until the retroversion had taken place, in consequence of which the os and cervix uteri had been tilted up behind the symphysis pubis, and having thus compressed its neck had caused the difficulty in pa.s.sing water.[52]

Whenever any force is applied to the fundus uteri at this period of pregnancy, either from external violence, or the action of the abdominal muscles pressing the intestines and bladder against it, it will be pushed against the r.e.c.t.u.m, in which case the r.e.c.t.u.m will be flattened at that part against which the fundus rests; and if any ma.s.s of faeculent matter be pa.s.sing along the intestine, its course will be obstructed at this point, and the r.e.c.t.u.m quickly become distended with an acc.u.mulation of faeces above, by which means the fundus will not only be prevented from rising, but in all probability be forced still lower down. If the force which has originally pushed the fundus backwards be of sufficient degree and duration to carry it past the promontory of the sacrum, the increase of s.p.a.ce which it will meet with in the hollow of the sacrum, and the straining efforts which are induced by the displacement itself, contribute powerfully to complete the mischief, and to bring the fundus so low into the pelvic cavity as at length to turn it nearly upside down.

As soon as the fundus of the uterus is pressed with any degree of force against the posterior parietes of the pelvis, its os and cervix will be directed forwards and upwards against the symphysis pubis, and from the pressure which they exert against the neck of the bladder, the patient either experiences complete retention of urine, or, at any rate, considerable difficulty in pa.s.sing it; hence, therefore, we find, that where retroversion has come on suddenly, the patient is generally sensible of the pain produced by the displacement, before she has experienced any difficulty in evacuating the bladder.

A modern French author of great experience, (_Martin le Jeune_, p. 178,) in enumerating the causes of retroversion, appears to take a similar view of the subject, and places retention of urine very far down in his list.

"Sudden and violent contractions of the abdominal muscles and diaphragm in attempting to vomit, to evacuate the bowels or bladder, or to lift heavy weights; the throes during an abortion at an early period of pregnancy; strong mental emotions; retention of urine; tumours in the neighbourhood of the fundus, which by their weight or pressure force it backwards towards the sacrum, are the causes which may produce a retroversion of the uterus."

Retroversion may also come on gradually, from "the uterus remaining too long in that situation which is natural to it when unimpregnated, namely, with its fundus inclined backwards. This may depend on various causes; such as too great width of the pelvis, or the pressure of the ileum full of faeces on the fore part of the uterus. In this case the weight of the fundus must gradually produce a retroversion, and she will be sensible of its progress from day to day." (Burns's _Anat. of the Gravid Uterus_. p.

18.)

It will thus be seen how peculiarly liable the uterus is to retroversion during the early months of pregnancy. At this time, the fundus is not yet free from the weight of the superinc.u.mbent coils of intestine; and if from any cause its ascent out of the pelvis be delayed beyond the usual time, its liability to retroversion is still farther increased; for, not only does the size of the fundus press it still farther backward, but any sudden contractions of the abdominal muscles, or external violence, act upon it with increased effect.

The _symptoms_ of this displacement are as follow:--the patient is seized with violent pain, bearing down, and sense of distension about the hollow of the sacrum, with a feeling of dragging and even tearing about the groins, produced by the violent stretching of the broad and round ligaments; the bearing down is sometimes so severe and involuntary as to resemble labour pains, and cases have occurred where it has been mistaken for labour. With all this she finds herself unable to pa.s.s faeces or urine, from the pressure of the fundus upon the r.e.c.t.u.m and of the os uteri upon the neck of the bladder. Upon examination per v.a.g.i.n.am, the altered position and form of this ca.n.a.l instantly excite our suspicion: instead of running nearly in a straight direction backwards and somewhat upwards, it now takes a curved direction upwards and forwards behind the symphysis pubis; the hollow of the sacrum is occupied with the globular and nearly solid ma.s.s, (the fundus uteri,) which is evidently behind the v.a.g.i.n.a, the posterior wall of this ca.n.a.l being felt between it and the finger; behind the symphysis pubis, the v.a.g.i.n.a is more or less flattened, and its anterior wall put violently upon the stretch, so much so that, according to Richter, the orifice of the urethra is sometimes dragged up above the pubic bones, (_Anfangsgrunde der Wundarztneikunst_, vol. ii. p. 45:) the os uteri is found high up behind the symphysis pubis, and in most cases can be reached, although with much difficulty; sometimes we shall be able to reach the posterior lip only, which is now the lowest: but "if the retension of urine has been of some duration, it will be impossible to reach the os uteri above the pubic bones with the finger. On examining per r.e.c.t.u.m, we shall feel the same tumour pressing firmly upon it, and preventing the farther pa.s.sage of the finger, thus proving that the tumour is situated between the r.e.c.t.u.m and the v.a.g.i.n.a; for, in such cases, the bladder forms a considerable swelling below it, and prevents the finger from pa.s.sing up." (_Op. cit._)

"The uterus being situated in the centre of the pelvis, between the r.e.c.t.u.m and bladder, its retroversion cannot take place without deranging the functions of these organs: the symptoms thus produced come on rapidly when the displacement is sudden, slowly when it is gradual. Their severity is in proportion to the size of the uterus, the degree of retroversion, its duration, and the various circ.u.mstances which increase the impaction of the uterus in the cavity of the pelvis: they also determine the degree of inflammation and gangrene of this organ and the neighbouring parts."

