EXTRA-UTERINE PREGNANCY.
Tubarian, ovarian, and ventral pregnancy.—Pregnancy in the substance of the uterus.
The ovum when impregnated does not always quit the ovary and pass along the Fallopian tube into the uterus. It may remain in the ovary and become here developed; it may pass into the Fallopian tube and remain there; or from some defect in the action of the fimbriated extremity of this canal, it may escape into the cavity of the abdomen, and become attached to some of the viscera. Hence, extra-uterine pregnancy has been divided into three species, viz.graviditas tuberia,ovaria, andventralis, according to the situation which the ovum takes. A fourth has been also described by M. Breschet, which he has calledgraviditas in substantia uteri, a modification probably of tubarian pregnancy.
aThe uterus, its cavity laid open.bIts parietes thickened, as in natural pregnancy.cA portion of decidua separated from its inner surface.dBristles to show the direction of the Fallopian tubes.eRight Fallopian tube distended into a sac which has burst, containing the extra-uterine ovum.fThe fœtus.gThe chorion.hThe ovaries; in the right one is a well marked corpus luteum.iThe round ligament.
This singular deviation from the usual course of conception is fortunately of rare occurrence, for few cases terminate favourably. If it be in the Fallopian tube or ovary, these become immensely distended into a species of sac or cyst, to the sides of which the placenta adheres: as the ovum increases, this at length gives way from excessive distension, and the patient usually dies from internal hæmorrhage. In ventral pregnancy, the sac is attached to the abdominal viscera, and is usually imbedded among the convolutions of the intestines: hence the duration of extra-uterine pregnancy will depend upon its situation; thus, if it be in the Fallopian tube, it rarely lasts beyond two months; whereas, ovarian pregnancy will continue for five or six months; on the other hand, in ventral pregnancy the fœtus will not only be carried to the full term, but far beyond that period, amounting to several years.[50]
Although the uterus does not receive the ovum into its cavity as it does in natural conception, it nevertheless undergoes many of those changes which are known to take place in regular pregnancy. The layer of coagulable lymph, which is effused upon its internal surface, and which forms the membrana decidua of Hunter, is present, and the uterus undergoes a slight increase of volume. As the ovum increases, excruciating pains are felt in the lower part of the abdomen, coming on at irregular intervals, and of irregular duration; in some cases lasting for a short time, in others continuing for twenty-four hours. These attacks of pain are generally accompanied with very painful forcing and tenesmus, and not unfrequently with a discharge of bloody mucus from the vagina. In tubarian pregnancy, however, the case generally follows a much shorter course: the patient is suddenly seized with an acute pain in the lower part of the abdomen, followed by nausea and vomiting; she becomes faint and weak; the abdomen evidently increases in size (from effusion of blood into the cavity;) the debility becomes more alarming, and death quickly follows.
In ovarian pregnancy the fatal termination is merely postponed till a later period, during which the patient has to undergo attacks of most terrible suffering: at length, after a paroxysm more than usually severe, and frequently attended with the sensation of something giving way in the abdomen, faintings come on, speedily followed by death. During the attacks there is obstinate constipation, which is attended with painful and fruitless efforts to evacuate the bladder and rectum; the face is pale, and expressive not only of the most acute suffering, but of great anxiety andmental depression; nevertheless, in the intervals of the attacks she feels easy, and appears well and cheerful.
The termination of a ventral pregnancy is very different; after a time the fœtus dies, and may either remain enclosed in the cyst for life, or it may be discharged in portions by means of an abscess, either through the intestines, uterus, vagina, or abdominal parietes. Cases have occurred where it has come away by the bladder; in the former case, where it is retained, it diminishes more or less in size, becomes hard and closely packed together, and, in some instances, encrusted with a layer of calcareous matter.
It is to our venerable friend, the late Dr. Heim, of Berlin, that we are indebted for much curious and interesting knowledge respecting extra-uterine pregnancy. Although the symptoms in the very early stages are so obscure as to render it nearly impossible to detect its presence, he has nevertheless observed some facts connected with it, which are peculiar, and deserve to be noticed. No morning sickness has been observed in cases of extra-uterine pregnancy, a circumstance which can easily be accounted for, if we bear in mind the causes of morning sickness in natural pregnancy: the patient could only lie on the affected side, and the abdomen was observed to swell irregularly, not in the same manner as in regular pregnancy.
