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        DISSERTATION




              ON





RETROVERSION OF  THE WOMB,






           &c. &c. 
 
A
DISSERTATION
RETROVERSION OF  THE WOMB,
INCLUDING SOME
OBSERVATIONS
                     ON


EXTRA-UTERINE  GESTATION.
/
by    \y
         SAMUEL MERRIMAN, M. D.

PHYSICIAN MAN-MIDWIFE TO THE WESTMINSTER GENERAL
     DISPENSARY, AND TO THE MIDDLESEX HOSPITAL.
  Multa certe fieri non posse judicantur priusquam sint facta; et in multis na-
ture vis fide caret, in iisque occultis natures operibus non ratio semper quse-
renda subtilius, sed cum admiratione spectandus effectus; fatendumque est
multa in corporibus nostrisquotidie fieri, quorum vim naturamque perspicere
non possumus.        Th. Bartholimis de insolitis partus humani viis.
^£cnl>S/?
*  LIEIIAPJ
PHILADELPHIA:  «>/$/fi^c */■
PUBLISHED BY THOMAS DOBSON AND SON, AT THE STONB
         HOUSE, NO. 41, SOUTH SECOND STREET.
                  William Fry, Printef.

                       1817. 
 
PREFACE.
  The substance of the following Dissertation was
originally  published in the  Medical and Physical
Journal;—it is here considerably enlarged.

  The Records of Medicine are abundantly sup-
plied with reports of cases of extra-uterine gesta-
tion: these we may divide into two classes:—First,
Where  the  conception has been   detained  and
nourished in some of the appendages of the utei us.
Secondly, Where the nourishment and maturation
of the foetus  has been supposed to be effected  in
a receptacle  separate and apart from the  uterus
and the uterine system. This last opinion seems  to
have been adopted too readily; at least it will, I am
fully persuaded, be found, upon a nice and accurate
examination of  this latter class,  that the writers  of
the cases were not so minutely exact  in their obser-
vations, nor so explicit  in the detail  of many very
important and essential  particulars,  as  to stamp,
with credulity,  an occurrence  so incomprehensi-
ble and so repugnant  to the usual operations  of
nature. 
VI
   A case of extra-uterine fcetus was published not
 long ago by a learned and observant physician, as
 a decided instance  of extra-uterine gestation,  in
 which he thought the ovum, instead of being  con-
 veyed into the uterus, had fallen into the abdominal
 cavity, where, like a parasitical  plant, it took root,
 and arrived at maturity. But,  upon  examining  the
 circumstances of the case, as they  are detailed in
 the sixth volume  of the Memoirs of the Medical
 Society of London, there seems no good reason for
 subscribing to such an opinion. It is there stated,
 that the woman  carried the  child within her seven
 or eight months  beyond the ordinary term of preg-
nancy, when, being worn out  with a long series of
insupportable sufferings, she died. On examination
after death, "the  uterus  was found nearly in its
natural state,  without  any  visible  sign of  im-
pregnation; and behind it was found  almost the en-
tire skeleton of a full-grown child, part of the bones
of which had perforated the  rectum, and the rest,
by their pressure, had rendered  the  lumbar  verte-
bras quite carious.', These circumstances, added to
the occurrence of ineffectual pains at  the end of the
first nine months of gestation, when, we  are told,
the os  uteri did  not  testify any sign  of pregnancy,
induced the author to consider the case as strictly
extra-uterine. Do these facts alone, unsupported by
 other evidence, warrant such an inference?  I con-
fess they appear to me by no means sufficient to es- 
vii
tablish so great a deviation from the usual and na-
tural course of conception and gestation.

  In  the following  pages I have endeavoured to
point out another method of explaining cases of this
kind,  viz. where the bones of the fcetus have  been
found, extra-uterum, in the hollow of the sacrum
between the vagina and rectum, or when they  have
been excluded through the anus  or through ulce-
rated openings in the adjacent parts. I think it very
supposable, that these cases have arisen from the
uterus remaining  in a retroverted  state beyond the
customary period of  utero-gestation;  when,  the
pains  of labour having proved insufficient to restore
the uterus to its proper situation,  and to expel the
child,  the incumbrance  has  been  removed   into
the cavity of  the pelvis,  either by a laceration or
suppuration of the parietes of die womb.

  At  present I can do little more, than throw out
hints  respecting  the probability  of  this opinion;
but in support of it I have  collected several strik-
ing facts from various authors, and have establish-
ed, by two very conclusive cases,  the possibility of
such  a position of the uterus at the termination of
the period of utero-gestation. At  all events  I  hope
that the arguments, which I here bring forward,
will have so much  weight  with gentlemen in the
practice  of Midwifery, as to induce  them, when-
ever they  may hereafter  meet with such  obscure 
Vlll
and rare cases, to  endeavour to ascertain, whether
the foetus, during the time it continued alive, were
not contained  within  the  uterus;  attention to this
circumstance  having, I think, been  too  much ne-
glected. 
DISSERTATION,

       &c. &c.
THE displaced position of the  Womb, termed
Retroversion, which  sometimes  occurs  in the
early  months  of pregnancy, and  occasions  a
suppression of urine and other ill consequences,
is an accident  not unfrequently met with in the
Practice of Midwifery. Some persons have sup-
posed that this complaint had  never been ob-
served till about the  middle of  the last century;
and if by this  is meant, that the real nature of
the case  has  only been  accurately described
within that  period, the observation  is correct:
but abundant  proofs may  be  collected,  from
writers on the Art of Midwifery, that suppres-
sions  of  urine from  this cause have  always
existed.

  When Mauriceau tells us, that the neck of
the bladder is sometimes so compressed, in the
                     A 
2
first months of gestation,  from the falling down
of  the  uterus, that the  bladder becomes com-
pletely  distended  with urine, and that the  pa-
tient suffers violent pain from  an inability  of
passing her  water;   and  when we  afterwards
learn that  this suppression is only to  be reme-
died by the introduction  of the catheter, which
must be repeated  again and again, till the patient
is  able to  pass her  water naturally, who can
doubt  that  he is  describing the  circumstances
of  a retroverted  uterus.* Or  when  we  learn
from La Motte, that, in a case of suppression
of  urine,  when the  woman  was  suffering ex-
treme pain, he could  not  introduce his catheter,
without first passing his  finger into the vagina,
in order to raise the uterus, which was pressing
with so much  firmness against the meatus urina-

  *  Sile col delavessie estpressepar rabaissementdupropre
corps de  la Matnce, comme il peut arriver dans les premiers
moiB de  la Grossesse, aux Femmes qui sont sujettes aux
Descentes de la Matrices pour lors la vessie se remplit en-
tierement d'urine, laquelle y demeure avec grande douleuv
n'en pouvant pas etre expulsee; d'autant que le muscle
Sfihincter a cause de cette  compression, ne peut pas s'ouvrir
si facilement qu'a l'ordinaire  pour la laisser ecoulerj—
pour lors on aura recours au  dernier Remede, qui est de
faire sortir PUrine avec une Sonde percee, et on fera dere-
chef uriner la Femme de la meme facon jusques a ce que
les accidents soient appaises.
             Mauriceau Maladies des Femmes Grosses. 
3
 rius,  as  entirely  to prevent  a  single drop of
 water from  passing;—who can believe that  all
 this difficulty  and  distress  was  occasioned  by
 the  mere descent of the uterus,  and  the pres-
 sure of the head  of a  five-months foetus  on the
 neck  of   the  bladder?*  It is not possible  to
 account  for  all the symptoms of this  case,  but
 by recurring to the idea, that  the  uterus was re-
 troverted.

   It is,  however, sufficiently  clear, that  neither
 Mauriceau, nor La Motte, nor any other writer
 of  that  time,  was acquainted  with  the  true
 nature of the case, when a suppression of urine
 was produced from this cause; and it is not a
 little  remarkable,  that  Deventer,  whose atten-

  * Une Femme grosse de cinq a six mois, m'envoya prier
 de venir la voir, souffrant les plus cruelles douleurs a Poc-
 casion d'une suppression d'urine—Je la trouvai dans le fa-
 cheux etat d'une entiere Suppression, qui lui causoit d'ex-
 tremes douleurs, ayant toujours  Envie d'uriner, et s'y pre-
 seatant sans cesse, sans qu'il s'en echapat une seule goutte.
 Je voulus introduire ma Sonde, mais y trouvant une Resist-
 ance insurmontable, quelqu' effort que je fisse pour en venir
 a bout,—j'introduisis mon doigt dans le Vagin, au moyen
 du quel je trouvai la tete de I'enfant tout proche, et appuyee
 sur la partie interieure de l'os pubis, entre lesquels etoit le
col de  la vessie,  qui souffroit une  compression si exacte
qu'elle  interceptoit absolument le cours de Purine.
                   La Motte,  Traite des Accouchemens. 
                       4
 tion was so  particularly called to obliquities of
 the  womb,  and who  has  so  well  described a
 Retroversion of the  Womb,  as  I shall  after-
 wards notice;—it is, I say, not a little  remark-
 able, that he did not discover  that such a posi-
 tion of the uterus must frequently be a  cause of
 the suppression of urine.

   The first  person who appears to have  enter-
 tained a tolerably correct idea of this accident,
 was Monsieur  Gregoire, an accoucheur of con-
 siderable reputation,  at Paris,  about the middle
 of the last century, and a lecturer on the Prac-
 tice of Midwifery.  Monsieur Gregoireys lectures
 were  attended  by many young  students, who
 afterwards became celebrated as accoucheurs;
 and among  others  by our countryman,  Smellie;
 yet his doctrine upon this subject seems to have
 been recollected by only two of his pupils,—
 viz.—the French accoucheur,  Monsieur Levret,
 and Mr. Wall,  from whom the accoucheurs of
 England first  gained  information of this com-
 plaint.

   The lectures which Gregoire delivered were
 never  printed, and therefore it is impossible to
 know  exactly  what  opinion he  had  formed of
 this accident;  but  that  he was  aware of  the
fundus  uteri being thrown  down between  the 
5
vagina and rectum, is  evident from  the direc-
tions  which he  gave  for  replacing it:  these
were, that with one finger  in the vagina  and
another in the  rectum,  an attempt should  be
made to  raise  the  fundus and to replace the
uterus. It  should  seem that he advised this to
be  done while the  woman  was lying on her
back,  which is by no means a favourable pos-
ture for effecting this purpose. Whenever this
manoeuvre  is  deemed  necessary,  it  may be
accomplished much more  effectually and expe-
ditiously  while the patient is  resting  on her
elbows and knees.

   In tHe year  1754 Mr. Wall, who had settled
in  London, was  called  to  attend  a woman
labouring  under  a suppression of urine, from  a
retroversion of the uterus, and being convinced
that it was a case of  the kind described by
 Gregoire,  he endeavoured to relieve  his patient,
according to the method above mentioned, but
failing in his object, he called in the assistance
of the late  Dr. William Hunter; their united en-
 deavours in various ways were however unavail-
 ing, and the poor woman died.

   Dr. Hunter  with the most laudable anxiety to
 disseminate knowledge,  and improve his pro-
 fession, having obtained leave to open the  body,
*) 
6
 invited a number of gentlemen of  the faculty of
 medicine to  a public lecture which he  read, for
 the purpose of  making the  disease  generally
 known; and having caused drawings to  be taken
 of the parts  as they appeared  on dissection,  he
 afterwards published an engraving of them, in his
 great work, The Anatomy of the Human  Gravid
 Uterus.

   The  case  of this unfortunate woman,  which
 was the means  of first  making British  practi-
 tioners  acquainted  with this disease, being now
 difficult to be procured,  and being in many re-
 spects curious and  useful, I  have  thought it
 advisable to insert  it at length, as originally
 published by Dr. Hunter, in the fourth volume
 of the Medical Observations and Inquiries.

   " A young woman about four months advanced
 in her first pregnancy,  after a  fright, was taken
 ill, and  could not without great difficulty go  to
 stool or make water. Her complaint grew worse
 daily, till on Saturday the  twelfth of October,
(1754) both these evacuations were entirely sup-
pressed.  The suppression  of  urine  continued
without any  relief  being given, till  Thursday
the seventeenth, when Mr. Walter Wall, surgeon,
was called to her assistance.  He drew off by
the catheter, about seven or eight quarts of urine. 
He then  attempted to throw up a clyster; but
very little passed up, and  it had no  manner of
effect.  In the  afternoon  about  three  quarts
of urine  mixed with blood were  drawn  off by
the catheter.

