T H O U G II T S 
ON 
CHRONIC INVERSION 
OF THE 
UTERUS: 
SPECIALLY WITH REFERENCE TO 
GASTROTOM Y as a SUBSTITUTE for AMPUTATION of the UTEEUS. 
J 
BY HENRY MILLER, M. D. 
PROFESSOR OF THE MEDICAL AND SURGICAL DISEASES OF WOMEN IN THE LOUIS- 
VILLE MEDICAL COLLEGE; LATE PROFESSOR OF OBSTETRIC MEDICINE IN THE 
UNIVERSITY OF LOUISVILLE; EX-PRESIDENT OF THE AMERICAN MEDICAL ASSO- 
CIATION; ASSOCIATE OF THE COLLEGE OF PHYSICIANS) PHILADELPHIA, &C, 
Reprinted from the Richmond and Louisville Med. Jour., April, 1870. 
LOUISVILLE, KY. 
BELL AND COMPANY, PRINTERS. 
1870. CHRONIC 
INVERSION OF THE UTERUS. 
These thoughts have been elicited by an interesting 
and highly suggestive paper of Prof. T. Gaillard Thomas, 
of the College of Physicians and Surgeons, New York, 
entitled "The History of Four Cases of Chronic In- 
version of the Uterus, with the Account of an Operation 
designed as a Substitute for Amputation."-(American 
Journal of Obstetrics for November, 1869.) 
Of the four cases of chronic inversion of the uterus, 
narrated in this paper by the distinguished author, two 
were his own patients, one was a patient of Dr. Thomas 
Addis Emmet's, and the other of Dr. Joseph Worster's. 
In both of the latter cases, Dr. Thomas was present, and 
assisted in the manipulations for the reduction of the dis- 
placed organ. To the credit of American gymecology be 
it said that, in all the cases, the object of the operation, 
viz: the restoration ot the uterus to its normal situation 
was attained, though not without indefatigable persever- 
ance, especially in the last case of the series; this was 4 
Miller, Inversion of the Uterus. 
one of Dr. Thomas' cases, in which, after having been 
foiled, in all the manipulations that have been hitherto 
practiced, he resorted to a novel method, bold and origi- 
nal in its conception and successful in its execution. This 
method, to indicate it generally, for the present, consisted 
in gastrotomy and the instrumental dilatation of the in- 
ternal orifice of the cervix-uteri-the supposed seat of 
the stricture, that had resisted all the efforts which had 
been made to reposit the womb. This invocation of sur- 
gery to the aid of manipulation was crowned with suc- 
cess ; the resistance was overcome, the uterus was lifted 
to its proper place and restored to its natural relations. 
Elated with the fortunate issue of this first trial of a 
method of treatment, which, as he tells us, he had fully 
elaborated in his own mind, two years before, Dr. 
Thomas comes before us, and confidently proposes it as a 
substitute for amputation of the inverted uterus. Before 
I discuss its claims to our acceptance, I must be permit- 
ted to clear away certain inveterate prejudices against 
the amputation of the womb, in cases of inversion, irre- 
ducible by manipulation. From several passages of his 
paper, and yet more from his practice, it may be inferred 
that Dr. Thomas entertains these prejudices, else why 
his protracted incubation of other means, even a hazard- 
ous surgical operation in aid of manipulations, rather 
than to apply the ligature or the ecraseur to the offend- 
ing organ ? His physiology is, I think, at fault, to begin 
with. From his locus standi, he regards the uterus as 
the dominant organ of the female economy, for he quotes 
with approval the often cited aphorism of Hippocrates, 
which has come down to us from hoary-headed antiq- 
uity, "propter uterum est mulier." The aphorism is true 
only in a restricted sense, namely, that a woman, de- 
prived of her uterus, cannot bear children ; it being em- 
phatically the child-bearing organ, but it is nothing more, Miller, Inversion of the Uterus. 
5 
and hence it is appropriately called by German writers 
frucht-halter, fruit-bearer; that is its function, and if it 
bear no fruit, it is of no use in the female economy. And 
hence, though the uterus be extirpated, a woman may 
retain all her other sexual characteristics, menstruation 
excepted, provided that her ovaries are intact. 
