AN ESSAY ON THE RETROVERSION, &c.

THE diſeaſe which is the ſubject of the following ſheets, is neither generally known, nor hath it been fully treated of by any author I have read; which ſeems rather remarkable in this enlightened age, when the induſtry and abilities of many of the faculty ſhine forth ſo conſpicuouſly, eſpecially as the diſorder is dan⯑gerous, and often proves fatal. There are indeed ſome caſes in print,^* which authenticate the diſeaſe, and partially deſcribe its ſymptoms; but, in my humble opinion, no remedy hath hitherto been diſcloſed which perfectly meets the evil, or is adequate to the removal of it.

DR. HUNTER, in his remarks on the retroverted uterus, aſſerts, that the very exiſtence of ſuch a caſe has been controverted. But, having myſelf met with a conſiderable number, in the courſe of thirty years practice, I am induced to believe, that this dreadful malady occurs more frequently than the faculty in ge⯑neral ſuppoſes. Nor do I apprehend that many of our practitioners, in the remote parts of the country at leaſt, ſuſpect it to happen till it is too late to adminiſter relief; for the diſorder, if long neglected, will moſt probably terminate fatally, as too clearly appears by the ſecond caſe hereafter to be related; and the event will be the ſame if it ſhould chance to be miſtaken. Here I muſt obſerve, that when I was a ſtudent under the late cele⯑brated anatomiſt abovementined, in the year one thou⯑ſand ſeven hundred and fifty-four, a caſe of this ſort occurred to him; and the Doctor, in a lecture extra⯑ordinary, which he gave to the faculty, with the parts before him, treated it as a new caſe,^* without aſſigning any ſatisfactory cauſe, or pointing out any competent [3]remedy. The opinion he formed of it afterwards may be ſeen in his remarks;^* which, however, were un⯑known to me when I hit upon my method of cure; and I muſt add, that ſince the year 1754, I have never heard ſuch a caſe mentioned in converſation by any of the faculty, except once, by Mr. Hey of Leeds, a gentleman in extenſive practice, who is a very accurate obſerver, and an ornament to his profeſſion.

FOR my own part, I have made no ſecret of the facts I have met with; but, on proper occaſions, made known to ſome of the faculty all thoſe caſes which have fallen immediately under my own care, together with my ob⯑ſervations upon them: and as I have been the happy in⯑ſtrument, under Providence, of relieving many afflicted perſons in this complaint, I thought it a duty incumbent on me to communicate to the public that method of cure which I have found effectual; hoping that it will be of ſervice to young practitioners in midwifery, and poſſibly not unacceptable to thoſe of longer experience.

PERHAPS I may not be able to make myſelf clearly underſtood in the deſcriptive part, but ſhall endeavour to ſurmount that difficulty as well as I can, and ſhall honeſtly propoſe the remedies which I believe to be effectual.

In the firſt place, then, I ſhall give the general ſymp⯑toms of the diſorder, from the time when they become ſpecific and unequivocal, till the happy or fatal termina⯑tion, together with an anatomical explanation of the uterus, in its retroverted ſtate, when the diſorder has taken place.

AFTERWARDS I ſhall ſubmit to the reader what I take to be the proper treatment of the diſorder; and will farther venture to add my ideas as to the cauſe of it, grounded upon a number of caſes which have fallen under my own immediate obſervation; and will take occaſion to ſhew the neceſſity of diſcovering the diſorder in as early a ſtage as poſſible.

I WOULD firſt generally obſerve that all the patients labouring under this complaint, whom I have been called to aſſiſt, were of relaxed habits of body, and that every one of them, when advanced into the third month of pregnancy, began to complain of making water with dif⯑ficulty, which before that time they had not properly at⯑tended to, generally attributing this complaint to their having been interrupted in the doing of it, or otherwiſe diſappointed of obeying the firſt calls of nature.

THIS difficulty of making water, when the uterus is inverted, daily increaſes, and is attended with a dull pain about the ſymphyſis of the oſſa pubis, until nearly a to⯑tal ſuppreſſion of urine takes place.

FROM that time the pain about the ſymphyſis of the pubis becomes more and more acute. To theſe ſymp⯑toms ſucceeds a great difficulty in going to ſtool, with a bearing down pain through the whole pelvis; every one of [6]which evils continue to increaſe, and at laſt no feces can be got rid of without the aid of clyſters.