In tubarian and ovarian pregnancy, the pain was in the pelvis, but in ventral pregnancy it occupied more or less the whole abdomen, the parietes of which were very tender upon pressure. In cases where the fœtus died at an early period, the symptoms gradually disappeared after a time, especially when followed by the bursting of an abscess through the rectum or any other part. One of the most remarkable facts which Dr. Heim observed, was a peculiar whining tone of voice, with which the patient expressed her sufferings during a paroxysm of pain; so peculiar, that when once heard, the sound can never be mistaken. On several occasions Dr. Heim was enabled by means of this symptom alone to decide confidently as to the nature of the case the moment he entered the room, a fact which would appear scarcely credible had not the results of the cases proved the correctness of his assertion. A most interesting case of this sort occurred, which he pronounced to be ventral pregnancy, and when it had gone the full term gastrotomy was performed, a living child was extracted but the unfortunate mother perished: she could not be induced to submit to the operation until inflammation had come on, and she died in two days after.
It must always remain a matter of great obscurity as to the immediatecausesof extra-uterine pregnancy, more especially of the ovarian and ventral species; and the more so as we are still ignorant of the mechanism by which the fimbriated extremity of the Fallopian tube grasps the ovary immediately over the impregnatedvesicle of de Graaf at the moment of conception. In many cases we are inclined to think that this function of the Fallopian tube is destroyed by adhesions between it and the ovary, a circumstance of not uncommon occurrence; but from the alteration in the shape and size of these parts, as also from the extensive adhesions which are usually found after death, in such cases it will ever be difficult, and perhaps impossible, to prove it.
Thetreatmentof extra-uterine pregnancy must be chiefly guided by the prevailing symptoms: where any portion of the abdomen is very tender to the touch, leeches and warm fomentations will be required; the pain during the attacks can only be alleviated by frequently repeated opiates; and constipation must be carefully guarded against by laxatives and enemata between the paroxysms. Where an effort is made by nature to discharge the fœtus by means of an abcess, the case will require all our care to sustain the powers of the system through a long protracted struggle. Portions of the fœtus come away from time to time, and if the exit afforded them be by way of the intestine, the suffering produced is very great, particularly when any of the larger bones are passing. The presence of such a mass of semi-decomposed animal matter in the abdomen is of itself sufficient to injure the general health materially: hence it is that patients, during the process of expulsion, suffer greatly from severe attacks of fever, which recur from time to time. Where the abscess opens through the abdominal parietes, the whole is completed with much greater ease and safety to the patient: in some instances the tumour has been opened, and a fœtus with a large quantity of putrid pus has been removed. (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, æt. 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 tympaniticprominence 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 mass, as large as the head of a six months’ fœtus, can be felt. Between this and the median line of the abdomen, and half way between the pubes and umbilicus, a small hard knob-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 pubes, 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 fœtal 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 vaginam, 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 mass 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 pulsewas 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 mass can be felt lying across the abdomen, half-way between the pubes 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 space where it is heard it is as remarkably loud as ever, but it gradually becomes indistinct towards the circumference. 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 vaginal 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 pass portions of fibrinous matter from the vagina, mixed with bloody mucus, since last report. The hard globular swelling at the left side of the abdomen is more distinct at times: the hand can almost pass round it: it has the precise feeling of the head; the mass which lies across the abdomen is also more distinct: the souffle is heard over a much smaller space and is diminished in strength.
June 27.—Much the same, except that, after severe bearing down and tenesmus, she has passed a considerable quantity of blood from the rectum and vagina. 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 vagina, which always give relief; is weaker than usual, and feels exhausted from the continued character of the pain; abdomen less swollen; the globular mass 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 mass appears much more compressed together and nearer to the pubes; it is extremely painful on the left side, and at the most painful spot the skin is red and inflamed; the bowels, appetite, &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.
InMay, 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 mass had descended between the uterus and rectum; 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 followingAugust.
