observations - history-of-obgyn.com · stalte, and the female has been subject to prolapsus uteri,...

SOME OBSERVATIONS

ON

INVERSION OF THE UTERUS;WITH A CASE OF SUCCSSFUL £XTlItPATION

OF TAAT ORAGAN-.

BY JOHN WINDSOR, F.L.S.MEMBER OF THE ROYAL COLLAGE OF SURGEON', AND ONS F TUR

SURGEONIS tO THE MANgHkST3R EYE INSTITUTION.

COMMUNICATED BY

MR. ASTLEY COOPER.

Read June 22, 1819.

OF 41 the accidents to which the act of parturi-tion is exposed, an inversion of the uterus itselfis one of the most formidable. If its reduction benot almost immediately effected, fatal conse-quences very frequently ensue, either at the time,from the violence of the hemorrhage, or at a moreremote period, the powers of life may, from thesame cause, be gradually exhausted.

The records of medicine afford sufficient evi-dence of the truth of these assertions, and there-fore I hope the following case, and accompanyingremarks, will not be thought uninteresting.

Medico-Chirurgical Trans 1819 V-10

history-of-obgyn.com

EXTIRPATI0N OL AN INVERTED UTERUS. 859

Inversion of the uterus is probably not so rarean occurrence as many suppose, even in the pre-sent day, when so much information on the parti-cular branch of medicine, of which it forms asubject, has been diffused by the mnedium of lec-tures, and the writings of numerous valuable au-thors; for as the accident is generally thought toimply -a degree either of carelessness or rashness,on the part of the accoucheur in the extraction ofthe placenta, he will endeavoar, with a view tosave his own credit, to keep the real nature of theaffection as secret as possible; and an early deathoften assists in throwing the shade of oblivion overthe patients themselves. Within a very short time,I am acquainted with three cases that have oc-curred in this neighbourhood only. One formsthe subject of this Paper; ffie second occurred toa midwife last winter, and terminated fatally in afew hours, -from severe hemorrhage; of the bodyof this person, I had an opportunity of witnessingthe inspectiou after death; the third, a chroniccase, is now under the care of a medical gentle-man, at a short distance fiom Manchester. Withinthe last few years, other instances of this accidenthave oceurred in this neighbourhood4.

Happily, however, the accident admits of re-medy, if an intellgent person be near at hand to

* Within the last few days, a professional geitleman, livingnine miles frotn this town, has informed me of a case he had,where the exhausting hemorrhage was fatal in about four years.

B B 2


MR. WINDSOR'S CASE OF

replace the -uterus in its natural situation; if thisbe done immediately, and if the hand of the accou-cheur be retained in the cavity of this organ, untilit has considerably contracted, and if the patientbe confined for some time afterwards to the re-cumbent posture, she will generally, I believe, dowell. This happened in the practice of a gentle--man about twelve miles from this town, nearlyhalf an hour after the occurrence of. inversion.In another case, about six miles hence, the accou-cheur removed the placenta before tthe uterus wasre-inverted, a plan perhaps less safe than removingit where the uterus is first replaced.; in both in-stances the patients recovered well.

Where the uterus and vagina are in a relaxedstalte, and the female has been subject to prolapsusuteri, I believe there is a greater disposition to theoccurrence of inversions at the time of labour,than when such a condition of the parts does. notexist. Tlhis was the case with Harriot Barwick.In such patients, therefore, it is desirable that themedical attendant be extremely attentive and cau-tious, in assisting the expulsion of the placenta. Iam acquainted with two sisters, both married, oneof whom has had a considerable procidentia vesice,since the age of fourteen or fifteen; and the otheris much troubled with a prolapsus uteri, so thatduring her last labour, the os internum descended

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EXTIRPATION OF AN INVERTED UTERUS. 361

even beyond the external parts, yet in both ofthem, by careful treatment, no tendency to inver-sion has manifested itself during parturition.

In all cases, it is highly proper for the accou-cheur to examine, after the expulsion of the pla-centa, if the os internum be free. At the sametime his hand may be placed on the abdomen, toknow if the uterus is in its natural situation, andthus ascertaia that there is no tendency to inver-sion.

In consequence of the neglect of this practice,it is to be feared that many lives have been lost;the true cause of the succeeding hemorrhage notbeing ascertained till too late, as happened in thefatal case that occurred to a midwifie hlere lastwinter, and that was alluded to above. The ge-na-tleman who was sent fbr, informed me that he hadvisited her twice before he became ilforn)ed of thetrue cause of the hemorrhage, and by this time allart was unavailing. The danger of these cases is indelay. If the replacing of the uterus be not verysoon accomplished, it geneially becomes, from thequick diminution of its cavity, and the thicknessof its contracted parietes, utterly impracticable.

