A. D., then aged twenty-four, and residing in Buffalo, gave birth to a female child, July 15, 1850. The midwife who attended her in her confinement, experienced some difficulty in the removal of the placenta, but finally succeeded in pulling it away. This act was followed by so much hemorrhage as nearly to destroy the woman's life. From this time until the day of the operation she suffered a continual loss of blood, which twice a month amounted to flooding. She consulted various physicians in relation to her condition, but received no benefit from any of them. This is not surprising when we are told that, until Dr Strong was called to see her in 1870, no physician had ever proposed to make an examination per vaginam with the view of determining the cause of the hemorrhage.

March 2, 1870, Dr. Strong was called to attend Mrs. D. He found her lying upon a bed, about which were evidences in abundance of the terrible flooding which had just occurred. Upon making a digital examination, he discovered a tumor about the size and shape of a small pear, occupying the vagina, which, after a careful specular examination, he diagnosed as an inverted uterus. Dr. S. informed his patient that he considered that her condition permitted the use only of palliative measures, and advised the use of tonies and local astringents. Afterwards, learning of Dr. White's previous, successful operations for chronic inversion of the uterus, a correspondence arose between that gentleman and himself, with reference to the case of Mrs. D., which resulted in an invitation to Dr. White to visit the patient, and, if upon examination he should think it advisable, to attempt the reduction of her uterus.

June 23. 1872, Prof. White, with Profs. Julius F. Miner and M. G. Potter, Drs. Geo. N. Burwell, W. C. Phelps, and the writer, whom he kindly invited to accompany him, proceeded to the residence of the patient in the town of Colden, N. Y. She was found to be feeble and very anæmic, and slight hemorrhage from the tumor was then occurring. Prof. Potter, who was requested to take charge of the anesthetic, administered some chloroform to the patient, and the tumor was then examined by several of the gentlemen present. It resembled in size and shape an ordinary hen's egg, and was suspended in the vagina by a long, narrow pedicle continuous with its upper and smaller extremity. This appearance, particularly the small and elongated cervix, led some who examined it to doubt its being a uterus at all, and to consider it rather a polypoid growth. But a probe could not be passed along the pedicle into the os, as might have been done had the tumor been a polypus, nor could the uterus be detected by palpation over the abdomen. A uterine sound passed into the bladder could be felt by the finger in the rectum above the tumor, and by the hand placed over the hypogastrium; also the finger, passed up the rectum, came in contact with the anterior abdominal wall as felt by the other hand. All these diagnostic means proved the absence of the uterus from the situation which it ordinarily occupies. By these negative proofs, Dr. White was entirely convinced that the tumor was the inverted uterus, and he therefore proceeded to attempt the reposition of the same in the presence of the above-named gentlemen, and of Drs. Strong, of Colden, G. H. Lapham, of Aurora, and Davis, of Boston. Dr. Potter had produced anesthesia by chloroform, which he now exchanged for ether, with which he kept the patient anesthetized during the operation. Dr. White assumed a kneeling posture in front and between the legs of the patient, who had been placed upon the side of the bed with her hips projecting a little beyond its edge, and her feet resting in the laps of Drs. Miner and Phelps, who sat on either side of Dr. White, each supporting a knee and holding a hand of the patient. Dr. White then introduced his right hand into the vagina, and began manipulating the tumor. This manipulation consisted in compressing the uterus, which relieved its congestion and rendered it more pliable, and in making gentle pressure in the line of the axis of the pelvis by the use of the uterine repositor. After continuing this a short time the doctor brought the tumor down to view, when a glance sufficed to assure the doubting of its true nature. By the pressure which had been exerted the neck had been

shortened and dilated, the body and fundus reduced in size, the superior angles (now inferior) were distinctly seen, and altogether the tumor then presented the normal outline of a uterus of small size. The repositor was again introduced, and a pressure of eight or ten pounds exerted by it, and, at the same time, compression was made by the hand within the vagina upon the portion of the uterus protruding beyond the os, the same hand also retaining the fundus uteri and the repositor in coaptation, whilst the left hand was employed in pressing above the pubes or through the rectum. When, in this manner, the cervix had been made to embrace the fundus, the uterine repositor was substituted by a large rectal bougie, with which pressure was continued until the close of the operation.