   " In order to discover the cause of these symp-
toms, Mr. Wall introduced  a finger  into the
vagina, which  could not pass on account of a
large tumor that lay behind  the vagina, and
pressed it close to the  inside of the ossa pubis.
As there was  not  room to pass the finger, he
could  neither  reach the extremity  of the va-
gina, nor could he  discover any  thing like the
os uteri.

   " After this he  examined  the rectum, and
found that  the  same  tumor  which  lay above
or before the gut pressed  it so strongly against
the inside of the os coccygis, &c. that the finger
could only be passed a very little way.

   " These circumstances made Mr. Wall recol-
 lect a case of retro verted  uterus,  which Mons.
 Gregoire had  given in his lectures at Paris. He
 then concluded that this was a case of  the  same
 nature,  and attempted to reduce the  uterus by
 laying the patient upon her back, and  by assist-
 ing with one finger  in the vagina, and  another 
8
in the anus, as Monsieur Gregoire had directed;
but without success.

   " This poor woman continuing in great pain,
Mr. Wall came to me on Saturday the nineteenth,
gave  me an  account of what had passed,  and
desired me to* visit her with him. We found
her exceedingly weak, and  suffering great pain.
She was lying upon her  back.  I passed  my
finger  between the  tumor and the  inside of the
os pubis,  a  little  to one  side of  the  urethra;
upon  which  a considerable  quantity  of urine
was discharged, as my finger removed the pres-
sure from  the  urethra.  We then  proposed  a
second attempt to reduce the uterus to its natu-
ral situation;  for which  purpose we placed  her
upon her knees and elbows, with her head and
shoulders as low as possible. Then I introduced
one hand  into the  vagina,  and  two fingers of
the other into  the  anus,  and endeavoured  to
replace the  uterus by pushing it up with the two
fingers, and at the same  time by trying  to draw
down the upper part of  the vagina, which was
considerably retracted from its natural situation.
But these attempts  were  all in vain;  she  became
weaker and weaker, and died on  the  Monday
following.

  "On Wednesday we  were  allowed to open 
                      9

the body, Upon cutting into  the  abdomen,  we
found  the  bladder  amazingly  distended  with
urine,  and filling up almost the whole anterior
region of the abdomen, like the uterus in the last
months of pregnancy.

   " When the urine was discharged by opening
the bladder, we observed, that the lower part of
the bladder, which is united with the vagina and
cervix uteri, and into which the ureters are in-
serted, was raised up, as high as the brim of the
pelvis, by a large, round tumor, (viz. the uterus,)
which entirely fill up the whole cavity of the pelvis.
We then passed a catheter up the vagina, and ob-
served that it  raised  up the bladder at the top of
the tumor; a demonstation that the upper end of
the vagina, and consequently the  os uteri, was
situated there: and upon making a crucial inci-
sion through the bladder and vagina, at that place,
we found that it actually  was so. The os uteri
made  the summit  of the tumor upon which the
bladder rested; and  the fundus  uteri was turned
 down towards the os coccygis and anus. The ute-
rus in that retroverted state was grown so large,
and  thence so wedged in the pelvis, that we could
not take it out, till we had cut through the sym-
physis of the ossa pubis, and torn  those bones
considerably  asunder, to enlarge the  space be-
tween the bones of the pelvis, &c.
                       B 
                      10
  "It is hard to say what was the cause of this
unfortunate  position of the womb;  for I can-
not think it was the effect of a fright. What-
ever was the cause, had the  case been known
soon after the unnatural situation of the  uterus
took place, that part might  have been easily
replaced by the method above mentioned. But
whenever the impregnated uterus is once thrown
into that  unnatural  position,  and   continues
in  it some time,  it will  probable  always re-
main so,  unless  reduced  by  art, before it  be-
comes so bulky as  to be locked  in the grasp of
the  pelvis:  and  in proportion as this process
advances, the discharge both of urine and stools
will become more  difficult, and at length both
will be  entirely suppressed.  When  such  sup-
pressions once begin, they aggravate  the  evil,
not merely by causing pain, but by occasioning
a load  of  accumulated urine  and faeces in the
abdomen above the uterus, which presses it  still
lower in the cavity of the pelvis, at the same
time that  the  distension of the  bladder, in  this
state,  draws up that part of the  vagina  and
cervix uteri with which it  is connected, so as to
throw the fundus uteri still more directly down-
wards.

   " The following  question  arises  from  the
nature  and unhappy event of  this  case.  Whe- 
11
ther it would not  be advisable in  such a case,
to perforate the uterus with a small trocar, or
any other  proper  instrument,  in order to dis-
charge the  liquor  amnii,  and thereby to render
the uterus so small and  so lax  as to  admit  of
reduction?   If  other methods  should  fail,   I
think such an operation  should be  tried. But
this  unhappy woman's health was so  impaired
by the great distension of  the bladder and such
long-continued misery, that had  it  been done
in the time  that I visited her, she would have
died, perhaps, under  the operation;  at least, in
all probability, she  could not have lived to reap
any great  benefit  from it; and as  the  case  ap-
peared  to  me  to  be so  desperate, I thought  it
most advisable to keep her quiet with opiates,
and to give her  the little  comforts  which cor-
dials and  humanity afford  in the  last  moments
of life.  However,  in  so deplorable  a case,  I
desired that Mr.  Wall would procure the opi-
nion of some  gentlemen of the profession, who
had more  experience  than  either of  us.  He did
 so, but it  was determined that nothing could be
 done to save her."

   This is the  substance of the lecture  which
 Dr. Hunter delivered  in the year 1754, but it
 was not printed and published till the year 1771,
 nor do  I  know of any publication in  England 
12
 upon the subject before that time. It is  indeed
 known, that many cases of suppression of urine
 from this cause happened within that period,
 some of which  were  relieved in consequence
 of the practitioners pursuing the mode of cure re-
 commended above, and others terminated fatally.
 Mr. Lynn, surgeon,  of Woodbridge, in Suffolk,
 was the first person  who published, in 1771,  a
 history of a fatal case from  a rupture of the blad-
 der; and Dr.  Hunter, at the same  time, publish-
 ed the  above  lecture as  an appendix to Mr.
 Lynn's account.

   In Holland,  however, two  curious  histories
 of fatal events  had been published by  Gualthe-
rus van Doeveren, Professor of Midwifery, at
Groningen, in his  Specimen Observationum Aca-
demicarum, ad Monstrorum  Historiam, Anatomen,
Pathologiam,  et  Artem Obstetriciam, prtecipue
 Spectantium;  printed in 1765.

   The first of  these is  entitled Vesicae urinaria
immanis Distensio et Ruptura lethatis, in gravida,
absque vera  Urines  Suppressione,  ante Mortem
ignorata.  From this  relation, we  learn,  that
the patient, twenty years  of age, in  the second
month of  her first  pregnancy, was  attacked with
pains in the loins,  and other complaints, which
 were supposed  to  be the precusors of miscar- 
13
riage: her  bowels were confined, and she had
some difficulty  of making  water;  but as she
every  day  passed some quantity  of  urine,—
(quotidie aliqua  saltern ejus copia  evacuaretur)
no  suspicion was entertained, that the retention
and accumulation of urine in the  bladder was
the cause of her  complaints. After the patient
had been some  time under  the care of another
physician,  without benefit, she consulted  Doe-
veren, who examined the abdomen,  and (misled
principally by the  circumstance of some  urine
being daily evacuated) pronounced her disorder
to  be  a dropsy of the  womb. In consequence
of which he prescribed  diuretics and such other
medicines  as  he thought suitable  to  her  com-
plaint;  but she found  no  relief,  and  after  a
short time  she  died. On dissection,  the  blad-
der was found to have been enormously enlarged
and ruptured;  the uterus almost entirely filled
up  the  cavity of the pelvis, and it pressed  the
meatus  urinarius so firmly against the ossa pubisf
that it impeded the flow of urine, and produced
that immense distension  of  the bladder.* Doe-
veren laments  very pathetically that he was  so
much deceived in  this case,  as he says, that  the

  *  Uterus itidem comprimebat meatum urinarium ad ossa
pubis, sicque retinendo urinam, Vesicae istam enormem ex-
pansionem excitaverat. 
14
 introduction  of  the   catheter   often   repeated
 would  have  relieved  the  symptoms,  till  the
 uterus progressively increasing  in  size,  would
 have ascended into the abdomen, and thus  the
 obstruction to the  proper  flow  of urine  would
 have been removed.*

   The second history is  called  Retentio Urines,
 et immanis Vesica distensio,  in gravida, a Renis
 dextri consumptione et  Hydrope  orta,  lethalis.
 This  is  an exact  description of a  retroverted
 uterus and over-distended  bladder. In this case
 there was likewise  a diseased kidney, the inter-
 nal  substance  of  which  was  completely  de-
 stroyed by suppuration,  and the  kidney  itself
 and the  ureter excessively enlarged, so  as  to
 form  an  immense  tumor.  Doeveren attributes
 the misplaced position  of the uterus and  blad-

  * Patet porro ex hac  Historia,  me non tantum in Diag-
nosi, et in curatione  hujus Morbi errasse, verum sympto-
mate illo memorato seductum, talem commisisse errorem,
qui aegrae (quod vehementer doleo, semperqne cum Animi
mei dolore recordabor) pessime nocuerit, quum recte per-
specta vera morbi causa, sanabilem esse morbum declaras-
set: fierique facile, praeter alia remedia,  potuisset  catheteris
in vesicam introductio, eaque saepius repeti, donee progres-
sa Graviditate, ultra  marginem pubis adscendens maxima
uteri moles,  non amplius tantopere comprimerat meatum
urinae hujusque facilior expulsio trist'i3simam segrse nostras
sortem praeveniret. 
15
der to this diseased mass, but his arguments  in
support of this opinion are not very convincing.
May not  this enlargement, and suppuration  of
the kidney,  &c.  have  been produced by the
accumulation and  retention  of  urine  in  the
bladder?

   Though  Doeveren  published these cases in
 1765, it is pretty clear that  he had  never  heard
 of Gregoire's lectures, nor of the public lecture
 which Dr. Hunter  delivered in  1754,  nor is it
 probable  that Dr.  Hunter  had  any knowledge
 of Doeveren's cases, when he published his first
 paper on the subject in 1771.

   The attention  of  practitioners   in  midwi-
 fery  being thus directed to  this singular com-
 plaint,  it began to be better  understood and  to
 be treated methodically. But the  more  usual
 causes of the accident were still to be investi-
 gated,  and upon  this  head much  difference  of
 opinion prevailed. Many of the alleged  causes
 were obviously inadequate to produce the effect
 attributed  to  them, and it will have been  re-
 marked,  that Dr.  Hunter was  quite dissatisfied
 with that to which the accident was ascribed in
 Mr. Wall's patient;  yet it deserves notice, that
 the same  occurrence,  viz.  a fright, has very 
16
frequently been  supposed to be the occasion of
this misplaced situation of the womb.

  From  the  explanation which  Dr.  Hunter
gave of this phaenomenon,*  it is to be inferred,
that  he  considered  the  displacement of  the
uterus to be  the original  cause  of the  sup-
pression  of urine,  and consequent  over-disten-
sion   of  the bladder.   He  supposed,  that  in
women with  a capacious  pelvis   the  fundus
uteri  might fall low down  into   the pelvis,
and  that, consequently,  the  os  uteri  would
be pushed  against the  cervix  vesicas, thereby
preventing  the  free egress of  the  urine,  and,
of course,  giving a disposition  to  the  bladder
to become  over-distended;  and,  that  corpu-
lent women were seldom,  or  never, subject  to
this  complaint,  because  the  quantity  of  adeps
filling up the pelvis would prevent the fundus
uteri  from falling to the lower  part of pelvis,
and thus the projection of the  os uteri towards
the meatus urinarius,  and the consequent diffi-
culty of making water,  would  not take place.
Upon this theory, Dr.  Hunter founded  his prac-
tice, of always giving manual assistance to replace
the uterus.

* Medical Observations and Inquiries, Vol. V. p. 389.1776. 
17
  Dr. Denman, on the contrary, attributed the
accident,  in almost every instance,  to  over-dis-
tension of the  bladder as the  primary cause,
independent  of any  pressure of  the  os  uteri
against the meatus urinarius;  and he now says,*
" from the first case in which I thought  I had
" reason  to suspect  this,  I  have so constantly
" observed  it, either by the reserve of women
" of superior  rank in life, or by the restraint of
" those in inferior situations, neglecting, or being
" prevented,   from  attending to the  calls  of
" nature, that there  does not remain  a  doubt
" concerning   it.  The  fact hath  also   been
" proved in a variety  of  cases by  practitioners
" of the first  eminence, who have  supplied me
" with the most  unquestionable testimonies of
" its  truth."