If the patient be enabled to survive the imme-diate effects of the inijury, and the reduction ofthe inverted uterus to its natural state cannot, bypersevering attempts, continued as far as her feel-


6IR. WINDSOR'S CASE OF

ings and safety will adlmit, be effected, then a train,of symptoms occur, from the severe hemorrhage,and the unnatural position of the parts, whichwill demand the watchful aid of the medical at-tendant. Some degree of inflammatory symptomsaccompanied with fever ensues; the abdomen be-comes full, tender to the touch, and at its lowerpart, sometimes rather hard; there is costivenessof the bowels, and, sometimes, retention of urine,requirinig for a time the use of the catheter. Bythe use of fomentations, enemata, laxatives, and anantiphlogistic regimen, the symptoms abate, thepower of expelling the urine, especially if theuterus is first raised a little in the vagina, is re-gained, and the patient gradually recovers the fullpower of this function.- Afterwards- she becomesable to walk about, suckles her infant, and per-haps enjoys, apparently even a tolerable state ofhealth; yet the sanguineous discharges are, gene-rally after a time, occasionally retuming profusely,and her exsanguineous countenance and emaciatedappearance sufficiently indicate the debilitatedstate of her constitutlon.

About the time she relinquishes the office ofsuckling, the menses return more regularly, thedischarges of blood are very considerable in quan.tity or of long duration, the mucous dischargesare generally copious at other times, and the con-stitution begins to sink under the reiterated lossesit sustains. The pulse beconmes frequent, the ap-

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EXTIRPATION QF AN INVURTED UTBRtJS. $6S

petite is impaired, a cough -with hectic symptonipsometimes occurs, and the patient is quite unableto pursue her usual domestic duties. In this statepalliative means, as the use of astringent and Qtherremedies, become inadequate to check the exhaust-ing progress of the complaint, and the unfprtunatesufferer must soon perish, except some decisivemeans are devised for her relief. In this painfulextremity, the extirpation of the uterus itself hasbeen proposed, as the most efficient means of re-lief, and, formidable as the operation at first viewseems, it is known to have been already performedwith success.

Besides the cases previously on record, partlydoubtful and partly authentic, a very successfulcase has lately been published by William Newn-ham, in his excellent treatise on Inversio Uteri*.To this gentleman the profession and public areindebted for the recommendation of extirpation,under certain circumstances, in the chronic stageof inversion of the womb. An individual case,however, is very insufficient to decide the prQprietyof a comparatively new mode of treatment; con-siderable time and experience are still necessaryfully to sanction so bold- a practice. On this ac-count, I beg indulgence for the detailed Tela-tion of the following case, to which I shall subjoin

* Since the above was written, there has been another succeoful cure by Dr. Davis.


MR. WINDSORPs CASE OF

a few observations and suggestions, on the bestmode of accomplishing the operation.

1817-January loth, 9 p. m.-I was- requestedto visit Harriot Barwick, aet. so, the wife of abaker, No. 9, Back Falkner Street, Manchester.From her own account, and that of the surgeonwho had attended her, it appeared that she hadbeen delivered of her first child on the morning ofthe preceding day. The labourshad gone on well,and she was congratulating herself amongst herfiiends on its comparative ease, when the difficultywith the placenta arose. After waiting about anhour, the surgeon, an intelligent gentleman, passedhis finger into the vagina, and finding the placenta,as he thought, descended, he extracted it, withoutthe employment of any immoderate force; how-ever, its removal created to the patient excessivesuffering; violent hemorrhage, tinnitus aurium, andsyncope followed, and she believed herself aboutto expire. Finding that a descent of the fundusuteri had accompanied the expulsion of the pla-centa, the accoucheur pushed it up beyond the osuteri; in the even-ing he examined, and found itnot in the vagina, but the following morning it hadreturned into the vagina.

At the time of our consultation this evening, itappears that she has lost much blood from theuterus; the abdomen, especially about the umbilicus,

364



is very tumid, hard (as if from the contracteduterus,) and tender. Pulse 120, and small. Nostool since the 6th instant, though oleum riciniand an enema have been used to-day. Has passedher urine tolerably; complains of thirst. On in-troducing two fingers within the vagina, I felt asubstance (evidently the inverted uterus) about aslarge as the fist, increasing somewhat in diameterupwards, and passing through the os uteri, whichwas in its natural situation, and considerably di-lated by it; it protruded into the vagina nearly tothe os internum, felt hard and rugous, and wastender to the touch, though not so much so as theposterior part of the vagina.

