Prolapsus uteri in pregnancy, as in the unimpregnated condition, may come on gradually or suddenly; it may also be a partial descent or a complete procidentia. This is especially apt to be the case when the pelvis is unusually large. In all cases of prolapsus uteri in pregnancy, whether the result of a previous habit or of more recent influences, it is simply necessary for the patient to remain quiet, and take the remedy indicated according to the conditions and symptoms of her case. The appropriate remedy, together with the increasing size of the ovum, will in a short time render any return of the prolapsus impossible.
For this, as well as for the other forms of uterine displacement in pregnancy, consult the remedies indicated in a preceding chapter for displacements of the unimpregnated uterus.
Anteversion is principally apt to occur in the more advanced stages of pregnancy, when the uterus has become very heavy; although some few instances are recorded in which this accident happened in the second and third months of pregnancy. In the milder forms of this displacement, the term obliquity is more applicable; while in complete anteversion the fundus uteri may even be engaged below the symphysis pubis. (*Compare Ashwell’s Diseases of Females, p.147; and Boivin and Duges, p.63) Perfect quiet; a recumbent position, and the judicious exhibition of the remedy indicated by the symptoms of each case, will almost always suffice to effect a complete cure. In cases where the fundus is actually engaged beneath the symphysis, the addition of a little manual assistance may be needed in order to replace the organ, – the patient lying on her back.
Retroversion of the uterus, in the pregnant as even in the unimpregnated condition, forms a very serious complication, whether it occur suddenly or slowly. In many cases the symptoms will scarcely lead us to suspect the presence of this form of displacement until the fundus is actually engaged beneath the promontory of the sacrum. In this condition the use of the elevator, described in a preceding chapter of the present work, may be found necessary. Retroversion is most apt to occur in the third and fourth months; but it may occur in the fifth, or even as late as the seventh month of gestation. It may take place very slowly, so as to become complete by the third month of pregnancy, – aided very much by the gravity of the ovum, when once it has become deflected from its proper position. This first beginning of the mischief may result from a too great and too long-continued distention of the urinary bladder. The complete or partial retention of the urine forms one of the most characteristic indications of the retroversion itself.
In order to facilitate the restoration of the retroverted uterus, it may be necessary to place the patient prone upon her face; thus as of the sacrum, its own gravity will enable it to resume its proper place in the pelvis. It will be necessary to distinguish this form of displacement from extra-uterine pregnancy, since very disastrous consequences must otherwise speedily result. And this will be best accomplished by a careful study of the conditions and symptoms of the case, and of the causes which have apparently produced the mischief, – in addition to the most careful exploration per vaginam and, if necessary, per anum. Retention of urine in the bladder, from want of opportunity to discharge it, as sometimes in travelling; accumulation of feces in the rectum; violent straining to lift a heavy weight; a fall backward; blows or other accidental pressure upon the navel, may occasion the retroversion; hence the presence of any one of these powerful causes of backward displacement would lead to the suspicion of retroversion in the case.
A previous retroversion is no doubt the most frequent cause of the retroversion of the uterus in pregnancy. In such cases the trouble is at first entirely unsuspected; as in the first weeks of gestation the increased size of the uterus scarcely occasions any more inconvenience than before conception. But after a while the os uteri-begins to press upon the bladder and hinder its evacuation. Then the sudden and severe symptoms, which are really the consequences of the gradual enlargement of a previously retroverted uterus, are supposed to result from a sudden displacement. Careful attention to the calls of nature, as well in respect to the bowels as to the bladder, will be important, in order to obviate any disposition to this displacement, particularly in persons who have suffered from it in former pregnancies. And where retroversion has either suddenly set in, as in consequence of an accident, or gradually developed from partial displacement of this kind existing previously to conception, it may be necessary to evacuate the bladder before any progress can be made in restoration. Then perfect rest, in a recumbent condition, for a longer or shorter time, according to circumstances, will greatly aid the proper remedy to effect a complete cure of this difficulty. The various pessaries proposed and used in such cases, we consider entirely unnecessary, and in many cases positively injurious. With the aid of the appropriate remedies, and of such favorable circumstances and hygienic conditions as are indispensable under any plan of treatment, Nature may be enabled to hold herself up; which she can never learn to do as long as she is propped up.
III. ABNORMAL SECRETIONS. – Leucorrhoea may occur in pregnancy, especially in persons constitutionally predisposed to this affection. The discharge is usually of a mild character; mucous, thick and white in its appearance, and sometimes profuse in quantity. The increased activity of the circulation of the uterus and its appendages incident activity of the circulation of the uterus and its appendages incident to pregnancy, extends to the muciparous glands of the vagina and cervix uteri; and an excess of the secretion which closes the cervix may occasion a constant discharge. In connection with this discharge may occur irritation, itching, heat and burning in the vulva and parts adjacent. And where the leucorrhoea is very profuse, other symptoms of debility may follow in consequence of the loss of fluids. All the attendant symptoms should be carefully collated and compare with the indications given of remedies under Leucorrhoea of Unimpregnated Females.
Hydrorrhoea. – In a previous section has been described the disposition manifested by some pregnant women to become affected with dropsy. The dropsical accumulation may be infiltrated into the cellular tissue, partially, so as to constitute oedema of the lower limbs; or generally, so as to result in anasarca. Or the effused fluid may occupy the peritoneal cavity, – forming ascites; it may accumulate within the womb, between its internal surface and the external surface of the membranes of the ovum; or finally there may be an excessive quantity of the amniotic fluid, constituting dropsy of the amnion. The two former, oedema and ascites, having been already considered at some length, it remains for us now to describe in brief the two latter of the dropsical affections; all of which may appear more or less fully developed in the same person, under the influence of constitutional predisposition brought out and aggravated by pregnancy.
Hydrorrhoea, or flow of water, is the name given to such discharges of water as occur from the womb in the course of gestation, without rupture of the membranes. And by the same phenomena the young accoucheur may be deceived, in parturition; a very considerable flow of water during a pain leading him to suppose the membranes are already ruptured, while upon subsequent examination he finds them still intact.
In the later months of pregnancy this affection is quite common; the uterus from time to time relieving itself of the undue accumulation without special muscular effort, very much as the urinary bladder does. An examination of the os uteri in such cases, will satisfy the practitioner that the discharge does not come from the interior of the womb; and that therefore there is no cause for alarm, as from a threatened miscarriage. The flow appears at irregular intervals, and without any especial provoking cause; neither does it occasion any remarkable symptoms, except where, from ignorance of its real nature, it is supposed to be the precursor of miscarriage.
The concurrence of other dropsical conditions, – such as oedema of the limbs, – the fact that the discharge arises spontaneously, and the almost entire absence of pains or uterine contractions, will enable the physician to diagnose the hydrorrhoea with sufficient certainty. The false waters may make their exit without any noticeable provoking cause, and without any more than the very slightest constitutional disturbance; while the membranes which enclose the true amniotic waters, can only be broken by some great bodily exertion, some special accident or positive effort, and their discharge of these waters cannot but be followed by strongly marked symptoms indicating the approach or actual existence of labor. Perfect quiet, freedom from excitement or anxiety, and the exhibition of the remedies indicated by all the attendant symptoms and conditions, will be all that is requisite to prevent serious mischief from this condition, – and to remove as far as possible its constitutional causes.
