J. C. Morgan (J. C. Morgan)
There are certain obvious causes of displacement, predisposing and exciting, to which authors and practitioners have given more or less attention, and to which a passing allusion will suffice. These are: laxity of tissue, ligamentous and muscular - local, forming, or not, part of a general atony; defective perineum; superincumbent weight of clothing, etc.
Another class of causes, not wholly neglected, yet not fully regarded, is found in direct relation with lateral curvature of the spine, and thus with the above-named muscular atony.
A third class, relating to the abdominal-pelvic anatomy itself, remains at once the most essential and proximate, and the most difficult and obscure of all.
Few physicians have ever made so careful a dissection of the intra-pelvic organism as seems absolutely needful to a just estimate of these, and to a correct practice in this department. Nearly all are content with plates and other helps, of a very general character, rather than surmount the inconveniences of intra-pelvic dissection. This ought certainly to be reversed forthwith, and special dissection of this region becomes the rule in every medical school, and with every student and physician. The first point requiring notice here is the form, structure, and consequent physical influence on the contained organs, inherent in the lower abdominal and pelvic cavities, considered as one. The consentaneous action of the upper segment will thereupon easily suggest itself and errors of either or both be fairly estimated as factors of uterine (or other) displacements. In addition, I would refer to my article on "The Pathological Relations of the Deep Fascia," published in the Transactions of the Homoeopathic Medical Society of the State of N. Y., 1868, as supplementary to this paper. The lower abdomen and false pelvis constitute together the body of an in closed funnel; or rather of two funnels, right and left, separately developed, from opposite directions in the embryo, fusing in the median line, but partially separated by the tension of the recti muscles, forming thus two communicating concavities. The upper mouth of this compound funnel (nota bene) like the bony pelvis itself, which rests, not on its floor, but on its brim, looks forward to the umbilical region; it is therefore placed in a reclining, semi-horizontal (not vertical) position, such as to allow the viscera, during locomotion, an easy compound play; forward over the pelvis, obliquely and alternately from either side, thence upward, and finally backward; terminating the whole oblique, spiral impulse at the lumbar projection of the spine, when that is normal. The nozzle of the funnel does not clearly appear in the dead body. But during life the iliac and psoas muscles form its boundaries aided by the promontory of the sacrum, and the rectum and bladder in situ, centering in the vagina. The uterus, is also, as it were, the stopper of this nozzle, introduced, as it were, from above, and is subject to whatever forces may affect it, and partly upheld by its conical form. The aggregate effect of all these relations is to form the associated viscera into the funnel-shaped mass, with its greatest volume and weight forward. Muscular action is greatest below, contracting the nozzle of the funnel more than its mouth; thus aiding the aforesaid "reclining position" of the funnel, in determining the upward and forward motion, and preventing displacement downward. The muscular action, per se, may be suitably described as an "upward squeeze;" and the visceral effect as "motion en masse;" upward and forward, laterally, backward and reverse. The normal filling and emptying of the healthy organs, especially of the bladder, and of the rectum, does not disturb the upward and forward tendencies of the uterus, etc. The curvilinear movements of the fundus of the bladder, for instance, operate perpetually upon the uterus as upon a wedge, pressing constantly upon its apex, below. In this the rectum thoroughly agrees. Abnormal changes reverse this conservative mechanism, hence come displacements. Secondly - experienced internal manipulation reveals certain important, neglected facts. The force of these facts leads directly to a comparison of uterine displacement, in its several varieties, with the well-studied phenomena of a physiological displacement, viz: that of the foetus (and of the placenta also,) in the movements of parturition. This is one of the principal theses which I would here advance and defend. The obstetrician, in common with all close observers, even of the laity, has been thoroughly impressed by the fact that all the contents of the pelvic organs invariably escape with a spiral motion. Every school-boy has found out so much as to his own forces and the urine. The accoucheur builds upon it the theory of rotation of the foetal head and trunk; very few, perhaps, have cared much for it in the delivery of the placenta, and they have incurred not a few evils in consequence. The bony pelvis only, is usually thought of as determining foetal rotation; but it is unphilosophical to disregard the conformity of the soft parts thereto. Dr. Constantine Hering's mind was early awakened to the universality of the spiral type in anatomical development, viz: during his zoological researches in South America. He once personally informed me that he