The surgeon who had been her accoucheur, nowattempted the reduction; but his efforts, continuedfor about a quarter of an hour, were ineffectual.The woman, during this, complained of muchpain, and there was a great discharge of blood;indeed, so much tenderness and inflammatory dis-position had by this time apparently invaded theparts, as appeared to render all further attempts toreplace it, both imprudent and unavailing. It wasnow, tlherefore, determined to sooth and palliatesymptoms as much as possible'; the abdomen wasordered to be frequently fomented; the domesticenema to be repeated, and a solution of magnesiaesulphas in infusum sennw, to be taken every threehours, till the bowels were opened.



January IIth, eight o'clock, a. m...-The enemaprocured two pretty free natural motions; abdo-men still tumid, hard, and tender; has had a con.siderable sanguineous discharge during the night;tumor in the vagina the same; has voided a miode-rate quantity of urine; pulse 120; some thirst; noappetite; skin of a natural warmth. The breastsbeing rather full and painful from milk, were di-rected to be drawn. To hav.e her belly well fo-mented every two hours, and to have a dose ofdiaphoretic mixture every three hours.

Eight o'clock, p. m.-Symptoms better than inthe morning; two stools to-day, and urine mode-rately free, but is often obliged to press up theuterus before it will flow, as she used to do withher prolapsus; abdomen subsided, softer, and lesstender; discharge rather diminished; teased witha cough, for which a mucilaginous mixture, withtinct. opii, and liquor antimonii tartarisat. was di-rected.

From the 12th to the 14th she was rather im-proving; the belly became softer and less tender;the bowels required occasional assistance of anaperient mixture; passing of urine difficult andpainful; cough much better; breasts less painful;3ochia diminished; pulse 96, and rather soft; tonguemoist; appetite better; lives chiefly on oatmealgruel. Was up a few minutes to-day, when theuterus protruded rather more than usual.

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EXTIRPATION OJ AN INVERTED UTERUS. 367

17th.-Has had a feeling of considerable heatin the abdomen for the last two days; pulse 96,and of moderate strength; tongue moist; greatthirst; appetite moderate; bowels open; dischargealmost colourless; urine passes with pain; sleepspretty well; -breasts rather painful, but less swelled.

2Oth.-Urine, for the last few- days, drawn offtwice daily by the catheter.

29tl,.-The os uteri is now so much dilated, aseasily to admit the fingers between it and the pro..truding uterus; from the latter there is some co-loured discharge; febrile symptoms gone off. Forthe last week has been able to void her urine, butthe evacuation of both it and the stools somewhatobstructed; appetite and sleep pretty good; milkfree.

February sth.-Since last report she says, that ateach evacuation of the fleces, the uterus comes lowdown; she then suffers much pain, and about halfa pint of blood is lost; evacuation of urine alsopainful especially about the end of the act; pulse76; appetite moderate. An alum lotion has beenused by means of sponge, but without apparentadvantage.

March 22nd.-Uterine tumor still in the samesituation, but appears reduced to nearly its naturalsize-; it Sdoes not fill up the vagina so completely



as before. The fingers pushed up through the' osuteri occasion considerable pain; and the uterusseems to have very nearly its whole length externalto this part; the sanguineous discharge has eon-tinued till within. the last few days, and after anexamination, the fingers are still covered with co-agula of blood. For the last few days has had con-siderable leucorrhoeal discharge.. Frequently feelsmuch pain on the left lower part of the abdomen.Urine pretty free; bowels sometimes rather cos-tive, and then the uterus descends more with thepassage of the stools.

August soth.-Is able to go about, and appearsto be in tolerable health.

September Soth.-The sanguineous flow returnsevery three weeks in considerable quantity, andsometimes in the intervening time, although shesuckles. The uterus protrudes downwards, at eachevacuation of the bowels.

May 20th, 1818.-Has weaned her child aboutthree months since. At the first menstrual periodafter weaning it, she had a very copious dischargeof blood from the uterus, amounting, she supposes,in two or three days, to several pints. Has had areturn of it twice since, but not quite to the sameextent. Complains of very great weakness.

August 15th.-The menstrual discharges con-

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EXTIRPATION OF AN IXVIERTED UTERUS. 369

tinue very profuse, or, if less in quantity, are oflonger duration. On one occasion, lately, I wasrequested to visit her immediately, as her friendsthought her about to die, from the excessive dis-charge; and I certainly found her much reducedby it. Complains much-of a pulsating feel inl thehead, and of a singing in the ears. Pulse quick;bowels generally costive; urine free; appetite tole.rable. Countenance very pallid; feels extremelyweak, and unable to follow any business. Has atroublesome cough. For the last two or tlhreeweeks the sanguineous discharge has been constantand free. On examining,per vaginam, to-day, theuterus found in the same state, the fundus reachingto near the os externum.

