come.

we can understand why failures were so frequent. The manner of reposition is this: The uterus is carried firmly up the vagina till it, the vaginia, becomes tense, being put upon the stretch it pulls upon the os uteri and reinverts it, and now making a depression or dimple in the fundus, we carry it upwards, and necessarily have four layers of the uterus passing through the os uteri at the same time. The contracted os uteri resists, and the large quantity of uterine fibres present an obstacle which cannot be overIn reposition accomplished in this manner, the uterine tumor begins to shorten at the fundus, for that is indented and pressed in. This method then, has its objections. I would now propose a method applicable to all cases, whether they be recent or long standing, which is simple, and I think, philosophical. The inverted uterus should be grasped in the palm of the hand and compressed firmly, so as to render it less bulky, by having its quantity of blood lessened. It should now be carried up into the vagina and pressed steadily; the vagina will become tense and reinvert the mouth; steady pressure should be maintained and the uterus will continue to double upon itself; evolution takes place, the uterine tumor shortens at its neck, complete reinversion is effected and no depression or dimpling of the fundus is at any time perceptible; and at no time, by this method, are there more than two layers of the uterus passing through the mouth. Having treated a case of this description in this munner, April 29, 1855, with success and with great ease, of which I made a verbal report in February last, I take great pleasure in recommending it to this society, and while my own experience proves its applicability in recent cases, I would state that Tyler Smith, of London, and our fellow countryman, James P. White, of Buffalo, have both recorded cases, one of twelve years duration, and the other of fifteen years, treated successfully, and I may say, triumphantly, by this method. Dr. Smith Reported his case to the Royal Medical and Chirurgical Society, April 13, 1858, and Prof. White communicated an account of his case at a meeting of the Buffalo Medical Association, April 6, 1858. This, gentlemen, concludes all I have to say in relation to the nature, causes, manner of occurrence and mode of treatment of inversion of the uterus, a subject invested with much interest and some obscurity; if I have in the smallest measure added to that interest, or in the slightest degree deprived it of obscurity, I shall then think I have discharged the duty which the society imposed upon me.

14. Inversion of the Uterus. By DANIEL P. BISSILL, M. D., of Utica.

Whatever relates to the uterus and its appendages, their structure, functions, and derangements, claims the highest attention of every student and practitioner of medicine. On their normal condition and unimpaired function, depend the welfare and blessedness of one-half of our race; in fact the very existance of mankind on earth is suspended on the perfect development and healthy condition of these organs.

The important rank which the uterus holds in the economy of the human organism, does not, however, shield it from danger, for perhaps there is no single organ in the body more delicate in its structure, more extensive and complicated in its relations and sympathies, or more liable to derangements and diseases, to accidents and injuries than the womb. While its complicated structure and perfect adaptation to subserve the high purposes of its designs, excite our admiration, its injuries and diseases should claim in a corresponding degree, our most patient study and investigation. Viewed in this light, no apology is necessary for presenting the subject here.

It is not my purpose, however, to present even a general view of the anatomy, physiology, or the diseases of the womb; nor is such a work necessary at the present day, for the reason that the labor has been already performed by many of the most learned and able teachers and practitioners of our profession; and performed too in such a manner that but little now remains to be done except to study and understand what has already been so well written on these subjects. I simply propose to call the attention of the society to one of the most fearful accidents which can befall the uterus, viz: inversion of that organ, and to mention such cases as I have witnessed, and especially to report a case which quite recently came under my care.

Fortunately this accident is of rare occurrence, nevertheless it is sufficiently frequent to demand a share of our consideration, as it is one which may happen in the practice of any of us. Perhaps the infrequency of this injury accounts for the fact that systema

tic writers on obstetrics have bestowed but little attention upon it. It would seem that the fearful nature of this displacement, and its fatal tendency when it does occur, should entitle it to more consideration. Nearly all of our standard authors mention it as possible to happen, and warn the young accoucheur against the danger of hastening the expulsion of the placenta, after de livery of the child, by "pulling and tugging" at the funis umbilicus, by which, in the opinion of most writers on the subject, this accident is alone produced.

Probably in a majority of cases the inversion is the result of rashness or haste on the part of the midwife, (whether male or female,) in hastening the separation and expulsion of the afterbirth, but in my opinion, it may be, and sometimes is produced by other causes. A case occurred in my own practice many years since, and one too, which made a strong impression on my mind at the time, which clearly shows that inversion may happen spontane ously, or be produced by causes from within as well as from without. Contraction of the fundus of the uterus, while the lower part and neck of the organ remain in an inactive and relaxed state is in my judgment competent to produce such a result.

