AN ESSAY ON THE RETROVERSION OF THE UTERUS; ILLUSTRATED WITH CASES AND OBSERVATIONS.
By WILLIAM COCKELL, of PONTEFRACT, M. D.
LONDON: PRINTED AT THE
LOGOGRAPHIC PRESS,
AND SOLD BY B. LAW, AVE-MARIA-LANE; G. KEARSLEY, FLEET STREET; J. DODSLEY, PALL MALL, AND J. TODD, YORK.
MDCCLXXXV.
[PRICE 1s. 6d.]
TO DR. OSBORN, LICENTIATE IN MIDWIFERY, PHYSICIAN AND MAN-MIDWIFE TO THE GENERAL LYING-INN HOSPITAL IN STORE-STREET, AND LECTURER ON MIDWIFERY, IN LONDON, This ESSAY is most respectfully didicated by THE AUTHOR.
PREFACE.
ENCOURAGED by the approbation of some of the Faculty, and considering that any useful discovery, in the healing art, though ever so trifling, must be of service to mankind, I determined to commit to the press the following very imperfect ESSAY. The disorder is not indeed new, though very little has been given to the world on the subject; this may be some excuse for my attempt, and if my unpolished language does not disgust, I am not without hopes that the mode of proceeding I recommend will meet with a favourable reception. If it be otherwise, conscious of having done what I thought my duty, I shall rejoice if something better should be published hereafter. To such as know more let me apply
—Rectius istis
Candidus imperti.—
To others it is my wish to be useful.
Pontefract,
May
2, 1785.
WILLIAM COCKELL.
ERRATA.
PAGE 5, line 11, for
inverted
read
retroverted.
PAGE 6, line 1, for
continue
read
continues.
PAGE 7, line 13, for
utere
read
uteri.
PAGE 8, line 5, for
inverted,
read
retroverted.
PAGE 11, line 12, ditto, ditto.
PAGE 15, line 3, for
it is
read
I conceive it.
PAGE 17, line 5, for
inverted
read
retroverted.
PAGE 19, line last ditto, ditto.
PAGE 20, line 18, for
further,
read
farther.
PAGE 30, line 11, for
inverted
read
retroverted.
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 dangerous, and often proves fatal. There are indeed some cases in print,
See Medical Observations and Inquiries, Vol. IV. and V.
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 general 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 celebrated anatomist abovementined, in the year one thousand seven hundred and fifty-four, a case of this sort occurred to him; and the Doctor, in a lecture extraordinary, which he gave to the faculty, with the parts before him, treated it as a new case,
This case has been communicated to the public.
without assigning any satisfactory cause, or pointing out any competent remedy. The opinion he formed of it afterwards may be seen in his remarks;
Medical Observations and Inquiries. Vol. V. Page 388.
which, however, were unknown 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 observations upon them: and as I have been the happy instrument, 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 symptoms of the disorder, from the time when they become specific and unequivocal, till the happy or fatal termination, 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 difficulty, which before that time they had not properly attended 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 total suppression of urine takes place.
FROM that time the pain about the symphysis of the pubis becomes more and more acute. To these symptoms succeeds a great difficulty in going to stool, with a bearing down pain through the whole pelvis; every one of 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 pregnancy, 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 exceedingly difficult, if not impossible; and then the most probable 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, attended 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 collum uteri cannot be better described than by comparing it 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 attending to, and steadily pursuing the following general directions, 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, except 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 rectum close to the os sacrum:—these impediments, however, being removed, the patient should have some proper 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 suffer the least exposure, and gradually dilate the os externum, until the hand can be passed into the vagina; which 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 sacrum; and towards that part directing his whole pressure, which must be considerable.
BY persevering in this mode, the os internum is somewhat 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 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 reducing the uterus, so wedged in the pelvis, I know of no better mode to answer than by referring to a case in midwifery, where the foetus must be turned, when the membranes 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 reducing 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 happen, upon examining the parts, not only the os internum 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
I have an observation to add, that seems to confirm this idea of the disorder being peculiar to relaxed habits; namely, that several of the patients whom I have attended and cured of this complaint, in some time after have died of dropsies.
: and that, when advanced in their third month of pregnancy, they have experienced 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 assistance.
I BELIEVE it will be allowed me, that in all such habits, 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 state than is natural in a robust habit of body; and consequently, the uterus is more loosely suspended in the pelvis, and extremely liable to motion from any preternatural pressure or impulse. In such a situation then, if there be either a difficulty in making water or a suppression 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 recede. But we find by experience, in every case of difficulty in making water, that the bladder scarce ever has the power of discharging the whole of it's contents without 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 disstended, 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 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 attribute the whole of this dire mischief: on which account I have always most earnestly recommended to pregnant women not to wait after, but rather to anticipate 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, sufficiently confirm the account I have attempted to give of this formidable complaint.
APPENDIX; CONTAINING FOUR REMARKABLE CASES OF THE GRAVID UTERUS INVERTED.
