II. Meeting, November 29th, 1878. 
W. IT. Byford, m. d., in the chair. 
Dr. Edward Warren Sawyer read the following report of a 
fatal case of Inversio Partialis Uteri Puerperalis. . 
Mrs. B , 38 Aldine square, aet. 35 years, of small, frail 
physique ; multipara, last labor five years ago. She fell in labor 
at midnight, Dec. 19, 1877 ; an hour afterward, I saw her for 
the first time. I was struck by the unusual size of the abdomen, 
which suggested multiple pregnancy. The lower extremities 
were very oedematous, and had been in this condition for several 
months. 
Upon examination, I found the os two-thirds opened, the 
vertex in advance, and still very high. Her pains, which returned 
with natural regularity and frequency, were short and sharp, 
lacking in force ; they were not well borne by the patient, who 
frequently demanded ether. 
At 2 a. m. the os was fully opened. Upon rupturing the 
membranes, there escaped the greatest quantity of liquor amnii 
I have ever encountered, the water inundating the bed and fall- 
ing upon the floor. Her abdomen soon assumed the size usual 
to this moment. The head was well engaged in the excavation, 
in the third position of the vertex (R. 0. P.), the anterior 
fontanelle occupying the centre of the field. In auscultating the 
tumor, I heard but one foetal heart, on the median line just 
below the umbilicus ; pulsations 144 in the minute. After wait- 
ing for several contractions of the uterus, which appreciably VI 
CHICAGO GYNECOLOGICAL SOCIETY. 
advanced the head, I began to allow the patient to inhale ether 
during the accession of each pain. During the intervals, she 
was quite conscious, and kept up an intelligible conversation 
with her husband and her attendant. The effect of this obstet- 
rical degree of anaesthesia was most happy ; the woman bore her 
pains without complaint, and they were noticeably increased in 
force, though still shorter and weaker than natural. 
At 4:30 a. m. the occiput had rotated forward, into the second 
position, and the head was well engaged in the outlet of the 
canal. I now carried the anaesthesia to the surgical degree for a 
moment, applied my short forceps, and delivered the head within 
ten minutes. All ether was discontinued from this moment. 
There was a pause of at least five minutes, when I became soli- 
citous for the infant, who did not close the gums upon my finger 
in the mouth, and so completed the extraction by hooking my 
finger into the leit axilla. During this time, the husband, under 
my direction, was compressing the uterus with both hands ; this 
compression he continued until relieved by me. The child 
required a vigorous slapping and cold douche before it would 
breathe. 
After the lapse of about ten minutes—the woman in the 
meantime seemed in a natural sleep—I passed my finger into the 
vagina, and found the placenta partly extruded through the 
mouth of the uterus ; I completed its delivery with less difficulty 
than usually obtains. The patient wakened at this moment, and 
simply said, “ Don’t.” I examined the abdomen, and felt the 
uterus very flaccid and reaching to the umbilicus, hut uniformly 
rounded. 
A few minutes later, not more than fifteen — the husband in 
the meantime keeping up compression—I noticed a pallor of the 
woman’s face, who opened her eyes and yawned. I quickly 
raised the bed-covering, and saw that a rather brisk haemorrhage 
was going on ; the pulse was rapid and very feeble. I put my 
hand upon the belly, but covld not plainly feel the outlines of the 
uterus. I sunk my hand deep downward, and had but little 
difficulty in compressing the aorta against the vertebral column, 
though the woman complained that my pressure was uncomfort- 
able ; this procedure completely arrested the haemorrhage. As INVERSIO PARTIALIS UTERI PUERPERALIS. 
soon as the nurse could pour a teaspoonful of Squibb’s fluid 
extract of ergot from a bottle, it was given to her. I called for 
ice, which was not in the house. While the husband went for 
ice, I slapped the abdomen with a cold wet towel. The dose of 
ergot was repeated twice in the next half hour. 
Ice was soon procured, and I hastened to rub the hypogastrium 
with a lump ; I also passed a lemon-shaped piece into the vagina 
as far as the mouth of the uterus, which presented nothing 
unusual. The uterus immediately contracted, and its outlines 
were easily made out through the abdominal parietes; the upper 
border was not now rounded upward, as the fundus usually is, 
but was represented by a straight, hardened edge, extending 
transversely across the hypogastrium, at a point nearly midway 
between the symphysis pubis and umbilicus. This edge was 
quite like the rim of a bowl. At either side, and resting upon 
this rim, a spherical body, continuous with a rounded cord, could 
be easily felt (the ovary and tube). 