was led to examine this subject, by noting that the embryos of snails, in their development in the ovum, underwent a constant spiral movement. Every one can pursue the thought for himself, observing the curvatures of mollusk forms, e. g., the shell of the oyster, better still, that of the snail itself, the spirals of plant-budding, the intestines and umbilical cord of mammals up to man; the bilateral muscularity of the abdomen, already mentioned; all illustrate the universal type. Even the lobulation of the lungs, the normal curvature of bones, in the total length of any given member, or of any trunkal group, of which the inclined planes of the pelvis, are but one expression; all the varied forms of the living body show this one common essential of organic evolution, the spiral method of construction and of physical action. To verify this it was that the young Dr. Hering (as related in the memorial paper of Dr. H. N. Guernsey, then a student) visited so persistently the dissecting-room of the old Penn. College, more than forty years ago. Thus he accounted for the curious shifting of symptoms, in drug-proving, from the upper left side to the lower right, and vice versa; and thus assured himself that in these provings Nature was a living presence, since no anatomical law was violated, but a recondite one was thereby emphasized and exposed, whilst the truth of our symptomatology was fully vindicated. (Those only who have looked less deeply have concluded otherwise.) The observations of Hegemann show that the human uterus, even at birth, retains the bi-cornuate form of the embryo; the double spiral is illustrated by the two ridges within the cervix being placed respectively to the left and front and to the right and rear, like the septa of the heart, but whether on a right or left spiral, is not stated. The spiral form and motion also, are most clearly observable in uterine displacements of all kinds, and all are but the reverse of corresponding normal kinds of spiral ascent, already indicated. I think I hazard nothing, when after more than thirty-three years of studious observation, I assert, as I here do, that no uterus ever descended in the pelvis, in toto or in part, in the simple antero-posterior curve usually but erroneously ascribed to the vagina. On the contrary, as the foetal head, in the vast majority of cases, presents (with the os uteri) at the left acetabulum, and descends upon the left anterior inclined plane of the bony pelvis, so does the whole uterus, in an equally large proportion of cases of displacement; the other positions occurring with about the same frequency as in foetal presentation, and these are owing, probably, to like individuality of form, and of personal habits, as posture, partial atony, "left-handedness," one-sided inflammation and softening, or special traumatic causation, and the like. As a matter of fact, most closely observed in the most inveterate cases, falsely attributed to "adhesions," such has been my experience with the typical displacements, one and all. In pursuance of this uterine rotation, how often do we find an interchangeable ante- and retroversion, right and left lateral version, etc. Thus, frequently, I first observe a forward and right position of the uterine fundus, corresponding with the descent of the foetal head into the superior strait of the pelvis, following, as does now the os, the left posterior inclined plane of the pelvis. This is the first degree, or stage, of uterine descent, in a slowly developing, chronic case. Sudden causes, of course, forbid so gradual a process, and traumatic action, such as a fall on one foot, may instantly bring down the os upon, for instance, the right anterior inclined plane, and, as I have seen, determine even a rupture of the right side of the hymen, alone, in a virgin. Even here, however, chronic indisposition may often account for the deviation. The very first change is sometimes seen, in a twist of the uterus itself, viz: the right cornu first rests on the right pubic bone, the os upon the left of the rectum. Pursuing the simile of foetal descent, I find a second degree, or shape, of the typical uterine descent, viz: right lateral version. Now the spiral fibers of the womb, as well as of the vagina, and the shape of the left anterior inclined plane of the pelvis, often become, now, joint intrinsic factors of error. Torsion of the (upper portion of the) cervix, and even of the womb itself, occurs, provided any inflammatory softening permit, in an obvious degree, constituting a form of flexion. The lower cervix often flexes at the very beginning, and can be reasonably explained in like manner. Of course, the same inflammatory softening may determine special flexions, which can exempt the whole womb from the typical descent, expending its influence so as to confine the typical mechanism to the fundus alone, which would be affected in but a trivial degree. Nevertheless, the cure of the inflammation, restoring the firmness of the organ, if not comletely curative, would be necessarily followed by typical malpositions; and who has not witnessed this provoking result and wondered at the "total depravity" of this "unruly member?" The third degree of typical uterine displacement, shows the fundus slipping down at the right sacro-iliac symphysis, upon the right posterior inclined plane of the pelvis, as does