Inversion of the womb is one of the most dangerous accidents that can happen to a lying-in woman; it is always attended with severe pain, and violent hemorrhage; and, if not early remedied, becomes irremediable, since it would be as easy to turn a non-gravid womb inside out as forcibly to restore an inverted one, when many days or hours have elapsed after the occurrence of the accident.

Those who have had the hand in utero in turning, can well appreciate the exceeding laxity of the womb when not affected with the pains; and they can conceive that the mere weight of the after-birth, still attached to the fundus, might, were the woman standing on her feet, cause a commencement of inversion, which could be completed by means of the woman's strong voluntary efforts to bear down her pains. It is not to be doubted that instances of inversion have occurred in which the practitioner deserved no further blame than that of not taking proper precautions against its occurrence, by commanding the patient to preserve the horizontal posture and abstain from all bearing-down efforts. Levret gave very special directions to keep the patient in labor in a horizontal posture; and where a woman is supposed liable to hemorrhage connected with too sudden a delivery, he charges us to rupture the ovum early, so that the expulsion of the child may take place slowly and safely.

Notwithstanding the occurrence might take place spontaneously, and immediately after the birth of the child, yet, in a major part of the examples, it has been produced by improper haste and impatience to get away the after-birth.

I have seen but four persons who had inversio uteri, and they are recovered; one of these persons, Mrs. S., was already the mother of two children when she again became pregnant of the child born in June, 1831. It seems that, having, on both the preceding occasions, suffered severely from the method adopted by the physician in removing the after-birth, and supposing a midwife would deal more gently with her, she engaged an old woman, much accustomed, as it was said, to the care of women in labor, to attend her upon this occasion. The child was born by a very easy labor, but the after-birth not coming away so promptly as was desirable, tractions were made upon the cord, which caused the after-birth to come into the vagina. This gave the patient exquisite pain. The midwife, who could not understand why the woman should suffer so severely, made haste to draw the placenta forth by the cord, which made her cry out so loud that it was said her screams were heard in the street. After the mass had come away, the good woman found it still adhering to something, so that she could not take it up, and put it into a basin. She therefore

continued to pull it with great force, not knowing that she held in her hands the after-birth still adhering to the womb, the whole of which was now completely drawn forth and turned inside out. The hemorrhage was enormous, and the patient soon sunk into the extremest weakness and exhaustion. Half an hour elapsed before the midwife thought proper to confess her incompetency to manage the case. I was sent for, after she had acknowledged her ignorance of the method of proceeding, and, when I arrived, the patient was without pulse, algid, suffering the extremest distress, with constant jactitation, and a thirst that was unappeasable. To all appearance the woman was in the agonies of death. I found the globe of the womb hanging down full half way to the knees, and still invested with the placenta and membranes, except where they had been torn and broken by the attempts of the midwife to pull the entire mass, womb and all, away.

Having endeavored to push the whole womb and placenta back into their natural position, and finding I could not succeed, I sent for my venerable friend Prof. James, who speedily arrived. Dr. James now made an attempt to reposit the womb, but he also failed. By his advice, I removed the placenta, but could not force the uterus up into the pelvis.

In making the attempt to restore it to its place, I followed the method recommended in the books; that is, I compressed the organ in both hands to reduce its size. At last, I observed that the more I handled it, the firmer and harder it became; in short, that I excited after-pains, just as we excite them by frictions on the hypogastrium after the child's birth. I therefore inferred that the proper way of proceeding would be to let it rest, and as soon as the relaxation of the organ should be complete, as it is in intervals between ordinary afterpains, to endeavor to indent its fundus like the bottom of a bottle, and then carry it upwards. I found, on observing it, that the womb repeatedly expanded or relaxed, and became hardened or contracted again. Taking, therefore, the moment of the completest relaxation, I indented the fundus with one finger, and, as it became more and more concave, I applied each of the fingers in succession, until I found that the progress of the fundus inwards was impeded by the os uteri, which, although completely inverted, yet resisted for some time the attempt at reposition. By perseverance, I finally had the pleasure to overcome the resistance of the os, and the peritoneal surface of the fundus was pushed upwards until at last the womb was completely restored to its natural position, but still containing my hand, which was now up as high as a little above the umbilicus. As no contraction came on immediately, I retained possession of the cavity of the womb, which

I gently excited by moving my fingers within it, until a contraction began which I suffered to push my hand out into the vagina. While I was withdrawing the right hand, I felt with the other the womb firmly contracted in the lower belly, and enjoyed the satisfaction of complete success in this distressing case.

I have said nothing of the brandy and volatile alkali that were given to the woman to keep her from dying. She took a very large quantity of those articles, besides laudanum, before I left her, which I was obliged to do in order to attend to another patient; and I feel under great obligations to my friend Dr. George Fox, who came at my request, and took charge of Mrs. S. for the remainder of the time that she continued ill. Her situation when I gave her up to his care was nearly desperate, from anæmia; nevertheless, by the administration of proper restoratives, and the judicious exhibition of stimulants during several hours, she rallied, and, in no very long time, recovered a good share of health.

From that period she was, for a long time, not quite regular as to the catamenia, which appeared at uncertain periods, and less abundantly than before her dreadful accident.