It now flashed upon me that the fundus of the uterus had 
fallen downward into the cavity of the organ. This discovery 
was made about forty minutes after the delivery of the placenta, 
and some twenty-five minutes after I had once felt the fundus 
flaccid, but rounded upward. I ceased my compression of the 
aorta, and no more blood wTas lost. From this moment, the 
uterus was in a state of tonic spasm, as if completely ergotized. At 
no time could I detect the slightest relaxation, though I long- 
ingly watched for this event. 
I passed my hand into the vagina, and found the uterus 
unusually high ; the os was opened to the extent of about four 
centimeters, and rigid. A segment of the prolapsed fundus could 
be felt looking through, and in contact with the open mouth. The 
contrast in the feel of this circular area of spongy fundus, with 
the smooth covering of the vaginal portion of the cervix, made 
it of easy recognition. 
I shaped my hand into a cone, which I impinged against the 
fundus, through the os, at the same time making a 'point d'appui 
with my left hand upon the upper rim of the uterus, through the 
abdominal walls. In this manner I was enabled to exercise a 
degree of force in attempting to push the fundus upward, such CHICAGO GYNAECOLOGICAL SOCIETY. 
as I feared would tear the uterine tissue ; but I made no impres- 
sion upon it; the organ felt like cartilage. The patient fainted 
during this effort at replacement; the pulse disappeared from the 
wrist, and I rvas obliged to desist. A dose of morphia, with 
brandy, was given by the mouth, and brandy was also thrown 
into the rectum. The trunk was surrounded with bottles of hot 
water, and frictions faithfully used ; the foot of the bed wras also 
raised. In a half hour, these measures were rewarded by a 
marked improvement; the color had returned to her face, and 
the pulse was quite strong at the wrist. I now made a seeond 
attempt at replacement, but with the same futile result; the poor 
woman complained of pain, and again fainted. The respiration 
soon became sighing ; there was great jactitation, and our united 
efforts were required to keep her upon the bed. She wras deliri- 
ous, jumped from one side of the bed to the other, crying, “ I 
shall be uncovered,” and no efforts of ours could prevent her 
kicking herself naked. The ensemble constituted a scene which 
can never be effaced from memory. 
All efforts at resuscitation were kept up faithfully, but without 
avail. The unfortunate lady soon became moribund, and died 
very quietly at eight o’clock, about three hours after delivery, 
rather more than twTo hours after the inversion was recognized, 
and about one hour after the second effort at replacement of the 
fundus. 
Dr. Byford reached the house some ten minutes before dissolu- 
tion, and recognized the utter hopelessness of the case. 
The abdomen was examined fifty-five hours after death, and 
the uterus, which was preserved, was found in the state already 
described. Its tissue was not torn. There was no difficulty in 
replacing the fallen fundus at this time. 
The child was a male, and weighed ten pounds. 
Remarks. 
This accident, which is one of the gravest that can befall a 
puerperal woman is, fortunately, one of extreme rarity; since it 
occurred but “ once in upwards of 190,800 deliveries at the 
Rotunda Hospital. ” * 
* Playfair, Treatise of Midwifery, Philadel., 1876. INVERSIO PARTIALIS UTERI PUERPERALIS. 
The result in this case was not exceptional.* Of seven cases 
seen by Hamilton, “ in one single instance only the woman sur- 
vived the shocking accident.” f 
It is a common observation, that the loss of blood and shock 
are greater in the incompletely inverted uterus, when the fundus 
is grasped by the body, than when the organ is turned quite 
inside out. J The most common variety is the incomplete; § 
hence the great mortality attending the accident. 
The reflections suggested by the case in point are: first, as 
to the cause of the accident. The undue distension of the uterus 
by the liquor amnii undoubtedly weakened the uterine walls, so 
that, when the organ was emptied, the fundus could easily fall 
into the cavity of the body. This enfeeblement was recognized 
before delivery, through the short, sharp, weak pains. The 
almost universal observation made by the older authors, that 
inversion of the uterus is generally caused by the attendant 
dragging upon the cord of the undetached placenta, has abso- 
lutely no application here; for the placenta was entirely detached 
spontaneously. Second, as to the management of the accident. 
Writers agree upon the importance of immediate replacement of 
the inverted organ. Surely it is to the reposition of the organ 
that we are to look for a relief from dangerous shock, and security 
against haemorrhage. As a rule, according to authors, the imme- 
diate replacement of the fundus is not difficult. But an insur- 
mountable obstacle in the way of such success in this case was the 
condition of tonic spasm, which at first seemed due to the adminis- 
tration of ergot. One cannot refrain from expressing a regret at 
this point, though it is true that the effects of ergot -were indi- 
cated by the post-partum atony of the uterus. There is consola- 
tion in the fact, moreover, that some portion of the uterus is usually 
spasmodically contracted, when there is atony of the organ, 
when no ergot has been given. || 
This patient succumbed to the shock incident to having the 
* Velpeau, Traite de l’art des Accouhemens, Paris, 1835, 
f Hamilton, Outlines of Midwifery 1784. 
