THE

AMERICAN JOURNAL

OF THE MEDICAL SCIENCES

FOR JULY 1858.

ART. I.-Report of a Case of Inversion of the Uterus Successfully Reduced after Six Months, with Remarks on Reduction in Chronic Inversion. By JAMES P. WHITE, M. D., Professor of Obstetrics in the University of Buffalo, and Accoucheur to the Buffalo Lying-in Hospital. (With four wood cuts.)

THE following report of a case of inverted uterus was made at a meeting of the Buffalo Medical Association, February 12th, 1856, and appears in its published proceedings:

On Monday, 28th January, Dr. Storck called at my office requesting my attendance, with himself and Dr. Dupré, upon a young female at No. 9 Huron Street, who had been delivered of her first child upon the Tuesday previous.

Accompanying him, I found the patient, 19 years old, exsanguine, with quick pulse, and greatly exhausted from loss of blood. I found that she had been attended, at the time of her delivery, by a German midwife, who stated that, after a brief labour, she had given birth to a male infant, weighing ten and one-half pounds. She also stated that the after-birth soon came away, accompanied by a large tumour, which descended into the vagina. This tumour she supposed to be a mole or false conception, and she stated that it was as "large as a cannon-ball." The flooding, at the time, she described as terrific, producing protracted syncope.

A day or two previous to my first visit, whilst making an effort to evacuate the bowels, the tumour had descended through the os externum and became suspended between the patient's thighs. All her efforts to remove the tumour proving unavailing, the midwife had sent for the gentlemen above mentioned for that purpose, and they now associated me with them in the treatment of the case.

The tumour was immediately recognized as the inverted uterus, as large as at the fourth month of pregnancy, which, with the external organs, was inflamed and tender. The uterus felt hard and inflexible, the body being appaNo. LXXI.-JULY 1858.

2

rently distended with blood from the ligated condition of the neck, and the parts had been rendered exceedingly irritable by manipulations for the removal of the supposed "false conception or tumour."

By grasping the uterus gently and firmly with both hands, which it completely filled, compression was continued until the organ was relieved of its engorgement and considerably diminished in bulk. By continuing this firm but gentle compression, I was at length enabled to carry it up into the vagina. At this time the patient, having lost some blood during the effort, became very faint, in consequence of which, and the sensitiveness of the vulva, it was deemed prudent to omit further efforts at restoration of the organ until the following morning.

Meanwhile the bowels were moved by an enema, followed by an anodyne, and fomentations were applied to the abdomen and external genitals. The patient was also directed to take freely of broths and stimulants.

The

Tuesday, 29th, 12 M.-Slept pretty well during the night; the hypogastric and vulval soreness is considerably diminished; the uterus lessened in size, and manifests some susceptibility to indentation upon pressure. hemorrhage has continued during the night; pulse 144, and feeble; has had a severe chill, and is greatly prostrated. During the last three hours Dr. Storck has, at my suggestion, applied extract of belladonna to the neck of the uterus. At 12 o'clock placed the woman across the bed, her pelvis resting upon its edge and her feet being supported, one in the lap of Dr. Dupré, the other in that of Dr. Storck. Prof. S. B. Hunt, who was kind enough to visit her, upon my invitation, gave her chloroform so as gradually to bring her moderately under its influence. This effect was maintained throughout the succeeding operation.

I now placed myself upon my knees between the limbs of the patient, a position admitting of free motion on my own part, giving complete control of the pelvis of the woman, and which could be maintained for a considerable period without unnecessary fatigue to the operator. Introducing the entire right hand into the vagina, the whole body and fundus of the organ were firmly and continuously compressed for some time. At length, keeping up the pressure, it was found, upon applying the thumb to the fundus, that a slight depression could be made. Having succeeded in dimpling the fundus, pressure was maintained with the thumb at that point until the hand became so fatigued as to be nearly powerless. To preserve this depression whilst the muscles of the hand were permitted to relax, a rectum bougie, about twelve inches in length and one in diameter, was carried along its palm fixed in the dimple, and pressure unintermittingly continued through it by the left hand outside the vulva. So soon as the intra-vaginal hand was sufficiently rested, pressure by it was recommenced and the bougie withdrawn.

Whenever these progressive efforts were resumed, the left hand was placed over the uterine tumour, which could now be distinctly felt in the hypogas trium. By means of the counter pressure above the pubis, a much greater degree of pressure could be made upon the depression in the fundus of the uterus without lacerating its vaginal connections. At length the fingers of the left hand being pressed well down into the abdomen, seemed to fasten upon or hook over the anterior uterine lip and aid in its reflexion over the organ. Thus securely held between the two hands, one within the vagina and the other upon the hypogastrium, these efforts at reduction were continued until I became nearly exhausted from fatigue. Gradually the concavity of the fundus was found to be deeper and deeper until it finally became completely restored. The bougie was now passed up to the fundus, penetrating twelve

or more inches beyond the vulva, and gently maintained there by Prof. Hunt, whilst the patient was replaced in bed. My fingers were benumbed and nearly deprived of sensation by the long-continued unremitting pressure, and at my request he also examined to ascertain whether the organs now occupied their normal relations. This being determined by him affirmatively, the bougie was gently withdrawn and the patient left with directions that an anodyne be administered, quietude preserved, and stimulants and nourishment given freely. It may be added that she seemed more comfortable than before the operation, and expressed herself as feeling better than since her confinement. The hemorrhage was, from this moment, completely arrested.

