The accumulation of limes in the intestine, above the iliac fosse, has been assumed as a cause. Desormeaux, Dubois and Depaul, although accepting this cause, think that it must be preceded by a certain degree of retroversion.
Other assumed causes are curvature of the sacrum, justo-major pelvis, insertion of the placenta at the fundus or on the posterior wall of the uterus, deformed pelvis, uterine prolapse, fibroid uterine tumor, ovarian tumors, abnormally wide vagina, adhesions due to old peritonitis, the multiparous state, feebleness of constitution, etc.
2. Sudden and Accidental Retroversion.— Besides the predisposing con ditions cited above, the following are given by different authors: efforts, blows, falls, pressure on the abdomen, sudden backward displacement of the cervix in prolapse, and emotions. Salmon quotes two cases of Rolland and Godefroy, in which it was due to violent and unavailing efforts to urinate.
Time of Appearance.—Retroversion is a disease of the first half of preg nancy. It occurs, generally, between the third and the fourth month (in nineteen out of Salmon's twenty-seven cases). It rarely takes place before the third month (only five cases). It may occur from the fourth to the fifth month (five cases). It may, very exceptionally, occur after the fifth month (three cases).
Signs. —The authors of to-day only admit two degrees of retroversion, although Hunter admitted three.
First Degree.—The uterus is inclined backward, so that its fundus is in contact with the upper part of the sacrum, the cervix resting behind the symphysis pubis, but being accessible to the finger.
Second Degree.—The fundus has executed an almost complete revolu tion and has descended so far into the hollow of the sacrum as to become accessible to the finger, or even, when the labia are pressed open, to be seen distending the posterior vaginal wall. The cervix is so high behind the pubes that the finger no longer reaches it. Ordinarily the second de gree succeeds the first, and this is particularly true of the chronic or slow form. But the physiological backward inclination of the uterus, during the first three months, must not be mistaken for a retroversion. After the third month, the uterus tends to quit the true pelvis, st-raightening itself, and approaching more nearly to the axis of the superior strait. But, if it encounters an obstacle, whether this be a too prominent sacro vertebral angle or a sigmoid flexure filled with fwces, the fundus is pushed backward while the cervix tends to approach the symphysis. Intestinal
and vesical disturbances now appear, (Fig. 17) accompanied by feelings of weight, of traction and of pains in the loins, while examination enables one to discover uterine displacement. Women walk and. stand with diffi culty, and these symptoms becoming aggravated and retention of urine becoming complete, the disease passes into the second degree.
Salmon thinks that an effort or some injury is necessary, in this case, on which point Depaul does not agree with him. When, however, retro version is suddenly produced, observation shows it to be always due to violence, to efforts, to fatipes or to traumatism. Then the acute symp toms are speedily developed, and more or less intense pain. occurs at the moment when the displacenient takes place.
'The chief symptom of retroversion is retention of urine, and it is never wanting in the second degree. The retention is generally complete, and the bladder may be much distended. Sometinies there is incontinence from overflow. The urine is red, strong-smelling, and, sometimes, colored with blood. There is usually, also, retention of fzeces, but it is less marked, and we often feel fiecal tumors through the abdominal wall. The patients complain of acute pain in the loins, the groins and the ab domen, and of weight at the perineum. Fever, anorexia, thirst, insom nia, emaciation and general debility then ensue.
Palpation shows, above the umbilicus, an elastic, fluctuating tumor be neath the abdominal wall, in which no ftetal member can be distinguished and in which ballottement is not present. If the catheter is used, which may be difficult, the tumor disappears and we reach the uterus, but it is iinpossible to bound it or to map out the fundus. On palpation, we some times feel only a single tumor, formed by the retroverted uterus pushing backward the posterior vaginal wall. More rarely, there are tWO tumors, one behind, which is the uterus, and the other in front, which is the bladder (Fig. 1S). Generally the finger does not find the cervix, and, sometimes, we only find it with great difficulty above the pubes, and then one can often only feel one of the lips of the cervix. Finally, one some times finds the fundus of the retroverted organ presenting the character istics of the pregnant uterus.