J Kilian, Die Opoiative Geburtshiilfe, Bonn, 1835. 
g Mauriceau, Traitie des Maladies des Femmes Grosses, Paris, 1740. 
|| Dewees, System of Midwifery, Phil., 1824. 
Smith, Lectures on Obstetrics, Gardner, New York, 1858. 16 
CHICAGO GYNAECOLOGICAL SOCIETY. 
fundus grasped by the spasmodically contracted body of the 
uterus. The shock may have been augmented, under the circum- 
stances, by the loss of blood ; but I have more than once seen a 
greater hgemorrhage with no appreciable effects upon the woman. 
Discussion. 
Dr. Miller : The subject introduced this evening by Dr. 
Sawyer, is one of more than ordinary interest to every accoucheur. 
The report of the case is admirable, and the specimen presented 
adds greatly to its value. I have no criticism to offer in regard 
to the management of the case, for it was faultless. The acci- 
dent happens but seldom. It was fortunate that in this case it 
occurred under the immediate observation of one so competent to 
comprehend its gravity from the initial stage, and who could pre- 
sent to us so clearly its complete history. 
The causes of inversion of the uterus are various — generally, 
I believe, mechanical; not always so, however. I can appreciate 
that inversion may take place as follows : The uterus in a state 
of complete inertia, from long continued labor, from too sudden 
delivery of the child, or from over-distension, as in Dr. Sawyer’s 
case, a slight cause may produce depression and end in inversion. 
That cause may be the increased weight of that portion of the 
uterus upon which the placenta was developed, if near the fundus, 
together with the other condition which obtains at the site of 
placental development, namely, the projection inward of that 
part of the uterus. The structure of the uterus, immediately 
surrounding the placental site, in the condition assumed, could 
offer no resistance to the further settling internally by gravity of 
this heavy circumscribed portion of the uterus — depression hav- 
ing occurred, inversion would follow. 
Another possible cause of inversion mayjibe mentioned, though 
not strictly applicable to the case reported this evening. When 
the uterus is in a state of complete inertia, and the placenta has 
been detached, and has lodged within the os uteri, the cavity of 
the uterus, as is usual in such cases, remains large, and is filled 
with blood. The extraction of the placenta will act as a piston 
upon the volume of blood in the cavity of the uterus, and this, 
in turn, will act upon the flaccid wall of the uterus ; the fundus INVERSIO PARTIALIS UTERI PUERPERALIS. 
may follow this forcible extraction of blood, till depression is pro- 
duced. Then inversion may be completed by the uterus itself. 
I am not certain that attempts at compressing the uterus may 
not produce a dimpling of the organ that will lead to inversion, 
especially if performed carelessly, or by a person not familiar 
with the physiology of uterine contraction. It appears to me 
that inversion is liable to be caused by the injudicious application 
of force to the uterus in a state of inertia. 
Dr. Roler : The case presented for discussion is an interest- 
ing one, but the cause of the inversion cannot be determined, as 
the attending physician has no knowledge of the exact moment 
of its occurrence. The delivery of the placenta evidently had 
nothing to do with the accident, as manipulation immediately 
afterward detected the outline of the uterus in a flaccid state, the 
fundus being near the umbilicus. Ergot w7as administered, and 
firm pressure applied both over the uterus and upon the abdomi- 
nal aorta. A little later, wThen contraction suddenly occurred, 
the cup-shaped depression was easily recognized by the hand over 
the abdominal parietes. 
The fundal sinking must have taken place before contraction 
set in, as symmetrical action of all the muscular fibers would in- 
sure safety against such an accident. The condition of ergotism 
may have been the chief cause of failure in the attempted repo- 
sition of the uterus, but the administration of the drug was clearly 
indicated, and Dr. Sawyer did as any intelligent physician would 
have done under the circumstances. 
I fully endorse the remarks of Prof. Miller with reference 
to careful manipulation in the removal of the placenta, even after 
uterine action has thrust it into the vagina. Leisliman, J. 
Matthews, Duncan, and others, state that if left alone it usually 
presents edgewise during expulsion, hut I think the bedside 
experience of every physician proves that, without meddlesome 
interference, it is often found foetal surface foremost, and 
“impacted” in the vagina. Of late years I have always, when 
removing it, waited until I found the uterus well contracted 
above the pubis. It ought to be brought out edgewise and slowly. 
Traction upon the cord would cause a vacuum above, which 
would be filled with blood from the open sinuses, or if atony was CHICAGO GYNAECOLOGICAL SOCIETY. 
present, possibly by depression of some part of the uterine wall. 