At the end of an hour and fourteen minutes, Dr. White was obliged to discontinue his efforts on account of the benumbed condition of his intra-vaginal hand, caused by the pressure upon it of the narrow and unyielding vagina. The fundus was at this time within the cervix and above the os, and the doctor considered the reduction substantially accomplished. He requested Dr. Miner to continue the manipulation, which he did, and in sixteen minutes, or just one hour and a half from the beginning of the operation, Dr. Miner enjoyed the satisfaction of announcing that the uterus, which for twenty-two years had been completely inverted, was now as completely reposited. Two hours after the operation, when we left her, the patient was quite as comfortable as could have been anticipated. An opiate was administered, and directions were given the attendants to keep her perfectly quiet for at least a fortnight. By letter dated June 27, Dr. Strong reports: "Mrs. D. doing better than we had dared to expect." July 2, Dr. Strong writes: "Our patient is doing well, and nothing has yet interfered with her progress toward recovery." July 19. "Since the operation upon Mrs. D., nothing has transpired to mar the beauty of the result. The pulse has at no time exceeded ninety per minute." At this time a careful examination "shows the uterus occupying its normal position, the intra-vaginal portion of the neck presenting the ordinary appearances of mild cervicitis. The patient is now about upon her feet some portion of her time, and everything points to a rapid, and I think, perfect cure. She has had no sanguineous discharge since the operation." On the 23d of August, two months after the operation, the following letter was received :

MY DEAR DOCTOR :-Allow me to congratulate you on the perfect success of your operation upon Mrs. D. I have delayed writing thus long that I might not be required to retract any statements made in regard to the success of the operation. The most sanguine could not have expected so good a result. She now does her own work, goes on foot to the neighbors', rides ten miles and returns over the hills, and in fine now seems competent to perform her part in life. At the expiration of four weeks from the operation, she had a regular menstrual discharge, which seemed perfectly normal both in regard to amount and character. Your obedient servant, O. C. STRONG.

In order to ascertain her subsequent condition, I addressed a note of inquiry to the doctor, and received the following reply:

COLDEN, Jan. 20, 1874.

MY DEAR DOCTOR :-Your note of inquiry is received. In reply permit me to say that Mrs. D. is in the enjoyment of good health; that her menses are regular; that in her present appearance one can see nothing to tell the tale of those twenty-two long years of suffering; nothing that speaks of terrible floodings; and, in fine, nothing to show that she ever possessed an inverted uterus. Very truly yours, O. C. STRONG.

It would seem an unnecessary expenditure of the time of this learned. body to detail the remaining nine cases. Those related fairly illustrate the state of the organ at the different periods of the accident, and the mode of operating for its restoration. The result has been, in all the cases encountered, restoration by manipulation on the first trial, and as is believed without serious injury to the tissues, thus confirming the conviction that all cases are curable, irrespective of their duration.

CASE OF RETROVERSION OF THE GRAVID UTERUS; TREATMENT BY PUNCTURE; RECOVERY.

BY

THOMAS F. ROCHESTER, M.D.,

PROFESSOR OF PRINCIPLES AND PRACTICE OF MEDICINE IN THE MEDICAL DEPARTMENT OF THE UNIVERSITY OF BUFFALO.

ON December 17, 1874, three children, the eldest ten years of age, were attacked with a severe form of scarlet fever. Their mother, with characteristic maternal devotion, was almost their only nurse, although at the time of their seizure she had commenced the second month of her fifth pregnancy. She was on her feet a great deal, and very frequently lifted and bathed the children, although herself of slight and delicate frame. To this she ascribed the unusual pressure and bearing down experienced in the recto-vaginal region, such as she had never felt in her previous pregnancies.

A little after midnight on March 17, 1875, her husband informed me that his wife feared a miscarriage, as she was in great pain, and flowing profusely. Visiting her immediately, and making a digital examination, I found the vagina filled with an elastic, globular mass, as large as the foetal head at full term. Nothing like an os uteri could be found. The sub-pubic space was tightly filled, as was also the perineal; it was impossible, by rectal exploration, to pass the finger above the lower segment of the tumor. The hemorrhage was free, and was found to emanate entirely from the urethra. A catheter was introduced with considerable difficulty, the instrument taking a backward and downward direction, and serving for the evacuation of about six ounces of very bloody urine. So impacted was the vagina, and so strong was the pressure upon the rectum, that it was impossible to make the vesico-rectal exploration by the catheter and finger.

