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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."
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 distention 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 ac
* Dr. Burns makes a similar observation. "In most cases the cervix will be found more or less curved; so that the os uteri is not directed so much upwards as it otherwise should be." (Principles of Midwifery, p. 284, 9th edit.)
cumulated 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 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 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.* 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 perseverance 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 from the swelling and engorgement with blood, the result of vascular excitement, a smart bleeding will afford great relief; the size and firmness of the tumour are di
"Sometimes it is perhaps better to introduce the fingers into the vagina only, and not into the rectum, not merely because we can act better and more directly upon the uterus here, but also because if we press the posterior wall of the vagina upward towards the sacrum, and thus stretch the upper part of it which is between the fingers and the os uteri, it will act upon the uterus like a cord upon a pulley, and greatly favour its rotation." (Richter, op. cit. vol. vii. sect. 57.)
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 distention 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 of PREMATURE 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 dysmenorrhoea 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 continues to 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 FETUS.
ABORTION. MISCARRIAGE. PREMATURE LABOUR.
LACTIC MEASURES.-EFFECTS OF REPEATED ABORTION.-TREATMENT.
THE uterus does not always carry the ovum to the full term of pregnancy, but expels it prematurely. The expulsion of its contents may occur at different periods, and is characterized accordingly: thus, among most of the Continental authors, it has been divided under three heads: those cases which occur during the first sixteen weeks coming under the head of abortion; those which occur between this period and the twentyeighth week are called miscarriages; and when they take place at the latter period, until the full term of utero-gestation, they receive the name of premature labours.
It is perhaps useful to distinguish those cases of premature expulsion which occur before, from those which occur after the fourth month, inasmuch as they seldom prove dangerous before that time, from the diminutive size of the ovum and from the slight degree of development which the uterine vessels have undergone; whereas, after this period the hæmorrhage is more severe, and the general disturbance to the system greater. In other respects it will be more simple to divide premature expulsion of the ovum under two heads only; those cases which happen before the twentyeighth week, or seventh month, being termed abortions, and after this period (as before) premature labours. This division is highly important in a practical point of view, since it marks the period before which the child has little chance of being born alive; whereas, after this date it may with care be reared.* A foetus may be expelled, at a very early stage of pregnancy, not only alive, but capable of moving its limbs briskly for a short time afterwards, but it is unable to prolong its existence separate from the mother beyond a few hours. Cases do occur now and then where a child is born in the sixth month, and where it manages to struggle through, but these are rare, and must rather be looked upon as exceptions to the general rule.
Abortions usually occur from the eighth to the twelfth week, a period which is decidedly the least dangerous for such accidents. "The liability to abortion is greater in the early than in the later periods of pregnancy; for as the union between the chorion and decidua is not well confirmed, as the attachment of the latter to the internal face of the uterus is propor
"Qui inter septimi et noni mensis, à prima conceptione, finem contingit partus, præmaturus vocatur: abortus vero quando ante dictum tempus embryo excidit; id quod circa tertium graviditatis mensem ut plurimum accidit. Vitalem esse præmaturum fœtum observatio nos docet, embryonem autem non manere superstitem constat." (Rederer, Elem. Artis Obst. cap. xxiii. § 716.)