Obrazy na stronie
PDF
ePub

+

give the patient directions as to the use of the catheter, and instruct her to introduce it every four or six hours, so as to make sure that no bladder-tension shall overthrow the womb again during your absence.

When you can venture to employ a pessary, which you cannot well do in the pregnant female, you should adjust one of sufficient magnitude to produce or extend the vagina. I say extend the vagina, and I say so, because there will be scarcely a relapse if you keep the vagina stretched to its full length. When it is so stretched, it carries the uterus upwards, and makes it move upwards coincidently with the curve of Dr. Carus. In order to a first retroversion, I esteem it indispensable that the whole womb should descend, see-sawing backwards; for I cannot imagine a retroversion, as taking place with a vagina four and a half or five inches long. Try the case in your own judgment; think how a womb could be retroverted, while it stands so high up in the pelvis. If you perpend the question carefully, I believe you will decide that it cannot be turned over by the bladder, without first descending along Carus' curve, so as to enable the fundus to get down lower than the promontorium, and when once down there, the tenesmus will complete the oversetting of it.

I have many times reposited a non-gravid womb, that had long been retroverted, and placed beneath it one of Dr. Physick's globe pessaries, of two and a half inches diameter. Such a pessary will keep the womb in its place pretty well; but, if the round ligaments have lost all their tone, a full bladder, aided by a fit of sneezing, laughing, or in straining at stool, will readily overset it again. I speak of the non-gravid womb, which, you know, is about two inches long, more or less.

You might well imagine that, when the womb is supported by such a pessary as I have just mentioned, the retroversion might take place upon the emptying of the bladder,-because, as the posterior wall of the bladder comes nearer the pubis, the less the water within it; so the anterior face of the womb, which is attached to it, must also approach the pubis; and being only two inches in length, and without support from its ligamenta rotunda, would readily tumble over backwards. I say that this is, to my knowledge, the case; and I say so, being grounded upon observations made, over and over again, especially in three individuals, whose names I have no right to make public. In all these women, I have repo

sited the uterus completely, and it has fallen over again immediately. I have reinstated it, and again it has become displaced: + nor could I get it to stay in sitû, until I had supported it at a great height, by means of Dr. Blundell's stem-pessary.

I have, in fact, come at last to the conclusion, that in one of t those exceedingly relaxed cases of round ligament, where the womb falls over as soon as you put it up, it is pretty much a hopeless task, the attempting to sustain it by any other than the stempessary. Yet, in a case where the uterus does not at once turn over again, after being reposited, I conceive the globe the least inconvenient, safest, and surest of all remedies.

If you prefer to make use of Dr. Dewees' disc, you can do so; but I apprehend a careful inquiry into the relative power of elevation of the two sorts of pessaries, will bring you to the conclusion that a two inch globe will lift and hold the womb much higher than a three inch disc-shaped instrument. As for the sponges and other horrid conceits of the sort, they are too detestable to be thought of. I disapprove of the glass ones-when strong, they are too+ heavy, when light, too frangible. A cork pessary is bad, because the wax that covers it comes off, and leaves the rough cork in contact with the parts. Such contact is dangerous-it is ulcerative.

tanit.

Do you expect I should say something more of those utero-abdo-itunes minal supporters? I deem them abominable. I have never used, and never shall use one of them. To think of curing a retroversion or prolapsus with them, is an anatomical absurdity. But I shall not dwell on them, because you will not forget what I said of them in my lectures.

I have written you a very long letter on retroversion, perhaps too long; and yet there remain many things I could say. Let us recapitulate before I close, some of the opinions expressed in this letter.

1. Retroversion consists in the turning of the top of the womb over towards the sacrum. The fundus uteri dips down into the hollow of the sacrum, and the posterior surface of it comes into contact with the posterior surface of the vagina, which it presses forwards and downwards towards the os externum, making a tumor there. The os uteri is directed up against the bladder, which it pushes against the symphysis pubis.

2. It causes dysuria, or retention of urine; or at least, mictu

[ocr errors]
[ocr errors]

+

rition. It also gives rise to pain in the course of the round ligaments, and the ligamenta lata. It is attended with pain in the region of the sacrum, loins and kidneys, and there is a sense of weight, pressure, or bearing-down, in the hypogastrium and pelvis.

3. When it occurs in the pregnant woman, it is fraught with danger both to the mother and child. If uncured, the mother is likely to be the victim of a dreadful death, from pain, inflammation, and from total obstruction of the pelvis.

4. The more advanced the pregnancy, the more dangerous the accident.

5. It is a diseased or debilitated state of the round ligaments that gives rise to the disorder. The cure consists in the restoration of the health and tone of those ligaments.