In regard to the forces which operate to bring about complete 
inversion, I would like to state my doubts as to the ability of 
the organ, by any contractile power, to invert itself. I am 
aware that it has become an accepted doctrine that the introverted 
part may be seized by the remaining portion, and be carried 
downward, thus completing the process by its own action. I 
do not think it has been satisfactorily proven by any one who 
has written on the subject. In what way can any expulsive force 
be developed when the fundus is not acting ? It is a matter 
of common experience when the uterus fails to contract symmet- 
rically, in any stage of labor, that the expulsive process is arrested. 
In irregular contractions, even the detached placenta is held in 
vice-like grasp until artificially removed. If the introverted part 
contracts, it shortens itself merely. If the encircling portion acts, 
the further descent must certainly be arrested by the grasp of 
the circular fibers. Are not the incomplete varieties owing to 
this fact ? When general atony exists, the weight of the descend- 
ing portion, aided by the straining on the part of the patient, 
will easily carry the fundus into the vagina. 
Irregular contraction is doubtless a primary condition in many 
cases, of incomplete inversion, the placental area being the para- 
lyzed portion, and sinking downward either from spontaneous or 
artificial causes. Yet, even in these cases, it can easily be under- 
stood how the shock thus produced, together with haemorrhage, 
might subsequently cause general relaxation and allow further 
descent of the fundus. 
Dr. Merriman was very much interested in the case, which 
had been reported in so clear and minute a manner. These 
dangers, although rare, were liable to occur at any time, and 
there was need to observe as closely as possible all circumstances 
connected with them, that the causes of the trouble might be 
more perfectly understood. He did not remember having seen 
an explanation offered for the first step in the process of inversion, 
namely, that of depression, except; 1st, the presence of a 
polypus; 2d, drawing upon an adherent placenta; 3d, pressure 
from above; but these were evidently not the only causes. Dr. 
Barnes gives as a circumstance frequently connected with this INYERSIO PARTIALIS UTERI PUERPERALIS. 
difficulty, the attachment of the placenta to the fundus uteri. 
Since the placenta undergoes absolutely no detachment during 
the strong contractile efforts of the uterus during labor, it seems 
probable that the placental seat is less affected generally by 
uterine contraction. If, then, the attachment should be at the 
fundus uteri, and an unusually relaxed state of the uterus exist, 
a very little pressure would be sufficient to start a depression 
which, once started, would readily go on from the contractile 
efforts of the uterus itself. 
He thought of one other explanation. If irregular contrac- 
tions should occur, they might affect only the external fibers of 
the uterine fundus, and it would readily be seen that this circum- 
stance would cause the wall of the uterus to bulge inward, thus 
producing the initial step in the process of inversion. He 
thought, in this connection, that the effect of ergot, which is so 
liable to produce irregular contractions of the uterus, should be 
carefully watched. 
Dr. Nelson : It has not been my fortune yet to see a case of 
puerperal inversion of the uterus, but I can readily understand 
that the piston-like action of the placenta, referred to by Dr. 
Miller, might be, in a relaxed condition of the uterine walls, a 
cause of partial or complete inversion, if the cord were drawn 
upon while the uterus was thus relaxed. For this reason I make 
it a rule never to attempt to remove the placenta until the uterus 
is contracting firmly. Then, if gentle traction on the cord, or 
the presenting portion of the placenta, does not readily extract it, 
and especially if it seems to be firmly held, while the foetal sur- 
face presenting at the os shows that it is at least partly detached, 
I bore through the presenting placental mass with the forefinger, 
to allow the air to pass through the placenta, and thus destroy 
this sucker-like action, and then the contents of the uterus may 
be readily removed. But until this is done, or in some way the 
air allowed to get behind the placenta, traction upon it or the 
cord will simply drag downward the uterus and its contents until 
the uterine contractions excited thereby expel the contents. I do 
not recollect to have seen this procedure described in any of the 
books, but I have, for several years, found it to greatly facilitate 
the removal of the placenta. CHICAGO GYNAECOLOGICAL SOCIETY. 
Dr. Sawyer’s exact description of this case suggests also 
another possible cause of inversion, when the uterine walls are dis- 
tended and relaxed, namely, pressure upon the uterus through 
the abdomninal walls by an assistant, especially if unskilled. 
For I well remember, in assisting Dr. Roler in a footling case, 
under ether, while pressing firmly upon the fundus of the uterus 
to hasten the delivery of the head and so save the child, I dis- 
tinctly felt the walls of the uterus dimple under the pressure, 
especially when too great force was momentarily exerted by the 
thumbs and finger points in attempting to relieve the hand, and 
while the uterus was not firmly contracting. Indeed, the inertia 
of the uterine walls was the very reason for using these vigorous 
external means to hasten delivery 
Dr. Sawyer describes the compression of the aorta from the 
outside, which seems to have been satisfactory in his case ; but, 
if the abdominal walls contain much adipose tissue, it might be 
more difficult. Following the teachings of my preceptor, Dr. 