  This  theory  is now almost  universally ad-
mitted to be  correct, and it has had  the good
effect of putting a stop to the rude, and  I may
say,  cruel expedients, which were adopted to
replace the womb,  when this  was thought to
be  essential  to the  safety of the mother.  We
have  been taught,   that  it  was  necessary to
introduce] the hand within the vagina; that the

      * Introduction to Midwifery,  4to. p. 97. 1801.
                       c 
18
fist being clenched with the thumb resting upon
the  palm  of the hand, and the fingers  spread
over it, every effort was to be made, by opposing
the knuckles and middle  parts of these fingers
to the tumor or fundus  uteri, to  replace the
womb.  We are  told  likewise,  " that it  will
" be necessary to employ considerable force for
" effecting  this." But, after  so  severe an  opera-
tion, it is recommended that the patient should
take an opiate,  and continue  in bed for eight
or ten days; as it is confessed, that a miscarriage
is  likely to ensue.*  This alone is sufficient to
show the danger of such  rough and  imprudent
treatment.

  Though  over-distension of the bladder may
be considered as the principal occasion of this
accident, and though it may be hardly possible
that the  complete retroversion  of  the  womb
should  take place,  unless the bladder  be so
over-distended,  yet  it  will frequently happen
that there  must be  the combination of some
external cause  to produce  it.  Great  emotion
of the mind,  or exertion of  the  body,  may
give that shock to  the distended bladder,  which
is  sufficient to  retrovert  the  womb; and this,

* CockelPs Essay on the Retroversion of the Uterus. 1785. 
19
perhaps,  would  not have  taken place,  at least
to so  great  a  degree, if such external cause
had  not  operated. This  will  account  for  the
popular opinions respecting  the causes of  the
complaint.

   A  suppression  of urine from  retroversion of
the uterus, may arise  at other periods of life, as
well as during a state of pregnancy, and gene-
rally from the same cause, viz.—over-distension
of the bladder. Thus, after delivery, the uterus
sometimes becomes retroverted, occasioning an
entire suppression of  urine, and excessive pain;
and the  same  thing, not uncommonly, takes
place  when  the uterus is in a state of disease;
and  sometimes at the period of life,  when the
catamenia usually cease.  At this period the  ute-
rus is apt to enlarge  and grow heavy, without
manifesting  any  other  indications  of disease;
and in this  state  I have  known more than one
instance of its becoming retroverted.

   The cases of retroversion of the uterus  after
 delivery, which have  fallen  under my observa-
 tion,  have principally occurred on  the second
 day after the birth of the child; probably because
 the degree of contraction, which the womb has
 by  that time undergone, has  reduced it  to  a
 size the most fit to suffer such a  displacement. 
20
It has happened after easy labors,  and notwith-
standing  the patients  had passed their  urine
naturally  once or twice. The second day after
delivery has  not, however,  been  invariably the
period  of this occurrence;  for, in March last,
I  was sent for to a patient of the Westminster
General Dispensary,  who was attacked with  a
suppression  of  urine  from this  cause,  on the
ninth day  after delivery.  This woman had been
delivered   by  a  careful  midwife,  her  labor
was very  favourable,  and her  recovery had pro-
ceeded, hitherto,  with  the  utmost regularity.
I  drew off  full three pints  of  urine  by the
catheter,  which gave  her immediate ease.  In
about  six hours she  made  water freely,  and
again  the next  morning, when   she  likewise
voided  a  large coagulum of  blood,  which  had
been  retained in the  uterus:  this  must  have
prevented  its complete contraction,  and  have
given  it  a   tendency  to become  retroverted.
Upon  enquiry,  I  learnt that  she  had   been
visited  by several friends a day or  two before
I  saw  her, in consequence  of which she was
necessitated to retain  her urine for a long space
of time, with great uneasiness to herself. As
soon as her  friends were gone,  she attempted
to relieve  herself, but could  only void a very
small quantity of water, with much pain  and 
21
difficulty; this hourly increased, till at length a
total stoppage was produced.

  When the womb is  enlarged  by disease, or
from  other  causes, it may become retroverted,
and  occasion great suffering to the patient, by
producing   a suppression  of urine. This has
been  noticed by Mr. Pearson, in  his " Obser-
" vations on Cancerous Complaints,"  and by
others;  but  it does not seem to  be generally
known.  In the  summer   of 1809,  I visited
a poor  woman, a patient  of  the   Westminster
Dispensary,  about forty years of age, who was
in excessive  pain from an entire suppression
of urine, occasioned  by a retroversion of the
uterus in  a diseased  state. When I first saw
her, I imagined  that she must  be pregnant, but
I was afterwards convinced that  this  was not
the case.  She  had  been,  for  many  months,
seeking relief from various medical practitioners,
who  had occasionally relieved her,  by purga-
tives,  emollients, and opiates. During all this
time  she experienced  great trouble and dif-
ficulty in  making water;  sometimes for  many
hours  together  she could  not  void a spoonful,
and  then only in a particular posture.  When I
first  saw her, she had been  unable to pass  a
drop of urine for sixteen  hours,  and she  was,
in consequence,  suffering  very  acute  pain.   I 
22
drew off her urine, which gave her immediate
ease;  she said  her  bladder  had  not  been  so
completely emptied  for  many  weeks. It was
necessary to  introduce the catheter for several
successive days, and once or twice I attempted
to replace  the  womb,  but  it  was so  firmly
fixed in  the pelvis, that I could not effect my
purpose,  without  using  more  force  than was
warrantable.  At length the  fundus uteri rose
higher in the pelvis,  and the  pressure of the os
uteri  against the  pubes was removed.   From
this  time,  she  passed  her urine without  any
further difficulty; but her health  was destroyed;
she grew very emaciated; and in about ten weeks
she died.

  I could enumerate other instances of a com-
plete  suppression  of urine from a retroversion
of the unimpregnated uterus;—partial suppres-
sions are however more  common in  cases of
diseased  uterus,  when  the  womb  being dis-
placed,   though not  fully retroverted, is  the
occasion  of  much pain  and distress in making
water. But  it is  unnecessary to do more than
merely to remark that this is the fact,  and that
it  is  not in  the state  of pregnancy only, that
this accident is to be looked for, as the  treat-
ment under all  circumstances  must  be  nearly
the same.   The  introduction of  the catheter 
23
must be the  primary resource, and  this alone
will  generally  perfect the cure  of  the  retro-
version.

  I  am  sorry, however,  to* have  occasion to
say, that I  have more than  once known  this
resource  most  unaccountably  overlooked.  I
have known  women  in a state  of pregnancy,
and  after delivery,  allowed to continue  in the
tortures  of a  total  stoppage  of urine for many
hours, who might have  been  easily relieved
by   the  introduction  of a  catheter.  A  few
years ago, a case occurred in which  a suppres-
sion of urine after delivery, had been permitted
by   the  attending practitioner to  last so many
days,* that when another accoucheur was called
in, and drew off the  water,  he was able from
its  appearance and smell  to  prognosticate,  that
so much mischief had  been  done  to the parts
by the long detention of the urine in the blad-
der,  as  must  infallibly occasion  the  woman's
death;  which  prediction  was  verified  a few
days after.  It should be  an  invariable iule  in
the  practice of  midwifery, if the patient, after
repeated  trials, finds an inability  to expel her

  * After  a very long and hard labor, this patient had re-
mained/oKr days without passing any urine. 
24
 urine,  never to let  it  be retained  more  than
 twelve or fourteen hours at the farthest without
 passing the catheter; otherwise,  much inconve-
 nience and distress may  be the consequence.

   Respecting the method  of curing  retrover-
 sions  of  the womb, enough has  been said to
 show, that the principal  reliance  is to  be placed
 upon  the  introduction  of  the   catheter;  this
 should be done twice  at  least, or oftener,  in
 the  twenty-four hours.  Care  is  likewise to  be
 taken to keep the bowels open,  and rest is  to
 be  enjoined. By  pursuing this plan  steadily,
 the  mal-position of the  uterus  is  usually over-
 come in a few days. It  is still  customary  with
 some practitioners of eminence  to  make  use  of
 artificial  means  for  replacing the  womb,  after
the bladder  has  been emptied, and the bowels
opened; and there can be no great objection  to
 making such an attempt,  provided it  be done
cautiously,  and that  no force  be made use of.
In  general,  however,  nothing of  this kind  is
either necessary or advisable. 
25
vwvwvwwv
   It has been  the  almost uniform opinion  of
writers on the retroversion of the Gravid Uterus,
that a suppression of urine must  necessarily be
produced by this unnatural situation of the womb,
and that  this suppression  must be   removed
by art;  otherwise, they  say, abortion will  take
place, or a  still more melancholy event,  morti-
fication,  or  rupture  of the bladder,  and,  conse-
quently,  the death of the  patient  will  ensue;
and, in  cases  where suppression of urine has
come on, this has unquestionably been the usual
progress and  termination  of  the   complaint,
unless proper  means of cure have been  had
recourse to  at  the  commencement  of  the  dis-
ease.

   It is,  however,  consolatory to know, that,
under  some  circumstances,  the  uterus may
remain  in   a state of retroversion  for a very
great length of time, even  to the  completion
of the period of utero-gestation,  without pro-
ducing  a total  suppression  of  urine,  or  any
other very   uncommon or alarming  symptoms.
                      D 
26
The  first  case  of this  kind, which  was  ever
published in proof of such a fact,  is  recorded
by Dr.  Seguin Henry Jackson, in  a  useful  little
work, entitled " Cautions  to  Women,  respecting
" the State of Pregnancy, &fc."  printed  in the
year 1798, which I here take the liberty of copy-
ing.*

  "  There is no instance on record, of a woman
" reaching  the  full  period  of  gestation  with
" a  retroverted uterus.  Such a  case,  however,
" I  had an  opportunity  of  seeing  about  two
" years ago, in company  with Doctors Bland,
" Denman,  Thynne,  Merriman,   and  Croft.
" The situation of the  patient at  first  appeared
" inexplicable,  and she continued several  days
" in labour, but  the gradual efforts of nature,
" at length,  completed her delivery, by  restor-
" ing the  womb  nearly to its natural situation.
" With great care she perfectly recovered, but
" the child, from the  peculiarity of  the  case,
"as well  as length of the labour,  was  still-
" born."

  * " Medical facts, when distinctly discovered, become ex-
tremely valuable. If  many of a similar  kind  are brought
collectively into  one view, the conclusions from them by
induction afford a high degree of certainty."
                                    Haygarth. 
27
  So  far Dr.  Jackson;—to complete  the case
I will just mention, that Mrs. Wifrkes, for that
was  the poor  woman's name,   never had  an
entire suppression of urine, but suffered severely,
from  partial suppression and dysury, between
the third and fourth months of her pregnancy.
It is probable  that the  occasional use of the  ca-
theter,  by  completely  emptying  the  bladder,
would then have allowed the uterus to recover
its situation; but,  being a poor woman,  and the
flow  of urine  never having been  entirely sup-
pressed, she did  not apply for any advice or as-
sistance at  that time.  As  she advanced  in  her
pregnancy, she was relieved from  much of this
inconvenience,  probably by  the  parts adapting
themselves to the situation she was in.

   In a  subsequent pregnancy,  Dr.  Merriman
afforded her his  gratuitous  advice during  the
whole time, and likewise gave her his  assistance
in her labor. By strictly adhering to  his direc-
tions, never to  retain her  urine   longer  than
four  hours, she proceeded to the  end  of her
reckoning  without  experiencing any inconve-
nience,  and was  delivered  of  a  living  child,
her  uterus  being found free  from  disease,  and
in its proper   situation.  She speedily and per-
fectly  recovered  from  this  confinement;  but
several  months  afterwards  was attacked  with 
28
 symptoms of phthisis pulmonalis, and died con-
 sumptive.    #

   In the  year  1806, another case  of retrover-
 sion of the womb continuing to the end of the
 ninth  month of  utero-gestation, occurred in a
 lady, who was a patient of  my uncle,  Dr. Mer-
 riman, senior. This labour,  I had an opportunity
 of attending with  him, from the commencement,
 and shall now proceed to detail the symptoms and
 progress of it.