CASE THE FIRST.
ON the eighteenth day of August, one thousand seven hundred and fifty-eight, I was sent for to Margaret, the wife of George Sharp, of Knottingley, three miles distant from Pontefract, in the county of York. She complained of great pain in her body, from a suppression of urine, which had been increasing for several days, with an odd dull pain at the symphysis of the os pubis; but she did not suppose it would lead to any bad consequence, believing the whole to have been occasioned by not making water at a time when she had a pressing call to it, a few days before the complaint began: she was then about three months gone with child.—I endeavoured to make her sensible of the necessity of passing the catheter, with which she complied; and, after drawing off two quarts of water, I ordered her some diuretic medicines, and prescribed an opiate to be taken at bedtime. I visited her again the next day, and found she had enjoyed an easy night, and had voided more water than for several days before.—I then recommended to her to continue the diuretic medicines, to keep her body open, and to take the opiate occasionally. But on the twenty-seventh I was sent for again, and found her much worse. She now complained of great pain in the pelvis, and could neither void water nor evacuate any thing by stool;—I again drew off the very same quantity of water as before, and ordered her a clyster, which answered the intention, and gave her great ease. But imagining that she was about to miscarry, I was desirous to examine her; to this end, having passed the os externum with my finger, I was surprised to find that I could by no means proceed in the usual manner gently up the vagina towards the sacrum, in search of the os internum, being obstructed by a tumor at the lower extremity of the sacrum, which stretched the vagina from side to side. I then passed my finger up the rectum, which I perceived was pressed close to the sacrum, by this tumor, situated betwixt the vagina and rectum; then advancing my finger to the symphysis of the pubis, found there the collum uteri pressed into a flat form, something like a middle sized mushroom just beginning to open. From all these circumstances, and at the same time recollecting the case given by Dr. Hunter, in the year 1754, I was convinced that this tumor could be nothing but the fundus uteri inverted.
THIS being the first case of the kind which had occurred in my practice, I was led to attempt a reduction of the uterus, in the manner which the Doctor had recommended; but, after several vain attempts, was obliged to leave her, only prescribing an opiate, till the day following.
In the intermediate time, having considered the case in every point of view, as far as I was able, with a female pelvis, and Doctor Smellie's tables before me, these being the only sources from which I could then derive any information, I determined upon the method of treatment already given at large, which at my next visit I put in practice. The first attempt failed, but I was happy enough to succeed in a second effort, and reduced the uterus into its natural situation. This was done on the twenty-eighth of August, ten days after my first seeing the patient.
AFTERWARDS she went on in her pregnancy without any further inconvenience, and had a natural and easy labour; nor did any evil happen in consequence of the complaint. And several years after, when I called accidentally at the house, I found both her and the child in good health.
CASE THE SECOND.
ON the twelfth of December, 1759, I was desired by a gentleman of the Faculty to attend the wife of Andrew Montier, of Knottingley, supposed to be then in a fit of the stone or gravel. Being that day engaged, I recommended what I thought most proper from the information given me, and desired if she was not relieved by the prescription, to be informed, in order that I might visit her.—I heard no more of the case from that day until the seventh of January 1760, when I was intreated to go and see her. I then found her advanced five months in her pregnancy, and in a most deplorable situation; she informed me that for a month past she had been in constant pain, which first began with a difficulty of making water, and a trifling pain about the neck of the bladder; for which her midwife ordered her something, and she had also taken medicines from her apothecary, in hopes to carry it off, but to no purpose. On the contrary, the pain increased every day, a suppression of urine came on, and it was with difficulty she could part with any stool for some time past: that about the twenty-ninth of December the pain in her body was very great; and, as she expressed it, bore down violently; and as she could neither discharge urine nor stool, that she had sent again for her midwife, believing she was going to miscarry, who staid with her some time, and gave every assistance in her power by opiates, clysters, &c. notwithstanding which her sufferings hourly increased with sickness and vomitings; nay, for twenty-four hours before I saw her, she had vomited up what ought to have gone down.
I FOUND her sunk and emaciated to the last degree; her pulse scarcely to be felt, and this attended with frequent faintings, cold sweats, and a cadaverous smell. But for a few hours preceding my visit, the pains in the pelvis had left her.
IN this most miserable situation I doubted whether or no I should attempt any thing; but, for satisfaction to myself, as her body was greatly distended, I passed the catheter, and drew off five pints of a dark grumous coffee-coloured water, which towards the latter end was bloody.
AFTER this I passed the os externum with my finger, and found the fundus uteri in the vagina, below the extremity of the os coccygis, pressing the perinoeum, and the anus dilated the breadth of a shilling, the parts discharging a most offensive matter. With some difficulty I passed my finger up to the symphysis of the pubis, where I found the collum uteri pressed quite flat against the pubis, at the very brim of the pelvis, the os internum being open the breadth of a sixpence. But the tumor pressed the rectum so close to the os sacrum, that I could not pass the os coccygis with my finger.