It becomes, therefore, a very interesting physiological 
and practical question, whether or not the oyaries are 
removed in the operation of extirpating the inverted 
uterus ? It is, I think, demonstrably true that the ovaries 
and fimbrise of the fallopian tubes are never included in 
the abnormal cavity of the uterus, in a state of chronic 
inversion. Only the ovarian ligaments and the proximal 
portion of the tubes, together with a part of the broad 
ligaments, are drawn down into the new uterine cavity. 
And even should the ovaries be drawn into it, at the time 
of the occurrence of the accident, they must necessarily be 
extruded from it, as the cavity gradually diminishes, by 
the contraction of its parietes, so that in the end, it is but 
little, if any larger than it was before the inversion took 
place. That such contraction does supervene, we have 
evidence from the examination of pathological specimens, 
which show that the cavities of inverted uteri, in the 
chronic state, are not often larger than a crow quill. More- 
over, after the amputation of inverted uteri the ovaries 
ace never found, so far as I am informed, in connection 
with the extirpated mass. Nor, indeed, does Dr. Thomas 
affirm to the contrary, though Dr. Worster does, implic- 
itly at least, in the record of his case, written by himself 
and copied into Dr. Thomas' paper. 
Dr. Worster's patient had come to him from the coun- 
try, for the special purpose of having amputation of the 
inverted uterus performed. "But," says he, "reflecting 
on the success of a previous case of chronic inversion, 
treated by manipulation, on the danger of amputation, 6 
Miller, Inversion of the Uterus. 
and influenced by the consideration that her naturally 
fine voice (she was an eminent vocalist) would suffer from 
the loss of her ovaries* even if the amputation succeeded, 
I decided to attempt its reduction by means of the hand, 
aided by the relaxing anaesthetic influences of chloro- 
form." 
But, though Dr. Thomas does not say whether or not the 
ovaries are removed with the inverted uterus, yet he speaks 
with emphasis of amputation of the uterus, as a mutilating 
surgical procedure; and so, indeed, it is, as are all ampu- 
tations; but why decry amputation of the uterus, and dep- 
recate it more than other amputions, should it as well as 
they become necessary to the salvation of life? In 
making such a distinction, it is assumed, of course, that 
amputation of the uterus is a more direful calamity than 
any or all other amputations. Is such an assumption 
sustained by the facts of the case? I think not. To this 
extent and no further, she is affected by the mutilation; 
she is effecually and forever incapacitated for child-bearing. 
But her feminality is not destroyed by it; she does not 
become masculine with hirsute appendage upon her lips; 
her voice is not changed, nor does it lose any of the sweet- 
ness or flexibility of its tones ; her breasts lose none of 
their plumpness, nor do her limbs become angular; she 
retains her sexual desires, and her conjugal relations are 
kept up as before the mutilation; her lite is not short- 
ened and her health is not impaired, but often it is better 
than ever before; and last, though not least, she is ever 
afterward exempt from the maladies that afflict multi- 
tudes of women, such as uterine congestion, inflamma- 
tion, ulceration, prolapsus, versions and flexions, fibrous 
tumors, cancer, etc., etc. 
In these views, which may be startling to some of my 
readers, I am fortified by Dr. McClintock, of Dublin,f 
- 
* The italics are miue. 
Memoirs on Diseases of Women, Dublin, 1863. Miller, Inversion of the Uterus. 
7 
who observes, "What the ulterior effects of this opera- 
tion (amputation of the uterus) are on the constitution, 
is a question of some physiological interest, and one 
which our present knowledge of the uterus and ovaries, 
and our actual experience enable us to answer. The 
capability of conception would, of course, be forever de- 
stroyed ; and menstruation would take place, only very 
scantily, or not at all. But the woman would retain 
sexual feeling, and all the external feminine characters. 
