The usual complications are neuralgic or rheumatic pains in certain viscera, in the muscles or in different nerves, particularly the vesical and rectal nerves. Luroth has seen a case of rheumatic meningitis, and period of pregnancy at which it occurs. When the pelvis is too roomy, but the straits of normal size, the uterus remains in the true pelvis much longer than under other circumstances. The uterus then presses upon the rectum and the bladder, irritating them. The woman experiences a sensation of weight at the anus and of painful traction at the groins, the loins and the navel. There is a fetid discharge. The patient can neither stand up nor walk easily, and she falls, gradually, into a state of marasmus. If pregnancy has just begun and the uterus is either very large or has de scended to a greater extent, the accidents are more deplorable still. Com plete retention of urine and obstinate constipation may result. The irri tation resulting in the uterus itself may lead to abortion. These compli cations generally cease when, at the fifth month, the uterus is unable to develop farther within the pelvis and rises above the superior strait.
Hiiter who, in 1860, collected all the cases up to his time, divides them as follows: 1. The gravid uterus being prolapsed, reduces itself during the first months, and pregnancy and labor follow their usual course; 5 cases.
2. The prolapse is not spontaneously reduced. Its artificial reduction and support must be undertaken; 8 cases.
3. Reduction cannot take place on account of incarceration; 3 cases.
4. The prolapse causes labor before term; 7 cases.
5. Prolapse occurs in the second half of pregnancy, and persists up to term and during labor; 3 cases.
6. Prolapse takes place shortly before, or during .abor, at term. In this case, prolapse may not have existed before labor, or, having existed before, was spontaneously reduced during the first months of pregnancy, or the prolapse was reduced and the uterus maintained by a pessary; 16 cases.
7. Prolapse occurs during labor and delivery; 15 cases.
8. Prolapse existed before pregnancy, but only became pronounced during labor; 16 cases, making a total of 73 cases.
was impossible for Fluter to divide the cases int,o those of complete and incomplete prolapse. Among sixty-nine cases, there were ten primiparie, twenty-seven multiparte and thirty-two unknown. In thirty-five patients, seven of them being primiparte, prolapse existed before pregnancy. In thirty-four patients, three being primiparte, this was not noted.
Hiiter concludes that antecedent prolapse is the cause of prolapse dur ing pregnancy, since it exists in one half of the cases. Miter states: 1.
That in sixteen cases, the uterus prolapsed before pregnancy, remained prolapsed during this pregnancy. 2. That, in five cases, prolapse which did not exist during a certain period of pregnancy, resulted from efforts and traumatism.
Among twenty-four women in labor, eleven of them being primi pane, the prolapse which existed before pregnancy recurred with it. Among fourteen women in labor, three of whom were primiparte, the prolapse occurred for the first time during labor, owing solely to the uterine contractions; in eight cases it already existed before pregnancy. In two primiparie it was due to traction with the forceps. One had already- had a prolapse before pregnancy, the other not.
In two cases, the pelvis was extremely large, and in one case the vulva. The most active causes, however, are the efforts of labor.
To recapitulate the causes: Multiparous state, pre-existence of pro lapse, efforts, traumatism, uterine contractions, the forceps, justo-major pelvis, large vulva, efforts during labor.
Fritsch attributes a powerful influence to arrest of uterine involution, after first labors. The enlarged uterus will have a better chance to de scend if the perineum has been lacerated. Labor has a particularly pre disposing influence when the membranes are ruptured before complete dilatation of the cervix. The fcetus pushes forward therigid cervix, which may thus be protruded through the vulva, dragging the vagina after it. If uterine involution is incompletely accomplished, the uterus will remain low down, for the over-stretched peritoneal ligaments will no longer sustain this organ.
Course.—Ordinarily, pregnancy proceeds undisturbed to full t,erm. In only ten cases did premature labor occur. In two cases death resulted from 'incarceration of the uterus.
In thirty-four cases the child presented by the vertex; in nine by the pelvic extremity.
In five cases the feet were brought.down by version. (Fig. 11).
In only six cases was labor normal, and four of tl.ese labors were pre mature.
In seventeen cases the presentation was not noted.
In two cases there were twins, which presented, in one instance, by the breech.
In all the other cases, save the six referred to above, intervention was necessary either because of tedious labor, due to slow dilatation in spite of good pains, or to inefficient action of the abdominal muscles, or because of serious complications (rupture in three cases, from excessively strong contractions and gangrene of a part of the prolapsed uterus).