Storer, of Boston, I should prefer to pass the hand directly into 
the uterus, and compress the aorta through the thin uterine walls. 
I have not found it difficult to introduce the hand into the uterus 
immediately after delivery, and the aorta can certainly be as 
safely compressed in this way upon the spine. Furthermore, the 
hand itself, in the uterus, will be a powerful means of exciting 
the uterine contraction, and should any portion of the walls be 
inverting, it would be in the best possible position to detect and 
replace it. It is also in position to detach the placenta, if this 
may have been the cause of the haemorrhage, or to remove clots 
resulting from the haemorrhage. I have had occasion to compress 
the aorta in this way but once, and saw no bad results. 
As the tetanic contraction of the uterus wras described in Dr. 
Sawyer’s case following the use of ergot, the query came to mind* 
will the use of ether, carried to complete anaesthesia, in such 
cases, overcome the action of the ergot ? 
I would also like to ask the members of the society what their 
experience is in the use of the corn ergot—the fluid extract of 
ustilago maidis ; will it produce, in full doses, these same tetanic 
contractions which the rye ergot frequently does? I have used 
the fluid extract of ustilago in my obstetric practice during the INVERSIO PARTIALIS UTERI PUERPERALIS. 
past year and a half, using it as I would the rye ergot, in doses 
of half a teaspoonful and more, and I have not yet seen the 
severe contractions occasionally produced by the rye ergot; 
neither is it as liable to disturb the stomach as that—perhaps 
because the taste is usually not as disagreeable to the patient. 
Dr. Jones said that he had little to add to what had already 
been said as to the etiology of inverted uterus. 
During the discussion, it had occurred to him that possibly, as 
in early abortions, a certain balooning of the upper vaginal 
and lower uterine ligamentous structures might occur after 
parturition, which would draw apart the inert walls of the womb, 
and suffer the flaccid fundus and upper segment of the organ to 
fall into the cavity thus made. Then, under the stimulus of 
invagination, active contraction, grasping the inverted portion, 
might be set up, which would tend to complete the “ perversion,” 
or render it impossible for the attendant to effect its reinstate- 
ment. It was possible that the ergot administered in the case 
reported might have proved a disadvantage, but that it had any- 
thing to do with the causation of the accident, he could not 
believe. He agreed with other speakers in thinking inversion 
due mainly to uterine inertia, and that the uterus was not prima- 
rily active. 
As for the commonly assigned cause—traction upon the funis— 
he averred his constant practice of that forbidden means of 
delivering the placenta, but always with the premise of normal 
uterine contraction. A case of puerperal inversion of the uterus 
had never occurred in his own pi’actice. 
Dr. Fitch : I regret exceedingly that I did not arrive in 
time to hear the opening of this discussion, and the history of 
the case presented by Dr. Sawyer. My experience in puerperal 
inversion of the uterus has been very limited ; indeed, in an 
active practice of twenty-seven years a case has never occurred 
under my own administration. 
The only case I ever saw was in consultation. About twenty- 
two years ago, I was called to see a woman four or five days sub- 
sequent to her delivery. I found the patient of light complexion 
and frame, pale and haggard countenance, pulse 130 to 140, and 
feeble ; skin cold, and covered with a clammy perspiration. Her CHICAGO GYNAECOLOGICAL SOCIETY. 
labor was apparently normal. No excessive haemorrhage had 
occurred, and no great degree of pain ; yet there was constant 
vomiting, and great prostration. The physician in attendance 
had made no diagnosis, but supposed she had “child-bed fever.” 
I proceeded to make an examination per vaginam. The 
uterus was low in the pelvic cavity; os open to the size of a 
silver dollar, and a hard, somewhat roughened convex body pre- 
senting, which I at once suspected to be the fundus uteri. I 
immediately applied firm pressure with two fingers against this 
body, and counter pressure upon the abdomen, for the space of 
five minutes ; the body gradually receded from the os, and sud- 
denly left my fingers, with a decided thud ; at the same instant 
the uterine tumor appeared in the hypogastrium. The vomiting 
ceased at once ; reaction quickly came on, and the patient made 
a good recovery. 
In regard to the influence of ergot in the production of this 
accident, I believe that its action is upon the entire organ, pro- 
ducing uniform contraction of its muscular walls ; therefore can- 
not favor the accident. My judgment is based on the use of it 
in probably 75 per cent, of all the cases I have attended during 
the past twenty years. I believe it is useful in assisting the 
delivery of the placenta; and further, by producing tonic contrac- 
tion, it thoroughly empties the uterus, and prevents accumulation 
of blood in its cavities. For these purposes it is given from 10 
to 20 minutes before the completion of the second stage of labor. 