BY the time the patient has advanced to the latter end of the third, or beginning of the fourth month of preg⯑nancy, aſſiſtance is generally called for. But ſhould the diſorder continue many days longer undiſcovered, the danger increaſes ſo as in a ſhort time to make the cure ex⯑ceedingly difficult, if not impoſſible; and then the moſt pro⯑bable means of ſaving the life of the patient in this ſtage of the diſorder, in my opinion, are thoſe ſuggeſted in my remarks on the ſecond caſe, and which I believe will be found generally practicable, and, for the moſt part, at⯑tended with ſucceſs.

HAVING been informed of all ſymptoms the patient can deſcribe, if they correſpond to thoſe mentioned in the 5th page, and the beginning of this, a very probable conjecture may be formed of the caſe, which to aſcertain more clearly, the following mode of examination may be tried.

LET the patient lie down on one ſide, with her back to you, and her knees drawn up towards the abdomen. Whilſt ſhe is in this poſition, the os externum muſt be paſſed with the fore finger; and the lower part of the vagina, towards the os coccygis, will be found greatly diſtended, and upon the ſtretch from ſide to ſide, ſo as to prevent it from collapſing upon the finger. This is occaſioned by a tumor preſenting itſelf at the lower part of the os ſacrum, which totally impedes the finger in its paſſage to the hollow of the ſame bone, where you might expect to find the os internum; but by paſſing the finger up to the ſymphyſis of the pubis, there the collum utere will be diſcovered, greatly ſhortened of its natural length, and cloſely preſſed againſt the upper part of the pubis, into the form of a round button, of the thickneſs of about half an inch, the os internum opening but little.

PERHAPS in this ſtate, the ſhape and form of the col⯑lum uteri cannot be better deſcribed than by comparing it [8]with a muſhroom juſt beginning to open, the concave ſide thereof being towards the pubis.

AFTERWARDS, by paſſing the finger up the rectum, you find the tumor, betwixt the rectum and vagina, which is the fundus uteri inverted downwards, and fallen into that ſituation.

THESE particulars being aſcertained, a perſon is then perfectly maſter of the ſubject; and by carefully attend⯑ing to, and ſteadily purſuing the following general direc⯑tions, there will be little doubt of a cure, by replacing the uterus in it's natural ſituation.

To accompliſh this deſirable end, I recommend the following method, which I never found inadequate, ex⯑cept in the deſperate inſtance which is recorded in the ſecond caſe, and where it would have been abſurd to make the attempt.

THE catheter muſt be paſſed, and all the water drawn off; which is not attended with much difficulty. It will be afterwards proper that a clyſter be adminiſtered, in order to free the rectum entirely of feces. But in doing of this moſt commonly greater oppoſition is met with than was expected, by reaſon of the fundus uteri preſſing the rec⯑tum cloſe to the os ſacrum:—theſe impediments, how⯑ever, being removed, the patient ſhould have ſome pro⯑per cordial to ſupport her, and alſo a little time to recover the fatigue which ſhe has neceſſarily undergone.

I COME now to the operation itſelf. Place three or four pillows upon the floor by the bedſide, upon which the patient muſt reſt her head and arms; at the ſame time, let her be well ſupported by two or three female friends, reſting her knees upon the edge of the bed, which ſhould not be a high one. The operator muſt then be placed upon the bed, behind the patient, taking care not to ſuf⯑fer the leaſt expoſure, and gradually dilate the os exter⯑num, until the hand can be paſſed into the vagina; which [10]done, let him bend the thumb into the palm of the hand, reſting its point juſt betwixt the roots of the little and third finger; then cloſe all his fingers upon the thumb, which brings the hand into the ſmalleſt compaſs poſſible; and in this poſition great power and ſtability will be given to the three firſt fingers, with which every effort muſt be made, by oppoſing the knuckles and middle parts of theſe fingers to the tumor or fundus uteri, and as near to the ſymphyſis of the pubis as may be, keeping in mind an exact idea of the ſituation of the upper part of the ſa⯑crum; and towards that part directing his whole preſſure, which muſt be conſiderable.

BY perſevering in this mode, the os internum is ſome⯑what drawn, by the vagina, towards its natural ſituation, which aſſiſts in the reduction. If the firſt efforts prove abortive, the attempt muſt be repeated and iterated, till the tumor is found to recede; which muſt be followed up, till the fundus uteri turns over; when it will appear that it has regained its proper and natural ſituation. For [11]it will be immediately diſcovered, that the os internum is moved from the ſymphyſis of the pubis to the hollow of the ſacrum.