It is here proper to observe, that about the mid-dle of March last she was seen by Dr. Hull, who,from that time, was interested in the progress ofthe, case.

The solutions of alum, with sulphate of zinc,were recommended to be applied to the part, andthe tinct. ferri muriati wa; administered internally.

The disease continued to resist all commonmeans of relief, and, indeed, she was less attentivethan we could have wished, in observing our di-rections, and in keeping herself quiet and cool,when the discharges were upon her. Her living,

s



also, constantly over a hot bake-bhouse, was proba-bly prejudicial.

August 22nd.-Since the 16th it has been de-termined to have recourse to the operation of tyingthe inverted uterus, which, for some time, has beenlooked up to as a last resource. Of late there hasbeen an evident decline in her strength, from thecopiousness and long duration of the uterine san-guineous discharges; the pulse generally from looto 120; frequent feeling of faintness. Her weakstate of health renders her life uncomfortable, anddisables her from aiding her husband in his businessas a baker.

These circumstances now render her desirous ofimmediately undergoing the operation, and it isappointed to be performed at four o'clock, p. mn. onthis day. A draught, with fifty drops of laudanum,was given a slhort time before the operation; fbrtwo days, also, before this, her bowels had beenkept open by an aperient mixture. We placed hersitting on the edge of the bed, with her legs raisedupon a chair on each side. Having her situatedin this convenient position, which Dr. Hull thoughtpreferable to the recumbent one, I anointed thefingers of my left hand with oil, and passed themup to the inverted uterus, the lowest portion ofwhich descended to about an inch within the osexternum. I unexpectedly found the uterus so

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EXTIRPATION OE AN NVICItTEID UTERUS. 07 l

relaxed, that I could draw it downi and withoutdifficulty brought it into Bight, about two inchesbeyond the os extemtim. A single ligature of theitrongest dentist's silk was thus easily passed round

it and tied as firmly as possible. Besides this, asimilar ligature, inclosed in a canula, was passedround the same part, and each end secured to aaing pced on each side of the base of this instru-ment; but the easy descent of the at-erus withoutthe os externum, rendered the means devised tofacilitate the tying, in a great measure unnecesAsary. The canula I used on this occasion wasmade of copper, slightly curved, (though a straightone would have done), and being flexible, wouldyield any way, about the diameter of a middlesized male catheters, and about twothirds of thelength of.that instrumentr

The uterus being thus tied, was pushed gentlyup within the vagina, to the place it previouslyoccupied. The patient expressed surprise at theoperation being accomplished so soon and so easily.About three ounces of blood issued from the uterusat the time of the operation, which altogether tookup only a very short time, perhaps ten minutes

The pulse,- just before the operation, was 96;she suffered little pain immediately afterwards, butin about five minutes it became severe, and thepulse was now 72; it continued severe about onehour and a half. The anodyne draught was re-



peated, and as she complained of a feeling of greatheat at the lower part of the abdomen, a camphor-ated spirituous embrocation was directed to beapplied by means of folded cloths, a little warmwater beitng each time added. She' was directedto take a dose of saline effervescing mixture everytwo hours, and to use light simple drinks for herfood. In the evening, pain diminished; pulse 76;no vomiting; belly soft and easy; slight sanguine-ous discharge from the vagina. A starch glyster,with a drachm of tinct. opii, was ordered to beinjected at bed-time.

August 23rd, 7 o'clock, a. m.-The enema wasretained; has slept pretty well, and says she hasnot felt better any morning for the last two months.Pulse 90; tongue moist; some thirst; urine free;no stool; occasional pain in the belly, but relievedby the embrocation; ordered an aperient mixture,with senna and sulphate of magnesia.

Half past ten, p. m.-Has slept much during theday. For about an hour this evening she felt agood deal of pain in the fore-part of the rightthigh, extending nearly to the knee; occasionallyhas felt pain in the lower part of the abdomen, butit is soft, and free from tenderness; complains alittle of her back; pulse 96; urine free; bowelsopened twice by the aperient.

I tightened the ligature on the canula about one-

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EXTIRPATION OF AN INV9RTED UTERuS. 873

fourth of an inch, this evening, and she felt consi-derable pain for a short time afterwards.

24th, seven o'clock, a. m.-Has slept about halfthe night. Pulse 104, and of toierable strength;thigh easier, but complains a little of pain in thelower part of the back; belly soft and easy; tonguemoist, and pretty clean; no appetite; bowelsrather-open; urine free. The ligature being tight-ened to-night, occasioned some pain, but it wentpff almost immediately.

