any return of the inversion, but of exciting more active contractions by its presence. The patient should avoid making any sudden efforts to raise herself, or to cough, strain, or by any means excite the abdominal muscles to exert pressure upon the fundus, for it is occasionally observed, that the disposition to inversion continues some time after the reduction has been effected.

Where some little time has elapsed before any attempt is made to reduce the fundus, the inverted portion begins to swell from obstruction to the return of blood, especially where the inversion is partial, and, therefore, tightly girded by the os uteri; the passages grow hot and dry, and the chances of reducing the tumour diminish in proportion. "Is it not reasonable," as Mr. Newnham observes, "to suppose that the first effect of the accident will be to bring on inflammatory action and tension of the parts, and that this very state will in itself be a sufficient obstacle to success?" (Op. cit. p. 18.) If, under these circumstances, we find that the attempt at reduction is attended with considerable difficulty, or is evidently impossible, it will be necessary to wait until the excitement of the circulation, and the congestion and swelling of the parts are reduced, and the passages duly relaxed by bleeding; besides this, the external parts should be well fomented, the patient should use the warm hip bath, or sit over the steam of hot water, and throw up emollient and sedative enemata, as recommended in our treatment of inflammation of the uterus: the operation which was, during the state of inflammation and feverish excitement in which the patient was, strongly contra-indicated, now becomes practicable and safe, and the difficulties, which before would have rendered it nearly or quite impossible, are now in a great measure removed.

Wherever the uterus is completely inverted, and there is reason to expect considerable difficulty in reducing it, we shall find great benefit in adopting the mode of practice recommended by Mr. C. White, of Manchester, viz., of firmly grasping the tumour until we have succeeded in considerably diminishing its size, and thus removing the chief obstacle to its reduction. "I grasped the body of it in my hand," says Mr. W., "and held it there for some time, in order to lessen its bulk by compression. As I soon perceived that it began to diminish, I persevered, and soon after made another attempt to reduce it, by thrusting at its fundus; it began to give way. I continued the force till I had perfectly returned it, and had insinuated my hand into its body: it was no sooner reduced, than the pulse in her wrist began to beat: she recovered as fast as we could wish." (White, on Lying-in Women, case 19. Appendix, p. 2d edit.)

Where the fundus is partially inverted, and the os uteri girds it very tightly, so as not only to produce very frightful symptoms arising from the strangulated condition of the organ, but also to render its reduction a matter of great difficulty, or even impossibility, Dr. Dewees has advised that, so far from attempting to push up the fundus, we should rather try to bring it down, and thus render the inversion complete; by this means, the "pain, faintness, vomiting, delirium, cold sweats, convulsions, extinct pulse," &c., will not only be relieved, but the farther danger from hæmorrhage prevented.

"The propriety and safety of this plan is, it must be confessed, predi

cated upon the happy result of a solitary case, but, from its entire and speedy success in this instance, it is rendered more than probable that it will be of equal advantage if employed in others; all reasoning upon the subject' is certainly in its favour; and experience, so far as a single case may be entitled such, is equally so. The patient is to be placed upon her back near the edge of the bed, and have her legs supported by proper assistants; the hand is to be introduced along the inferior part of the vagina, but sufficiently high to seize the uterus pretty firmly; it is then to be drawn gently and steadily downward and outward, until the inversion is completed: this will be known by a kind of jerk, announcing the passing of the confined part through the stricture. Traction should now cease, and the part be carefully examined; if the inversion be complete, the mouth of the uterus will no longer be felt, and there will be an immediate cessation of pain and other distressing sensations." (Dewees, Compendious System of Midwifery, § 1318.)

Chronic inversion. Where some time has already elapsed since the occurrence of the accident, and the more distressing symptoms have subsided, the inversion now passes into a chronic state, which, although not immediately dangerous to life, will ultimately be not less fatal. The form of the tumour gradually alters; it assumes a more polypoid shape, from the increasing contraction of its mouth narrowing the upper part of it; and now the diagnosis from polypus sometimes becomes exceedingly difficult, the more so as the pressure produced by the os uteri diminishes the sensibility of the fundus. Hence, as Mr. Newnham observes, we may conclude, "that it is always difficult and sometimes impossible, with our present knowledge, to distinguish partial and chronic inversion of the uterus from polypus; since, in both diseases, the os uteri will be found encircling the summit of the tumour, and, in either case, the finger may be passed readily around it. And if, in order to remove this uncertainty, the entire hand be introduced into the vagina, so as to allow the finger to pass by the side of the tumour to the extremity of the space remaining between it and the cs uteri; and if we find that the finger soon arrives at this point, it will be impossible to ascertain whether it rests against a portion of the uterus which has been inverted in the usual way, or by the long-continued dragging of the polypus upon its fundus. And if, under these embarrassing circumstances, we call to our assistance our ideas concerning the form of polypus, its enlarged base and narrow peduncle, we must also recollect the abundant evidence to prove that the neck of such a tumour is often as large, and sometimes larger, than its inferior extremity, and we shall still be left in inexplicable uncertainty."

