A careful examination of the recorded cases of uterine hernia leaves it doubtful if the pre cise form of the hernia has been, or indeed could be, determined in every instance.
Ventral hernia has been observed only of the gravid uterus, which may become, in part at least, included in a large umbilical hernia, or it may result in cases of separation of the recti muscles where the uterus has ascended sufficiently high to fall forwards over the brim of the pelvis. And it has been supposed to occur after the cicatrisation of a supra-pubic abscess, and as a consequence of a Qesarian section.
Of craral hernia an interesting example is given by Lallemand *, in a woman aged eighty two, whose body he examined. The hernia appeared at the age of forty, after labour. It remained as an irreducible tumour in the right groin, and was twice accompanied by symp toms of strangulation. After death, the sac of the hernia was found to contain the uterus, ovaries, Fallopian tubes, and upper part of the vagina, together with two folds of omen tutn.
Inguinal hernia. — Chopart relates a case of hernia in which the uterus with the Fallo pian tube and left ovarium occupied a sac be yond the inguinal ring. The uterus was small, flabby, and elongated. Lallemand t gives a ,corresponding case where the uterus and right tube and ovary were found in a hernial sac on the right side in a woman who lived to the age of seventy-one.
The most remarkable examples are those in which the uterus either became pregnant while so situated, or was protruded during pregnancy.
In two examples of this kind, related by Sennert, the precise nature and situation of the hernia is, perhaps, doubtful, but they are nevertheless very interesting.
In the first, a swelling in the left groin followed the blow of a stick. Soon the swell ing expanded, and it became in time evident that this was caused by the presence of a gravid uterus. The tumour, covered by inte gument, bung forward like an oblong gourd; by degrees movements of the fcetus were per ceived, and the woman having at length reached her term of pregnancy, the integu ment and uterus were laid open, and the child and placenta extracted.
In Sennert's second case, some injury had been received in the first confinement, but it was not until after the ninth delivery that a swelling appeared in the left groin, and gra dually increased to the size of a cow's bladder; finally it hung down to the knees. The tu
mour was opened, and a living child extracted. Both cases ended fatally to the mothers.
The best authenticated case is one which occurred at Salamanca, and is related by Pro fessor Ladesma. A wotnan, age 42, mother of seven children, and the subject of an irre ducible inguinal hernia, when 3 to 4 months pregnant experienced a sudden increase of the tumour after stooping. The swelling, now of a different consistence, could not be reduced, and after a time fcetal movements were perceptible within it. Labour ensuing in the usual way, the liq. amnii escaped per vaginam, but it was necessary to extract the child by incision into the sac. The tumour contracted ultimately to the size of an ordi nary scrotum, and formed a permanent hys terocele in the inguinal ring.* In addition to these forms of uterine hernia, a partial displacement of the organ through the obturator foramen or ischiatic notch ap pears possible. This latter is distinguished by the not very appropriate title of hernia dorsalis uteri.
Prolapsus.—Falling of the Womb.—Bearing down.—Two degrees of this displacement are recognised. In the first the uterus occupies a situation lower than usual, the cervix rest ing upon or near the floor of the pelvis, yet without any protrusion of the organ exter nally. In the second, the uterus is protruded partly or completely through the vulva. The former is distinguished as partial, and the latter as complete prolapsus or procidentia uteri.
Prolapsus in the first degree is not neces sarily accornpanied by any material change in the condition of the uterus itself. The fol lowing alterations, however, in its relations to surrounding parts usually result. The whole organ occupies a lower position than usual in the pelvis. The vagina is more or less completely filled, its upper part becoming folded upon itself like the half inverted finger of a glove.. The cervix is abnormally directed forwards. The uterine appendages become in part displaced in following the descent of the uterus, while the neck and posterior wall of the bladder, and sometimes a small portion of the rectum, are likewise drawn down on account of their attachments to the cervix uteri.