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Ante Version.—Anteversion in degree sufficient to cause symptoms rarely exists, and is then usually relieved spontaneously in the progress of time. When such a displacement is the cause of annoying frequency or pain in urination, relief may frequently be obtained by recommending the patient to pass as much time as possible in the recumbent position and upon the back, but in any case where the distress is sufficiently extreme to demand immediate relief, this may usually be obtained by the introduction of a suitable pessary, such as is ordinarily used in anteversion of the non-gravid uterus.
Retroversion And Retroflexion.—Backward displacements are by far the most common malpositions of the pregnant uterus, and are also by far the most troublesome; giving rise to many reflex troubles, as, for instance, the extreme degrees of nausea and vomiting; and moreover exposing the patient to no small danger of incarceration. When either of these displacements is due to the existence of firm adhesions between the fundus uteri and the posterior wall of the pelvis, abortion is almost certain to follow; when they are uncomplicated by such adhesions, treatment during the early months is easy and effects prompt relief. It should consist in the reposition of the displaced organ, and its retention in place by a Hodge or other suitable pessary, the form known as the " patent process" being again preferred.
Incarceration.—If retroversion of the pregnant uterus be allowed to continue without treatment, the natural increase of the organ may effect spontaneous reduction of the displacement, but is more likely to result in the incarceration of the enlarged fundus beneath the promontory of the sacrum—an accident which, as time progresses, necessarily leads to a progressive increase of the displacement, until, in extreme cases, the fundus is found to have depressed the posterior vaginal wall almost to the perinaeum, while the cervix points almost directly upward. The amount of sacral pain and vesical distress which the traction of such extreme displacements necessarily causes can easily be imagined.
Treatment.—In simple cases it is sometimes possible to effect reposition by pressure in the posterior cul-de-sac with two or more fingers of the examining hand, and with the patient in the lithotomy position; but if this attempt fails, as is usually the case, the patient must be placed in the left latero-prone, or better in the knee-chest position. In this attitude, if the abdomen is left thoroughly free by the removal of all pressure of the clothing, retraction of the perinaeum, with the consequent entrance of air into the vagina, may effect replacement by the influence of gravity alone; to which end the patient should be instructed to make a number of forced respirations, while the physician retracts the perimeuiu with the speculum, and watches the motions of the cervix. This effort failing, two fingers of the left hand should be introduced into the rectum, and should make pressure upward and forward upon the fundus of the uterus, while the thumb of the same hand, or the forefinger of the other, is introduced into the vagina and attempts to hook the cervix down, the fundus being allowed to pass to that side of the promontory to which it seems naturally to incline.
If, as is common, incarceration uncomplicated by adhesions has been attended by the production of extreme oedema and congestion, the reposition of the uterus should be preceded by an attempt to relieve the swelling due to this cause by means of the persistent use, if necessary for many days, of a glycerin tampon in the vagina. This tampon should be small, should be soaked in a mixture of equal parts of glycerin and water, must be renewed at least twice in twenty-four hours, and should be kept continuously in position. After the reduction of the swelling, or if, after several days' use of the tampon, no effect is perceptible, a prolonged and persistent attempt at reposition should be made under ether by the method already described. Should this attempt fail, it may be justifiable to make an effort toward reducing the size of the uterus by the use of prolonged hot-water douches, or even local scarification, to be succeeded, if successful, by a further attempt at reposition before proceeding to the induction of labor, which is always indicated in case of a final failure to reduce the incarceration, but which may sometimes be far from easy on account of the position of the cervix.
If the case is complicated by the presence of adhesions, or if in uncomplicated cases persistent efforts by the preceding methods fail to effect the ascent of the fundus, it may be regarded as certain that the situation is such that, in view of the serious dangers of incarceration, an abortion is to be hoped for rather than feared, and that a far more heroic method of treatment must therefore be adopted; and it is generally best in such cases to proceed at once to the use of a systematic tamponade of the vagina, introduced through the Sims' speculum in the manner described by all text-books on gynaecology for the relief of retroversion. This procedure will frequently be followed by miscarriage, but may occasionally result in replacement without disturbance of pregnancy; in view, however, of the probability of its resulting in the production of abortion, it should never be adopted without consultation with another physician, and then only after explaining to the family the circumstances of the case.
If even this attempt fails, the induction of labor is indicated, but owing to the position of the cervix its performance may be a matter of considerable difficulty. If the os be within reach of the finger, digital dilatation and rupture of the membranes offers the most effective and ready treatment, but if the position of the cervix makes this impossible, the object may sometimes be effected by the use of the following mechanical device. The end of a small metal catheter should be cut off, and the last inch of the remainder bent sharply upon itself; the instrument may then be passed along the anterior surface of the cervix, under the guidance of the finger, until its end can be hooked into the uplooking external os, and if this position be once attained, a flexible strip of whalebone or a soft probe may be passed through the catheter, and following its curve, may be made to enter the uterine cavity and effect rupture of the membranes. In case of failure by all other means, aspiration of the liquor amnii through the vaginal wall may be attempted, under the most strict of antiseptic precautions, but this operation is not devoid of danger, and fortunately is rarely necessary.
Abnormalities of the Sexual Organs.