The periodical hæmorrhages, with profuse leucorrhoea during the intervals are too common, both to chronic partial inversion and to polypus, to afford any certain means of diagnosis; and the gradually increasing debility, from the constant drain upon the system and ultimate breaking up of the general health, may be as much the result of the one as of the other. The rugged uneven surface of the inverted uterus, the smoothness of a polypus, are distinctions not of long continuance; for, after awhile, the uterus gradually becomes smoother, whereas, a polypus rarely continues long in the vagina without its surface becoming irregular from exeding ulceration.

It might be a question whether it would not be possible to detect the menstrual fluid at the catamenial periods oozing from the surface of the inverted uterus: that this is quite possible in cases of complete inversion, is a well-known fact, but how far it can be detected in the partial form is not so certain, as the position of the tumour, pretty high up in the vagina, would prevent our ascertaining it, especially when there is more or less hæmorrhage going on. In most cases, the history of the case, and our not being able to pass up a catheter far beyond the os uteri, which completely surrounds the neck of the tumour without adhering to it, are the chief points upon which we must found our diagnosis.

"Whilst the inverted uterus remains in the vagina, the discharge (excepting at the periods of menstruation,) will be of a mucous kind; but if the uterus falls lower, so as to protrude beyond the external parts, the exposure of that surface, which in a natural state lined the cavity, to air, as well as to occasional injuries, may induce inflammation and ulceration over a part or the whole of its surface; and the mucous discharge may be changed to one of a purulent kind, so considerable in quantity as to debilitate the constitution, and to cause all the common symptoms of weakness." (Sir C. M. Clarke, on the Diseases of Females, part i. p. 155.)

Although such a length of time has elapsed since the inversion, that it has become of the chronic kind, still we are not justified in giving up all hopes as to the possibility of returning it. Dr. Churchill has given an interesting summary of cases where many days, and in one case even twelve weeks, had intervened, and yet, nevertheless, where the reduction was successfully effected. (On the Principal Diseases of Females, p. 331.) We may also add two very remarkable cases related by Boyer (quoted by Kilian,) viz., where the uterus had resisted every endeavour to reduce the inversion, which in one case had remained fourteen days, in the other more than eight years, and where, in consequence of a sudden and violent fall upon the nates, reduction followed spontaneously and permanently.

Extirpation of the uterus. Where, however, the powers of the system are rapidly breaking, from the profuse hæmorrhages at each menstrual period, and not less profuse discharge during the intervals, the only means of saving the patient is by treating the case as one of polypus, or, in other words, removing the uterus by ligature. Numerous cases are on record where this has succeeded perfectly, although during the process the patient suffered from several attacks of pain and even inflammation, occasionally requiring the ligature to be loosened for awhile. In the case recorded by Mr. Newnham, rather more than three weeks were required before the separation of the tumour was effected. When once this source of irritation is removed, the hæmorrhage and other discharges which had so greatly reduced the patient cease, and, as in cases of polypus, a most striking and favourable change is produced, the health and strength return, and the recovery of the patient is complete.

CHAPTER VIII.

ENCYSTED PLACENTA.

SITUATION IN THE UTERUS.-ADHERENT PLACENTA.-PROGNOSIS AND TREATMENT.— PLACENTA LEFT IN THE UTERUS.-ABSORPTION OF RETAINED PLACENTA.

By the term encysted placenta, we mean that state of irregular uterine action after the expulsion of the child, where the lower portion of the uterus, particularly the os uteri internum, is closely contracted, while the fundus contains the placenta enclosed in a species of cyst or cavity formed by itself and the body of the uterus.