InJanuary, 1840, she returned to the hospital, all her former sufferings being greatly aggravated. The abdomen had subsided still farther; early inFebruaryshe passed a quantity of putrid purulent matter from the rectum, after which the abdomen diminished considerably. The pain appeared to be chiefly situated in the upper part of the rectum, accompanied with severe bearing down, and on examining per vaginam the mass was felt deep at the posterior part of the pelvic brim: the debility and emaciation increased, and she died early inFebruary. 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 mass 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 mass of the fœtus 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 quantity 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 secondpregnancy; 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, andprofuse fetid sweats:” an abscess formed in the abdomen, which was opened, and a vast quantity of extremely fetid matter was discharged; the opening was enlarged, and a fœtus 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 quantity.”
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 quantity 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 circumstance 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 passes 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 fœtus 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 fœtus seemed to have its origin. This inferior sac we nowfound 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.
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, calledretroversion, in which the fundus is forced downwards and backwards into the hollow of the sacrum, between the rectum and posterior wall of the vagina, and its os and cervix are carried forwards and upwards behind the symphysis pubis.
a aHalf the bladder on each side turned over the spine of the os ilium.bAnterior extremity of the vertical incision by which the bladder was opened.cOne turn of the rectum, 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.) Œtius, 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 rectum, 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 astonishing 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 passing 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 quantity 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 vagina and cervix uteri, andinto 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 anus.” (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 circumstances 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’sAnatomy 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 passing 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 rectum, in which case the rectum will be flattened at that part against which the fundus rests; and if any mass of fæculent matter be passing along the intestine, its course will be obstructed at this point, and the rectum quicklybecome distended with an accumulation of fæces 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 space 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 passing 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 fæces 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’sAnat. 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 superincumbent 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.
Thesymptomsof 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 pass fæces or urine, from the pressure of the fundus upon the rectum and of the os uteri upon the neck of the bladder. Upon examination per vaginam, the altered position and form of this canal 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 mass, (the fundus uteri,) which is evidently behind the vagina, the posterior wall of this canal being felt between it and the finger; behind the symphysis pubis, the vagina 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, (Anfangsgründe 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 rectum, we shall feel the same tumour pressing firmly upon it, and preventing the farther passage of the finger, thus proving that the tumour is situated between the rectum and the vagina; for, in such cases, the bladder forms a considerable swelling below it, and prevents the finger from passing up.” (Op. cit.)
“The uterus being situated in the centre of the pelvis, between the rectum 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 circumstances 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 thepoint of bursting: this is not so much the case with the rectum, the passage of fæces 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 accumulated fæces 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 vagina 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 rectum, 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 fæces 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 rectum, from which the principal danger of the disease arises. (Burns’sAnat. of the Gravid Uterus.)
Thediagnosisof 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 vagina and rectum, 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 rectum and bladder; but then the examination, per vaginam, will present such a totally different condition of parts as to preclude all possibility of mistake: the vagina merely shortened, neither altered in direction or form; the os uteri at the lower part of the tumour, which is in the vagina; 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 circumstances, wecannot 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 rectum and vagina, 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 fœtus is discharged, either by the rectum or vagina, as in a case of ventral pregnancy.
In thetreatmentof retroversion of the uterus, our object should be, first, to remove the accumulated contents of the bladder and rectum, 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 pass 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 pass 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 pass 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 rectum 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 assistance. 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 accumulated urine and fæces; 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 isto 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 vagina, we should hook down the os uteri, while with one or two fingers of the other hand passed into the rectum, we endeavour to push the fundus out of the hollow of the sacrum. Some object to any attempt being made through the rectum. (Naegelé,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 vagina must endeavour to raise the fundus, and in doing so may be assisted by one or two fingers in the rectum according to circumstances; the very effort to press per vaginam against the fundus, necessarily puts the anterior wall of the vagina 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 Naegelé recommends the introduction of the whole hand into the vagina, by which we gain much greater power. Under such circumstances 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 vagina. 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. (See Mr. Hooper’s Case,Med. Obs. and Inquiries, vol. v. p. 104.)
