terior fornix is depressed by an elastic tumour which fills the pelvis, and is found on combined recto-abdominal examination to be the retroflexed uterus. The bladder is lifted upwards into the abdomen (v. Vol. I., p. 34). Reposition may occur spontaneously after the urine has been drawn off and the bowels have been thoroughly emptied by a purge and enema; the patient is instructed to pass water every hour. After a day or two if reposition has not occurred, or at once if the uterus is found to be firmly wedged and the symptoms are distressing, we replace it in the following way. The patient is placed in the genupectoral posture, and steady pressure is made on the bulging tumour in the posterior fornix by two fingers

Retroflexion of the Gravid Uterus producing, through compression of the urethra, distention of the bladder; it also presses on the rectum (Schroeder).

per rectum; the cervix is at the same time drawn downwards with the volsella (v. Fig. 212).

An interesting process of gradual spontaneous reposition occurred in one of the four cases referred to. The portion of the uterus above the brim, as it increased in size, drew the portion wedged in the pelvis upwards into the abdomen.

Sometimes the pregnant uterus expands into the abdomen while a portion remains wedged below the promontory. Such a condition seriously complicates the labour, as in the case reported by W. L. Reid.'

On a Labour Obstructed from an Unusual Cause: Trans. Edin. Obst. Soc., Vol. V., Part III., p. 36. This condition is also referred to by Pallen: A Case of Abdominal Pregnancy Treated by Laparotomy: Amer. Journ. of Obst., July, 1880.

CHAPTER L.

EXTRA-UTERINE GESTATION.

LITERATURE.

Bandl-Die Krankheiten der Tuben, etc. Stuttgart, 1879, S. 41. Barnes-Op. cit., p. 339; and Lond. Obst. Trans., XIV., p. 325. Hecker-Beitr. zur Lehre von der Schwangerschaft ausserhalb der Gebärmutterhöle: Monats. f. Geburtskunde, Berlin, 1859, Bd. XIII. Hennig-Die Krankheiten der Eileiter u. die Tubenschwangerschaft: Stuttgart, 1876. Parry-Extra-uterine Pregnancy: Lewis, London, 1876. Reeve-A Case of Extra-uterine Pregnancy, with Successful Application of Electricity: Amer. Gyn. Trans., 1879, p. 313. See discussion on this paper. Schroeder-Lehrbuch der Geburtshülfe: Bonn, 1880, S. 401. Spiegelberg -Lehrbuch der Geburtshülfe: Lahr., 1878, S. 308. Thomas-Op. cit., p. 765. The student will find the pathology most fully in Bandl, the diagnosis and statistics of the various modes of treatment in Parry.

THIS Comparatively rare condition concerns the gynecologist as much as the obstetrician; the cases come under notice at an early period of pregnancy and, in symptoms and diagnosis, have much in common with purely gynecological cases; the treatment belongs more to operative gynecology than to obstetrics.

PATHOLOGY.

The following is the course of the fertilized ovum in its passage to the uterus: Graafian follicle, fimbriated end of Fallopian tube, canal of Fallopian tube, interstitial (within uterine wall) portion of Fallopian tube, horn of uterus. It may be arrested at any point in this course and, becoming attached, pass through the stages of fœtal development just as it does in the uterine cavity.

Of extra-uterine gestation, there are therefore the following varieties: ovarian and abdominal, tubo-ovarian, tubal, interstitial, and that which occurs in an isolated horn.

As to the frequency of extra-uterine gestation, Bandl mentions that

out of 60,000 gynecological and obstetrical cases (received during seven years at the cliniques of Carl Braun and Späth in Vienna) there were only 5 cases.

As to the relative frequency of the various forms, tubal gestation is the most common-about two-thirds of all the recorded cases.

Whether there is an ovarian gestation, by which we understand that the ovum is fertilised in the Graafian follicle and continues to grow there, is a disputed point; Schroeder holds that many cases described as ab

Gestation in the detached left horn. a, right horn of uterus; b, neck; c, vagina; d, point of right horn; e, right Fallopian tube; f, right ovary; g, right round ligament; h, detached left horn; i, its connection with uterus; k, left round ligament; 7, muscular fibre springing from the left round ligament and passing to the right horn; m, margin of peritoneum dissected off; n, left Fallopian tube; o, left ovary with corpus luteum; p, seat of rupture with everted margins; 4, placenta; r, membranes; s, cord; t, foetus (Kussmaul, reported by Heyfelder).

dominal were really ovarian, that is that the ovum was fertilised while in the ruptured Graafian follicle and developed within it.

After the gestation has gone on for some months, the structures in the broad ligament become displaced by the tumour and obscured by adhesions, so that it is impossible to say where the ovum began to grow. Cases of abdominal gestation probably begin as tubal or tubo-ovarian.

Gestation in the isolated horn of a uterus bicornis has been already re

ferred to (v. Vol. I., p. 248) and a case of it has been described (v. Fig. 145, Vol. I.); Fig. 344, taken from Kussmaul, represents a case reported by Heyfelder.

In interstitial gestation, the fertilised ovum has been arrested in the tube at its uterine end where it passes through the substance of the wall of the uterus; in these cases it was supposed that the ovum was growing interstitially, in the substance of the wall. This form of gestation is seen at Fig. 345.

Interstitial gestation. a, body of uterus; b, cavity laid open from the front; c, embryo sac in wall of uterus; d, ovum with branching villi; e, place where the placenta is forming and is still adherent to the wall of the uterus; f, Fallopian tubes; g, ovaries; h, broad ligaments; i, cervix; k, vagina.

The two structures which call for special notice are (1) the wall of the gestation sac and (2) the placenta.

The wall of the sac consists, in a tubal gestation, of the dilated Fallopian tube; this does not develop with the developing foetus (as the uterine wall does) and hence, when the latter has grown till about the 2d or 3d month, it ruptures from the strain. When the ovum is growing at the fimbriated end or in the abdominal cavity, the wall is formed by adhesions; these yield, and when they rupture new adhesions form outside;

hence the sac is capable of increasing in size. Tubo-ovarian and abdominal pregnancies go on for a longer period than tubal-even to full time.

The Placenta. The mucous membrane of the tube hypertrophies and forms a highly vascular areolar tissue; a structure analogous to the decidua serotina is thus formed, in which the chorionic villi are embedded (Rokitansky).

The uterus itself undergoes the changes of pregnancy. It becomes softer and larger, a decidua forms in its cavity (Fig. 346); these changes are most marked in interstitial, less constant in tubal, and still less so in

Fallopian-tube gestation which has burst. 4, uterus with decidua; B, bladder; C, vagina; D, gestation sac which has ruptured at F; E, posterior layer of broad ligament turned up so as to show ovary with corpora lutea; G, foetus (W. Wilson).

tubo-ovarian. Fig. 347 shows the size of the uterus in a case of tuboabdominal gestation of seven months' duration, described by Bandl. The vagina, cervix and mammæ undergo the changes of pregnancy and thus aid in the recognition of the condition.

ETIOLOGY.

The cause must evidently be some mechanical obstruction to the paspase of the ovum through the Fallopian tube. Pelvic peritonitis, producing adhesions, will constrict the lumen of the tube (Hecker). Bandl