Since the occurrence of the above-recited events, Mrs. S. has been twice safely delivered of healthy children by my friend Professor Bache. It is worthy of remark that the placenta was adherent in these cases also; and Dr. B. was not able to effect the delivery of the afterbirth, until he had separated it from the womb by the hand introduced into its cavity.

I cannot refrain from mentioning here the case related by Mr. Charles White, of Manchester, in which he succeeded in restoring an inverted womb to its natural state by compressing it and then pushing it up. In his case, the inversion could not have been complete, since, although he represents the inverted uterus to have been as large as a child's head, it was never expelled through the external organs, and it is impossible that, if fully inverted, it could be retained in the excavation. Mr. W. regards his method as of the very highest importance, and thinks he should never have succeeded but for the compression of the womb in the hand.

I am ready to admit that it might happen that a tonic contraction of an inverted uterus should come on at once, and last so long as to prevent, for some time, the employment of the plan that I suggest, but think it probable it would always be practicable to return it, in any case where it had not been inverted more than four or five hours, by waiting for the moment of its greatest relaxation,--such a moment must surely arrive, and then, first indenting the fundus, and after

wards pushing it steadily upwards through the os uteri, carry it at last into the abdomen again.

Since the last edition of this work I have had an opportunity to confirm my views of the propriety of waiting for an interval of relaxation, before we attempt to reposit the inverted womb. In the autumn of 1855 I was called on by a gentleman, who seemed much agitated, to hasten to his residence, and carry with me an instrument for the ligation of a uterine polypus. He was sent, he said, by the physician in attendance, who had just delivered the lady of a child, and who found that she had a large polypus requiring instant attention. On hearing this statement, I at once concluded there must be a serious mistake, and that the supposed polypus was an inverted womb. Nevertheless, as the medical gentleman had sent for me and my instrument, I concluded to take Gooch's double canula, and drove to the rendezvous.

The woman was algid, pulseless, voiceless, and to all appearance moribund. The physician told me that she had a polypus uteri, which he wished me to examine. After touching it with my hand, I informed him that it was not polypus, but inverted uterus. So complete had been his misinterpretation of the case, that he had put a strong ligature on the neck of the supposed tumor, which was tied as hard as the nurse, who tied the knot, could draw the ligature. As soon as I explained the case, he cut away the ligature, and then asked me to try to return the womb into the abdomen, which I was so fortu nate as to do; but I tried first Dr. White's method, above mentioned, and found the same impossibility of succeeding as in Mrs. S.'s case. Indeed, I should have never returned the womb to its proper position, if I had not watched for and seized the favorable moment of relaxation to indent the then flaccid fundus, and so, thrust it upward through the corpus, the os uteri and the vagina, into the belly, after which I withdrew my hand. Many hours elapsed before the pulse at the wrist returned-but I am happy to say that the lady recovered her health in the course of a few weeks.

It has been stated that, when the womb is only half inverted, the woman is liable to greater pain and danger than where it is turned completely inside out, in consequence of the strangulation of the part that is griped by the os and cervix uteri, and it is thought by some persons good practice, in such cases, to make the inversion complete. I am unable to speak of this point from any experimental knowledge that I possess, nor do I know that the probabilities of recovery would be greater with a complete than with an incomplete inversion. Inasmuch as the muscular action of the womb is always found to alternate

with periods of relaxation, it would probably be in the power of the accoucheur to succeed in curing this partial inversion, by getting his hand within the cervix, and keeping it there until he should find the womb relaxing. As soon as the relaxation should be considerable, he might thrust the inverted vault back to its place, as was done by both Levret and Leroux, according to the relation of the latter named author. Such an attempt, if cautiously and wisely made, could be productive of no harm. If unsuccessful, the woman must be committed to the chances of a spontaneous reposition.

But, if there be any ground to hope for a spontaneous replacement, as I shall hereafter contend, it seems to me that it would be wiser to let the incomplete inversion alone, trusting it to the power of nature, rather than incur the hazard of wholly inverting it, which would greatly lessen the prospect of a future spontaneous cure.

Of course, I am understood as recommending this confidence, or rather hope in nature, only for those in whom every reasonable attempt to restore by the hand has utterly failed and been quite abandoned.

A careful and attentive practitioner of midwifery will never fail, after the delivery of the placenta, to examine by palpation of the hypogaster, the state of the uterine globe; and there can exist but few individuals in whom such an examination would not disclose the absence of that proper degree of convexity of the fundus uteri, should it exist, which is the sure demonstration of the truth that inversion, either incipient or complete, has taken place. As inversion can only take place by the falling in of the dome of the uterus, such fall is sure to show the upper part of the organ concave instead of convex, upon palpation of the hypogastric region.

I delivered a woman some time since who was moribund with hemorrhage from placenta prævia; when I turned the child and brought it away by the feet, the womb, which was as flaccid as a wet oxbladder, sank inwards, allowing the placenta to come forward to the os uteri. I took the placenta away, and the dome of the uterus came into the vagina. I pushed it back; it made no resistance; and when I withdrew my hand, it followed it again. The patient expired in a few minutes.

I considered her to be dying when I reached her bedside.

The utter flaccidity of this uterus has convinced me that the cases reported, of spontaneous inversion, may have been really so, and independent of any rash manoeuvres; for the weakness of the mus cular apparatus may be so complete, that the rest of the component tissues of the womb cannot prevent it from becoming inverted under