Since the uterus and vagina are both produced by the coalescence of Mtiller's ducts, which in the early stages of development are double and bilaterally symmetrical, an arrest of their development may result in the persistence of a median septum in any portion of the uterus or vagina or even throughout the whole parturient canal; thus we may have a double uterine cavity with a single cervix, a double cervix with a single body, or even a complete duplication of the uterus; and any one of these deformities may exist in conjunction with a single or double vagina. Some of these malformations are of practical importance at the time of labor, but as they are rarely discovered during pregnancy and are of no importance at that time, no further description is deemed necessary here.
Hernia.—Hernia of the uterus is rare under any circumstances, and hernia of the gravid uterus is of still more infrequent occurrence. Should it be found to exist, it is always a sufficient reason for the immediate induction of labor, unless the displacement can be easily reduced by taxis.
Unnecessary surgical operations are to be avoided during pregnancy, because possibly productive of abortion, but minor operations upon tissues unconnected with the reproductive system are rarely followed by this accident, and may be performed if sufficient indications exist. Operations upon the genital tract, including operations upon the breasts, are followed by abortion in the large majority of cases, and this although the extent of the wound may be slight; such operations should, therefore. S
never be performed unless in the presence of imperative necessity, either on account of the existence of serious risk to the life of the mother if the operation be deferred, or because the presence of a new growth or other pathological condition offers an insuperable obstacle to delivery.
Cancer Of The Cervix.—Cancer of the cervix is likely to increase rapidly during pregnancy, and if at all extensive is best removed by the curette or by amputation of the cervix so soon as the child has reached the period of viability, on account of the serious and even fatal haemorrhage which may follow upon the laceration of such tissues during parturition.
Ovarian Cysts.—Intra-pelvic ovarian tumors may frequently be raised into the abdomen by a proper taxis, and if this be possible should be left undisturbed until after the termination of pregnancy, unless their growth is sufficiently rapid to threaten miscarriage per se; but if this is the case, the immediate performance of laparotomy is justified by the number of cases, now considerable, in which such an operation has failed to interfere with pregnancy, and in view of the liability to miscarriage without operation.
Trauma.—The results of accidents bear about the same relation to pregnancy as those outlined above for surgical operations; the chance of miscarriage being proportional to the extent of the injury, and to its anatomical proximity to the pregnant uterus. In the after-treatment of operations, and in the treatment of accidents among pregnant women, absolute restriction to the Tecumbent position and a free use of opiates are to be especially enjoined.
Both accidents and surgical operations are less well borne at the periods when the catamenia would naturally have occurred than at other times, and are especially likely to be followed by miscarriage at the third or seventh month. If a surgical operation is indicated during pregnancy, "it should always, if possible, be deferred until the period of viability is reached.
Diseases Of The Ovum.
Endometritis.—This disease rarely originates during pregnancy, but the continuance of a pre-existent intra-uterine inflammation is thought to be a frequent cause of blighted ovum and adherent placenta. It can rarely be diagnosticated during pregnancy, but is said to be accompanied by undue sensitiveness to the movements of the child.
The catarrhal form of endometritis is supposed to be the cause of the affection known as hydrorrhoea gravidarum. The existence of this disease is signalized by the discharge at varying intervals, during the middle or later months of pregnancy, of a thin albuminous fluid, in quantities which vary from a drachm to several ounces; discharges which are unaccompanied by pain, and never followed by miscarriage. The affection is of no pathological importance, and no treatment is indicated.
Hydramn'ion.—The condition known as hydramnion is essentially the presence of an abnormal amount of liquor amnii, and has been accounted for by many different theories, about which considerable difference of opinion still prevails. It is not infrequently coexistent with foetal monstrosity.
The discomfort due to it must be endured until the mother's existence is actually threatened by an embarrassment, or partial arrest, of circulation or respiration as a result of distention. It may then be treated by puncture of the membranes, or by an aspiration of the uterus through the abdominal walls. This latter operation, if done with sufficient care and with absolute asepsis, should be ordinarily attended by no danger; and is usually the better treatment, since it may be followed by a continuance of pregnancy to term. The puncture should be made at that spot at which it seems least likely to injure the foetus—a point which can usually be determined by careful palpation; and the withdrawal of liquor should be stopped as soon as the distention is definitely relieved, in order to minimize the risk of exciting labor.
Death Of The Fcetus.—Death of the foetus may result from any general disease of sufficient severity. When it results from acute illness it is usually succeeded by prompt abortion, but a foetus which dies a slow death from chronic affections is often retained in utero for a considerable length of time, and may even be carried to full term. It is sometimes important to be able to diagnosticate the occurrence of foetal death, which is usually accompanied by more or less marked symptoms.
Pregnant women are frequently alarmed by a disappearance of the foetal movements, which is due to some change in the position of the child that makes them imperceptible to the mQther for a period of a few hours or days. This intermission of the movements is by itself of no importance, but possesses some significance when it occurs in connection with other symptoms. Cessation of movement due to the death of the child is often preceded by an increase of movement, probably of convulsive origin.
Death of the child is frequently followed by swelling and turgesoence of the breasts, accompanied in some cases by the appearance of milk, and followed by a marked decrease in their size. The patient frequently complains of malaise, fatigue, and general lassitude, and sometimes of a sensation of weight and coldness in