684 



UTERUS AND ITS APPENDAGES. 



taneous reposition cannot be effected, are 

 usually premature expulsion of the ovum or 

 sloughing of the uterine parietes and slow 

 discharge of the contents by fistulous open- 

 ings into the vagina, rectum, or other parts. 



b. Hernia of the uterus. Hysterocele, Me- 

 trocele. This displacement is rare. The 

 uterus may escape from the pelvis by some 

 of the natural openings which ordinarily ad- 

 mit of hernia, or by an aperture artificially 

 formed, as, for example, between the muscular 

 fibres of the abdominal walls. In uterine 

 hernia, the displaced organ is often accom- 

 panied by other parts, almost always by its 

 own appendages, and commonly by a portion 

 of intestine, or omentum. Uterine hernia may 

 be congenital or acquired. It may occur to 

 the unimpregnated or the gravid organ, and 

 in the latter case the development of the foetus 

 may proceed to the full extent while the organ 

 occupies this unusual situation. 



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 fail 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 Caesarian 

 section. 



Of crural 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- 

 turn. 



Inguinal hernia. Chopart f 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 J 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 



* Bulletin de la Fac. de Med. torn. i. 1816. 

 t Boyer, Traits' des Mai. Chir. t. viii. p. 381. 

 j Mem. Soc. Med. d'Emulation, 3 me Ann. p. 323. 



that this was caused by the presence of a 

 gravid uterus. The tumour, covered by inte- 

 gument, hung forward like an oblong gourd ; 

 by degrees movements of the fetus 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 woman, 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 foetal 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. Searing 

 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 accompanied 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. 



In extreme prolapsus or procidentia, the 



* Edinb. Month. Journ. Pt. vii. 1841. 