  Mrs. F***.*, of  Welbeck-Street, Caven-
 dish-Square,  became pregnant for the first time,
 about the month  of  September,  1805. She did
 not  suffer  more, during  her pregnancy,  than
 most other women, except  that for  the last two
 or three months, she  was troubled with difficulty
 of parting  with  her  urine,  and   considerable
 pain in the act  of passing it; yet her sufferings
 in this particular were not so great as to induce
her to consult her accoucheur upon  the subject.
 She neither at this time, nor at an earlier  period
 of her pregnancy, experienced a total  suppres-
sion of urine, nor  does  she recollect  having ever
 retained it long enough to occasion any consi-
 derable inconvenience.  When about five months
 advanced in her pregnancy, she was much terri-
 fied  and affected on  hearing   of  the sudden 
29
death of an aunt; which, as she herself expressed
it, seemed to turn her whole inside upside aown;
and  to  this she  imputes that alteration in the
situation of the womb,  which she was given to
understand either then  or at some other time
took  place. At least this sudden surprize and
fright seemed to her the only mode of accounting
for it.

   Mrs. F* * * * was taken with symptoms of
labor, viz.-^-a serous discharge from the vagina,
which was supposed  to be  the  liquor amnii
dribbling  away,  on  Monday,  June  16, 1806;
and  strong pains recurred at distinct  intervals.
These pains became so distressing in the course
of the  day, that it was thought necessary to
make an examination of the state of  the  os
uteri, and progress  of the supposed labor; but,
upon such examination, no  os uteri  could  be
felt,  the passage of the finger towards the  os
sacrum  being prevented  by  the  attachment,
as it seemed, of the posterior  part of the vagina,
to a  large hard semi-globular substance,  which
occupied  the  whole  of  the vagina,  descending
through  the pelvis, and bearing down  gradually
towards  the  perinasum.   This hard  substance
felt exactly similar  to   the womb,  enveloping
the head of the child, which  sometimes  occurs
in cases of pendulous belly.  In these cases the 
oO
 close and rigid os uteri is thrown very high up
 in the  vagina  backwards, pressing against the
 upper part  of  the os  sacrum, and the lower
 vertebrae  of the  loins.  But  there  was  this
 material difference between the two cases, that
 in the  case  of pendulous  belly,  when the os
 uteri is tilted against the  os sacrum, the finger
 can be  passed to its  utmost extent  between the
 uterus and the sacrum; whereas, in  this case,
 the finger could not be  carried more than an
 inch  within  the  vagina  towards the  sacrum,
 before it  encountered a  resistance,  (like  what
 the French call a  cul de sac,) arising from the
 firm  attachment of  the vagina to  the  tumor,
as above  stated;  while forwards,  betwixt  this
 substance and the  ossa pubis, the finger  might
be passed, though  with some  difficulty, as high
as it could reach,  but without  discovering any
traces of the os uteri.

  By introducing a finger into the  rectum  this
tumor could be more distinctly traced; and the
 idea then  presented,  was,  that the fundus uteri,
containing either the head, or the  nates,  of  a
child, had fallen down  between the vagina and
rectum, thus filling up almost  the  whole space
of the pelvis. These circumstances convinced
Dr. Merriman, (who had been engaged in at-
tending, and  who,  indeed, had  delivered  Mrs. 
31
Wilkes, the poor woman,  whose case  s  above
described,) that this was another case of retro-
version of the uterus at  the full period of ges-
tation; and  as  there  were  no alarming  symp-
toms present, he determined to leave  her  to the
efforts which nature seemed to be making in her
favour.

   The patient in the mean time,  and during the
whole of  Tuesday  the 17th, was tormented with
very frequent  and excruciating  pains,  which
made no  apparent  impression  on  the uterus,
except bring  down  this  semi-globular sub-
stance nearer  to the perinasum.  Though every
method was adopted to keep  her in a  cool and
temperate state, the severity of  the  pains  at
length brought on a considerable degree of fever
and delirium, and  she was seized  with violent
convulsion fits, to the great alarm of her friends
and attendants.

   Dr.  Merriman,   on being  now  summoned
to her again,  and  finding  her in  this  alarming
situation, directed  that she should immediately
lose ten  or twelve ounces of blood:  A  stimu-
lating clyster was likewise  injected, which ope-
rated freely; and an anodyne draught  was then
exhibited.  By  these  means the  fever  was
stopped in limine,  and gave  no farther  alarm; 
32
 the convulsions ceased,  and  she became in a
 few  hours perfectly  calm  and   rational;  the
 pains likewise diminished both in frequency, and
 violence;  and, at intervals she enjoyed  several
 hours sleep.

   Under  a plan of strict  and regular  attention
 she continued  in nearly the same state two  or
 three days, during  which time she  passed her
 urine and faeces frequently, and  without  diffi-
 culty.  The  pains  were  regular   and  distinct,
 but  much less severe and distressing than  at
 first, indeed they resembled very much  the com-
 mon slight preparatory pains of labor; yet they
 produced  no  sensible alteration in the  situation
 of the womb and  its contents.  Even on Fri-
 day, June 20th, five  days after  the access  of
 labor, it  was impracticable to carry the finger
 backwards in the vagina towards the  sacrum,
 for it was, involuntarily,  as  it were,  directed
 by  the uterine tumor  towards the ossa  pubis.
 Still it was impossible, by the most particular
 and  careful  examination,  to   discover  the  os
 Aeri by the touch; but this day,  on  withdraw-
 ing the finger from  above the  ossa pubis,  a
 mucous discharge, tinged with blood, was  per-
 ceived upon it, which furnished  a convincing
proof that the  os  uteri was  situated  in  that
direction,  and  encouraged us  to  hope that an 
33
alteration  in  the state  of the  uterus  was  at
hand.

  We had  repeatedly endeavoured to  explain,
to the husband  and the other  friends of  the
patient, our opinion of the nature of this case;
they  were  informed,  that  very  little chance
remained  of saving  the life of the child, (indeed
the mother had never felt it move since the attack
of fever and convulsions,) but that we entertained
great hopes  that  the labor would  terminate
favourably with  regard to the mother; and that,
consequently,  in her  present state, we should
deem it  highly  injudicious  and reprehensible,
to attempt by any artificial means to procure an
exit for the child.

  While  this  labor  was thus slowly proceeding,
several  opportunities offered of conversing with
professional gentlemen respecting it, and among
others, with Dr.  Denman, of  whose great  expe-
rience and  high  reputation  no practitioner of
midwifery can be ignorant.   From  the verbal
description  which was given  to him, he seemed
inclined  to consider  this  as a case of extra-
uterine  fcetus,  fallen  down  with  the  head
between  the  vagina and  rectum:  yet  did  not
appear so  confident in this opinion  as to venture
to propose  any operation  for the  release  of the
                      E 
34
 child;  on the contrary,  he approved of delay,
 as there was now no alarm either on account of
 the fever or  the convulsions, and  confirmed the
 opinion which we  had given,  that it would be
 prudent to wait still longer, in  hopes that nature
 would point out  some safe way for the patient's
 relief.  Dr. Denman very kindly offered his atten-
 dance  in this extraordinary case, if any circum-
 stances should occur to render it  desirable; and
 this friendly offer  being readily accepted, he ac-
 cordingly visited  the patient.

   There was one  circumstance  which  seemed
 very strongly to support  the  opinion, that,  in
 this  case,  the fcetus  was  extra-uterine.   By
 applying the hand on the abdomen,  there could
 be very distinctly  felt  two tumors  in  the left
 hypogastric region, which appeared to be covered
 only by the external  integuments.  These tu-
 mors were supposed to be formed by the head
and shoulder of the child, and they  felt to  be
 lying so very near to the surface, that we could
 hardly  conceive, that  the parietes  of  even  a
remarkably  thin  uterus  could  be  interposed
between the  integuments  and the  child;  and
yet, from feeling the fundus uteri through the
rectum, we were led to believe, that the parietes
of the uterus were of the usual thickness. 
35
  On Saturday,  June the 21st, the sixth  day
after the  commencement of the labor, a consi-
derable  alteration was discovered in the pains,
and in the situation of the hard  semi-globular
substance which occupied the pelvis.  The pains
pressed the uterus closer against the ossa pubis,
between  which and the  body  of the uterus
there was evidently to  be  felt a thick fleshy
substance of a flattened form,  descending  gra-
dually by the effort of the pains into the vagina,
at the same time that the tumor, formed by the
fundus  uteri, which  had been contiguous to,
and  pressing   on   the  perinaeum,  began  to
recede.

   We  were, at  first, a good  deal at a loss  to
account for this  fleshy  substance,  which was
forced  down by the pains. It was evidently
occasioned  by  the pressure  of  the uterus twist-
ing  itself round  into its  proper  situation;  but,
as it was still impossible  to reach the os  uteri,
this substance was  not  suspected to  proceed
from the uterus; but we imagined it might  be
the fundus of the urinary bladder forced down  by
the unnatural position of the  womb.

   In order to ascertain  the truth of this  sus-
picion, Dr. Denman proposed,  that  an  attempt
should be made to  introduce a  catheter  into the 
36
bladder, which was accordingly done. It passed
almost in a  straight  line without any difficulty,
and drew off about a tea-cupful of straw-coloured
urine;  thereby refuting the conjecture  we  had
formed, and ascertained the sound  state of the
bladder and urethra.

  In a few hours more, by the increased action
of the uterine pains,  the womb was gradually
restored  to  its proper position, and the os uteri
could now be distinctly felt coming down from
a considerable height above the pubes, and the
child's head behind it.

  As the flattened fleshy substance, just men-
tioned, came  more within  reach,  it was per-
ceptibly distended by  some fluid during every
pain,  and as  it approached  the  os externum,
resembled, to the touch,  the  membranes dis-
tended with  the liquor amnii, but  those mem-
branes much thicker  than  in  the  natural state.
Shortly after some of the bones of the cranium
became loosened,  and were  forced clown into
this  bag or pouch; and now it  became  evident,
that this was only the scalp  of a dead and putrid
child, and that its distension was owing to the
contents of the cranium being forced into it  by
the pressure of the pains. 
37
  The death  of the child being  thus clearly
ascertained, Dr.  Merriman determined  upon
making an opening through the distended scalp,
in order  to  evacuate  its  contents, which he
received in a  bason, nearly to the amount of a
pint;  it consisted entirely of  grumous blood,
and  the brains of  the  putrid foetus.  Having
now a good purchase by means of the scalp, he
proceeded  to  assist, during a  pain, in extract-
ing  the  collapsed  head,  which  passed easily
through the vagina, and  no further obstacle was
presented  to  the  delivery:  the placenta, which
was  detached  from  the  uterus by the last pain,
followed almost immediately.

   Thus happily terminated a labor, which  could
not  be contemplated at  first, without  much
apprehension for the result, and which we should
have been entirely at a  loss how  to understand
and  manage, had not Mrs. Wilkes's case previ-
ously occurred. The patient had afterwards the
most favourable symptoms, and recovered per-
fectly in less than a fortnight; but lost the cuticle
of the  whole  body, which peeled off in like
manner  as it does after  scarlatina,  and  other
violent and dangerous fevers.

   Mrs. F * * * * has not been pregnant  since,
so that no opportunity  has presented of know- 
38
ing the exact state  of  the uterus;  but  there
is no  reason to suppose that  it sustained  any
injury  from  the awkward situation into which it
was thrown.
   Though there may be no instance on record,
 before the publication of  Dr. Jackson's book,
 of a  woman reaching  the  full period of gesta-
 tion  with a  retroverted  uterus;  yet,  I make
 no doubt that such  an accident has frequently
 occurred; and such a position of the womb has
 been mentioned  by various authors,  though the
 circumstances of the case have not been under-
 stood.  Deventer, in   his  chapter on the Obli-
 quities of the  Womb,  has  described, with con-
 siderable accuracy, this situation of  the  uterus.
 He  says,*—it  sometimes  happens,  that  the

  * In hoc pravo uteri situ, obstetrix probe attenta os uteri
aut omnino non, aut parum saltem tangere poterit, nisi jam
late satis pateat, atque tum adhuc aliquam  saltem circuli
partem, attingere Iicebit:—atque tum digiti prudenter adhuc
et  caute inter cervicem vesicae et os uteri immittendi sunt.
Obstetrix enim digitos posticam .versus ad intestinum rec-
tum intrudens nil nisi sacculum clausum offendit, et parum
validus premens prae insciua facile sibi persudeat, infantis 
39
midwife cannot  touch the os  uteri, or at least
only a small edge of it, and  that  only when  the
os  uteri is widely  open.  In  order to touch it
then she must pass up her  fingers, cautiously,
between the neck of the bladder  and the mouth
of  the  womb; for if she introduces her  fingers
backwards  towards the  rectum, she will find
nothing but a kind of pouch or bag into which
there is no opening; if she presses a little forci-
bly against this, she may ignorantly  conclude,
that she  is feeling  the  head  of  the  child,  not
considering  that it  is  still  inveloped  by  the
uterus,  and   that  she  would in  vain  expect
its  descent.  In this state of  things the skilful
midwife  may discover,  near the  neck  of  the
bladder, somewhat  like  a  semicircular  margin;
this is the edge of the os  uteri.—Here, if her
fingers can  reach   high enough,  the  midwife
may  even  feel  the hard globular part  of  the
child's head, and the soft  part,  or aperture, of

se capitulum sentire, non  dijudicans utero adhuc tectum
esse, ac se  frustra ejus descensum praestolari. Obstetrix
sagax, in hoc rerum statu, proxime cervicem vesicae sentiet
oram aliquam lunatam, quae oris uteri est, quod  si digitis
iliac penetraverit, etiam capitis  partem duram, globosam,
laevemque sive vertieis aperturam sentiet, unde certo  colli-
gere potest, infantem pariter cum utero spinae dorsi nimis
apprimi.
                       Deventer de  Utero Obliquato. 
40
 the  vertex; whence it may be  collected,  that
 the  body of the child, together with the uterus,
 is pressed too much against the back bone.