6. It is in some cases incurable, from adhesions tying the womb down in the excavation.

7. It should be treated-1st, by evacuating the bowel; 2d, by drawing off the urine; 3d, by repositing the womb; 4th, by supporting the reposited womb with a pessary; 5th, by carefully enjoining an attention to the state of the bladder, which should never be allowed to get too full.

8. Lastly, I ask you why a pessary should be able to cure the round ligaments? I am sure of your answer. It is this: every tissue of living beings that is not compelled to extend, has a tendency to condense or contract itself. This is true, whether of muscle, cellular tela, lung, skin, and all the rest. While the round ligaments are extended by an overturned womb, they cannot become shorter, they cannot exert their natural tendency to condensation. To lift up the womb, and keep it up, to empty the bladder, and prevent it from being overfull again, is to give to the round ligaments an opportunity to act out their nature-that is, to regain their natural length, strength, and tension-which is effected by time, by tonics, by wholesome food, and by whatever tends to consummate the state which you call health. Take care that when they do recover, they go not beyond the state of recovery, and contracting too much, bring on the very antithesis of retroversion, I mean an anteversion of the womb, which shall be the subject of my next letter. Farewell.

C. D. M.

LETTER XVII.

ANTEVERSION OF THE UTERUS.

GENTLEMEN:-The state of the uterus described in my last letter, under the title of retroversion, is much more common than its opposite, the anteversion of the organ, a case in which the fundus is drawn or pressed towards the bladder of urine, and permanently maintained in that position. In such circumstances, the external signs are perhaps not different from those that attend upon the retroverted state; and they consist chiefly of pelvic pain, misery, bearing-bown sensation, micturition, and pain and weakness of the lumbar and sacral region, which are increased by exercise, and by the standing position. I do not think that I should be able, from any complaint, or relation proceeding from the patient, to discriminate between the affection attendant upon the anteverted and the retroverted state of the organ; nor do I suppose that any physician could correctly and confidently make such a discrimination, except upon information acquired by means of the

TOUCH.

I said that the anteverted is not so frequently met with, as the retroverted deviation. I am, indeed, of opinion that it is a rare malady, for, in more than thirty years, I have had few opportunities of observing it, whereas, I have met with a very considerable number of the contrary sort; a number so great, that I think it not very much disproportioned to simple prolapsus, as to frequency of occurrence.

The anterior face of the non-gravid womb, as high up as the middle of the corpus uteri, is in contact with the bladder; which, as I remarked in my former letter, pushes the womb backwards when filling, and draws it forwards towards the symphysis pubis as it becomes emptied; the round ligaments being put upon the stretch in the former, and completely relaxed in the latter pro

cess.

The only natural anatomical power that can draw the fundus uteri to the pubis, is to be found in the bladder of urine; for the

round ligaments do not, as a physiological act, draw the womb nearer to the pubis than the middle of the pelvis, where it ought to be coincident, as to the direction of its axis, with the curve of Carus; whence it appears to me, that in all cases where the fundus uteri is permanently drawn against the bladder, and near the pubal bone, we must resort to one of two modes of explanation of the occurrence, one being, that it is pushed there by some body lying upon and behind it; and the other, that it is drawn or pulled in that direction by the ligamenta rotunda, which have become so short as to prevent the womb from retracting towards the sacrum when the bladder, being full, tends to send it off in that direction. Here, then, are two possible causes of anteversion; one, pressure from above or behind; and the other, traction or drawing from before.

Now, the causes that might act on the organ from above and behind it, are tumors fallen down into the pelvis, or developed in its superior parts; which, by their weight or volume, compel the uterus to assume a sort of horizontal attitude, pointing the os uteri backwards, and the fundus forwards;-or, the compressing cause may consist in a tumor, or tumors developed on the superior and posterior parts of the corpus and fundus uteri, extending backwards in their growth, until meeting with a point d'appui on the back part of the pelvis, and unable to extend farther in that line, continue to grow, but always finding space by thrusting the organ from which they spring towards the bas-fond of the bladder.

Doubtless such may be the true rationale of some of the cases, yet admitting this to be true, it is still clear to me, that a contraction of the ligamenta rotunda is much more generally the cause of anteversion. I can form no other conclusion from my own observations, and, on several occasions, I have had opportunities to test the thing in my practice; I having, in some of the samples, in vain tried to push the fundus off from the vicinity of the pubal symphysis, with one, or with two fingers, introduced far upwards behind the shear-bone. Upon making such attempts, having failed to move it out of its fixed position, I have been obliged to adopt the opinion, that the womb was tied down by a contraction or condensation of the tissue of the ligaments, so often named. What other opinion, indeed, could, or can be reasonably adopted in a case where the most careful exterior palpation clearly

« PoprzedniaDalej »