25th, ten 6'clock, p. m.-Pulse 100. A littlepain on left side of belly, probably owing to flatu-lence from eating potatoes at noon; one naturalstool to-day; appetite moderate; no thirst; theligature being- tightened firmly to-night, she feltmuch pain from it.

An anodyne enema to be given directly. Thewarm camphorated embrocation to be applied, andtAvelve leeches, if the abdominal pain increase; adose of the aperient early in the morning.

The ligature we thought it best to tighten daily,and to tighten it very much, in order to deaden theuterus as effectually as possible; on introducing afinger this evening, the ligature seemed to havemade a considerable impression, a pretty large fissure being very distinct.

VOL. X. C C


34K. WINDSOR'S CASE OF

26thi eight o'clock, a. m.-Slept moderately,After tightening the ligature, last night, she felta good deal of pain in the uterus, but more alongthe fore part of the thigh; and on awaking attimes in the night, was troubled wkh flatulent painsih the belly. Took a draught of the laxative mix-tfre early this morning, which was rejected, pro.bably from the opiate having disordered the sto-mich; has had one rather free natural stool; urinenatural; appetite moderate, and food well retained.The injection and aperient mixture to be repeated.

H'alf pasts nine, p. m.-On the wlhole has sufferedmore to.day, than on any preceding day since theoperation, from pain in the belly, especially on theleft side, in which part she hias, ever since her ac-couchement, had occasional pain. Pulse 106; twoloose free stools from the enema and apeiientt; in-gesta all retained. The ligrature tighlltened thisevening, gave her pain. Ten leechles were appliedto the ab(lomen this afternoon, and are directed tobe repeated in the nighlit, if the pain should returnseverely. Has had lier anodyne draught as usualthis evening about an hour before the tiglhteningof the ligature. To have an opiate enema, andthe purgative mixture to-morrow morningr.

27thl, hialf past seven o'clock, a. m.-Has passeda nearly sleepless night, from pai in thc belly,back, and thighs, but is easier since. Seven leeches

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were applied to the belly this morning,. Pulse120, and small; tongue clean; great tfiirst;ine free; no stool since yesterday morning,

thoutgh the aperient mixture was taken twice thismorning; skin of a natural temperature, yet com-plains of a burning feel in the belly; nausea,, butno vomiting. Let the purgative mixture andenema be repeated.

Ten o'clock, p. m.-Ias been easier, and hiasslept moderately this afternoon; rejected hier purg,-ing nmixture; a powder of hydrarg. subiiur. gr. v.cum pulv. antim. gr. ij. taken about noon, was re-tained, and she has had two free loose stools thisafternoon. Pulse 116; skin of moderate tempe-rattire; abdomeii less tender, and feeling of heatin it diminislhed. In tightening the ligature thisevening, a considerable fissure could be perceived;for two or three days a rathier fcetid discharge hasbeen inoticed, for wlhichi she has occasionally useda cliamomile iinjection. To continue the salinemixture, and to take one grain of opium imme-diately.

28th.-Tie ligature was tiglotened as usual eachevening, from a quarter to hialtf an incl; shealways complains of muchi pain from the tig,hten-ing, but it soon goes off.

29tlh, half past seven, a. rn.-Slept about fourhours last nig,ht, after the use of thle pills aind ano-

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6II. WINDSOR'S CASE OF

dyne enema, but the pain after the tightening ofthe ligature continued for two or three hours; hagconsiderable tenderness of the belly this morning,owing chiefly to the leech bites, and at present feelspretty easy. Pulse 106, moderately full andstrong; tongue clean; some thirst; complains ofbeing frequently sick, and of occasional vomiting.

Ten o'clock, p.m.-We, for the first time, reluc-tantly omitted tightening the ligature this evening,as she was much afraid of a repetition of the painshe suffered last night.

soth, seven o'clock, p. m.-Has had a very goodnight. Pulse 106; some pain in the belly, but notension; and it may be here observed, that she isusually of an exceedingly irritable complainingdisposition. Tongue clean and moist; bowelsopen; urine free; stomach tolerably tranquil.

This morning I brought down the uterus, as atthe first tying; it appeared rather enlarged thandiminished in size since it was first tied; the ulcer-ation had now extended about three quarters orfour fifths through it. A single waxed ligaturewas again tied vergjfrmly round it; at the sametime, the ligature in the canula was tightened, andthen the uterus was raised into the vagina to itsusual situation. It was our intention, ifthe fissurein the uteru4 was not found considerable, to pass aneedle through the remaining portion, armed with

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EXTIRPATION OF AN INVERTED UTERUS. V7I

a double ligature, so as to divide it into two por-tions, tying each separtely, and thus to acceleratethe process of separation, a mode, perhaps, veryeligible at the first tying, where the uterus can bebrought into view; but on examination, so smalla portion remained, that we thought it unneces-sary. In drawing down the uterus, without theos externum, care was taken to do it as gently"aspossible, ia order that any adhesions t6 the bladder,rectum, or surrounding parts, might, if they ex-isted, be disturbed as little as possible. Opiatesboth in draught and in glyster, were prescribed,and the saline mixture continued.