   These  extracts tend to show that  Devejnter
 was describing a wrong position of the uterus,
 under the denomination of an obliquity of the
 womb,  which  was  in reality a retroversion  of
 that  organ;  for, how  could  the  passage  of
 the finger towards  the os sacrum be prevented
 by a substance in the vagina, feeling like the
 head of the child, while the os uteri was almost
 out of reach above  the  ossa; pubis,  but  by a
 retroversion of the uterus?-—Or, how could the
 os uteri be so situated, as to make it almost im-
 possible  to touch  it,  unless the  fundus  was
 thrown  down between the rectum and vagina?—
 Or what, except this  position of  the  womb,
 could occasion the very great danger,  both to
the mother  and child, which De venter so feel-
 ingly laments? If  the fundus of  the gravid
uterus at nine months merely rested  against the
back-bone without   being retroverted, how  is
it  possible that the os uteri  should  rise out of
reach towards the  cervix  vesicae?—It might
indeed,  be turned more  than usually  forwards
towards the  pubes;  but could not  possibly
ascend out of reach from  this cause. Besides,  if
this  alone were the case,  what should  prevent 
                       41

the labour-pains  from restoring the  os uteri to
its  proper situation  in a few hours?  This posi-
tion of  the womb  might,  indeed,  occasion  a
tedious  and a hard  labor,  but could scarcely
expose the life of the woman to much  danger;
whereas Deventer represents the situation of the
womb as  most perilous, in  which  both mother
and child, after suffering a very long and painful
labor, often lose their lives.*

  I am well  aware  that  many  authorsf have
denied  the  possibility of  the  position of  the
uterus,  which Deventer  has  here  described;
and it is now very much the custom  to consider
his opinions on the obliquities of  the womb as
more  the  result  of  a fanciful imagination, than
of  actual  experience. I confess, however, that
I  see reason  to  believe,  that  what  he calls  a

  *  Non raro parturientem, biduum, triduum quin  et qua-
triduum laborare, neque tamen partum eniti contingit, et
quod plus est, primis nonnunquam diebus  dolores maxime
Vigent, ita ut irritis defatigata laboribus infanti animam in-
scienterextinguat:—deniquenullofere aut languido doloris
impulsu infans mortuus sponte quasi excluditur, sed singu-
lari Dei providenlia id  fit, ad conservationem matris, qu*
alias fxlerumque simul occumbit, et moribunda stfiefoetum edit
exanimem.                Deventer de  Utero Obliquato.

    t Sir  Fielding Ould, Dr. Leake, Baudelocque, &c.
                          F 
42
 posterior obliquity of the womb was, in reality,
 a retroversion. It is true, he does  not  commu-
 nicate  any specific instance of  such a  position,
 neither does he, in so many words, describe the
 fundus uteri thrown  down  between the vagina
 and rectum; yet the description which  he gives
 of this obliquity, coincides  in so many  particu-
 lars with the  circumstances that attend a retro-
 version of the  womb at  the  same  period of
 gestation, as leaves no doubt upon my mind,  that
 he had met with one or more cases of retro-
 verted  uterus  at the termination  of the period
 of pregnancy.  It is remarkable, that the authors
 who  followed  Deventer  upon the subject of
 obliquities  of  the  uterus, and who copy  his
 description of this position, do not once speak
 of it  as having occurred in their own  practice
 or knowledge; but Deventer positively  affirms,
 that he had himself met with it; and, I  believe,
 his  integrity   has  never been  called  in ques-
 tion:—Experientid ego  edoctus sum,  says  he,
 uterum loco nativo emotum, nimium  saperesupi-
 nari,  aut ad spinam  dorsi  adigi,  unde  os  vel
 ostium ejus  alte nimis  in ventrem elevatur. It is
 by no means improbable, that  such an occur-
 rence as this first turned Deventer's  thoughts
towards  the oblique  positions of  the  uterus,
of which he afterwards formed a system; this'
as is well known, was, for many years, received 
43
with much deference and approbation, and  still
influences the  practice of  many accoucheurs,
particularly upon the continent.

  Though  neither  Deventer,  nor  any other
author on the  Obliquities of the Womb, have
given  actual cases  of  this position,  yet there
are, upon record, several curious histories, which
were  probably cases of retroverted  uterus mis-
understood.

  Whenever a  retroversion  of the  uterus shall
have  taken  place, and  have continued  to  the
end of  utero-gestation,  it  may be expected
that  the case would  terminate in one  of  the
following ways:—

   First,__The  good  form  of the  pelvis,  the
health and strength of the mother,  and  the effi-
cacy  and  continuance  of  the  pains, may all
combine  to replace the uterus and produce  a
favourable issue.

   Secondly,—The want of some, or all,  of these
fortunate circumstances, or  injudicious manage-
ment during  the labor, may  occasion the poor
woman to fall a victim to this untoward position
of  the womb, in the course of a few days, either
by a rupture  of the  uterus  producing  speedy 
44
 death, or by an active inflammation or mortifica-
 tion of the parts.

   Thirdly,—The uterus being unable  to extri-
 cate  itself  out of  the  awkward  position  into
 which it is thrown, may  passively  submit  to
 the  burthen,  till by the slow process  of ulce-
 ration, the foetus may  be excluded  through
 the  rectum or vagina, and the  mother remain
 alive.

   Of  the  first  mode  of  termination,  I  have
 already described two instances.

   Of the second and third modes of termina-
 tion, several instances are,  if I mistake not, to
be found in authors, some of which I shall take
noiice of.

   The first, which  occurs to me  as being of
this kind, is the case related by Nicholas  Patuna,
a surgeon of  Venice, of a  lady from whom he
extracted, through the anus, the body of a child,
which had  been retained twenty  months  in the
 abdomen of  the mother.* The  circumstances

  *Relazione di Niccolo Patuna,  Chirurgo in Venezia, in-
torno al cadavere di un feto, che dopo essere stato nascosto
e come perduto nel ventre della Madre per venti mesi, 
45
which induce a belief  that this was an instance
of  retroverted  uterus, are the  suppression of
urine in the early part of her pregnancy,  and
the great discharge from the  uterus of serous
fluid  tinged with blood  during  the ineffectual
pains of labor.

   This lady had  borne two children at the full
time, and had  once miscarried.  In  the month
of October, 1724, she conceived again, and about
six  weeks  after conception  was attacked with
violent pains in the lower belly, and was unable
to pass her urine,  except  when  lying on her back
in bed.

   From  this time, till  July,  1725, when she
entered her  ninth month   of pregnancy, she
suffered much, at various times, from pains  in
the  belly, and  loins, and other complaints. At
the  beginning of this month she had a profuse
flow  of milk into her breasts, which ran  out,
and  kept her very  uncomfortable.  About the
middle of the month, her reckoning being then
completed, labor pains came on, and the birth

finalmente  fu da lui  cavato dalla parte posteriore, essendo
restata viva e sana la Madre medesima, che piu di tre musi
prima di questa estrazione ne aveva abortito un altro.
                   Seconda Edizione, in Venezia, 1727. 
46
  of the  child was every moment  expected, but
  Was not accomplished.

    Four or five days after this, there was a great
  discharge from  the  uterus of  a  serous  fluid,
  tinged with  blood,  very putrid and offensive;
  after this  profuse discharge  had  abated,  there
  still continued a draining from the  uterus, which
 lasted many  months.—She  was now distressed
 with an obstinate costiveness, or else she  had a
 discharge  of  thin  watery  stools,  and,  occa-
 sionally,  suffered much  from  pain and  fever.
 The idea  of her having been pregnant  began
 now to  be given up, and her complaints  were
 attributed  to  other  causes:  the  physicians who
 attended  her being  divided in  their opinions
 about her case.

   After  some months her general health began
 to  improve,  and  she again  became  pregnant
 in  July, 1726,  and so continued  till January,
 1727,  when  she  miscarried  of  a  male fcetus
 of the size that is usual at  six months. Being
 recovered  from  this  miscarriage,   she  under-
 took  a  journey to Venice,  during which she
 received  a  severe shock of the whole body from
the carriage breaking  down. In  the month of
March she had an attack  of fever, accompanied
with vomiting and diarrhoea; and  after  every 
47
stool, suffered very much from violent forcings
downwards, and pains about  the os sacrum.
It was  at  this  time that Patuna  first  visited
her.

   In order to judge of the  state of the  womb,
which had been supposed  to be  diseased,  he
made  an  examination  per  vaginam;  at  the
superior part  of which towards  the  rectum,
he  felt  a  hard tumor,  not  very  large,  nor
giving  much  pain   upon  pressure.  Believing
that this hardness, of whatever nature it might
be, was situated in the rectum, he introduced
his finger  into  that part,  and  there found a
hard pointed  substance by which his finger
was  scratched.  He  then procured a small pair
of  forceps, and laying hold of the substance
by them, he cautiously, and with  some diffi-
 culty, extracted it.  This substance proved  to
 be one of the  bones of a  foetal cranium; soon
 afterwards he  extracted portions  of two other
 bones. In  a  few days he succeeded in  extract-
 ing, in  one mass,  all  the remaining  part of
 a  female  fcetus, (for it was sufficiently entire
 to allow of the sex being ascertained)  without
 in the least  lacerating, or injuring, the  rectum
 or anus,  through  which it passed.  Eight days
 after, the  placenta, in a very putrid state and 
48
  much diminished in size, was excluded naturally
  through the same passages, and the health of the
  mother was speedily restored.

    Thomas  Bartholine, in  his  Dissertation,  De
 Insolitis partus humani viis, has collected  many
 histories of foetuses excluded through ulcerated
 openings at the  navel, in the rectum,  and other
 parts.  Some of  these  foetuses  were  contained
 in the ovaria, or  fallopian  tubes, but  others
 appear to  have  been brought to  perfection in
 the uterus,  and  the birth was  probably pre-
 vented by  the unnatural position of the uterus
 not yielding to the pains  of labor.  Respecting
 one of these  cases, in  which the  bones of the
 child  were  voided through the anus, Bartholine
 says,  there  could  be  no doubt  that  it was
 detained in the uterus,* as  there was a discharge
 of pus from the womb at the  same time, and
 pains  like  labor  had been felt about the pubes
 and groins.

  * Notandum diligenter, involucra membranosa hie excreta
fuisse, et sensim per  partes ossa camemque putridam, quae
quidem in utero exulcerato adhuc haesisse, donee excerne-
rentur, id indicium est, quod etiam per uterum pus fluxerit,
doloresque veluti pariturae circa pubehi et inguina oborti,
et in uterum injecta sint decocta.
        Bartholinus de Insolitis partus humani Fits. p. 34. 
49
   It will, however, be more satisfactory to recur
to modern times for histories of this nature.