Where the pain in the pelvis indicates considerable pressure of the uterus upon the surrounding parts, arising probably fromswelling and engorgement with blood, the result of vascular excitement, a smart bleeding will afford great relief; the size and firmness of the tumour are diminished, the soft parts in which it is imbedded are relaxed, the general turgor and sensibility are alleviated, and if the moment of temporary prostration which it has produced be seized upon by the practitioner, he will find that the reposition of the uterus, which was before nearly impracticable, is now comparatively easy.
Where, however, the circumstances of the case are so unfavourable, and the fundus so firmly impacted in the hollow of the sacrum as to resist the above-mentioned means, Dr. Hunter proposed, “Whether it would not be advisable, in such a case, to perforate the uterus with a small trocar or any other proper instrument, in order to discharge the liquor amnii, and thereby render the uterus so small and so lax as to admit of reduction.” (Med. Obs. and Inq.vol. iv. p. 406.) Dr. Hunter did not live to see this plan carried into execution. In latter years, several cases of otherwise irreducible retroversion have thus been successfully relieved: the remedy, it is true, necessarily brings on premature expulsion of the fœtus sooner or later. Under such circumstances, this result cannot be made a ground of objection. In cases of such severity as to require paracentesis uteri, there can be little or no chance of the fœtus being alive; and even if it were, of what avail would this be, when almost certain death is staring the mother in the face, unless relieved by this operation?[56]Puncture of the bladder has also been tried where the urine could not be drawn off.[57]
Cases have now and then been met with where the retroversion of the uterus has continued to an advanced period of pregnancy without producing serious injury to the patient: Dr. Merriman has even recorded some, where the uterus has continued in this state up to the full term. Some of these had been actually published as cases of ventral pregnancy; but for their history he has shown that they evidently were cases of retroversion: the patient had been subject to occasional suppressions of urine and difficulty in passing fæces; these symptoms had gradually diminished as pregnancy advanced; the os uteri could not be felt,or, if it were capable of being reached, was found high up behind the pubes, the head of the child forming a large hard tumour between the rectum and vagina. The condition of the vagina afforded strong evidences of the nature of the complaint: on introducing the finger in the usual direction, it was stopped, as if in a cul-de-sac: but on passing it forwards, the vagina was found pulled up behind the symphysis pubis. In some of these cases the uterine contractions gradually restored the fundus to its natural position: the os uteri descended from behind the symphysis, and the child was born after long protracted suffering; in others, which have been mistaken for ventral pregnancy, the fundus has inflamed and ulcerated, and the child has been gradually discharged by piecemeal.
DURATION OF PREGNANCY.
There are few questions of great importance and interest respecting a subject under our daily observation, about which such uncertainty and so much diversity of opinion exists, as the duration of human pregnancy; and yet, as is the case with the diagnosis of pregnancy, upon a correct decision frequently depend happiness, character, legitimacy, and fortune. In like manner it frequently happens, that the data upon which we have to found our opinion are exceedingly doubtful and obscure; and to increase the difficulties of the investigation still farther, we have not uncommonly to contend with wilful deception and determined concealment.
The duration of pregnancy must ever remain a question of considerable uncertainty so long as the data and modes of calculation vary so exceedingly. “Some persons date from the time at which the monthly period intermits; others begin to calculate from a fortnight after the intermission; some reckon from the day on which the succeeding appearance ought to have become manifest; some are inclined to include in their calculation the entire last period of being regular; and others only date from the day at which they were first sensible of the motions of the infant.”[58]
“A good deal of the confusion on this point seems to have arisen from considering forty weeks and nine calendar months as one and the same quantity of time, whereas, in fact, they differ by from five to eight days. Nine calendar months make 275 days, or if February be included, only 272 or 273 days, that is thirty-nine weeks only instead of forty. Yet we constantly find in books on law, and on medical jurisprudence, the expression “nine months or forty weeks.” Another source of confusion has evidently had its origin in the indiscriminate use of lunar and solar months, as the basis of computation in certain writings of authority.”[59]
It is owing to this uncertainty that a considerable latitude has been allowed by the codes of law in different countries for the duration of pregnancy, in order to prevent the risk of deciding where the data are so uncertain.