Half past nine, p. m.-"-Has slept well to-day.Pulse, which came down to 80 after the tying, isnow 104. Bowels opened freely this afternoon bya domestic enema; belly soft, but still pain in it,and in her back ; tongue clean;- considerablethirst; moderate appetite. A poultice to be laidon the belly. The pills, with calomel and anti-mony, to be repeated, and the occasional use ofanodyne injections continued.

S1st, eight o'clock, a. m.-Pulse 96, moderatelyfulal and strong; had five or six hours' sleep in thenight; slight sickness and vomiting; pain andsoreness in the belly, back, and thighs; urine free;no motion since last night. She sometimes rejectsthe saline effervescing mixture. The pills to berepeated.



rTwo o'clock, p. m.-Pulse_ 125, and weaker, butrespirations only about 28 in a minute; feels veryfaint and weak belly sore; domestic enema wasreturned very little changed; no vomiting sincemorning; complains of much beating sensation inher head. Six leeclhes, followed by a poultice, tobe applied to the abdomen.

Eight o'clock, p. m.-!-Pulse 120, and ratherfirmer; had a yellowish free loose stool about threeo'clock in the afternoon, whlen the ligature wastightened, and soon afterwards the usual coinpos-ing enema was administered. Eas slept tolerablyto-day, yet complains of soreness of the belly, andpain of the part, but is somewhat easier than in theafternoon; no vomiting since morning; skinrather warm and moist; tongue, as usual, clean;urine free; troubled, somewhat more than usual,with a cough. On the whole she certainly is worseto-day than at any time since the operation. Asaline mixture, with tincture of opium, was pre-scribed.

September 1st.-No vomiting, excepting a littleof her medicine; two free dejections after takingsome magnesia. Pulse 124, moderately full andstrong; belly rather tender; pain in back, and onanterior part of the right thigh, down to the knee,nearly similar to wliat often occurs in dysmenor.rhcea; urine free; skin warm; cough better;respiration easy. I tightened the ligature this

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3.78



morning, afterwards she had nine drops of theblack drop in a draught, and the anodyne inje'-tion.

Four o'clock, p. m.-A good deal of pain to-day:in the part, and in the back, but has slept tolerablywell at intervals.

Nine o'clock, p. m.-Has vomited a little curdledmilk and fluid slightly tinged with bile. Bowelsopen; urine moderately free; skin warm, andmoist; tongue moist and clean; pulse 120;. bellyrather tender, but not tense or tumid. She willnot permit the ligature to be tightened this evening.

Rep. haust. anodyn. hac nocte et mane.

2nd, half past seven, a. m.-Slept pretty well.Pulse, 114 in a minute; but after tightening theligture this morning, it diminished, as usual, andfell to 100. Fcetor ,ofvaginal discharge continues.Complains of general soreness over the breast,belly, and thighs. A mucilaginous linctus withtinct. of opium, was prescribed.

On examining this evening, which is the twelfthday since the first application of the ligature, thethin, or rather broad peritoneal surface of. theuterus appeared to be the only portion remainingundi-vided. It was, therefore, thought advisableto complete the separation, by dividing this part


0MR. WINDSOR9S CASE OF

with a pair of scissors, which gave her very littlepain. No hemorrhage followed. The pulse afterthis fell to 108 in a minute. The remaining cer-vix uteri was now gently raised, and supported bya little sponge introduced, and another piece ap-plied externally with a T bandage over it, so tlhatcompression might be used, if any bleeding shouldoccur. The anodyne draught was repeated.

The removed uterus measured three inches fromthe fundus to the cervix, and the same from sideto side, being nearly square, but a little roundedoff at the fiundus; colour chiefly red, but probablyfrom incipient putrefactive process, marked a littlewith greyish spots and lines; the circumferenceof the whole around the fundus and cervix exactlynine inches.