I have entertained the opinion that acute puerperal inversion 
was unnecessary ; and that, when it did occur, it was usually due 
to neglect in the management of the delivery, or by too active 
interference. 
To avoid this accident, as well as post-partum haemorrhage, I 
am in the habit of pursuing the following course: As soon as 
the child’s head is delivered, I direct the nurse, or other con- 
venient person, to apply the hand to the hypogastrium, and follow 
the receding walls of the abdomen, with pressure directed upward 
and backward. The person is retained in that position till I 
have attended to the child, tied and severed the cord. I then 
place the patient on her back, and apply my free hand to the 
abdomen, over the uterus, grasping the organ with the thumb and INVERSIO PARTIALIS UTERI PUERPERALIS. 
twTo or three fingers, with the little finger resting on the fundus, 
for the purpose of promptly detecting any depression or dimpling. 
If the uterus does not contract promptly, I squeeze it forcibly. 
As soon as contraction occurs, I apply traction on the cord, equal 
to a weight of one half lb. to six lbs., at the same time pressing the 
lateral walls of the uterus, for two purposes: 1st, to assist in the 
expulsion of the placenta ; 2d, to sustain these walls in apposi- 
tion, and thus prevent inversion. Should dimpling be felt, I at 
once desist from traction; or should tearing be felt in the cord, 
traction should cease. 1 have never torn off a cord or inverted 
a uterus. 
Dr. Etheridge remarked that the specimen before the society 
seemed an unusually large puerperal uterus. 
Dr. Jackson had nothing to add to what had already been said 
in reference to inversion of the uterus. He had never been so 
unfortunate as to encounter a case in his own practice, and the 
specimen now before the society was the first he had ever seen. 
He only desired to express his surprise at the opposing views to 
which utterance had been given in reference to what should con- 
stitute the proper treatment of the third stage of labor, in its 
bearings upon the causation of the accident in question. One 
gentleman considered it dangerous to make pressure upon the 
fundus of the uterus in order to aid the expulsion of the placenta, 
while another thought this method the best and most favorable. 
Several regarded traction by the cord as highly dangerous, while 
others again, on the other hand, habitually delivered by pulling 
at the cord, and only limited the strength of the pull by the 
strength of the cord. 
A number were in the habit of administering a dose of ergot 
to aid the expulsion of the placenta, while another was afraid to 
give it lest it should not be expelled at all. 
Inversion of the womb was usually considered to be a very rare 
complication of labor ; and yet, after listening to this discussion, 
it seemed wonderful that it was not a very common one. He 
thought the efficiency of some of the alleged causes was exaggera- 
ted. Certainly traction of the cord was. If it ever caused in- 
version, it must be only in exceptional cases; for he believed 
that fully 90 per cent, of all placentae wrere delivered by more or 24 
CHICAGO GYNAECOLOGICAL SOCIETY. 
less traction by the funis. His own impression was, that puer- 
peral inversion occurs usually from a passive, inert, relaxed con- 
dition of the uterine walls, produced by over-distension, as in the 
case described by Dr. or from some other causes. 
Dr. W. H. Byford believed that mere atony of the uterus 
was not a sufficient cause of inversion of the uterus. This con- 
dition might be a predisposing cause, and it was probably in this 
state of the womb that pulling on the cord and other injudicious 
efforts to deliver the placenta were rightly blamed as causes of 
inversion. He thought, however, that inversion more frequently 
resulted from irregular contraction of the uterus, in the sense 
that some of its fibers were acting strongly, while others were not 
contracting at all. In other words, there was partial, instead of 
general atony ; one or more patches, limp and flabby, prolapse 
into some part of the globular arch of the contracting organ, and 
thus form the dimple so generally supposed to be necessary as a 
start toward inversion. The vehemence of contraction which 
this intruding portion would cause, is recognized by most writers 
as sufficient to complete the displacement. This state of partial 
atony must occupy fibers partially paralyzed by some circum- 
stance existing during gestation, or occurring at the time of 
labor. 
In the case of Dr. Sawyer, reported with so much intelligence 
and minuteness, the condition of the uterus anterior to delivery 
was sufficient to account' for a weakened state of the fibers. 
