We would suggest that the routine palpation of the abdomen, at each visit, is an ample precautionary measure. We are opposed to vaginal ex amination after labor, except in the presence of strict indication.
For detailed analysis of the main causes of inversion we refer the reader to this interesting paper.—Ed.] For our part, we are inclined to side with Rokitansky's view, for we believe that, in the majority of instances, the cord will break before the uterus yields, in case inertia of the uterus is not present.
The phenomena accompanying inversion are, at the outset, painless. to become intensified as the process increases, and the pains are the greater the more sudden the inversion. As a general thing, the hemor rhage is not serious, although it may be profuse. Cases have been re ported where there has been absolutely none, such as those of Brown. Chapman, Hamilton, Daillez, Burns and others. The chief symptoms are: Acute pain accompanied by the presence in the vagina of a more or less voluminous tumor, limited above by a ring formed by the cervix, de pression or absence of the uterus from the hypogastrium, at times projec tion at the vulva of a livid red tumor, to which the placenta or a fibroid may be adherent, hemorrhage, syncope, all these phenomena occurring so to speak, instantaneously. Such are the symptoms of recent inversion, with which alone we are here concerned.
In case of inversion with the placenta still adherent, should we first remove the placenta or reinvert the uterus, with the latter adherent? The answer for us is self-evident. We should only reduce the inversion after the removal of the placenta. The hemorrhage will thus possibly be a trifle increased, but the volume of the uterus will be diminished.
The prognosis depends on the rapidity of intervention. Reduction is the more difficult the greater the delay, and the greater the delay the I more serious becomes the condition of the woman. Finally, the intes tine may lie in the depression, and is there subject to strangulation.
If the uterus is in a condition of inertia, the whole hand should be in serted into the vagina, and with the closed fist the projecting portion should be pushed up, the other hand externally taking account of the progress. Spiegelberg, with justice, lays stress on the point that pressure should be made particularly in the pelvic axis, to avoid impingement on the sacral promontory. If the cervix is contracted around the tumor, Kilian and MacClintock advise grasping it in the palm of the hand, so that the fingers lie at the constriction. The uterus is then to be com
pressed so as to push through the os first the portions which were inverted last, pressing up, at the same time, the fundus with the palm of the hand. Reduction once accomplished, the hand should remain in the uterus un til the organ contracts regularly, and ergotine should be administered subcutaneously.
Meissner recommends the following procedure: The tumor is grasped by four fingers of each hand, and the thumbs are applied to the lowest part of the fundus uteri. At this point the aim is to make a depression, and to increase this by gradual and moderate pressure. Courty and others recommend section of the constricting ring. Longitudinal inci sions are to be made so as to cut the circular fibres of the isthmus, one in front, and another posteriorly. Courty substitutes for Barrier's method the following: " The cervix is immobilized by two fingers in the rectum, while the fingers of the other hand endeavor to push the tumor through, pressure being made towards the pubes, (instead of towards the sacrum, as Barrier advised.) The fingers in the rectum hold the cervix towards the sacrum, being spread widely apart, between the utero-sacral liga ments." Tate proceeds as follows: With the patient in the dorsal dear bitus, the two thumbs are inserted into the vagina, two fingers of one hand into the rectum, and the index of the other into the bladder. These fingers aim at fixing and steadying the cervix, while the thumbs press on the tumor at its centre, and seek to push it through the cervix, which is distended by the fingers in the rectum and bladder.
Finally various instruments have been devised as redressors, but all authorities agree in considering them more dangerous than useful, and in giving preference to the hand.
[The best method, possibly, of overcoming a recent inversion, is that of Noeggerath. It has yielded the best results of any. It consists in plac ing the index finger on one cornu of the uterus, and the thumb on the other, and in endeavors to push in first one and then the other. When this has been accomplished, pressure is made at the centre of the inverted mass, until it is reduced. The other hand, externally, makes counter pressure. Whatever the method resorted to, ana3sthesia is a pre-requisite to success.
As for the methods of use for the reduction of chronic inversion, they do not belong here. Munde gives a succinct account in his Minor Sur gical