   The late Dr.  Colin  Mackenzie, a celebrated
lecturer on midwifery, in a letter to Mr. Per-
fect, gives the outlines of a case,  which seems
to  have been  a  retroversion of  the  uterus at
the  full period of gestation.  He mentions it
in  these  words:—"  I  knew an  instance of  a
child found without  the  uterus in the abdomen
of its mother. The pains came  on, and a mid-
wife  was  employed; this woman finding  an
enlargement in the vagina, mistook that  for the
membranes,  which  she  attempted  to  break
through by repeatedly  scratching it  with  her
nails, in which she succeeded  so far as to eva-
cuate the waters. However,  the birth  of the
child  being still  retarded, a man-midwife  was
procured,  but to no  purpose, the woman  grow-
ing worse and worse,  till at length she died.
Now had I been present,  I flatter myself, that I
might, in all probability, have saved both the mo-
ther and child; for, I  believe, I should have ven-
tured to make an incision through that part of the
vagina, which was thrust forward by the propel-
ling force;  and,  perhaps,  by this means,  might
have delivered the child."  Perfect's Cases in Mid-
wifery, Vol. II. p. 171.
                       G 
50
   I think it not  improbable,  that  the  case
 which occurred  to Dr. Simpson,  as related by
 himself in the third volume of the Edinburgh
 Medical Essays  and Observations,  was of this
 kind. Dr. Simpson informs us, that  the woman
 had once before  been delivered by the  crotchet.
 In her second labor  he   could  not find  the
 smallest opening into the uterus, and,  therefore,
 judged, that  the  lips of the os  uteri had grown
 together.*

   As  it  was  impossible  to find  any opening
 into the uterus, it was determined, in a  con-
 sultation,  to make an  incision, with  a scalpel,
 through  the part where it  was  supposed  that
 the os uteri was  situated. The  place where the
 opening  was made,  was as  hard  as  cartilage,
 and it was  necessary to make  several  incisions
 with the scalpel through it, in  order to enlarge
 the aperture. After  this operation,  which  was
 performed in a most  rude  and  slovenly manner,
 it became necessary to employ  the  crotchet,
 by which, with  much  difficulty,  the child was
 extracted.  It can hardly be necessary to add,

  * What could have occasioned this coalescence of the os
uteri is not explained; there is no account of any inflamma-
tion about these parts after the conception  had taken place. 
51
that the mother died in about twenty-four hours,
but leave could not be  obtained  to  open  the
body.

  Now, in this history, one circumstance is men-
tioned,  which goes  strongly to prove, that there
was a retroversion  of the  womb.  Dr. Simpson
states  that  the  liquor amnii  made  its  escape
early  in the labor; and  he imagines, that  this
evacuation  was effected  through  the  urethra,
between which and  the uterus,  he supposes,
there was some opening,—the effect of a former
inflammation of the parts.  Is it not much more
probable  that the liquor amnii was evacuated
through the  os  uteri,  tilted very high  above
the pubes,  as in  Mrs.  F* * * *'s case?*  and
that the incision which Dr. Simpson made,  was
not through the coalesced os uteri, but through
the posterior part of the vagina and  the fundus
 uteri?

   In the eleventh volume of the Medical and
 Physical Journal, a case is related by Mr. Kelson,
 surgeon,  of Seven Oaks, Kent, which I think
 strongly  confirms  the opinion  which I am at-
 tempting to establish.

                   * Page 28. 
52
  Mr. Kelson was sent for, in June, 1801, to
Mrs.  Townsend, who was  suffering  very con-
siderable pain from a partial  suppression, both
of urine and stools: she  supposed  herself, qt
this  time,  to be about ten weeks  gone with
child.  Mr.  Kelson did  not examine her, but
ordered an  opening  medicine, which  afforded
her much relief. In the course of a few days
she was  suffering again in  the same way, and
was relieved by the same means.  Shortly  after,
a total suppression  of urine  took  place, and,
upon examination, the  uterus was found retro-
verted, the lower part of the pelvis being  com-
pletely filled  with a hard  tumor, and the os
tincae  could with difficulty be felt.  This sup-
pression  of  urine  lasted  about  a  fortnight,
during which time the  catheter was daily intro-
duced. At the end  of that time, the impedi-
ment  to the flow of  urine was removed, the
uterus taking pretty much  its  natural situation.
The motion of the child was now sensibly felt;
but the mother always said, that it was different
from  what  she  felt with her  former children;
it  never appeared  to  move in front,  but  on
each  side  and  at  the  back bone.   From  this
it may be inferred that the uterus  did not fully
acquire its  natural situation in the pelvis;  that
the uterus so far altered its  position as  to  occa-
sion no further impediment to  the flow  of  urine 
53
is  sufficiently manifest; but  the  sensations  of
the mother,  when the child moved,  seem  to
prove that it  still remained retroverted:  or,  as
Deventer would have expressed  it, spina dorsi
nimis adactus.

   In the beginning of January,  1802, she was
seized  with  pains like labor, returning periodi-
cally, but they were not very quick nor pressing;
Mr. Kelson, therefore, left her, expecting to be
called  to her again  soon.  The pains,  however,
did not return for three weeks; but at  that time
they came on again  much  stronger and quicker
than before;  he was, therefore, induced to stay
with her five or six hours, but as the pains gra-
dually subsided he did not examine her.

   After this he visited her daily; she continued
languid and  unwell, and  on the  fourth day she
had shiverings,  succeeded by some feverish heat.
Her breasts filled with  milk, which  distended
them to a great degree. All these symptoms led
 Mr. Kelson  to  suspect that the foetus was extra-
 uterine; he, therefore, examined her, and " found
 the parts somewhat in confusion, the child plainly
 to be felt through the vagina, the uterus  not en-
 larged, but forced upwards and  forward,  the os
 tincse quite closed." 
54
  About  fifteen months after this, she became
indisposed, and after suffering severely, having
violent night sweats, total  loss of appetite, and
other alarming complaints, she  began to void
a large quantity of very  putrid slimy matter
from the  anus, and afterwards the bones of a
foetus, the whole of which were  not  discharged
when this  account was published.

  It is to  be lamented that, in the foregoing case,
no notice  was taken of the situation of the  os
and fundus uteri during the progress of the labor;
but, I think, enough is told, to satisfy the reader,
that the uterus had  been in a retroverted state,
occasioning a suppression of urine, that after the
suppression was removed, the  uterus  had  not
completely regained  its proper situation, that it
remained  in an untoward position till the termi-
nation of  the full period of utero-gestation, and
that the pains  being inadequate to the restoring
it to its natural state, the parietes of  the womb
had, either from a laceration or from  ulceration,
given way, and allowed the escape of the fcetus
into the hollow of the pelvis between the vagina
and rectum.

  The case which  Mr. Coleman, of Norwich,
published in the second  volume of the Medical
and Physical  Journal,  gives  a  more  particular 
55
detail of the progress of this sort of labor,  and
is a valuable  addition  to the series  of facts,
by which  I hope to prove,  that retroversion
of the uterus, at the full period of pregnancy,
is no very  uncommon  occurrence, and that it
deserves greater attention on  the part of prac-
titioners of midwifery,  than it has hitherto ex-
perienced.

   " Mrs. Cooper, of Lakenham, sent for a mid-
wife, on the 25th of December, 1798, who in-
formed  her, she would be delivered  in a  very
short time, and caused her great  pain, with  a
small  discharge of  blood, which continued for
some days; I  suppose,  by endeavouring to rup-
ture the membranes, mistaking the vagina, press-
ed  down before  the head of the child, for the
membranes.

   "She was, at that time, at the full period of
 her reckoning.  On the 7th of January,  1799,
 I was sent for,  and as she had no pain, I waited
 a  considerable  time;  and,  on  examining her,
 found  a globular substance very low in the pel-
 vis, which  I supposed  to be  the head of the
 child;  but  I could not discover the  os  uteri.
 I staid with her some  time longer, and told her
 nothing could be done;  but desired they would
  send  for me  if her  labor  came on. She had 
56
 borne children  before, and had been accurate in
 her reckonings.

  " The very deep snow of 1799,  falling soon
 after  this time,  rendered the roads, from Nor-
 wich  to Lakenham, impassable  for some  days;
 and I thought  she had  been obliged to call in
 such  assistance  as  could  be procured  in  the
town, till I was informed by one  of her rela-
tions, whom I attended, that she was vtry un-
 well,  but not delivered:  I, therefore, called upon
her, as I thought there must be something sin-
gular in the case.

  " She told me, she had felt nothing of the child
since  Christmas day;  but  that she was certain
she had previous to  that time, although different
from  her  sensations on  similar  occasions. The
body  had nearly  the same appearance as in  natUr
ral pregnancy, with an unevenness a little above
the os pubis.  The  whole  had not exactly the
usual globular form of the impregnated  uterus.
 She had,  at this time, exceeded her  reckoning
more  than two months.

  " I found the child's head  pressing down
very low, and could not discover the os tincae
in its  usual  situation,  but thought I discovered
it above the os pubis. On  endeavouring to pass 
57
the finger towards the sacrum, (the  usual situa-
tion of the mouth of the uterus where it lies
high,)  it  could not pass, owing  to the vagina
obstructing it  in every direction  backwards.—
I could pass  the  finger  very high  by the pubes,
in which situation I found the os uteri as before
described.

   " I  mentioned my suspicions of its being an
extra-uterine foetus  to  Mr.  Cooper, surgeon of
the  third Lincoln Militia, and requested him to
see  her with  me. He  thought  it  was the  os
uteri  above the  pubes,   which  could  not be
felt very distinctly, as it  was situated very high.
I  examined her  again, and concluded it was an
extra-uterine  foetus,  lying between the rectum
and the womb, pressing  the  uterus up against,
and chiefly above, the pubes.

   " Mr. Rigby, (whose opinions upon these sub-
jects are much  respected) having  seen  her in
the earlier part  of her pregnancy,  I  mentioned
the case to him,  and asked him to see her with
me. I was prevented being  present at the time
appointed, but requested  he would examine her;
his opinion was,  that there was  something extra-
ordinary in the case,  but  was  not fully confirmed
that it was extra-uterine.
                       H 
58
  " Her  health was very much  impaired, being
 affected  with  diarrhoea, for  which  she  occa-
 sionally  took  opiates and  astringents.  I  was
 sent for  to her on the third of May, she being
 now more than four months past her reckoning.
 I  found her very weak  and  low, her  mouth
 sore, pulse quick, and the  diarrhoea continuing:
 she had ejected during the night a considerable
 quantity of foetid  bloody water.  On  examining
 her, I  found an opening  unlike the os uteri,
 and my finger passed  immediately into the head
 of the child;  she  had  no  pain except what I
 gave her, as I  used  some  force, pressing  upon
 the inside  of  the bones  of the cranium,  and
 endeavouring  to dilate the  opening.  I left  her,
 and  called  again,  taking Mr. Rigby with  me,
 who examined and brought away a  portion of
 the  cerebrum, which  was  very  offensive.  I
 afterwards  brought away  one parietal and  the
 occipital bone, and  also  one of the temporal
 bones: she was very much  exhausted and faint;
we  therefore  left  her,  fearing it  would be  im-
possible  to  extract  the whole  of  the  foetus.
Mr.  Rigby  called on me on the fourth,  and
after some conversation I saw Mrs. Cooper, and
found the ether parietal bone in the situation
it was  left  on  the third, or  nearly so,  which
I,  with  difficulty, brought  away.  By  intro-
ducing  my  fingers  into  the  opening in  the 
59
Vagina,  and fixing them  upon the vertebras of
the neck, I brought two of them away; but find-
ing the shoulders obstructed by a part of the va-
gina, I pushed my hand  past it, got my  finger
into the arm-pit, and at last succeeded in bring-
ing away the remaining part  of the  fcetus, in a
highly putrid state, no portion of the navel  string
remaining.

   " It appeared to be a  male  child at the full
time when it died, both  from  the formation of
the bones and the  size of  the  foetus. The woman
was  so  faint and  exhausted,  that I  thought it
more prudent  to  desist  from introducing the
hand to examine for the  attachment of the pla-
centa, concluding that the least evil would be to
trust to nature for its expulsion, if it was not al-
ready dissolved, and in  a state  to  come away
with the discharge.

   " On  the fifth,  I  called again,  with  Mr.
Aldhouse,  and found her very  low and  faint;
she had  purged,  and  her mouth was covered
with  aphthae,—the discharge considerable, and
very  offensive;  the  womb  was nearly  in  the
state  before described, but lower, the opening
in the  vagina through  which the  foetus  was
extracted, extending nearly to the neck  of  the
uterus.  We could  now  distinguish  the  neck 
60
of the  Uterus, and  the uterus  itself, by the
touch;  the  finger passing backwards into the
large  cavity from  which  the child  was  ex-
tracted. There was  no doubt  of a communi-
cation  between the bowel  and  the  cavity, as
some seeds  of a cake eaten the day before,  came
away on Mr. Aldhouse's fingers,  with a portion
of foeces.  Some foeces likewise  passed daily by
the vagina,  although  she had  a natural evacua-
tion every day.

