In some cases there exist, simultaneously, retroversion and retroflexion, and then another difficulty arises for the diagnostician, because the cervix may be displaced, and the facility with which one reaches the cervix dis arms the suspicion of a retroversion. Ordinarily it is almost inaccessible, but rectal touch allows us to examine a large part of the uterine tumor and to appreciate the characters of this tumor. What is most striking, at first. is the slight depth at which we encounter this tumor, and, in exam ining with care, we see that it is not continuous with the uterus, which is only displaced and flattened by it. Besides, in combining vaginal and rectal palpation, we feel that the finger in the rectum is only separated from that in the vagina by the thickness of the folded and swollen vaginal wall. It is only in exceptional cases that the finger can reach beyond the end of the tumor.
In view of the existing stage of pregnancy, auscultation gives no in formation, but we generally discover the uterine souffle. In exceptional eases, on separating the labia, we have been able to perceive the tumor, but, in general, that which is striking in these cases is, often, the swelling of the labia majors, and minora and the presence of a vaginal prominence large enough to pass for a prolapse of the vagina.
When the affection has reached its acme, and inc,arceration has taken place, all the above symptoms are aggravated. The pain becomes intoler able, the fever is more and more intense, and to retention of the urine and of the faeces are joined emesis, singultus, delirium, irregularity of the pulse and a state of prostration and adynamia, more or less pronounced, with emaciation and exhaustion of the patient. If abortion does not set a limit to these accidents, gangrene of the bladder and rupture of the uterus aggravate the situation, or even result in death.
Diagnosis.—This embraces, according to Salmon, five problems.
First. —The diagnosis between retroversion of the gravid uterus and intra-uterine fibrous tumors, in a healthy or in a retrovertcd uterus. Fibroids are distinguished by the hemorrhages, the slow progress of the disease, the resistance of the cervix compared to the softness of preg nancy, and the statements of the patients relative to the existence of an old tumor.
Second.—The differential diagnosis between retroversion of the preg -nant uterus and tumors of the pelvis or of the abdominal cavity. This is, sometimes, very difficult, as the diagnostic errors, reported by various authors, demonstrate. The characteristic which deserves particular at tention is the retention of the urine and the possibility of generally pass ing the finger behind the pubes. The concomitant symptoms of preg
nancy, but especially the character of the cervix, will often make the diagnosis. Retroversion has also been confounded with extra-uterine pregnancy, ovarian tumors and retro-uterine hematocele.
Third.—The differential diagnosis between simple pregnancy, with retention of urine, and pregnancy with retroversion.
.Fourth.—The diagnosis between retroversion during normal pregnancy and retroversion in cases of hydatidiform moles. In Salmon's case there was no retention.
Fifth.—Finally, the diagnosis between retroversion of the gravid uterus and retroversion of the unimpregnated uterus.
The differential diagnosis of extra-uterine pregnancy really presents the greatest difficulty, and we shall return to the subject under that heading.
is always very grave, but is more so in proportion as pregnancy is far advanced, for the complications are then more grave and develop more rapidly, and the treatment is more difficult of application. Although the affection often ends in recovery, it may also end in abor tion and in death from peritonitis, from gangrene of the bladder, from rupture of the uterus and from partial gangrene of that organ. In some cases, the fundus uteri has contracted adhesions to the rectum, a com munication has formed between these two organs, and the disintegrated fcetus has been expelled piece-meal through the bowel. In a very inter esting case, which we saw at the Clinique, the diagnosis was doubtful, and, in spite of two examinations, Depaul hesitated. An examination to de cide regarding intervention was appointed for the following day, when, during the night, the woman fell outoof bed. The disturbances ceased as if by magic, but the patient was confined in the forenoon. This was, probably, a case of spontaneously reduced retroversion.
Treatment. —There are, according to Depaul, three methods.
First : leaving the uterus in its acquired position, treating complications, destroying probable causes of retroversion, or, at least, removing obstacles opposed to reduction. Thus: 1st, catheterism, which is not always easy and sometimes demands the use of the fine elas tic sound in place of the ordinary catheter, and is to be repeated three or four times in the twenty-four hours. 2d, combatting constipation, by enemata given through a long canula, but particularly by laxatives, especially castor oil. Depaul does not believe that the position of the woman. has any influence, at least in severe cases. If complications occur, resort to the second method.