(_Martin le Jeune_, p. 178.) Hence we frequently observe in the earlier stages of retroversion, before the displacement has become complete, that the patient is able to relieve the bladder to a certain extent, although very imperfectly, and that with some difficulty; a slight dribbling of urine continues to a very advanced stage, when the bladder is enormously distended, and upon the point of bursting: this is not so much the case with the r.e.c.t.u.m, the pa.s.sage of faeces being generally completely obstructed at an early period, partly from the pressure of the fundus against it, and partly from the solid nature of its contents. "When such suppressions once begin they aggravate the evil, not merely by causing pain, but by occasioning a load of acc.u.mulated faeces in the abdomen above the uterus, which presses it still lower into the cavity of the pelvis, at the same time that the distension of the bladder in this state draws up that part of the v.a.g.i.n.a and cervix uteri with which it is connected, so as to throw the fundus uteri still more directly downwards." (Dr. W. Hunter, _Med. Obs. and Inquiries_, vol. iv. p. 406.) These conditions of the bladder and r.e.c.t.u.m, and the retroversion of the uterus, act reciprocally as cause and effect; for the continuance of the distension of the bladder and the descent of the faeces from the part of the intestine above the obstruction, must elevate still more the os uteri, and depress to a still greater degree the fundus. The retroversion, on the other hand, increases the affection of the bladder and r.e.c.t.u.m, from which the princ.i.p.al danger of the disease arises. (Burns's _Anat. of the Gravid Uterus_.)

The _diagnosis_ of retroversion is, generally speaking, not very difficult, the os uteri tilted up behind the symphysis pubis, and the fundus forced downwards and backwards between the v.a.g.i.n.a and r.e.c.t.u.m, are sufficiently characteristic of this displacement. We cannot agree with Dr.

Dewees that it can easily be mistaken for prolapsus uteri; in cases of sudden prolapsus which has been caused by great violence, there will be, it is true, intense pain in the pelvis, with sensation of forcing and tearing in the direction of the broad and round ligaments; there will also, probably, be inability to evacuate the r.e.c.t.u.m and bladder; but then the examination, per v.a.g.i.n.am, will present such a totally different condition of parts as to preclude all possibility of mistake: the v.a.g.i.n.a merely shortened, neither altered in direction or form; the os uteri at the lower part of the tumour, which is in the v.a.g.i.n.a; the mobility of the tumour itself, all conspire to show that the case is one of prolapsus not retroversion.

We occasionally meet with cases of retroversion where the os uteri, although carried more or less upwards and forwards, is not forced, to that extreme height behind the symphysis pubis as is usually observed. Instead of looking towards, or rather above, the symphysis, the os uteri itself looks downwards, the neck or lower part of the body of the uterus being bent upon the fundus like the neck of a retort.[53] If, under such circ.u.mstances, we cannot satisfy ourselves as to the existence of pregnancy, we might easily be led to form an erroneous diagnosis, and to conclude that some tumour had forced itself down into the hollow of the sacrum, between the r.e.c.t.u.m and v.a.g.i.n.a, and had thus pushed the uterus upwards and forwards, above the brim of the pelvis. An extra-uterine ovum of the ventral species may occupy this situation, but its slow and gradual growth, its greater softness and elasticity, and the slight degree of uterine displacement produced in its early stages, would enable us to ascertain its real character. The same would hold good to a certain extent with an ovarian tumour, although in all probability this would produce more or less displacement of the uterus to one side.

The danger in retroversion of the uterus chiefly arises from the distension or rupture of the bladder, and from the gangrenous inflammation which may then take place, not only in it, but also in the uterus and neighbouring parts. The very displacement itself is sometimes immediately attended by alarming symptoms, such as faintness, vomiting, cold sweats, weak irregular pulse, as seen in cases of inversion or strangulated hernia. In some cases the suffering at first is but trifling, and only increases in proportion to the degree with which the bladder is distended.

Retroversion not reduced may experience a spontaneous termination in two ways, either by abortion being excited, after which the uterus, now diminished in size, returns to its natural situation, or it may go on to increase in this position until a more advanced period of pregnancy, when if it be not capable of being replaced by the action of the pains, sloughing takes place in the fundus, and the foetus is discharged, either by the r.e.c.t.u.m or v.a.g.i.n.a, as in a case of ventral pregnancy.