Upon examination externally, we find the fundus pretty firmly contracted, but probably somewhat higher up the abdomen than usual; the vagina and os uteri externum, or os tincæ, are usually found dilated, the passage gradually tapering like a funnel to the os uteri internum, or upper end of the canal of the cervix.

Situation in the uterus. This state has been very generally considered to arise from a spasmodic contraction in the circular fibres of the body of the uterus, by which it was as if tightly girded by a cord at its middle, and, from the form it was supposed to take, was called hour-glass contraction of the uterus.

From the observations of later years there is much reason to suppose that the true hour-glass contraction, as now described, is of very rare occurrence, even if it does take place at all; and that, in by far the majority of cases, the stricture is either produced by the upper part of the cervix, as we have already mentioned, or resides in the os uteri externum or inferior portion of the cervix.

Baudelocque was the first who pointed out the neck of the uterus as the real seat of the stricture in these cases: "That circle (says he) of the uterus which is round the child's neck, according to the general laws of its contraction, must narrow itself much quicker after delivery than the other circles which compose that viscus, because it is already narrower, and its forced dilatation at the instant of the expulsion of the child's trunk is only momentary, and because it has naturally more tendency to close than the other circles have, since it is that which constitutes the neck of the uterus in its natural state." (Baudelocque, Heath's Trans. vol. ii. § 969.)

Dr. Douglas, of Dublin, also investigated this subject, and came to a similar conclusion: he considered that encysted or incarcerated placenta from hour-glass contraction resulted either from morbid adhesion of the placenta, or from inactivity of the uterus, and does not occur as a primary affection; his observations lead to the conclusion that the stricture in hourglass contraction "does not form from the middle circumference of the

uterus; it is formed by the lowest verge of its thickly muscular substance, at the line of demarkation of its body and cervix." "Thus, then, it would appear that the upper chamber comprises in its formation the entire of the body of the fundus; whilst the lower chamber engages only the cervix uteri and the vagina." (Medical Transactions of the Col. of Phys. vol. vi. p. 393.)

The late W. J. Schmitt of Vienna considered that the stricture was produced by the os tincæ, or os uteri externum.

From our own experience we would say that the seat of the stricture varies considerably in different cases; that in the simplest form it is nothing more than a contracted state of the os uteri externum; that in others it is formed by the upper portion of the cervix uteri, or os uteri internum; but in other instances it appears to be formed by the inferior segment of the uterus itself. The contraction in this part of the uterus, which, according to the observations of Professor Michaelis, comes on when the os uteri is fully developed, and, by closely surrounding the bead, is one chief means by which prolapsus of the cord is prevented, may easily produce a state of stricture after the birth of the child, and thus retain the placenta; it may, however, be questioned whether this portion of the uterus, when fully dilated by pregnancy, and which then forms its inferior segment, would not become the os uteri internum when the uterus is empty and contracted.

Hour-glass contraction of the uterus is liable to occur where the action of the uterus has been much deranged or exhausted, either by the unusual rapidity or excessive protraction of the labour. In all cases where the child has been rapidly expelled before the uterus has had time to contract regularly and uniformly, the disposition in the os uteri to contract, as pointed out by Baudelocque, will manifest itself. This state may also be induced by great previous distention, as from twins, or too much liquor amnii; by irritation, as by improperly pulling at the cord, by having used too much force in artificially delivering the child, by the introduction of the hand or instruments too cold, &c. The most frequent cause, however, is over-anxiety to remove the placenta; the cord is frequently pulled at, and at length the os uteri is excited to contract; in this case we generally find the stricture at the os tincæ, which yields without much difficulty, either by gentle friction with the hand over the fundus, and cautiously pulling the placenta in the axis of the superior aperture, or by introducing the hand and bringing it away.

Adherent placenta. When the placenta is still attached either wholly or in part, there are generally some preternatural adhesions to the uterus, which, by keeping its upper portion distended, give rise to partial contractions below. This condition of the placenta is observed to attend nearly every severe case of hour-glass contraction; in some instances its whole surface appears as if grown to the uterus, forming an adhesion so close and intimate as to be overcome with the greatest difficulty; we have met with cases where the placenta tore up into shreds which still adhered to the uterus as strongly as before; in others, however, the adhesions are of smaller extent, varying from the size of a shilling to that of a crown piece, sometimes there being only one, sometimes two or three, in the same pla

centa.

The nature of these adhesions is but little understood; it is generally