THESE parts being in a state of mortification, all farther attempts were vain:—I thought it my duty however, before I left her, to make the apothecary and midwife who attended, perfectly sensible of the disorder being incurable. The poor creature expired next day.
OBSERVATIONS.
THIS dreadful case naturally led me to consider what relief might have been given to the patient before the parts were so injured as to leave no hopes of recovery, i. e. before the mortification had taken place.
THE means which then occurred to me as the only probable and practicable ones, in so desperate a situation, were these;—first to draw off the water and clear the rectum of feces:—secondly, to endeavour by some method to rupture the membranes, and discharge the liquor amnii, which would greatly reduce the uterus in magnitude; and having gained these two points, then at last to attempt a reduction in the way I have in general recommended.
In every case that hath occurred to me in practice, I have always been able to reach the os internum with my finger, and clearly to discover its form and situation. I have not therefore any doubt, even in such a situation, where the collum uteri is flat, and the os internum opens a little, that I could, by persevering in my efforts, pass the os internum with my finger, and rupture the membranes; at least the trial in a case of such imminent danger is warrantable. For it might save the patient, and could do no injury. But should it prove impracticable with the finger, then I think it would be right to make the attempt with a female catheter, or some instrument of that kind, having a point much more curved or hooklike.
IN doing this, whilst I had one singer at the os internum, I would pass the instrument up on one side of the symphysis of the pubis, with the point towards the other side; and, when advanced as high in the pelvis as the os internum, insinuate the point into it; and then, by pushing the point downwards, and against the membranes, rupture them, and so discharge the liquor amnii. After which the reduction should immediately be set about as in general directed.
THESE are speculative suggestions only thrown out for others of kappier talents to improve upon. But were a case of this description to fall under my care, even though the os internum should not be at all open, I would most certainly adopt the mode of proceeding now described, without the least doubt of success.—This at least, I can affirm, is the only case that has occurred to me, in which I did not save the patient.
CASE THE THIRD.
ON the eighteenth of September, 1761, James Hunter of Ledsham, six miles from Pontefract, believing his wife was about to miscarry, called on me to visit her, as the midwife of the place, who was with her, could give no assistance, and was at a loss what to do.
As it was then late in the evening I sent her an opiate; and visiting her in the morning following, was glad to hear from herself that she was better; which she attributed to having made more water than usual; but at the same time she told me, she had been labouring for many days under a difficulty of making water, attended with an uncommon pain about the neck of the bladder; that for the three or four last days she could make little or none, nor could she have a stool without the assistance of medicine, and concluded with saying that she had had a great deal of bearing-down pain in her body which hourly increased. All this she supposed was owing to her condition, being her first pregnancy.
FROM this information I concluded what the case was, and upon examination found the uterus inverted in the manner I have already described. I therefore drew off the water, evacuated the rectum, and set about the reduction exactly as I have generally directed.
BUT I did not find it an casy task, as the force requisite to be employed was very great: however, at the third effort I succeeded, and the uterus reverted into its natural situation.
AFTER she had continued in bed a week, I found the parts in their proper form and situation; and no symptoms of abortion appeared. She even went on to her full time, without any kind of inconvenience, and on the eighteenth of March, 1762, she had a natural labour; when, being again sent for, I delivered her of a daughter, and all did well.
CASE THE FOURTH.
ON the twenty-sixth day of February, 1764, I was called to the same patient a second time, whom I found in the like situation as before; only according to her own reckoning, a little farther advanced in her pregnancy; and though she had so lately experienced the very same complaint, yet on this occasion she did not apprehend any dangerous consequence, believing her indisposition to proceed merely from holding her water too long, which did not by any means appear a serious matter to her.
AFTER taking every previous step to facilitate the reduction of the uterus, I set about it in the usual way; but found the uterus so fast wedged in the pelvis, that I was obliged to make many efforts before I could accomplish the reduction, the force required being very great. And I must observe, that immediately before the uterus receded, a smart gush of water came down upon my hand, which at the instant I supposed could be nothing but the liquor amnii: of which I was convinced by what followed. The uterus being replaced, the patient was put to bed, and the usual directions given. But when I called upon her four days after, I discovered symptoms of an approaching miscarriage, which I foretold, and it accordingly happened the next day. My patient soon recovered, and in a short time after removed to a town called Kippax, about two miles distant, in a high dry situation, where she acquired a more robust habit of body. Since that time she has had several children, without any return of the retroversio uteri, and now lives at Kippax in perfect health, March the first, 1785.
I SHALL conclude with remarking that I could produce a considerable number of other cases, in which the Gravid uterus has been retroverted, that have fallen under my own immediate care; but as they contain nothing new, differ very little in their symptoms from the First, Third, or Fourth; and being treated exactly in the same way, terminated happily; I forbear to enumerate them, conceiving it would only give the reader unnecessary trouble.
FINIS.