a retroflexion, raise up the womb to let the ligamenta rotunda contract, and condense themselves. You see that the pessarium is in this case, in the same predicament as the Satyr's guest on the mountain, who blew his fingers to warm them, very reasonably, and then blew his porridge to cool it, which was also quite a reasonable action. Don't you, like the Satyr, turn him out for blowing hot and cold with the same breath. That Satyr was but a Satyr at best. What reason, then, had Father Æsop to expect philosophy in such a beast, or to set him up as an example of wisdom and justice? If it be a retroflexion, use a large globe; if it be an anteflexion, take an oviform pessary of silver gilt, and choose one as large as a Normandy hen's egg; adjust it, so that the lesser pole of the egg shall look towards the uterus, while the larger pole shall lie in the lower segment of the vagina. I have found such an one efficacious in pushing off the uterus from the bladder, and at the same time in producing or elongating the tube of the vagina.

I said, in a note to Colombat, p. 150, that I had met with but one sample of the true anteversion of the womb up to the date of that writing, which was nearly three years ago. Since that I have met with several cases of anteversion.

I had seen many instances in which the vaginal cervix was angular, either in the anteflected or retroflected form, but they were instances derived evidently from the pressure of the flexible cervix, against the posterior wall of the vagina, and did not interest the principal portion of the long axis of the uterus; probably such cases scarcely deserve to be classed among the true anteflexions of the organ.

I shall say nothing in this letter as to the lateral obliquities of the womb. I shall probably advert to them when I come to speak with you on the disorders and accidents of pregnancy. In my next, I shall offer you some observations upon inversion of the womb, several samples of which have fallen under my notice.

LETTER XVIII.

INVERSIO UTERI.

GENTLEMEN:-The term Inversion of the womb, is applied to express that state in which the uterus is turned inside out; as a stocking or a glove is turned inside out by drawing it off the foot or the hand.

Dr. John Green Crosse, of Norwich, in England, published in + rt this 1845, an 8vo. volume, Part I., entitled An Essay Literary and werke te Practical, on Inversio Uteri, which is so full of learning, research, ca and that practical good sense that distinguishes all the writings of by Dad br that able gentleman, that I am under no little temptation to give you the whole of it as a letter; but I should, in that case, violate the rule laid down, to render this volume as nearly as possible an original one. I shall only, therefore, advise you to take the first opportunity to read Mr. Crosse on the subject in question. Doing so, you will learn that he says at p. 8,

"Inversion signifies not only a turning inwards of the uterine walls, but a turning inside out of the whole organ, by its passing successively through the os tincæ, converting the lining mucous, membrane into an exterior covering of the uterus, and creating a new cavity, which is lined with peritoneum, and communicates superiorly with the cavity of the abdomen."

Mr. Crosse, in another paragraph, says, "inversion of the uterus is either partial or total; the latter can exist only in one degree, and admits of no subdivision. Partial inversion, on the contrary, comprises very many degrees, and there are both physiological and practical reasons for noticing and describing three, by way of classification, namely, depression, introversion, and perversion.”

Such are the divisions of our malady proposed by Mr. Crosse, and he next goes on to show, that depression, which is the slightest degree of partial inversion, is present when any portion of the entire thickness of the walls becomes convex towards the cavity of the uterus. Introversion is the case where the depression has gone so deep, as to bring a part of the fundus within the grasp of

the portion of the uterus into which it is received. Perversion is when a portion of the fundus projects through the os tincæ.

This, then, is Mr. Crosse's classification, which, as you perceive, furnishes easy terms of communication, whenever in conversation or in writing, you desire to treat of the several degrees of the accident in question. It serves, also, to keep in the remembrance the fact, that where the womb is in danger of inversion, that danger may be greater or less, according as the accident has proceeded to a greater or less degree.

You may know that the womb is inverted by several signs; which are, pain, hemorrhage with its attendant phenomena, absence of the uterus from its usual place, a tumor in the vagina, or in the womb, or depending outside of the vulva, also by a concavity felt in the fundus of the womb, instead of its natural convexity ascertainable by palpation of the hypogastrium.