the right temple of the foetus in typical labor - and the os uteri presenting at the left acetabulum - the so-called "right lateral retroversion." At this stage, another and collateral force may detain it, and will be presently discussed. In labor, this agrees with the rotatory effect of the left anterior inclined plane of the pelvis upon the left side of the vertex of the child. Fourth degree or stage. Just as labor often ceases at this stage, and demands our interference, so the uterine displacement often becomes inveterate and stationary (without adhesions) at the same point. Or, it may, like labor, proceed another step, first, viz: further rotation may occur; the fundus falls, like the face of the child, into the hollow of the sacrum, and complete (and supposed simple) retroversion is the result. Both parturition and uterine descent may end at any stage, so far as nature controls it, and so, again, at this. In every stage, be it remembered, the vagina is displaced too, and descends proportionately with the womb itself, impairing both its form and its tension. Fifth degree, or stage. Expulsion of the whole uterus - procidentia - now becomes the final counterpart of childs birth, in the evolution of uterine displacement. Or, as a still further completion of the parallel, we may include as a mere variation from typical procidentia, those cases of utter relaxation and downcome of all the soft parts, except, perhaps the sphincter vaginae and perineum; these may inhibit the complete expulsion of the head in labor, and in non-parturient cases may likewise determine simple prolapsus, so-called; both conditions being often seen in muscular working women. The vagina, altogether ceasing to be a flattened spiral tube, becomes now merely a misshapen cavity. Conical Os. - In typical displacements, as we have seen, the vagina accompanies the uterus downward, becoming a "misshapen cavity." But sometimes this descent is limited to the womb itself, at least in the beginning. The result of this is a sort of protrusion of the cervix into the vagina, accompanied by an upward stripping of its vaginal covering, with a possible contraction of the superior sphincter; * constituting a sort of paraphymosis of the cervix. This I believe to be the meaning of the so-called "conical os" of virgins, often coëxisting with dysmenorrhoea. Influence of the Rectum. - It has been remarked, that in displacement of the third degree, there exists a special cause of continued and of recurrent displacement. It is potent in other forms as well. This is the rectum, in its peculiar position, structure, and action, or inaction, and in its diseases also. Dr. H. R. Storer of Boston, and others have hinted at this fact, but I have failed to find anything definite and satisfactory in their treatment of this topic, so far as concerns displacements of the womb; and have been forced to learn for myself what its deleterious influences may be, not only in the third, but also in other stages. In the first place, the normal rectum passes above, behind, then under the vagina and os uteri, at and to the left of the median line. Even when empty, much more when full, it may constitute a secondary cause of several malpositions of the os, and hence of the corpus uteri. In the first degree of uterine displacement above described, it greatly aggravates the right-sided tilting of the fundus, in many cases the os slipping completely over the gut, into the left side of the pelvis.
Secondly. - If the womb stand in its normal position upon a full rectum, this often directly flexes it, aided or not by the softening of the menstrual, nisus, and thus becomes a serious promoter of obstructive dysmenorrhoea in girls; which, again, favors congestive softening, increased flexion, and the whole "vicious circle" of uterine pathology. Anteversion, with cystocle, may also occur, particularly after childbearing. Cure of the constipation is the sine qua non in all such cases, as also in the next series.
Thirdly. - When retroversion obtains, a loaded rectum is one of the commonest sources of aggravation, and of recurrence, even to inveteracy, after replacement; the feces piling upon the fundus like an incubus; surely tilting, and, often with great tenesmus, forcing it downward.
Fourthly. - Besides this, the gut is often excessively atonic, loose and flabby, descending, along with the vagina; or separately, as a rectocele; and actually dragging the fundus down by its posterior attachment.
Fifthly. - The shape of the rectum may be faulty, owing to causes operating both before and after puberty, heavy clothing being foremost. Let it be recollected here, that the rectum is also formed, notwithstanding its name - "the straight gut" - on the spiral * type, but opposite in curvatures to that of the vagina, † but is alterable, like the vagina itself, and that all its atony (lodged as it is in the loose connective tissue forming the ischio-rectal fossae), or, its deformity or displacement, or what not, is directly productive of vaginal and uterine deviation, and aggravation and complication. The mucous membrane reveals the spiral form, when its "longitudinal" and "semilunar" folds are carefully studied. Digital exploration is proportionately complex. Of these facts, no experienced physician can be wholly unaware, and no cure can be effected without giving them due attention.