There was a very considerable dropsy of the chorion, and the 
uterus contained an extraordinary amount of liquor amnii. This 
fact, interpreted, means that the fibers were stretched. In normal 
pregnancy the uterine fibers are not stretched ; the whole organ 
is hypertrophied, and the actual addition of tissue, or growth of 
the muscles of the uterus, form a receptacle for the ovum that 
contracts uniformly and with vigor for the expulsion of its con- 
tents. Now, if an abnormal amount of fluid is secreted, it is 
accommodated not by a further increase of the muscular tissue 
forming the uterine globe, but the organ is distended, and the 
muscular wall becomes thinner by the distension. Thus stretched 
and thinned, for perhaps weeks before confinement, the fibers 
become weaker, and the labors succeeding this state of things are INVERSIO PARTIALIS UTERI PUERPERALIS. 
precisely the kind described by Dr. Sawyer. The contractions 
are painful and inefficient, the fibers acting discordantly until the 
foetus is expelled or removed, as it was in this case. It is almost 
certain that the efficiency of some portions of the fibers is more 
impaired than that of others. It is well known that in uteri 
thus over-distended we have the hour-glass contraction — the 
incomplete contraction — accompanied by.haemorrhage, etc., and 
why not also inversion ? 
If the ergot had any injurious influence in the reported case, it 
was not in causing the inversion, but in rendering the fibers more 
resistent to efforts at reposition. Dr. Byford further said that 
the treatment instituted by Dr. Sawyer was such as would sug- 
gest itself to most intelligent obstetricians. 
It was quite apparent, however, from the tenor of the discus- 
sion to-night, as well as the diverse theories of inversion promul- 
gated by writers on obstetrics, that there is yet much to be learned 
in reference to this most interesting subject. 
With reference to the cause of death, he thought there could 
be no doubt but that it was due to shock, and the haemorrhage 
was not sufficient to contribute materially to that end. In ex- 
pressing this opinion, he would remind the society that the over- 
whelming influence of shock upon the nervous system depended 
as much upon the incapacity of certain persons to rally from ner- 
vous depression, as upon the force of the causing influence. What 
would kill some persons would not, on account of the inscrutable 
elasticity possessed by others, have any effect upon them. 
Dr. Sawyer: I feel indebted to the Fellows for the full and 
very intelligent discussion which my report has elicited, as well 
as for the very charitable willingness which has been shown to 
exonerate me from responsibility in the unfortunate termination 
of the case. The only point which was raised in my mind upon 
reflection, was concerning the administration of ergot; not that 
its use in any degree caused the inversion; there is not one fact 
which could suggest such a presumption, but that the condition of 
tonic spasm of the uterus, which prevented the immediate reduc- 
tion of the displaced organ, might have been excited by the drug. 
I am assured, however, by the remarks which have been made, 
that such a spasm might have been induced by the presence of CHICAGO GYNAECOLOGICAL SOCIETY. 
the fundus in the cavity of the uterus. In this they are con- 
firmed by no less an authority than W. Tyler Smith, a reference 
to whom has been made in my report. 
The remark made by Prof. Miller, viz: that the fundus may 
be indented by the tips of the fingers, when compression of the 
uterus is injudiciously made, I hold to be of paramount import- 
ance. In this connection I may be permitted to allude to the 
dangers attending Crc-de’s method of expressing the placenta. 
In using this method, we are instructed to seize the uterus in both 
hands, and to squeeze out the after-birth. Practically one does 
not compress the uterus uniformly in all its axes ; the abdominal 
parietes render the posterior surface of the organ inaccessible, 
and the tips of the fingers are forced to press upon the fundus. 
Nowq under certain conditions, is it not reasonable to suppose that 
the paralyzed fundus may be indented in this manner ? In fact, 
I have no question but that, in the case under discussion, the point 
of departure was in the compression which was used under my 
direction. 
The plan of compressing the abdominal aorta from within the 
uterine cavity, alluded to by Dr. Nelson, has long found a place in 
the literature of the subject, and is spoken of by Cazeaux. IVhen 
the uterus is large, the procedure has the advantage claimed for 
it, namely, that of quickly recognizing any descent of the fundus. 
But it is an agonizing operation. Moreover, in order to compress 
the artery, the hand must be carried above the fourth lumbar 
vertebra, or nearly to the umbilicus, and this interferes with the 
proper retraction of the uterus. On this account, I give prefer- 
ence to compression through the abdominal parietes. 
Concerning the cause of puerperal inversion, all observers have 
remarked that unusual distension of the uterus, as exists in some 
cases of multiple pregnancy, and in drops}7 of the amnion, is a 
condition which favors the accident. But upon the initial step 
in the process of inversion, the profession seems divided. One 
class of observers hold that it is a condition of irregular contrac- 
tion of the uterus, whereby it is inverted; in other words, that 
the process is an active one in its very beginning. Prof. Byford 
has very clearly given us the modus operandi of this process, for 
which he has expressed his preference. It is especially dwTelt INVERSIO PARTIALIS UTERI PUERPERALIS 
upon by W. Tyler Smith, its author, who has likened the process 
to inversion and intussusception of the intestine, upon the one 
hand, and speaks of its relations to spasmodic rigidity of the os 
uteri, and so-called hour-glass contraction with retention of the 
placenta. It may be said, in support of the active process, that 
the virgin uterus has been known to Invert itself by unceasing 
contraction of the organ. 