The uterus being cut open, exposed a part of tlhefallopian tubes, and the ligamenta rotunda; theovaries and the fimbriated extremities of the tubes,it was found, were left behind. The length of thefallopian tubes removed measured two inches anda halfon each side; the extremities of them-on thenaturally internal rugous surface of the uterus ad-miiitted a bristle; coagulated lymph in small quan-tity, and but slightly adherent, was observed ontlle peritoneal surface, but the uterus was open atthe part where it was divided, the opposed-peri-toneal c6verings having not become sealed. to-getlier by the adlhesive inflammnation. - The mouths

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380.



of a few blood-vessels appeared on the rugoussurface.

srd, half past seven o'clock, a. m.-Has sleptmoderately since three o'clock; one copious de-jection; no vomiting; has still a feeling of gene-ral soreness; same appearance of aphtha in themouth; belly soft; has had no bleeding from thiepart, though she soon removed the sponge, as itproduced uneasiness; urine free. Pulse 108, andof moderate strength. The embrocation to becontiniued; and to take, e-very two or three hours,a draught with ten grains of subcarbonate of soda.

Ten o'clock, p. m.-Has slept moderately to-day; less pain in the back and thighs; mouthalso better; some cough, with mucous expectora-tion. Foetid discharge gone. Complains of weak.ness, and of soreness of the belly, to which com-mon poultices are directed to be applied.

sth.-The inside of the lips and cheeks exhibitsnumerous small superficial ulcers, attended with analmost constant flow of saliva. Appetite. prettygood, but deglutition rather difficiult, from a feel-ing of soreness in the primae vie; very little sore-ness in the part, or in the abdomen; pain in theback and thighs diminished; has little cough; res-piration easy. A little magnesia was added to thedraught.


MR. WI$DSDR'S C4PE 0O

6tb.-Ulcerated state of nioutj, with slight ptyialism and difficult deglutition continue, and pre-vent lher rest. Pulse 114; bowels open; urinepretty iee and cleay but the voiding it ra14herpzipful; appetite tolerable; still a, little pain inthe back and belly no pain! in th1e part, an4scarcely any discharge from it. The anodyne tobe taken occasioially; a linctus, with soda andtinct. camphor. comp. to be used, and a draughtwith half an ounce of infusion of calumba, to betaken every three hours.

7th.-Pulse 112; pains and soreness much di4minished; mouth and throat rather better; bowelsopen; urine free; a littlle whitish discbharg ordyfrom the vagina. To take a little wine with hergruels and jelly.

8th."-Slept mwdruately, but complains of feelingvery weak; ulcerated state of nmputh, with almostconstant spitting out of saliva, and occasionalhawking up Q.f mucus, troublesome - had two de-jections yesterday, containing some blood andslime; tlroat sore; a little pa4p and feeling of&itus in the abdomen. pulse 120, and rathersmall; appetitq mo4erate; bI¶t deglutition diffi.cult. An enema, of- milk, in which aniseed- andcarraway.seeds were boiled, was given. A poulticeto be applied to the abdomen; and a draught, withinfusion of cascarilla, to be given every four or sixhours.

$82


EXTIRPATION OF AN INVERUE'I UTERUS. 383

Oth.-Pulse 120; rather fiFmer than yesterday;appetite moderlate; food consisting principalJy. ofeggs, milk, jellies, and gruels, with softened >read.Edges of the tongue less sore; bowels regular,and evacuations more natural in appearance; urinefree and natural; slight soreness in the part, withscarcely any discharge.

ioth.-Not quite so well as yesterday, felt veryfaint last night; slept moderately as usu;al buthad some delirium; pulse 1S; bowels regular *urine free; no great pain, but some soreness ofthe belly, the leech-bites having many Qf thenmsuppurated; stomach tranquil. Superficial ulcersof mouth continue, with spitting out of saliva andmucus.

To use a gargle with kinio, borax, tincture ofmyrrlh and honey.

14th.-Sleep moderate; pulse 114, and of to-lerable strengtlh; complains of general soreness,but no particular pain; soreness of mouth and sa-livary fluid slightly dimniniphed.

17th.-Pulse 108; a little cough, with someexpectoration for the last few days, which is nowrelieved by using a mucilaginous linctus; sorenessand slightly ulcerated state of mouth continue,though somewhat better; no discharge per va-guiam.


MR.' WINDSOR'S CASE OF

-23d.--Feels better; pulse 100, and of goodstrength ; was dressed yesterday for the first time;remained up two hours, and ate a pretty heartydinner; slight ptyalism and a little cough con-tinue.

24th.-To-day I examined the state of the parts,just three weeks sinbe the uterus was removed. Thevagina appeared to be short, perhaps between twoand three inches long, having at its upper part inthe middle a small opening, feeling to the fingervery like the natural os internum; it would admitthe tip of the finger, but as the attempt gave herpain, I desisted from pushing it further, since itwas from a promise not- to give her pain, that Iwith difficulty obtained her permission to makethe examination. From this, however, we havereason to conclude that the dilated os uteri, afterthe distending cause is removed, soon returns toits naturally contracted state.