On the 30th, at 11 A. M., upon visiting her, with the same medical gentlemen who were present the day before, found her feeling better, with less pain and much more hopeful. The pulse had, however, but slightly diminished in frequency (140) or increased in force, and she still looked exsanguine.

Continued the treatment of the day previous, giving as much beef essence and brandy as the stomach will retain.

On Thursday, 31st, at 11 A. M., Dr. Storck informs me that the irritability of the stomach, which had been troublesome from her delivery, was now greatly increased, and it was with difficulty that she retained the smallest quantity of fluid. The pulse is more feeble, and she is evidently sinking. Notwithstanding the free use of quinine and brandy, she expired at 5 P. M. on the same evening.

Feb. 1st, at 12 M., the post-mortem was made by Dr. Lemon, in the presence of Drs. Storck, Dupré, Hauenstein, and Prof. Hunt, the last of whom, at my request, furnishes the following report of the condition of parts as they were found upon examination :

"The examination was held eighteen hours after death. Only the abdominal cavity was opened. All the tissues were extremely bloodless. The stomach and intestines were fully inflated with gas, but almost without any liquid contents. The walls of the intestines were white and translucent, and no trace of inflammatory injection could be found either upon them or any portion of the peritoneum. There was, however, a little serous effusion within the peritoneum, and between some of the convolutions of the intestines a very little lymph was exuded. The uterus was drawn up and removed with as much of the vaginal canal as could be reached from within. Externally the uterus presented its normal shape and position, there being no trace of its recent inversion. The vaginal mucous membrane and the os uteri presented the dark colour usual to the organ at this period after labour. The tissues were not softened, nor was there any laceration of them at any point. Upon section through the posterior wall, the same pale, bloodless appearance, noticed elsewhere, was presented. The uterine cavity contained a little altered blood. Upon washing the surface it presented no unusual appearance. The situation of the placenta was marked by the usual rough, flocculent surface.

"The examination revealed no cause of death, unless the anæmic condition of the tissues may be considered as such. I have never before seen so bloodless a subject, with one exception; that of a girl who died from purpura hæmorrhagica."

The uterus and its appendages were then submitted to the association for inspection.

This case is regarded as interesting in many respects. It will encourage the growing belief among accoucheurs that reduction may be undertaken with reasonable hope of success, at a period much later than most writers have heretofore advised. Denman, Dewees, Velpeau, and others believe any

effort at restoration useless after a very few hours. In a valuable paper upon this subject from the editor of the Buffalo Medical Journal, to be found in the November number, 1853, sixty-seven cases are collected, and all the facts pertaining to their reduction, so far as they could be obtained, are given. Most of the cases which were successfully treated were operated upon very soon after the accident. Thirty-two of the sixty-seven were not reduced, and a few "exceptional cases" at various periods after the first day. By this table Dr. Hunt has shown that treatment has, though very rarely, resulted in success at a later period than was formerly supposed practicable, and the above case furnishes another instance in support of the same position.

I have witnessed but three cases of inversion of the uterus. The history of one is given above. One of the others was seen and reduced soon after the accident; whilst the third was not visited until the fifteenth day-no effort at reduction being attempted. With my present views upon this subject I should abandon such a case as hopeless only after a prolonged effort at reposition. The accident occurred in 1842, and the female, then but 19 years old, now enjoys tolerable health, though the uterus still remains inverted in the vagina. The case is referred to, and the course of treatment pursued given in part by Prof. Hunt at page 335, in the paper already cited. The position in which the patient was, in the present instance, placed for the operation is deemed worthy of note. It will be perceived that it gives complete control of the pelvis, permits free motion of the person and arms of the operator, and may be maintained for a long time without fatigue. In this position he is able to render important assistance in the most difficult stage of the operation, with the left hand over the hypogastrium. Nor was the use of the bougie unessential; by its assistance continuous pressure was maintained, whilst the hand was relieved for a short period, thus, as it were, tiring out the circular fibres of the neck. How much of the success of the operation was due to the relaxation of the neck from the application of the belladonna, if, indeed, any beneficial influence was exerted by it, I cannot determine. The moderate anæsthesia, continued during the efforts of manipulation, doubtless saved the patient much pain and lessened involuntary resistance. Whether the patient's chances of rallying were improved by the reposition, may, by some, be deemed doubtful. There were no lesions of the utero-vaginal connection found, indicating that such a degree of force had been used as to impair the integrity of, or excite inflammation in those tissues. The hemorrhage, which had been considerable during the previous twenty-four hours, ceased with reduction, and the woman was much more comfortable the day following than the one preceding. The patient doubtless died from loss of blood immediately attending the delivery of the placenta and inversion of the uterus, the disturbance of the system occasioned by the unnatural position of that organ during eight days, and the continuous drain by hemorrhage during the same period. I believe it to be the opinion of all present that the shock of the operation was fully compensated for by the increased comfort of the patient and arrest of flooding. She had, however, lost too large an amount of blood, reaction could not be established, though nature was aided in her efforts by all the resources of art.

Fully convinced, from the result of the efforts made in this instance eight days after inversion, of the feasibility of restoring the uterus in many cases heretofore considered irreducible, I did not meet with any opportunity of putting my convictions again to the test until the month of March last.