The causes of inversion are chiefly to be found in improper or accidental tractions on the cord in child-bed. They are improper whenever an ignorant person takes hold of the umbilical cord, to pull forth the after-birth, without first ascertaining that the womb is contracted; the accidental causes are where too short a cord inverts the womb which has just forced the child into the world, aided in its contraction by the contraction of the abdominal muscles. A woman is sometimes suddenly delivered while standing upon her feet, or in rising from the close stool; in such a case, the fall of the child towards the floor, is apt either to break asunder the cord, or if the uterus become suddenly relaxed, it may draw the adherent placenta still attached, and the whole fundus and body out at the genital orifice.

A womb may also be inverted, by rudely pressing or kneading the hypogaster with the hand in order to enforce its contractility. To press rudely, in this way, upon the top of the fundus, and immediately expect the woman to bear down, is not very safe, since if a depression, as Mr. Crosse calls it, should have been produced by your palpation, and the woman should at once begin to bear down, she would probably convert the depression into an introversion, then into a perversion, and so at length, into a complete inversion. Even the act of straining at stool, or at urine, after the delivery of the placenta is completed, might suffice to cause an inversion, provided it should be done at a moment, when the womb is lying within the belly flaccid, and loose as a wet bladder.

I have found the womb to fall down as it were spontaneously, seemingly because it was destitute of any solidity capable of resisting the ordinary pressure of the abdomen, even when not under a tenesmic irritation.

A polypus, or other tumor, growing within the cavity of the womb, comes to be so large in the course of time, that it passes out of the circle of the os uteri, and takes possession of the vagina. Here is naturally set up a powerful uterine tenesmus; the depression makes its appearance, the introversion follows, and so from step to step, the patient lapses into true complete inversio uteri.

The diagnosis of inversion in its different stages, is not without great difficulty in some of the cases. It is so in reference to the similarity of the appearances presented by some of the fibrous, and even by some of the cellular polypi, with those exhibited by the inverted womb, and as this special diagnosis is not only a very difficult but a very important one, I beg that you will always very seriously incline yourselves to great cautiousness and slowness, before you make, and especially before you announce your opinion of any case.

Where you are called in to witness, and give counsel or aid, in an inversio uteri that has just taken place, you can have no difficulty in making a correct opinion. But in those that have happened long before, and in which the womb, though inverted, has recovered nearly its non-grayid size; take, I beseech you, very great care not to make a mistake; don't think you are dealing with a uterine polypus, when you in fact are dealing with the womb itself; because, when people deal with a polypus they cut it off, when they deal with the womb, they let it alone, which is a very great and a very important difference.

I repeat, that it is difficult in some of the instances, to discriminate between the inverted uterus, and the polypus uteri. In neither is there an os uteri to be felt; they are both reddish looking, softish, bleeding, rather insensible masses, about as large as the larger end of an egg, save when the polypus is larger; I mean in the chronic forms.

In passing the finger or two fingers upwards in the vagina, a ring like what the French call a bourrelet, is felt through which the tumor passes outward, into the cavity of the vagina. If you look at them through a speculum uteri, you will scarcely be able from the light to discriminate betwixt them.

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You must carefully gather the whole history of the case, as for example by the following method.

"How was it with the after-birth? Did it come away soon?" "No, sir, it was a long time coming."

"Did it hurt you?"

"I guess it did, indeed; she pulled me so hard, I screamed till

you could have heard me a square off."

"Well, what happened next?"

"I don't know, for I fainted away and was a long time so weak, that I cannot tell what happened."

"Did you flood very much?"

"Flood! why I was fairly covered with blood."

"How long before the discharges stopped?"

"Why, it's never stopped in fact, for I am more or less unwell

every day, especially if I do any hard work."

"You look very pale."

"Bless your heart, I used to be as red as a rose."

"Have you any appetite?"

"Yes, pretty good, thank you.'

"How are the bowels, regular?"

"Oh, no, quite costive."

"Any trouble of making water?"

"Very much; often obliged to go, and to get up at nights. It's a great trouble to me."

"You must let me examine the case; I can't tell what it is except you allow that."