The case was presumptively one of retroversion, or rather of complete eversion of the pregnant uterus, at or exceeding four months. The condition was so grave that the attendance of my colleague, Prof. James P. White, was obtained in consultation as soon as possible. He made a most critical examination, and was, like myself, unable to find the os uteri. We concurred in the opinion that it was either complete eversion or an immense hæmatocele, and that, in the former event, any attempt at restoration was out of the question on account of the strong pressure and great size of the tumor, and that the attempt would probably be followed by metritis or rupture, or both.

It was resolved to puncture the mass with a small exploring trocar, and the tumor was accordingly pierced at its most depending portion, when about four ounces of clear, straw-colored fluid passed through the canula. There was no blood, the fluid being evidently liquor amnii. Half a grain of morphia was administered, and the patient was left to obtain a few hours of much needed rest. At 5 P. M. the patient was very comfortable. She was now placed in the knee-face position, and an endeavor was made to lift the fundus; but this could not be done. The

bloody urine was still passed, but not as frequently or as painfully as before. The morphia was repeated.

On the morning of the 19th, slight labor-pains set in, and increased in force and frequency very gradually. With each pain the mass sensibly contracted, and the everted fundus was lifted a little toward the rectum. Shortly after midnight, on the 19th, the pains became forcing, and, at 3 A. M., a flattened sphere, the foetal head, emerged under the pubic arch. At 4 A. M. a male foetus, nine inches long, was expelled, and very soon after was followed by the placenta and membranes. The intra-vaginal tumor was now diminished about one-half in size, but still retained its completely capsized position, and it was still impossible to feel the os uteri. It was not thought proper to make any immediate effort towards restoration. At 5 P. M. eight ounces of urine, slightly tinged with blood, were removed by the catheter, and during the two following days the urine was drawn, morning and evening, constantly improving in appearance.

On the 22d, copious alvine evacuations followed a soap-suds enema, and on the evening of the same day the os uteri was distinctly felt under the pubic arch, and the fundus had receded to the sacral hollow. From this time forward the catheter was not used. On the 22d, there was an abundant lacteal secretion, which disappeared spontaneously in about ten days. The patient was instructed to lie upon her face and sides, and to avoid straining at stool. By April 5, she was apparently perfectly well, the lochia had ceased, and there was no vesical or rectal irritation. The uterus became gradually reduced in size, but still retained its retroverted position, and it was still thought safest to defer attempts to replace it. The patient was in fact too well to be disturbed, and had manifested no serious symptoms, except local ones, during the severe ordeal through which she had passed. She was always bright and hopeful, suffered little pain, and had at no time any febrile movement; her pulse was only accelerated to 100 for the two days preceding the expulsion of the fetus. She was instructed to use warm vaginal and rectal enemata daily, to maintain the recumbent or semi-recumbent position, and to await the proper time for interference, which she very patiently did.

On May 1, her menstrual period came on, and lasted five days. On May 13, Simpson's sound was passed in, to the depth of three inches, and the uterus was by its aid placed in the proper position, from which, however, it fell back within a day or two. This operation was repeated, once a week, until the second period returned, which was on May 31. On June 10, the uterus was placed in position; on the 19th, it had receded again, was restored with the sound, and was now retained in position with a cradle-shaped, hard-rubber pessary. This was worn with entire comfort for six months, and was then removed. The uterus has since retained its proper position. The patient is apparently perfectly well, but has not been again pregnant.'

Remarks. This case has been presented, certainly not for its novelty, but to illustrate the successful result of a method of treatment. When

1 June 11, 1877. The patient is again three months advanced in pregnancy. She consulted me at the end of the second month, when the uterus was again found retroverted. It was replaced by the repositor, but it was found necessary to retain it in situ by a pessary, and the three-winged instrument of Thomas was employed successfully, after failure with the cradle-shaped one previously worn. At the present date, gestation is progressing favorably.

892 ROCHESTER, RETRO VERSION OF THE GRAVID UTERUS.

we consider the number of fatal cases on record, and when we further consider the serious injury that has frequently resulted to both bladder and womb, either from entire neglect or from repeated and protracted attempts at restoration, and when we remember that in the greater proportion of cases of retroversion of the gravid uterus, even if the organ is replaced by posture and manipulation, the operation is almost always followed by abortion and metritis, may not the procedure which has been described be more safe than the treatment usually adopted? I do not wish to be understood as advocating puncture or tapping of the womb, through its walls, in preference to separation or rupture of the membranes through the os uteri, when this is accessible; but only when, as in the case reported, the os cannot be reached.