Experience has shown that the ordinary term of human pregnancy, wherever it has been capable of being determined with any degree of accuracy, is 280 days or forty weeks; and this period seems to have been generally allowed even from the remotest ages. As, however, it is so difficult to fix the precise moment of conception, it has been customary in different countries to allow a certain number of days beyond the usual time; thus the Code Napoléon ordains 300 days as the extreme duration of pregnancy, allowing twenty days over to make up for inaccuracy of reckoning. In Prussia it is 301 days, or three weeks beyond the usual time. In this country the limit of gestation is not so accurately determined by law, and therefore gives rise occasionally to much discrepancy of opinion.
The grand question which this subject involves, is, whether a woman can really go beyond the common period of gestation. A great number of authors have considered that thepartus serotinus, or over-term pregnancy, is perfectly possible; but by far the majority use such an uncertain mode of reckoning that little confidence can be placed in them.
Two questions here arise, the determining of which will greatly assist us in forming a correct view of this intricate subject, viz.first, what has been the duration of those cases of pregnancy where the moment of conception has been satisfactorily ascertained?secondly, what are the causes which determine the period at which labour usually comes on?
The circumstances under which it happens that we are able to ascertain the precise date of impregnation occur so rarely, that it is nearly impossible to collect any considerable number of such cases. Three have occurred under our own notice, in which there could be little doubt as to the accuracy of the information given, and in each of these the patient went a few days short of the full period. One, a case of rape, was delivered on the 260th day; in the two others, sexual intercourse had only occurred once; in one case she went 264, in the other, 276 days. We could have mentioned several others, but where even the slightest shadow of doubt as to their accuracy has existed, we have rejected them as inconclusive.
The mode of calculating the duration of pregnancy, which is ordinarily adopted, viz. by reckoning from the last appearance of the catamenia, although the chief means which is afforded us for so doing, is nevertheless much too vague and uncertain to ensure a decided result; for although it is a well-known fact, that conception very frequently takes place shortly after a menstrual period, there can be no doubt that it is liable to occur at any part of the catamenial interval, and particularly so shortly before the next appearance: hence, by this mode of reckoning, we are not more justified in expecting labour in nine months time from thelast appearance of the catamenia, than at any part of the interval between this and what would have been the next appearance.
Dr. Merriman, who has devoted much attention to this intricate but important subject, says, “When I have been requested to calculate the time at which the accession of labour might be expected, I have been very exact in ascertaining thelast dayon which any appearance of the catamenia was distinguishable, and having reckoned 40 weeks from this day, assuming that thetwo hundred and eightiethday from the last period was to be considered as the legitimate day of parturition” (Synopsis of Difficult Parturition, p. xxiii. ed. 1838;) and gives a valuable table of “one hundred and fifty mature children, calculated from, but not including, the day on which the catamenia were last distinguishable.” Of these,
so that about one-third were born three weeks after the 280 days from the last appearance of the catamenia; a circumstance which is perfectly easy of explanation, from what we have just observed, without the pregnancy having overstepped its usual duration: in other words, it would appear that 28 of these cases had conceived one week, 18 two weeks, and 11 three weeks after the last appearance of the catamenia.
The question therefore of thepartus serotinus; as far as these data are concerned, remains still undecided: of 10 cases which have occurred under our own immediate notice, where the patients determined the commencement of their pregnancy from other data than the last appearance of the catamenia, a similar variation was observed, viz. that nearly one-third went beyond 280 days, six of these individuals reckoned from their marriage, and four from peculiar sensations connected with sexual intercourse, which convinced them that impregnation had taken place: of these, seven did not go beyond the 280th day, two having been delivered upon that day, and three went beyond it, viz. to the 285th, 288th, and 291st days: the two former reckoned from their respective marriages; the latter, who went 291 days, from her peculiar sensations.