   " She remained in the greatest  danger for
some time;  her  mouth  very  sore,  purging at
times, &c.  Her  plan of medicine was cordials,
astringents,  and  opiates, as occasion  required,
with wine and nourishing soups, as the stomach
would bear  them.

   " She is at  this time, August  16, 1799,  able
to manage her domestic affairs,  she passes her
stools naturally, but is obliged to wear a cloth, as
some foeces pass by the opening of the  vagina.
The quantity which  passes the latter way being
much lessened within the last  month, makes me
entertain hopes that the opening  into the bowel
may close."

   Another  interesting case has been  published
in the second volume of the  Transactions  of a 
61
Society for the  improvement of Medical and
Chirurgical Knowledge,  by  Mr. Mainwaring,
under the title of A case of an extra-uterine Fcetus
discharged by the Rectum.

   It  does not  appear  from  this account, that
the  conception  was detained  in  any  of  the
appendages of  the  uterus;   on the  contrary,
there is reason to believe,  that the uterus itself
was the nidus of the embryo.   In the earlier part
of her pregnancy, the patient  " complained of a
considerable sense  of fullness about the lower
part of the pelvis,  attended  with  frequent and
strong desire to go to stool, and she passed very
small quantities of urine, with much difficulty and
uneasiness."

   When she had attained between the second and
third month of her pregnancy, she had strong
symptoms of  being about to miscarry,  but  no
ovum came away.

   About  six weeks  after  this a  tumor was felt
in the  left  groin;  and, upon  a  more  accurate
examination,  another  tumor was  felt  in  the
right groin, which extended almost  as  high
as  the  navel,  occasioning   considerable  pain,
whenever even a small  degree of pressure  was
applied  to any part  of the  abdomen.   " A 
62
coffee-coloUred fluid was now discharged from
the urinary bladder, in quantity nearly amount-
ing to  three  pints in twenty-four  hours.  Before
this period the quantity of urine was less." How
many days this discharge continued, is not men-
tioned.

  The foregoing symptoms  appear  to me to be
such as would very probably be present in a case
of retroversion  of the uterus, where  the  flow
of  urine  was  considerably impeded  by  the
uterine tumor,   but  not   entirely  suppressed.
The immense  degree of  distension  of which
the urinary bladder is capable, may be  judged
of,  by an inspection of Dr.  Hunter's  engraving
of the  retroverted  uterus;  and if  a  part  only
of  the urine were evacuated every  day,  the
distension of the bladder would  be permanent,
occasioning  excessive pain  over  the  whole  of
the abdomen;  but  it might  not  prove abso-
lutely  destructive  to  the patient.  In   Doeve-
ren's patient, already spoken of in page  12, the
bladder became  at  last  so  much distended  as
to burst,  though a quantity of urine  was daily
voided.*

  * Illustrant ea, quae  sunt  exposita; quomodo tenesmi,
ab irritamento urinae nati, validasque vesicae constrictiones
excitantes, causam istam comprimentem ssepius vincere, 
•
                       63

   Let  us now advert  to  what was discovered
by an  examination per vaginam, which  was
submitted to  for  the  first  time,  in the month
of July, 1796, the patient having  then attained,
as I  apprehend,  the  sixth  month  of  her preg-
nancy.

   " A  tumor was  found in the hollow of the
sacrum, occupying its  whole  extent,  and pro-
jecting  so  much forward as  nearly to  fill the
cavity of the  pelvis.  It  seemed to lie  between
the vagina and rectum,  and was  less  than two
inches within the pelvis, reckoning from the ex-
ternal orifice.

   " The  os uteri was  altered in  its shape and
situation, being pressed against the bladder and
pubes.  The  cervix uteri  was  so  fixed  in  its
situation,  as  to resist  any  attempt which  was
made to move it  upwards.  From these circum-
stances the urine was passed with difficulty.

urinae aliquam copiam exprimere, et quotidianum illud
stillicidjum  ejus, verae morbi causae larvam obducens, pro-
ducere, potuerint; eademque explicant, quomodo hanc  ob
causam lentius ad tantam expansionem pervenerit vesica,
ut crepuerit, aegraeque moriendum fuerit.
             Doeveren, Specimen Obs. Academic, p. 90. 
                      64

   " The shape of the tumor in the hollow of the
 sacrum  was nearly  round,  but somewhat flat-
 tened upon the anterior part. In breadth it was
 supposed to be between three and four  inches,
 and in thickness from  two to three.  It felt mo-
 derately firm."

   Had any circumstances led to an examination
 of Mrs. Wilkes and Mrs,  F * * * *, when about
 six  months  advanced  in  their  respective preg-
 nancies,  I cannot figure to  myself any material
 difference that  could possibly have been found
 between  the  symptoms  and appearances  here
 described, and what might be  expected to be
 present in them.  It  must not,  however, be
 omitted,  that   Mr.   Mainwaring takes  notice,
 " that  the tumor in the pelvis was  lower  than
 that which is found  in cases of retroverted  ute-
 rus; and that  the posterior  part of the  vagina
 was without  the puckering occasioned in that
 disease by the  fundus uteri falling down behind
 the  vagina."  But, I think,  these  two circum-
 stances cannot  be looked upon as proofs  that
 the tumor was  not occasioned by  the  retrover-
 sion of the womb. The situation of the  tumor
 in the vagina, described before in Mrs. F****'s
 case, was much lower than is  ordinarily  met
with in retroversions, and the surface of it was
quite smooth and free from puckering. Indeed, 
65
the increased size of the womb at a later period
of pregnancy is sufficient to explain these pecu-
liarities; for it  must not only  gradually descend
lower into the pelvis to acquire more room, but
must likewise distend the vagina  more fully,
which would obliterate the rugae, or puckerings
upon its surface.

   After  a long  series of  sufferings  this poor
woman's case  terminated favorably, by a  dis-
charge of  the  bones, &c.  of a  foetus through
the  rectum.  The process took up a much  lon-
ger time than happened to Mr. Colman's patient;
for this occupied a period of  two years and up-
wards: but when  the account was written, Mr.
Mainwaring's  patient was restored to  a  more
perfect state of health than Mr. Colman's.

   I must  not  pass over a remark, with which
Mr.  Mainwaring  concludes his  valuable  com-
munication/ as  it  tends  to  shew  that  there
remains  a contraction of the  uterus from loss
of  substance. " The projecting part of the cer-
vix  uteri  into the  vagina was found* to be
shorter  upon the left side than upon  the right.
The  vagina might be said to be somewhat con-
stricted upon  the left side,  so that the cervix

* About eighteen months after the discharge of the foetus 
66
uteri  was less moveable  there than upon  the
right, and some pain was felt upon touching
that  part  with the finger."  Now this, I think,
is  an  additional  proof,  that  the  foetus was,
at  first,  contained within  the womb,  which
being  pressed  down in  a  retroverted  state
between  the  vagina  and rectum,  and unable
to  extricate itself from  that  position, under-
went the process of inflammation,  adhesion, and
suppuration, and thus was relieved  of its con-
tents;  but  was  consequently diminished  in
size.
   Mr.  Kelson, Mr. Colman, and  Mr.  Main-
waring, have  all denominated their communi-
cations, cases  of  Extra-uterine Foetus.  If by
this  is merely meant that the foetus, after being
brought   to  maturity,   or  nearly  so, in  the
uterus,  was excluded  from  thence into the
cavity of  the  abdomen, either  by a rupture of
the uterus, or  by an ulcerated  opening through
its parietes, and afterwards, by  the same pro-
cess, discharged through the rectum or vagina,
I completely accord in  the  same opinion; but
if, as I understand, it  is supposed  that these
foetuses were actually  nourished, and  brought
to perfection  in the cavity  of  the abdomen,
unconnected with, and  perfectly distinct from, 
67
that  system of organs and vessels  which  have
been  expressly  set  apart by nature for this pur-
pose, I must confess myself not at all convinced
by  these cases of  the existence of  a fact, so
completely at variance with all we  know of the
laws of nature, and of the animal economy.

  I  mean not  to deny that foetuses  have  been
found  in  the  cavity of the abdomen,  entirely
disengaged from  the uterus, or its appendages;
but I think that in such instances a rupture of the
womb, of the tube, or ovarium, or an ulceration
through their parietes, had permitted the escape
of the full grown foetus,  and not that the concep-
tion  had advanced  to maturity in a part appa-
rently so illy adapted for such a purpose.

   It is very justly remarked  by  Dr. Clarke,*
that  " there are so many obstacles  to prevent
the ovum, when first detached from the ovarium,
from  acquiring an adhesion in the cavity of the
belly, where the intestines, bladder, &c. are, from
the  very nature of their functions, in perpetual
motion, as to  make the  possibility  of it  very
doubtful." He is,  therefore, disposed  to  con-

  * Observations on the case of a woman  who died with a
foetus in the fallopian tube.
           Transactions of a Society for the Improvement
                of Med. and Chir. Knowledge, Vol. II. 
68
 elude, that in all cases supposed to be extra-
 uterine, the foetus is really nourished and  pre-
 served  by the uterus, or its appendages; in con-
 firmation  of  which  opinion,  he  adds,  " Some
 years ago,  I  had the opportunity  of  seeing a
 case which had  been examined, and was  sup-
 posed  to  be a true ventral case; but by a more
 critical  investigation  of the case afterwards, it
 appeared, that the cyst,  containing  the  ovum,
 was certainly a part of the appendages  of the
 uterus, because it was supplied  by the sperma-
 tic artery."

   Every  one  of  the instances of extra-uterine
 gestation  which  I  have  had  an  opportunity
 of perusing has  been deficient  in some of the
 particulars,  or symptoms, which are necessary
 for confirming the fact, of  a  fcetus being nou-
 rished  in  a cavity, and  by vessels  intended  for
 other purposes, and distinct  from the  uterine
 system;  and  at  the same  time  the case  was
 capable of being explained in a more  rational
 way. The two cases which are  the most relied
on,  and  seem to  approach  the  nearest to a
 proof of such an extraordinary mode of gesta-
 tion, are  Dr.  TurnbulVs  Case of extra-uterine
 Gestation, of the ventral kind,  originally pub-
lished in the third volume of the Memoirs of the
Medical  Society  of London;  and  Dr.   Charles
Kelly's Case of an extra-uterine Foetus, in the third 
69
volume of Medical Observations and Inquiries,
by a society of Physicians in London.

  It is, I presume, to Dr. Turnbull's  case, that
Dr.  Clarke alludes  in the above remark,  that
the sac which contained the foetus was supplied
by  the  spermatic artery;—a  very  convincing
proof, that  the gestation  was not wholly  sepa-
rated from the influence of the uterine system.
But, besides this, there is much which requires
explanation.—The  patient  in  question,   sup-
posing herself  to be in labor, from having
been seized with a violent  paroxysm of pain,
attended with a flooding, sent for her midwife;
but before the midwife arrived, something was
 expelled from the uterus, with the appearance of
 the placenta,  and  which the midwife, on examin-
 ing,  declared to  be  so.  Now this  is  assuredly
 more like  the circumstance of a rupture of the
 uterus,  than  of an  extra-uterine  pregnancy;
 but further we  are told, that, upon  dissection,
 when the  infant was found  lying among the
 intestines   of  the mother,  "the  placenta was
 so extremely delicate,  and possessed so little
 of its natural characteristics, that, at  first view,
 I conceived  it to be a  thin  membranous sub-
 stance,  formed by an exudation from the sur-
 face of the  bowels  in  consequence  of  inflam-
 mation. The  membrane, in which the  vessels
 were exceedingly small,  (so as to render the tra- 
70
 cing them with the knife impracticable) did not
 exceed  in  thickness  one-tenth  of  an  inch."
 This  would, at first view,  seem to shew,  that
 a rupture of the uterus did actually take  place,
 that the placenta had really been discharged per
 vaginam, and  that  this membranous substance
 among the intestines was merely produced by
 the  efforts of  nature,  to preserve  the  constitu-
 tion from the ill effects, which an  extraneous
 body  was likely to produce.  It is to be recol-
 lected that this  foetus  lay within the abdomen
 six months after the access of the labor pains,—
 a more than sufficient time to produce the unusual
 appearances and diseased formations which were
 discovered upon dissection. The principal reason
 which seemed to influence the  opinion of the
 gentlemen who saw this case, that  the  foetus
 had  not been received  into the uterus, was  the
 small size of that organ, it  being of its usual
 unimpregnated  size:   it  was  not,  however,
 always so  small; for, about a  month after  the
 expulsion of  the placenta, (so  called by the
 midwife)  Mr.  Fitch,  an  accoucheur, found
 the os tincse  so  very  much dilated,  that  with
great ease, he  introduced three fingers into  the
 uterus, the internal surface of  which was found
 very irregular.
  From the  situation  of  the uterus and of the
fcetus among the intestines, it may be presumed 
71
that, at the time the rupture of the uterus took
place,  it was in its natural position within  the
pelvis; but, in the case of Dr. Kelly's patient the
uterus was probably retroverted.

