RETRO VERSION AND IMPACTION 
OK THE 
GRAVID UTERUS, 
COMPLICATED WITH CANCER 
THE PREGNANCY CONTINUING TO TERM. 
BY 
GEO. B. FUNDENBERG, M.D., 
Cumberland, Md. 
Reprinted from the American Journal of Obstetrics and Diseases of 
Women and Children, Vol. X, No. III., July, 1877. 
NEW YORK: 
WILLIAM WOOD & CO., 27 GREAT JONES STREET. 
1877. RETRO VERSION AND IMPACTION 
OF THE 
GRAVID UTERUS, 
COMPLICATED WITH CANCER 
THE PREGNANCY CONTINUING TO TERM. 
BY 
GEO. B. FUNDENBERG, M.D., 
Cumberland, Md. 
Reprinted from The American Journal of Obstetrics and Diseases of 
Women and Children, Vol. X., No. III., July, 1877. 
NEW YORK: 
WILLIAM WOOD & CO., 27 GREAT JONES STREET. 
1877. RETROVERSION AND IMPACTION OF THE GR.YVID UTERUS, 
COMPLICATED WITH CANCER, THE PREGNANCY 
CONTINUING TO TERM. 
BY 
GEO. B. FUNDENBERG, M.D., 
Cumberland. Md. 
I wish to premise the report of this case with the remark 
that, if I regarded my own reputation more than the interests 
of medicine, I would be quite willing to let it sink into obli- 
vion. But as I believe it to be a case nearly unique in the 
annals of gynaecology, and one which recorded may prevent 
others as unskilful as myself from committing a similar mistake 
in diagnosis, I feel compelled to place it on record. 
On the 20th of January, 1876, I was called to see Mrs. , 
a widow, aged 35, the mother of three children, the young- 
est three years old. She has had no abortions, and has enjoyed 
good health until after the birth of her last child, from which 
event she dates the beginning of her ill health. She has felt 
ever since a weight and bearing-down in the pelvis. On the first 
day of August, 1875, her menses, regular and normal before, 
ceased, and on the 15th October she was compelled to quit her 
employment as chambermaid in a hotel, on account of severe 
bearing-down pains, accompanied with discharges of blood per 
vaginam. These symptoms increased until January 1, 1876, 
when she took to her bed. A physician was called at this time, 
but made only a cursory external examination. I saw her first, 
as above stated, on January 20th. She was then confined to bed, 
was quite anaemic and much emaciated, and was suffering with 
severe and continued sacro-lumbar pains, with dysuria.and con- 
stipation. She stated that in November she had a copious 
vaginal hemorrhage, and a second one in December, both 
accompanied with severe bearing-down pains. A digital ex- 4 
Fundenberg: Retroversion and 
amination revealed a hard, nodulated, not very sensitive, and 
irregular tumor, about two and a half inches in diameter, very 
low down in the vagina, the os uteri with indurated hypertro- 
phic lips being jammed tightly against the pubis, the anterior 
lip above the bone and beyond the reach of the finger. The 
posterior wall of the vagina was infiltrated and nodular, the 
tumor occupying the vagina quite immovable. The uterus 
was evidently retroverted. The abdominal examination 
afforded only negative results. There was no tumor above the 
pubis, no distention of the abdomen, its walls being soft and 
flaccid. The diagnosis was scirrhous cancer of the uterus, 
with retroversion and impaction, and with implication of the 
vaginal walls in the cancerous infiltration, of which character, 
I had no doubt, were the vaginal tumor and nodules. 
I saw her several times during the ensuing eight weeks, in 
which time she had several hemorrhages, with great increase of 
suffering, rendering it necessary to give relief by opiates. 
On the 6th of April a careful vaginal and rectal examina- 
tion showed that the tumor in the vagina had increased in size 
very rapidly, measuring now at least three and a half by four 
inches in diameter, the cavity of the vagina being almost 
obliterated by its downward extension. A separate tumor as 
large as a walnut had now also developed in the recto-vaginal 
septum, close to the sphincter ani. The anterior vaginal wall 
showed several nodular projections, and numerous ridges and 
irregularities had developed over the surface of the main tumor. 
The abdomen now began to exhibit some hardening above the 
pubis, which subsequently extended half way to the umbilicus, 
but never any higher. This induration in the hypogastric and 
iliac regions we attributed to the upward extension of the can- 
cerous infiltration. The abdomen above the boundary of the 
hypogastric tumor presented no signs of hardness, but was soft 
and flaccid. The patient was now very much emaciated, and 
the pains were so severe that large doses of opiates were un 
avoidable. She had considerable vaginal discharge, without 
odor, and presented no signs of cancerous blood contamination 
Constipation was excessive, the tumor quite occluding the rec 
turn, and she urinated with increasing difficulty. The patien 
was seen at this stage by three other physicians, who, after care Impaction of the Gravid Uterus. 
5 
ful explorations of the abdomen, vagina, and rectum, concurred 
in the diagnosis. 
On the 20th of May, not having seen the patient for a week. 