The calculation from the date of marriage is liable to the same objections as that taken from the last appearance of the catamenia; for if it had been solemnized (as is usually the case where it is possible) shortly after a menstrual period, and if conception didnot take place until a fortnight or three weeks afterwards, the patient’s pregnancy would thus have appeared to have lasted so much longer than the natural term. The case, however, which is stated to have gone 291 days, does not come under this head, for here the pregnancy really appears to have lasted 10 or 11 days beyond the full period, which cannot be accounted for in the way above mentioned: we should not have ventured to quote this, if a similar instance had not been recorded by Dr. Dewees. “The husband of a lady, who was obliged to absent himself many months, in consequence of the embarrassment of his affairs, returned, however, one night clandestinely, and his visit was only known to his wife, her mother, and ourselves. The consequence of this visit was the impregnation of his wife; and she was delivered of a healthy child in 9 months and 13 days after this nocternal visit. The lady was within a week of her menstrual period, which was not interrupted, and which led her to hope she had suffered nothing from her intercourse; but the interruption of the succeeding period gave rise to the suspicion she was not safe, and which was afterwards realized by the birth of a child.”[60]
Although it is to be regretted that this case has been calculated in the ordinary vague manner of calendar months, yet it is perfectly evident that the pregnancy was longer than the ordinary duration. We shall, therefore, endeavour to investigate the possibility of over-term pregnancy still more closely by a consideration of the second question, viz. what are the causes which determine the period at which labour usually comes on?
It is now ten years ago since we first surmised that “the reason why labour usually terminates pregnancy at the 40th week is from the recurrence of a menstrual period at a time during pregnancy when the uterus, from its distension and weight of contents, is no longer able to bear that increase of irritability which accompanies these periods without being excited to throw off the ovum.”
Under the head ofPremature Expulsion, we shall have occasion to notice the disposition to abortion which the uterus evinces at what, in the unimpregnated state, would have been a menstrual period: for some months after the commencement of pregnancy, a careful observer may distinctly trace the periodical symptoms of uterine excitement coming on at certain intervals, and it may be easily supposed that many causes for abortion act with increased effect at these times. Where the patient has suffered from dysmenorrhœa before pregnancy, these periods continue to be marked with such an increase of uterine irritability as to render them for some time exceedingly dangerous to the safety of the ovum. Even to a late period of gestation, the uterus continuesto indicate a slight increase of irritability at these periods, although much more indistinctly; thus, in cases of hæmorrhage before labour, especially where it arises from the attachment of the placenta to the os uteri, it is usually observed to come on, and to return, at what in the unimpregnated state would have been a menstrual period. We mention these facts as illustrating what we presume are the laws on which the duration of pregnancy depends, and also as being capable of affording a satisfactory explanation of those seeming over-term cases which are occasionally met with.
From this view of the subject it will be evident, that the period of the menstrual interval at which conception takes place, will in great measure influence the duration of the pregnancy afterwards; that where it has occurred immediately after an appearance of the menses, the uterus will have attained such a dilatation and weight of contents by the time the ninth period has arrived, that it will not be able to pass through this state of catamenial excitement without contraction, or, in other words, labour coming on: hence it is that we find a considerable number of labours fall short of the usual time, so much so that some authors have even considered the natural term of human gestation to be 273 days or 39 weeks: for a somewhat similar reason we can explain why primiparæ seldom go quite to the full term of gestation, the uterus being less capable of undergoing the necessary increase of volume in a first pregnancy than it is in succeeding ones.
On the other hand, where impregnation has taken place shortly before a menstrual period, the uterus, especially if the patient has already had several children, will probably not have attained such a volume and development as to prevent its passing the ninth period without expelling its contents, but may even go on to the next before this process takes place: it is in this way that we would explain the cases related by Dr. Dewees and Dr. Montgomery. We are aware that, under such a view of the subject, the duration of time between the catamenial periods of each individual should be taken into account, some women menstruating at very short, and others at very long, intervals; but although this will affect the number of periods during which the pregnancy will last, it will not influence the actual duration of time, as this will more immediately depend upon the size and weight of contents which the uterus has attained.
The valuable facts collected by M. Tessier respecting the variable duration of pregnancy in animals, which have been quoted by some authors in proof of the partus serotinus, are scarcely applicable to this question in the human subject; the absence of menstruation, and the different structure of the uterus, prevent our making any close comparison.
PREMATURE EXPULSION OF THE FŒTUS.