Sixthly. - Flattening downwards is a very common defect, similar to that of the vagina. The silicea type of constipation is the observed result. Thus the loose, shapeless, capacious lower rectum often entangles the retroverted or retroflexed fundus in a maze of unmanageable tissue, directly opposing and even preventing its liberation. Aggravating this, the lower half of the gut lacks the support of a peritoneal covering, and is obliged to endure the weight of the small intestines, and, in part, of the uterus itself. Such cases may be wrongly attributed, along with other bad forms, to peritoneal adhesion, which diagnosis I deny, invariably, and in toto, save when there is a distinct history of pelvic cellulitis, or peritonitis. The same erroneous diagnosis is to be particularly guarded against in the next class of cases, which is, if possible, still more inveterate.
Seventhly. - Here, another special anatomical thesis requires to be established - but previously hinted at in a footnote. In somewhat recent issues of our journals, repeated mention has been made particularly by Drs. Comstock and Helmuth, of the "sphincter tertius" - the third and upper-most sphincter or constrictor muscle of the rectum - described by Hyrtl, and situated about four inches from the verge of the anus. Apropos of the sphincter tertius, Dr. J. Marion Sims, in his "Uterine Surgery," dwells, without allusion to this, on the importance of a corresponding band of vaginal fibers * encircling the os, and called by him the "superior sphincter of the vagina." Now, both of these are developed in different degrees in different individuals, hence they can not always be easily clearly demonstrated in the living; yet they may be observed at times, in normal, tonic individuals. Now, the union of adjoining sphincters in figure-of-eight form, is the rule in anatomy; and out of this fact grows my second anatomical thesis, viz: that the superior sphincters of the vagina and rectum constitute together a figure-of-eight shaped muscular band, acting on the uterine cervix from the meso-rectum, as a fixed point; creating and maintaining a special malposition of the cervix and os uteri, to wit: in contact with the left iliac vessels, and consequently a somewhat transverse attitude, of the whole womb, with elevated os, and fundus at the coccyx; agreeing best, but indifferently, with the third and fourth positions of uterine displacement above described, and constituting a principal cause of the inveteracy of a few, at least, of those important but usually unsatisfactory patients, whose bed-ridden helplessness excites so much comment, in our days. Extensive throbbings, coccyodynia, are sometime symptomatic. Such is my experience - and the care of such cases is often the despair of physicians. Such was the nature of a celebrated case of sixteen years' standing, a lady from Ohio, who was under my care in the Hospital a few years ago. Such, too, were two other inveterate cases, of many years' duration, or, as I suspect, of gradual development in both instances, from childhood, formerly also under my treatment. In not a few other cases I have believed that the malady began in childhood, as the salient symptoms did so. In one, the worst I ever knew, the characteristic symptom was "bursting pain in the left groin, as if a wedge were pushed outwards, butt-end foremost." (Cannabis.) Reduction effected only by the sound, relieving this sensation, but it always soon recurred, with renewed displacement. The cervix was drawn upward, and to the left, lying along the vaginal wall; the fundus low at the right sacro-iliac symphysis. When reduced, this sensation gave place to a "pulling pain, along the left ilium." (Cocculus?) During manipulation, a strong band was felt, (just as in the first-named case), extending from the cervix to the upper and left posterior aspect of the pelvis, i.e. , towards the rectum and meso-rectum. It was always necessary to over-stretch this, to effect complete reduction. It appeared to be about three-fourths of an inch in extreme length from the cervix, and about one-fourth of an inch thick, apparently imbedded in and identified with the posterior part of the left lateral ligament of the uterus. This band was very tense, so that stretching was difficult, even with considerable upward pressure by the finger - and it firmly held the womb. I once considered the propriety of its submucous division. Smith's modification of the Hodge lever-pessary, and every other, as usual in such cases, failed to retain it in position. Within twenty-four hours the os would invariably be found slipped over the left limb of the pessary, standing upon it if the womb were rigid enough; or pinched between it and the upper left wall of the vagina; in either case, the pain speedily became exquisite, inflammatory symptoms were awakened, and the pessary would have to be removed after a few days at furthest - the uterus immediately relapsing, and the bursting pain augmented in its turn. The case was complicated with anal fissure (with hypogastric "constriction"), with other rectal troubles, yet to be mentioned, adding no little to the sufferings of the patient. The sometimes recurrent fissure always yielded to cocculus, high. There was also an obstinate acne rosacea faciei, which aurum met. 1600, improved; likewise spasm of the recti muscles, clonic, and very distressing, yielding to china 200; spasms of the anterior vaginal wall; a variety of nervous symptoms, of course, being super-added, particularly a horrid uneasiness and numbness of the left upper and lower limbs. Eighthly. - Pseudo-membranous inflammation of the rectum, with or without rectal ulcer, is another concomitant of this and other cases of displacement, and of some cases of chronic metritis also. Constipation prevailing, enemata would bring away not only faeces, but as well a variable quantity of false membrane, which, under the microscope, showed a fibrinous, fibrillated structure, with the usual lymphoid and epithelial cellular forms. When fresh, it appeared to the naked eye as a coarse reticulum, or shreddy mass. Aurum * and silicea cured this. The pains were better or worse, a good deal in coincidence with rectal amelioration or aggravation. The liver and spleen suffered occasional attacks of soreness and swelling, in the case referred. Lycopodium 200 and silicea 64 did the most good. In another case, ranunculus bulbosus, high, did good service; indicated by stitching pains from the left abdomen to the chest.