In the _treatment_ of retroversion of the uterus, our object should be, first, to remove the acc.u.mulated contents of the bladder and r.e.c.t.u.m, and secondly, to endeavour to restore the uterus to its natural position. The relief of the bladder must be our first aim, for here is the greatest source of danger. The elastic catheter should always be used in these cases, and greatly facilitates the operation of drawing off the water. The altered direction of the urethra must be borne in mind; in many cases we must pa.s.s the catheter nearly perpendicularly behind the symphysis pubis: by pressing the uterus backwards, we shall diminish its pressure upon the urethra, and thus enable the catheter to pa.s.s with great ease.[54]

"The catheter should be employed occasionally, and the bowels emptied daily, either by medicines of a mild kind, or by injections: if this plan do not succeed in restoring the fundus, we should then consider the propriety of mechanically replacing it. To aid us in our judgment, we should consider, first, the period of gestation; secondly, the degree of development the uterus has undergone; thirdly, the nature and severity of existing symptoms. The period of gestation ought almost always to influence our conduct in this complaint, and we may lay it down as a general rule, the nearer that period approaches four months, the greater will be the necessity to act promptly in procuring the restoration of the fundus: the reason for this is obvious, every day after this only increases the difficulty of the restoration from the continually augmenting size of the ovum. The degree of development should also be taken into consideration, as some uteri are much more expanded at three months, than others are at four. The extent or severity of symptoms must ever be kept in view; as, for instance, where the suppression of urine is complete, and not to be relieved by the catheter, in consequence of the extreme difficulty and impossibility to pa.s.s it: here we must not temporize too long, lest the bladder become inflamed, gangrenous, or burst; for the bladder, from its very organization, cannot bear distension beyond a certain degree, or beyond a certain time, without suffering serious mischief." (Dewees, _Compend. Syst. of Midwifery, 6th Ed._ -- 276.) Our next step should be to relieve the r.e.c.t.u.m of its contents by emollient enemata; this is not always very practicable, owing to the flattened state of it: hence a glyster pipe of the ordinary sort is too large, and meets with much resistance; in such cases it will be desirable to use a common elastic catheter, or thin elastic tube without an ivory nozzle, which will, therefore, better adapt itself to the form of the bowel. A few doses of a saline laxative should be given to render the contents of the bowels more fluid, and the enemata repeated until a sufficient evacuation has been effected. Where the retroversion is not of long standing, and the patient not far advanced in her pregnancy, these means are generally sufficient; and the uterus, in the course of a few hours, will return to its natural position, either spontaneously or with very slight a.s.sistance.

Where, however, the uterus is large and firmly impacted, where it has already been displaced more than twenty-four hours, where the suffering from the very beginning has been acute, independently of that produced by the distended bladder, we cannot expect that the spontaneous replacement will follow the mere removal of the acc.u.mulated urine and faeces; nor must the uterus be suffered to remain in the state of retroversion, as not only will its pressure on the neighbouring parts produce serious mischief, but from the increasing growth of the ovum, every day will add to the difficulty of moving it out of the pelvis. In determining upon the artificial reposition of the uterus, it must be borne in mind that the chief difficulty is to raise the fundus above the promontory of the sacrum, for if we can once succeed in gaining this point, the rest will follow of itself; our object, therefore, will be to raise the fundus upwards and forwards, in a direction towards the umbilicus of the patient.

To effect this purpose various methods have been proposed: some have recommended that, with a finger in the v.a.g.i.n.a, we should hook down the os uteri, while with one or two fingers of the other hand pa.s.sed into the r.e.c.t.u.m, we endeavour to push the fundus out of the hollow of the sacrum.

Some object to any attempt being made through the r.e.c.t.u.m. (Naegele, _Erfahrungen und Abhandlungen_, p. 346.) We agree with Richter in the utter inutility of attempting to bring down the os uteri; in most instances we can barely reach it with the tip of the finger, and even were we able to lay hold of it, we should run little or no chance of moving it so long as the fundus is impacted in the hollow of the sacrum. The fingers which are in the v.a.g.i.n.a must endeavour to raise the fundus, and in doing so may be a.s.sisted by one or two fingers in the r.e.c.t.u.m according to circ.u.mstances; the very effort to press per v.a.g.i.n.am against the fundus, necessarily puts the anterior wall of the v.a.g.i.n.a upon the stretch, and thus tends of itself to bring the os uteri downward.[55] In all cases where the reposition of the uterus is at all difficult, Professor Naegele recommends the introduction of the whole hand into the v.a.g.i.n.a, by which we gain much greater power. Under such circ.u.mstances it is desirable to place the patient upon her knees and elbows, as in a difficult case of turning, because now the very weight of the fundus will dispose it to quit the pelvis. The only difficulty which we shall meet with in thus using the whole hand, is the violent straining and efforts to bear down, which the patient is involuntarily compelled to make, from the presence of the hand in the v.a.g.i.n.a. Dr. Dewees in such cases very judiciously recommends bleeding to fainting, not only to obviate these efforts which would have prevented our raising the fundus, but also to relax the soft parts as much as possible. In our attempts to replace the uterus we must not be discouraged by finding that at first no impression is made upon it; by degrees it will begin to yield, and with a little more perserverance we shall be enabled to push the fundus above the promontory of the sacrum.