IF it be aſked what force is neceſſary to apply in reduc⯑ing the uterus, ſo wedged in the pelvis, I know of no better mode to anſwer than by referring to a caſe in mid⯑wifery, where the foetus muſt be turned, when the mem⯑branes are broke, the liquor amnii is diſcharged, and the uterus contracted. All who practice in the obſtetric art muſt be ſenſible of the great power required to effect this; ſo much force I have found to be neceſſary in re⯑ducing the inverted gravid uterus.

AFTER the operation the patient muſt be put to bed, and take an opiate, and ſhould continue eight or ten days without being moved therefrom. During this time ſhe muſt be ſupported with light nouriſhing diet, and avoid all force either in making water or going to ſtool.

AT the expiration of this period, if no miſcarriage hap⯑pen, upon examining the parts, not only the os inter⯑num will be found in its proper ſituation, but the collum uteri reſtored to its natural form; and at the ſame time, as the uterus and foetus will have acquired a conſiderable bulk, ſo as to reſt upon the brim of the pelvis, there can be little danger of a relapſe; at leaſt I never experienced any.

AS the late Dr. Hunter, in the Lecture which I have mentioned in the beginning of this paper, did not give any opinion reſpecting the cauſe of the diſorder; and as I have not at any time ſince, either heard or read of it's being accouted for by any one, what follows upon the ſubject I ſubmit with the greateſt deference, as the reſult of my own obſervation and experience; hoping that it will at leaſt induce others, who are more competent and have better opportunity, more fully to inveſtigate this ſubject, which I could wiſh, for the good of ſociety to be perfectly well underſtood.

IT has been before obſerved that all thoſe who have been afflicted by this diſorder, at leaſt all whom I have ſeen, were of relaxed habits of body^*: and that, when ad⯑vanced in their third month of pregnancy, they have ex⯑perienced a difficulty in making water; to which at firſt they paid little or no attention, ſuppoſing it to have been either natural in their then condition, or occaſioned by not having obeyed the calls of nature; thus contenting themſelves, until the increaſing difficulty, terminating in a ſuppreſſion of urine, obliges them to ſend for aſ⯑ſiſtance.

I BELIEVE it will be allowed me, that in all ſuch ha⯑bits, every part of the body is equally ſubject in a certain degree to the conſequences of relaxation; which granted, it ſeems not unreaſonable to imagine that the ligaments of the uterus, ſo circumſtanced, muſt be in a more flaccid [14]ſtate than is natural in a robuſt habit of body; and con⯑ſequently, the uterus is more looſely ſuſpended in the pelvis, and extremely liable to motion from any preter⯑natural preſſure or impulſe. In ſuch a ſituation then, if there be either a difficulty in making water or a ſuppreſ⯑ſion of urine, no matter by what cauſe occaſioned, the bladder will be preternaturally diſtended, and preſſing in every direction, as it riſes in the pelvis, and above the ſymphyſis of the pubis, the ligaments of the uterus muſt give way, and the fundus uteri is thereby forced to re⯑cede. But we find by experience, in every caſe of dif⯑ficulty in making water, that the bladder ſcarce ever has the power of diſcharging the whole of it's contents with⯑out aſſiſtance. And in all ſuch caſes, that difficulty, not being at firſt ſufficiently attended to, hourly increaſes, till it ends in a total ſuppreſſion: In our caſe, by parity of reaſoning, the bladder becomes daily more and more diſ⯑ſtended, and the preſſure againſt and over the fundus uteri muſt be continually increaſing, from the ſize and weight of the bladder, by the power of which the fundus is forced [15]back and downwards in the pelvis, between the vagina and rectum, as hath been before deſcribed. And when this has once taken place, it is impoſſible for the uterus to return to its natural ſituation without aſſiſtance. To ſuch canſes, how ſlight ſoever in the begining, do I at⯑tribute the whole of this dire miſchief: on which ac⯑count I have always moſt earneſtly recommended to pregnant women not to wait after, but rather to antici⯑pate the calls of nature.

Four caſes, which I have ſelected out of a conſiderable number that fell under my care, are added by way of Appendix to this little Eſſay; and will, I hope, ſuffi⯑ciently confirm the account I have attempted to give of this formidable complaint.