October I1.-I met her walking out alone in thestreet to-day, which she has done for several days;she still looks pale and delicate, but has no com-plaint; has a good appetite, and is improving fast.

November 16th.-Has now regained a very com-fortable state of health, is considetably stouter,and her complexion, though naturally pale, is muchimproved ; is able to- go about, and to superintendthe bakehouse. To-day I carefully exam.ined the

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EXTIRPATION OF AN INVERTED UTERUS. S85

state of the vagina, and both it and the os uteri(which as usual projected somewhat into the va-gina) did not appear to me to deviate at all fromthe natural condition. It is three inches in lengthat the posterior, and two and a half at its anteriorpart; the long diameter of the os uteri is directedlaterally, and will admit the tip of the middle fin-ger. There has been no sanguineous dischargesince the operation, nor has any disposition to pro.lapsus of the os uteri as yet manifested itself.

Before concluding the subject I shall offer a fewsuggestions on the best mode of removing theuterus, in those cases of inversion, where palliativemeans are insufficient to arrest the fatal tendencyof the disease; and this more for the purpose ofinviting others to the subject than from any thingimportant that I can produce.

In Mr. Newnham's operation, the separation ofthe uterus was accomplished by the ligature only.In the above case it was effected partly by ligatureand partly by excision.

To the patient the operation by ligature is cer-tainly very tedious and very painful, (though per-haps amply compensated by future comforts andprolongation of life); to the surgeon it is fraughtwith protracted anxiety for the event. 'Wotld itnot therefore greatly curtail and diminish the pa-tient's sufferings, and the practitioner's suspense


MRL. W wDSORa,s CASE OF

of x iifd, if the e*cisiori of the uterus could besafely adopt-ed at ofte instead of the slower actionof the ligature? We have on record cases whereexcision of the uterus seems to have been followedby recovery; but much will depend on the care ofthe 'operator, and on the constitution of the pa.tient. We have, however, one case where theoperation was performed under very unfavourablecircunistances. In this case, mentioned by Wris.berg, and- related at considerable length by Dr.Hull, p. 119, 126, Letter II. the uterus was cutaway by an ignorant midwife, immediately af.ter the in'version, and consequently the peritonealcavity (if I may use the expression) must havebeen extensively opened, yet the succeeding in-flammation was rather of a sanative than destruc-tive nature, and the patient recovered.

Where inversion occurs, the uterus, I believe,is generally contained in the cavity of the vagina,tlhe ovaria and fimbriated ends ofthe fallopian tubeslie hewre on the brim of the inverted part, but notwithin it, as I have seen in one case: probablythese parts become somewlhat agglutinated by ad-hesive inflammation, and also connected by thesame process to the'bladder before and to the rec-turm behind; and hence there may be less dangerof opening the peritoneal cavity if excision is prac-tised in the chronic stage.

In-some cases, either originally or by time, the

s8s


EXTIRPATION OF AN- INVERTED UTERUS. 387

peritoneal connexions becoming elongated, the in-verted uterus. may have its fundus projecting be-yond its external parts; and here the ovaria andfimbriated ends ofthe fallopian tubes may be withinthe cavity of the inverted uterus.

In the above case of Harriet Qarwick, adlhesiveinflammation had not connected the opposite pe'n.toneal surfaces-, where the uterus was separated,but it might previously have occurred higher up,thus diminishiing the danger of general peritonealinflammation in the operation.

After the protruding uterus is removed, the osuteri seems to be soon restored to its contractedstate, whiich will assist in p)reventing any prolapsusof the abdominal viscera thirough this part.

Before practising excision, it would probably bebest first to secure the uterus above by a ligature,in order that any hiemorrhage mighit be more easilycommanded; in a day or two the adlhesive inflam-mation might be powerful cnougli to prevent anyfurther danger of hiemorrhiage, and thle ligaturemight then be safely removed.

If, lhowever, the ligature should be preferred tothe operation by excision, the process of separa-tion miight be considerably accelerated by passinga needle throughi thle uterus, aid using two canul1instead of one, eachi ligature comprchending half


888 MR. WINDSOR S CASES &C.

of the uterus, nearly in the same way as the ton-sils are tied; a process suggested by Dr. Hull.

After- the uterus is separated, the truncatedcervix seems to recede a little, the os utenr con-tracts, and the vagina is restored to its naturalstate.'

P.S. Nov. 15th, 1819.-Harriet Barwick hasnow, for a considerable time, enjoyed a very ex-cellent state of health.


observations - history-of-obgyn.com · stalte, and the female has been subject to prolapsus uteri,...

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