Ninthly. - Again, the bladder, with a spiral structure, resembling the rectum, both affects the position of the womb, and is itself affected by it. The latter fact has great influence in producing that very troublesome affection, cystocele.
Tenthly. - In addition to the foregoing agencies of displacements I am satisfied that the shape and structure of the vagina itself is an important factor at times. The former may be in part due to rectal or vesical or spinal fault, or to the weight of clothing, etc., but nearly always, in displacement, this part fails, per se, to realize its supposed character of a muscular, tonic, and antero-posteriorly "curved and flattened tube," altogether. It is commonly, as previously intimated, a somewhat globular lax cavity, sometimes indeed, saucer-shaped, offering no support of tubular muscularity to the cervix, nor to the body of the womb above. On the other hand, I have known it to be affected by spasms of a severe and clonic kind, especially of the anterior wall, and easily felt corrugating the mucous membrane under the finger. Tonic spasm is probably more common than has been suspected in displacements. But paresis is most frequent. Now, this inverted, pear-shaped organ, in the normal tubular tonicity of the vagina, the superior sphincter included, is necessarily clasped somewhat as with the hand - being thus compelled to rise in the pelvic curves, high up into the superior strait. Thus, too the muscularity of the vagina, if increased by medicinal and hygienic measures, must become of vast importance in effecting a cure.
Eleventhly. - Again, the shape and consentaneous mass-motion of the intestines and uterus, in the normal state, suffers disintegration from all these causes; hence in motion (walking) the womb is deprived of the upward (peritoneal) "suction" or traction exerted by the normal mass upon each of its parts. A few words must be added concerning the mechanical causes which may excite a predisposition of the pelvic anatomy into actual uterine displacement. The pelvic and sub-pelvic appear to me of far less importance than the supra-pelvic in the great majority of cases. Among the latter, I will specify: 1. Errors of the abdominal parieties; 2. Errors of the abdominal contents. 1. Parietal errors include first, changes in the normal curves of the spinal column, viz: the lumbar anterior, and the dorsal posterior curves (with the cervical anterior). Dr. E. P. Banning has well illustrated the effect of meerly straightening out these normal curves, as modern habits surely do. The purpose of his "brace" is, primarily, its correction. The direct consequences are, loss of the forward, semi-vertical pelvic position; loss of purchase by the straight and oblique muscles of the abdominal walls, by approximation of their origins and insertions; consequent flaccidity, and loss of the upward squeeze of all the viscera; loss of the anterior inclined planes of the hypogastrium, along with the aforesaid nearly vertical position of the pelvic brim, whose combined normal effect in walking is to propel the uterus toward and beyond the umbilicus at every step, alternately right and left; substituting a horizontal position of the pelvic brim, flaccid vertical and lateral muscles, and a downward motion of the uterus in stepping. 2. Besides these effects, the suspensory ligaments of the viscera in general approximate toward the pelvic cavity, and the organs themselves, deprived also of their rest on the anterior lumbar curve, likewise seek the pelvis, and rest upon its contents, depressing and tilting the womb. The leading causes of this state of things are bad habits of attitude, in sitting, standing, and even lying, whereby the normal vertebral curves are annulled; and these bad habits, if one-sided, add the disadvantages of lateral curvation of the spine ("scoliosis"), the sure sign of which is round shoulders, or shoulders or hips of unequal height, and I may add, a flattened bust. But the most active of all causes, relating to the supra-pelvic conditions, especially in virgins, who furnish, as they should not, the largest number of troublesome displacements, and one of the potent promoters of scoliosis, as well, is artificial long-waistedness. Young ladies who would be shocked at the idea of wearing the masculine attire, insist on moulding their chests and upper abdominal regions to the typical masculine form. Ashamed of the naturally prominent stomach, and its regular slope, curving, in a semi-ellipse; from the sternum to the navel, thence backward and downward to the pubis, they suppress this