   From  Dr.  Kelly's  relation  we  learn, that,
when  he first saw  the  patient,  which  was  not
till she had been seven days in labor,  "the child's
head seemed so  far advanced  into the  pelvis,
as  to  require only  two  or three pains to bring
it  into  the  world;  yet, though the  head  was
but the length  of a finger-joint from the four-
chette, the os  tincae  was  situated  close  to  the
symphysis pubis,  and so  high  up  that  it  was
difficult  to  reach it; at the same time  it  was
impossible to pass a finger  between  the tumor
made  by  the child's head, and the  back part of
the vagina."  These  appearances coincide  so
very minutely  with those  that were  observed
in  Mrs. F * * * *'s case, as make me confident,
that whoever had  seen  the one, would  have
thought the other precisely  of  the  same kind.
The result, however, was very different, for  Dr.
Kelly's patient  died undelivered, the day after he
first saw her.*

   * In Dr. Kelly's patient, the head of the child was found
lying in the hollow of the sacrum, between the vagina and
rectum; admitting therefore that the  foetus was contained
and nourished within the womb, the head must have been
towards the fundus, and the nates and feet  towards the -os 
72
   It is to be  regretted  that  very little  infor-
 mation could  be  obtained  by  examining  the
 body after  death.  The examination was  under-
 taken  in secret, during the absence of  the hus-
 band,  who  had  given express  orders  to  the
 contrary; he was every moment  expected home,
 and  it was  feared,  would  treat those  very
 roughly, who  had ventured  to  act counter to
 the  orders he  had left. The  inspection of the
 body was, therefore, made without that delibera-
 tion and accuracy  that  could be wished, and so
 hastily  that the appendages of the uterus were not
 examined at all.

   The  principal   difficulty  in  explaining this
 case  upon the  supposition of its being a retro-
 version of the womb,  is  the small size  of the
 uterus, that  being  found  not larger than in the
 unimpregnated  state;   but  under the  circum-

uteri; and we may  be assured that the position of the child
was nearly the same  in the cases  where the foetus was
evacuated through the reetum; for the first bones that were
voided, were either portions of the cranium, or of the supe-
rior extremities. But in Mrs. Wilkes's and Mrs. F * * * *'s
cases, the heads of the children were contiguous to the os
uteri, and the nates were towards the fundus, for the heads
were the first  parts felt protruding through  the  os uteri
above the pubes. This  position of the child is evidently so
much more favorable than any other for the efforts of nature
to accomplish the  delivery, as to afford  a very satisfactory
explanation of the  different results of these cases. 
                      73

 stances in which the dissection took  place, it
 is not  improbable  that a  rent  in  the  uterus
 might be  overlooked.  There  is great difficulty
 in explaining the case in  any other  way; while
 this supposition renders the  explanation more
 easy  and  satisfactory.  This will  account  for
 the situation  of the child; for its being alive,
 and  plainly  felt  to move during the time of
 labor;  for the  length  of  the labor; and  like-
 wise, for  the pains  which  continued  strong,
 even  to  the  day  before  the woman's death:
 indeed, a  midwife,  who  was  then  called in,
 was so deceived by these  pains, and the situa-
 tion of the child, that she made  no doubt of
 the  labor  being soon  over, and  accordingly
 ordered  what was  necessary for  the child to
 be  got ready immediately.  Not a word  is said
 in the whole  paper,  which could induce us to
 think,  that that these were other than genuine
 uterine pains; but  it cannot  be supposed, that
 such pains could be produced in a  womb of the
 unimpregnated size.  In cases of ovarian and tubal
 gestation, we know that pains like labor come on;
 but in those cases the uterus enlarges as the preg-
 nancy  proceeds;  and at the proper time contrac-
 tions  of the uterus take place, as if to expel the
fcetus; but  these pains are never described to have
happened when  the uterus was so small as here
represented.
                      K 
74
  In  confirmation  of  what is  now  advanced,
I shall take the liberty of  quoting  a  passage
or two from An Account of a  Ruptured Uterus,
by  Dr. John  Sims.* "In the anterior part of
the  cervix  uteri, next  the  bladder, was a rent
through  its  substance,  about  three quarters
of an inch  in  length,  the sides of which were
nearly contiguous, but ulcerated,  and not dis-
posed to  heal."  " The uterus, very little larger
than it is to be found in its unimpregnated state,
was in its natural situation in  the pelvis; and
the  fallopian tubes  and  ovaries were  without
any  morbid appearance."  Dr.  Sims  concludes
his   account with  these  words.  "A  know-
ledge of this case has  led  me to  suspect, that
many of the supposed instances of extra-uterine
gestation, have, in  reality, been cases  of rup-
tured uterus; and I have little doubt of refer-
ring hither, a supposed ventral gestation, lately
published.  For,  had the rent  in  my patient's
womb healed by  the  first intention, (and by
the   close contact of its sides, it  appears that
this might  have   very readily  happened,) all
access of  the   external  air  being  prevented,
the  child  would probably have remained long
in the cavity of the abdomen, without  under-
going  much putrefaction.  And, upon  exami-

    * Medical  Facts and Observations, Vol. viii. 1800. 
75
nation after death, who would then have suspect-
ed, that this child had ever been within the cavity
of the womb."

   The  proof  which I have established, that the
uterus  may remain  in  a state of  retroversion
till the termination of the usual period of preg-
nancy, explains several other cases of what  have
been supposed extra-uterine gestation; for, should
the pains of  labor not be sufficient to  restore
the uterus  to its  proper situation,  or to expel
the child, it must, should the mother survive,
undergo the process of inflammation, adhesion,
and suppuration, to relieve itself of its  contents;
and this has,  I  make no doubt, been the case
in most of the instances were  the foetus has
been   discharged,  either  entire  or in  pieces,
through the anus and vagina; and  I  have very
little  hesitation  in saying, that this was  the in-
tention of nature,  if I may be so allowed to ex-
press  myself, in the curious  case recorded  by
Dr. Bkckburne,* " in which the substance of the
uterus  was  in a great measure destroyed during
pregnancy." In this  case, unfortunately  for the
poor  woman,  the  process hastened  from the in-
flammatory to the suppurative stage, before any
adhesion had  taken place, and the patient in con-
sequence died.

       * London Medical Journal, Vol. viii. 1787. 
76
   " The  remains of  the  uterus  rested  upon
the sacrum, having  sunk down to the  bottom
of the pelvis. The head of the child  occupied
the fundus uteri, the substance of which had been
so entirely wasted away, that the hairy scalp was
left uncovered, and was separating from the sub-
jacent cranium.  The whole was so putrid as to
emit a most intolerable stench, and could not be
preserved."

  Upon a review of all the circumstances already
adverted to, I think  I am warranted in drawing
the following conclusions:—

  First,—That  the uterus, which  has  become
retroverted in the earlier stages of pregnancy,
may continue in  that state till  the full period of
gestation has elapsed.

  Secondly,—That, when this time is perfected,
pains  will be  excited  which, under favourable
circumstances, will  occasionally  be  sufficient
to  expel the child  through  the  natural pas-
sages.

  Thirdly,—That  circumstances  not   being
favourable for  the  expulsion  of  the child,  a
rupture of the  uterus may  take  place, or so
great  a degree  of inflammation, or fever, may 
77
come  on, as  speedily  to cause  the  mother's
death.—Or,

  Fourthly,—That the fcetus may be expelled
by  an  ulcerative process through  the  parietes
of the  uterus into the rectum or vagina, as hap-
pened  in the casts of Sig. Patuna and Messrs.
Kelson, Colman, and Mainwaring.

  It becomes  then an object of great impor-
tance to determine, what method of treatment
ought  to be adopted, when  the  uterus at the
time of  labor  is found  to  be retroverted.  Dr.
Hull, in  his elaborate defence of the Caesarean
operation, considering all these cases  as extra-
uterine,  recommends,  " to  cut   through the
back part  of  the vagina, and to bring the child
through  the os externum;"  and the same ope-
ration has been recommended by Dr. Mackenzie
and Dr. Kelly. There is a case quoted by Dr.
Hull, which  happened  to  Monsieur Lauverjat,
in which the child  was extracted  by an incision
into the  uterus through  the  vagina.   There
is a great want of accuracy in describing the
situation  of  the womb; but I can only con-
ceive of it, that it was in  a retroverted state;
and that the  incision was made through the
posterior  part, of  the vagina into  the uterus.
Unless this were the position, I  see no reason
that there could be for operating at all. " Une 
78
 femme enceinte  pour la premiere fois, et  par-
 venue   au  moment  d'accoucher,  eprouvoit
 des douleurs  si  vives,  que  Lauverjat voulut
 s'assurer  de l'etat des  choses.  II  fut surpris
 de trouver la vulve  occupee par  un corps qui
 la  remplissoit, et  la depassoit,  et qui  cedoit a
 I'impulsion  des  doigts,  excepte" dans  le  tems
 des douleurs.  En  parcourant  cette  tumeur,
 il ne trouva a la circonference qu'un cul-de-sac
de  demipouce de  profondeur, sans ouverture,
 qui peut permettre  la sortie  de I'enfant.   Des
 confreres  mandes  pour  ce cas extraordinaire,
 voulourent voir  aussi comment  les choses se
 passoit.  Us trouverent sur  la tumeur  une de-
 chireure  qui n'interessoit  qu'une   partie  de
l'epaisseur  de  ses  parois.  Cette  dechireure
leur parut le lieu,  ou  il falloit  inciser. L'ope-
 ration   faite,  le  doigt  entra  dans  la poche
dans  laquelle I'enfant etoit contenu.  II  sortit
beaucoup d'eau bourbeuse. L'enfant  se presenta
et franchit Pouverture, qui venoit d'etre  prati-
quee, et a laquelle il se fit une petite dilaceration
du  cote droit. Lauverjat  ayant porte  la main
dans la poche, ne  trouva aucune  trace de col
ni d'orifice. Du reste il  ne survint point d'acci-
dens, et  les  ecoulemens se  firent  a  travers
l'ouverture,  qui  se  ferma  par degres. Deux
mois  apres,  le  col  et  l'orifice  de  la  matrice
etoient  dans  leur etat naturel."  Sabatier De la
Medicine Operatoire, T. i. p. 316. 
79
  The event of this case would doubtless, under
some circumstances, justify an operation;  but,
considering the possibility, not to say probability,
of all such cases  being retroversions  of the ute-
rus, and having the knowledge of two, which ter-
minated  so favourably from the sole efforts  of
nature, as  Mrs. Wilkes's and Mrs. F * * * *'s,
it is impossible that I can  recommend an opera-
tion, especially at the commencement of the pains,
and while the strength, habit of body,  and general
health of the patient are uninjured.  So long as
these circumstances remain propitious, there is
great reason to expect that the  pains alone may
be able to rectify what is amiss, and  to effect the
delivery, per vias naturales. The observation of
Cicero, Naturae  solertiam, nulla ars, nulla manus,
nemo opifex consequi  potest imitando, should, as
far as possible, be our guide in the  Practice of
Midwifery;  in which we find, that  women are
seldom injured  by  a long  continuance of  labor
pains, provided their  spirits are not  hurried, nor
their blood inflamed,  by injudicious  attempts to
give assistance, and by the improper use of cor-
dials and stimulants.

   If, however, nature gives up the point, if it is
found that the pains are unequal  to the  task of
 restoring the uterus to  its place,  and of  accom-
 plishing the delivery of the woman, it remains to 
80
be considered, whether it is not more for the ad-
vantage of the  patient, that  such  an operation
should be performed, and that she should by this
means be released from her burthen, than that she
should continue in the deplorable condition, which
attends the slow process of discharging a foetus
through an ulcerated opening into the vagina  or
rectum; in which process  there  must  always be
great pain and suffering for many months; and in
which, though several women have happily passed  jHF*
through it, yet others have perished miserably,
exhausted with pain and debility.

  A  justification  of such an   operation  may
doubtless  be found, and perhaps it may, in some
rare instances, be advisable; but we know, from
woful experience,  that  incisions  into the uterus
have been so very generally fatal,  (in this country
in particular) that the experiment ought never to
be tried, while any  reasonable expectation  can
be indulged of saving the patient by other means.


                   THE END. 
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