of

The case to which I refer was a primipara-the patient 24 years age; robust and of plethoric habit. The labor of the birth of the child, was in all respects natural, although somewhat protrac ted, and the pains very frequent and of unusual force. After the expulsion of the child, she was greatly exhausted, and therefore allowed to remain perfectly quiet until she revived, giving a little wine and water to sustain her. In about twenty or twenty-five min utes reaction took place, when the patient was seized with severe pains, or rather suffered continued pain, attended with great rest lessness, sickness of the stomach, and profuse hemorrhage. I at once introduced my hand to ascertain the nature of the derangement, and found the fundus of the uterus inverted and forced down into the neck and os tincæ, with a portion of the placenta attached, while much the larger part of it lay in the vagina. The womb was folded inwardly upon itself, but not entirely inverted. The diagnosis was clear, but the knowledge which it afforded was anything but satisfactory or encouraging to a young man in the first years of his practice. It may be supposed, therefore, that I felt the full responsibility of my position, and earnestly enquired of myself, "how shall I proceed ?" The violence of the flooding admitted of no delay. My patient was rapidly sinking. Under the circumstances. I resolved to detach and remove the afterbirth, before

reducing the womb. This was readily accomplished, but in the operation the uterus was entirely inverted by an action within itself, and now rested on the perineum. Here the whole process of inversion was self-induced. In separating the placenta, I endeavored to sustain the fundus and prevent its further descent, but the pain or effort of the patient which effected the expulsion of the afterbirth, completed the inversion, notwithstanding my best endeavors to prevent it at the moment when it occurred. The reduction was readily and easily effected, in the following manner: Supporting and steadying the womb with my left hand, I made pressure on the most dependent part of the fundus with the fingers of my right hand folded together, and soon succeeded in carrying it up through the neck and in restoring it to its nor. mal position; my hand being within the cavity of the reduced The irritation of the hand soon caused the womb to conorgan. tract, and I gradually withdrew it, leaving the uterus self-sustained in its true position.

In this case it is entirely certain that neither the "rashness of the midwife " nor the imprudence of the patient caused the inver. sion; for after the birth of the child no effort whatever was made to extract the placenta, nor was the woman allowed to move until after the occurrence of the accident. The cause of it, therefore, must have been internal and involuntary. "Contraction of the fundus" of the womb, while the lower portions of the organ were in a state of relaxation and inactivity, aided perhaps by the weight of the placenta which was attached to the fundus, are the only assignable causes for the displacement.

Perhaps it would have been more in accordance with modern practice if the uterus had been reduced before separating the placenta, but so much of it was already separated when I made the examination, and the flowing was so profuse, I deemed it more safe and expeditious to complete the separation before attempting the reduction, and the result proved the correctness of the course adopted for as soon as the afterbirth was removed and the inversion perfected, the hemorrhage was greatly diminished and the sufferings of the patient equally relieved; in fact I cannot con ceive what benefits or advantages can be derived in any case of inversion by returning the placenta into the womb again when the separation of it can be so easily and safely accomplished before the womb is replaced. The perfect success of the operation in the manner described, the comfortable state of my patient during confinement, and her rapid recovery therefrom, all tend to

impress upon my mind the propriety, at least, of the mode of redress which was pursued.

A few years since another case occurred in a neighboring town which was somewhat similar to the one which I have related. This happened also in a first labor. The patient was the wife of a farmer, of about twenty-six years of age, strong and robust, the labor natural, as I was informed, until the head of the child was delivered, but the pains were frequent and very severe. The physician who attended the woman informed me that for the last two hours before the expulsion of the head of the child there was very little cessation of the pains, but after the head was delivered all efforts of the uterus ceased, and he was compelled to make strong traction to bring down the shoulders and deliver the body of the child. He also stated that after waiting some time to allow the woman to recover from the exhausttion and fatigue of this part of her labor, he applied his hand to the abdomen so as to feel the womb, as he supposed, and to manipulate upon it, (a practice which I think should never be omitted,) at the same time making slight traction at the funis umbilicus; this, he said, aroused the uterus to action and excited pains, attended with an alarming hemorrhage.

The patient soon after became faint, her skin cold, and all the powers of life seemed to be rapidly sinking. The physician now became alarmed for the safety of his patient, and I was sent for, and saw her about an hour and a half after the birth of the child. She was cold and nearly pulseless when I arrived, extremely restless and looking pale and ghastly. The prostration, &c., seemed to be as much the result of the shock which the nervous system had sustained through the partial inversion of the womb as from the loss of blood, notwithstanding the flowing had been quite profuse. I was requested by the attending physician to examine, and if possible, relieve the patient from her imminent peril. On introducing my hand I found a part of the placenta in the vagina and mouth of the womb, while much the largest portion of it was held in the lower part and neck of the uterus by a fold of the fundus falling down upon and confining it there. At this time there was but little hemorrhage, and yet the patient seemed to be rapidly sinking. Brandy and laudanum were administered, while I carried my hand readily through the neck of the womb and restored the fundus to its natural position. Very soon some degree of contraction of the organ was excited, and I succeeded in separating and in bringing away the afterbirth. This arrested the hemor