Another class of observers believe the first step in the process 
to be passive, so far as the uterus is concerned, and that the fundus 
falls into the body by its own weight, or is pushed, or drawn down- 
ward through some external force. 
I am impelled to accept the latter as correct. It is true that I 
can only speak upon the authority of a single case, but it will be 
conceded that the opportunity for observation was as good as it 
was rare. At a given moment, I felt the outlines of the sym- 
metrical but flaccid uterus, its fundus reaching nearly to the um- 
bilicus. Shortly afterward, the organ had contracted, and its 
fundus was gone. Now, what occurred in that short interval ? 
Of course positive knowledge is precluded, because the fundus of 
the uterus cannot be inspected, and my hand was not in the cavity 
of the organ. Bnt of one thing I feel convinced, namely, that 
there was no contraction, partial or complete, of the uterus be- 
fore the fundus had fallen. In reality, the recognition of the con- 
traction and the discovery of the absence of the fundus were sim- 
ultaneous. From this moment, however, till the last, the uterus 
was in a state of tonic spasm. Had the victim survived the 
shock, I can easily understand how this contraction may have 
propelled the fundus, and have made the inversion complete. 
There is one other condition which I think can have an influ- 
ence in determining this accident. Dr. Merriman has called our 
attention to a predisposing cause laid down by Barnes, namely, 
the location of the placenta at the fundus. I desire • to ask the 
Fellows if it ever occurred to them that the location of the pla- 
centa at the fundus is extremely infrequent, quite as accidental, 
and, it may be, as rare as its location in the cervical zone? Per- 
haps in this fact Dr. Jackson, and others, may find one explana- 
tion of the great rarity of puerperal inversion of the uterus. I CHICAGO GYNAECOLOGICAL SOCIETY. 
have many times determined the location of the placenta, through 
the uterine souffle, but have never yet found the area of the great- 
est intensity of the souffle to be at the highest part of the uterus. 
I regret that the location was not ascertained in the case before us. 
The usual site of the placenta, in the right or left lateral 
half of the uterus, upon its anterior or posterior wall, 1 hold is 
not a matter of chance, but is determined by a condition of the 
uterus which obtains in the very earliest days of pregnancy.— 
You will recall that when the impregnated ovule reaches the cav- 
ity of the uterus, it finds the lining of the organ, the decidua, so 
swollen that the walls of the uterus are in apposition, and no cav- 
ity can be said to exist. Observation has shown, however, that 
the nearest approach to an unoccupied space within the uterus, is 
at the superior angles of the organ. When the ovum escapes the 
uterine opening of the Fallopian tube, it is not impelled to insin- 
uate itself between the apposed deciduae, but attaches itself natur- 
ally at the upper angle of the body, where, as we have just seen, 
there is the most room. It is the attachment of the ovum which 
determines the location of the placenta. 
After the third month of pregnancy, the fundus of the uterus 
contributes most in forming the increasing cavity of the body. 
So disproportionate is this growth that, at the end of pregnancy, 
the Fallopian tubes seem to be attached to the uterus in its lower 
third, instead of near the superior point, as in the unimpregnated 
state. The placental site remains the same, and though it may 
increase in size by its own growth, it can never be carried up- 
ward by the gradual ascent of the fundus. I am aware that 
when the empty uterus contracts upon itself after delivery, the 
highest border of the uterus very nearly approaches the placental 
site ; still then the greatest portion of the latter will be inferior to 
a line drawn between the uterine opening of the Fallopian tubes. 
If my reasoning is well founded, the conservative design of 
nature must be acknowledged ; for we are told by Barnes that a 
momentary paralysis of the placental site usually exists after 
labor, and Prof. Miller has said that the uterine tissue is thicker 
and heavier at that point. I cannot but think that this paralyzed, 
heavy area would very frequently descend from its normal plane, INVERSIO PARTIALIS UTERI PUERPERALIS 
29 
if the site were at the highest part of the uterus. But, grace to 
the fact that the site is mostly upon the side of the spheroid, its 
tendency is to fall outward. 
I am not aware that these views have been expressed by others, 
but I have held and communicated them to my class for three 
years, and have confirmed the observation concerning the usual 
site of the placenta by many auscultatory examinations. 
I desire again to thank the society for the interest which has 
been shown in the subject and specimen introduced by me.