essentially short-waisted, semi-elliptical line of feminine beauty, by the cruelty called a corset, and by all other means, even to the habit of perpetually stroking downward the gastric segment of a curve, with sacrilegious hands, trying to appear long-waisted. What results? The semi-ellipse being flattened and incurved above, its contained viscera flee to find accommodation below; the lower abdomen doubly projecting in an unsightly globular bulge above the pubis - after child-bearing, sure to be "pendulous abdomen." This is what is known as a "stylish and elegant form;" - Heaven save the mark! (In intense contrast to this, let one study carefully that charming artistic gem, the second prize holiday card of Prang and Co., recently so popular.) Now are fulfilled all the conditions of the coming collapse; a little extra dissipation, or exposure, may - nay, must - determine the result for which the infatuated advocate of false versus true art, and hence versus nature, has so carefully planned; unless, indeed, by the inheritance of an iron constitution, nature should, after all, get the best of it.
Inferences and Suggestions as to Treatment. -
First, reverse all known causes. The dress should conform, so far as may be, to the principles of the "Boston Reform Suit." Local and general functions must be made normal.
Secondly. - Of specific curative influence, do all things which can promote muscularity, such as the use of the health-lift, and the india-rubber pocket gymnastics, carefully and systematically directed, and regulated. Give special care to the development of the abdominal and intra-pelvic muscles, the psoas and iliac.
Thirdly. - In inveterate cases (of retroversion), do not attempt replacement by direct elevation of the fundus; rather, move it, in the reverse spiral order, laterally, in the direction of least resistance; then upward. Cases previously irreducible often are thus quickly reduced.
Fourthly. - For mechanical support, as a rule, use only external means, with this exception, viz: that internally, temporary help may be given, often with the greatest comfort to both patient and physician, by means of the plain cotton dumb-bell pessary. This is made of choice jewelers' cotton, a piece nearly as large as the hand, being simply rolled up, and its middle third sewed with darning-cotton, the ends remaining to facilitate its removal after about two days, when another is to be introduced. This introduction is best effected with the speculum, but may be done without, by resorting to the knee-elbow position, and permitting, first, the ingress of air to the vagina - which also aids in reposting the womb - then, retracting the perineum by the fingers, and inserting the cotton. The dumb-bell cotton pessary is applicable to every sort of displacement, provided a little ingenuity be adopted, viz: after introduction, the patient lying upon her back, or otherwise, must be so manipulated, by operating upon its outer end first, and then upon the inner, so that the descending part of the womb may obtain the needful support.
Last, but not least, what can medicine do? I answer, every thing, after taking the above precautions; allowing, of course, for anomalous cases, which may call for special means. The old drugs, as indicated by Guernsey - the new remedies, as advised by Hale and others - and a careful regard to the teachings of our pioneers, will enable us to accomplish the desired result. But time and space forbid me to give the details. I attribute to pulsatilla a specific influence, however, on the spiral muscular fibers of the uterus, etc., and incidentally thus explain and justify the too much ridiculed use of it in malpositions of the foetus in utero.
Prolapse of the Funis in Labor. - I can not omit here to say, that there are several other important applications of the foregoing principles to displacements, other than the uterine proper. Thus, my method, which has proved successful, with prolapsed umbilical cord, in labor, consists in continuous rotation of the index finger jointly upon it and upon the inner surface of the os, in the direction opposite to the spinal rotation and descent of the foetal head - until fairly lodged above the presenting part.
Replacement of Protruding Haemorrhoids, and Prolapsus Ani. - This is rendered easy, by simple observance of the following rule: after thorough oiling, grasp the protruding mass with the right hand in supination. Then, rotate to pronation, pressing upward; thus reversing the spinal rotation of descent. Digital and instrumental explorations should be guided in like manner.