I was called to see her, when her mother invited me into an 
adjoining room, and exhibited a full-grown still-born child, to 
which the patient had given birth during the night! It was 
neither putrid nor macerated, was of average size and weight, 
with a well-developed and properly shaped head. I found the 
placenta protruding from the vulva and removed it with con- 
siderable difficulty. It was solid, thick, and rolled together 
like a sheet of paper, a shape which it retained after its 
removal. It presented the appearance of having been sub- 
jected to continuous pressure during its growth, giving it a 
character and density totally different from the normal succu- 
lent placenta. The patient stated that she had felt the mass 
protruding for six or eight hours after the birth of the child. 
On the day after this, the patient, although relieved of pain, 
had considerable fever. I removed by the catheter three pints 
of turbid, fetid urine. The vagina and urethra were exqui- 
sitely sensitive. During the following eight days I was com- 
pelled to use the catheter, the urine being mnco-purulent and 
fetid ; washed out the bladder daily with a solution of car- 
bolic acid. In ten days after the birth of the child the patient 
began to improve. The febrile irritation subsided and her 
appetite improved. The supra-pubic tumor is lessening, but 
she now complains of a tumor in the rectum, giving her great 
uneasiness and a constant bearing-down'sensation. An exam- 
ination shows nodular induration, both in the recto-vaginal 
and vesico-vaginal septa. 
eJune 4th.-The patient is emaciated to an extreme degree. 
The urine has regained its normal character. The supra-pubic 
tumor has nearly disappeared. She has no control over the 
sphincter ani, but can retain her urine. 
June 28th.-Found the patient out of bed. Can walk with 
the aid of crutches. Legs and feet eedeinatous, and strength 
apparently improving. All trace of cystitis has disappeared. 
Complains of a constant pain in the left hip. Has no control of 
the bowels, but has appetite and sleeps well without opiates. 
A digital examination shows an increased size in the recto- 
vaginal and vesico-vaginal indurations, and as far as the touch 6 
Fundenberg: Retroversion and 
can reach a mass of nodular tumors are presented, which by 
their arrangement confuse all diagnosis as to the position and 
condition of the os uteri. An ocular examination without the 
speculum discloses a number of vaginal tumors transmitting a 
yellow color through a normal mucous membrane. 
July 10th.-The patient has now a very offensive watery dis- 
charge. The cancerous contamination shows itself strongly 
in the straw-colored complexion and the facies cachectica. 
She has passed a piece of sloughed tissue three inches long and 
one and a half inches broad. 
Aug. 4th.-(Edema of face and hands. Pulse and strength 
failing ; complains principally of left hip. 
Aug. 12th.-Died to-dav. Hemorrhage during the last hours 
of life. 
Post-mortem, eight hours after death.-Emaciation extreme. 
Skin bright straw-color. The body of the uterus, the ovaries, 
tubes, and broad ligaments untouched, but the cervix, the os, 
the vagina, and the recto-vaginal and vesico-vaginal septa infil- 
trated and ulcerated. The inner coat of the bladder injected, 
and at the internal orifice of the urethra granular masses were 
beginning to form. Yellow-colored nodules were projecting 
on the inner surface of the bladder, but no perforation had 
occurred. The infiltration into the vaginal walls had so elon- 
gated that canal, that the uterus could not be reached by the 
touch. The infiltration extended to the labia minora, and 
there was erosion of the labia majora. The pelvis was unfor- 
tunately not measured, but was obviously of unusual capacity. 
The pubic arch was broad and prominent, the sacrum deep 
and long, and all the diameters above the average length. 
This remarkable case affords a text for several observations. 
It is quite probable that the cancer existed before conception, 
and favored its occurrence, for it is well known that incipient 
malignant disease of the womb increases the desire for sexual 
gratification. That abortion did not occur at the third or 
fourth month, the usual periods in cases of retroversion with 
impaction, may be attributed to the cancerous infiltration of 
the os and cervix, which prevented their dilatation. Repeated 
efforts, as shown by the hemorrhage and bearing-down pains 
occurring at various stages of pregnancy, were made by the 
womb to throw off its burden, but such was the induration and Impaction of the Gravid Uterus. 
7 
inelasticity of the cervix, that it was not until the full term was 
completed and the womb distended to its final capacity that 
this became possible, and it was then probably facilitated by 
laceration of the friable tissue of the cervix. 
That the pregnancy was not discovered by myself or any of 
the three other physicians who examined the case may appear 
to those whose large opportunities afford ample material for 
the exercise of diagnostic skill, as a remarkable instance of de- 
ficiency in observation, but we console ourselves by the remem- 
brance of even grosser errors by much more distinguished ob- 
servers. The mistakes made in this department by Boivin, 
Dubois, Beclard, Doeveren, Dupuytren, Capuron, Lisfranc, 
Maygrier, and Londe, only show that no eminence or skill will 
lead to infallibility, and that even in the present advanced 
state of gynaecological knowledge the era of absolute perfection 
in diagnosis is yet far distant. 
And, as regards the case above reported, it must be remem- 
bered that it was disguised by a disease which, by its extensive 
structural changes, destroyed the normal relations of the parts 
in a remarkable manner. If no such complication had existed, 
doubtless the pregnancy would ha\e been discovered. From 
our errors we learn most of all.