As the uterus does not discharge any vital function in the 
economy, the only way in which its removal might affect 
her physical health would be, by the stoppage of the 
menstrual discharge, and a priori we might reasonably 
suppose, that it would certainly do so. But I do not 
know of any well marked case in support of this. In 
most instances the general health greatly improved after 
the removal of the uterus. Dr. Clarke saw his patient 
(a very young lady) at the end of three years from the 
time of the operation, and she was so fat and so improved 
in appearance, that he scarcely recognized her. She 
complained only of bad appetite, and that she had never 
had her changes. Dr. Johnson told me, that one of his 
patients became a widow, and subsequently married 
again. The subject of case 2 was only twenty-two years 
of age, and when I saw her six months after the ex- 
tirpation of the uterus, she was fat and robust, and 
her only source of complaint was the disappearance of 
the catamenia. She admitted that her sexual feel- 
ings had undergone no change."* In addition to the 
the well-authenticated cases mentioned by Dr. McClin- 
tock, I had one under my own observation, equally strik- 
ing and to the point. The patient is a woman residing 
in this city, Mrs. R., who was delivered of her fifth child 
The italics are mine. 8 
Miller, Inversion of the Uterus. 
about six years ago, being about thirty-five years of age 
at the time. I am not informed whether there was any 
difficulty during her labor, or immediately afterwards; 
but after getting up, she was attacked with profuse 
uterine haemorrhage, which returned at irregular inter- 
vals, and Dr. Isaac H. Keller was called to attend her. 
Dr. Keller had Dr. G. W. Bayless, the Professor of Sur- 
gery in the University of Louisville, summoned in con- 
sultation, whose diagnosis was that there was a tumor in 
the vagina, and that the tumor was a polypus of the 
uterus. Accordingly a ligature was applied to the sup- 
posed polypus, which caused the patient to suffer such 
severe pain that Dr. Bayless came to my house to consult 
me about it, and I gave my opinion, without seeing the 
patient, that the case was one of inversion of the uterus 
which had been mistaken for polypus. But considering 
that the organ had been already strangulated, and that it 
was, therefore, too late to attempt its replacement by 
manipulation, my advice was that the ligature should be 
slackened, to relieve the pain, but tightened afterwards 
from time to time, as she could bear it. Dr. Bayless 
obligingly furnished me with the following memoran- 
dum : "The ligature was applied on the 12th April, 1864, 
it broke on the fourteenth day after the operation, and 
and the uterus came away on the nineteenth day." The 
specimen preserved by Dr. Bayless, which I have care- 
fully examined, shows that it was only the body of the 
uterus that was amputated by the ligature; certainly 
there is no trace of the ovaries. About three years after 
the operation I visited Mrs. R., in company with Dr. 
Bayless, and made a digital and specular examination of 
the sexual organs. I found the os uteri perfect, with 
about its usual projection into the vagina; its lips were 
full, rather pouting, smooth, perfectly healthy, and a 
probe readily passed into the cervix half an inch or so, Miller, Inversion of the Uterus. 
9 
where its cavity terminated in a cul-de-sac. The case ap- 
peared to have been one of incomplete inversion of the 
uterus, and after the separation of the body of the organ 
by the ligature, the neck of the tumor was retracted 
within the os in the progress of cicatrization. 
In reply to our questions, Mrs. R. informed us that her 
health had been good, since she had recovered from the 
operation ; that she had neither menstruated nor felt any 
menstrual nisus; that she had no leucorrhoea or other 
trouble of the sexual organs; that her sexual feelings were 
unimpaired; and her conjugal relations the same as be- 
fore the operation. 
Dr. Dewees* quotes freely from an Essay of Mr. Newn- 
ham's on "Inversion of the uterus," on the uncertainty of 
the diagnosis between polypus and inversion, felt by Mr. 
Newnham, in all its force, when he was about applying a 
ligature to a tumor in the vagina: and then Dr. Dewees re- 
marks : "The case which gave rise to the above conclu- 
sions, proved to be an inverted uterus ; itwas successfully 
removed by the ligature; and the woman was restored 
by the operation to perfect health, and without the loss of 
those feelings which it is thought have their origin in the 
ovaria ; it was therefore presumed that these bodies were 
not removed with the uterus; neither did they appear to 
be attached to the removed portion of the uterus." 
Knowing all these facts, I was, I confess, surprised by 
the statement in the paper of Dr. Thomas, in depreciation 
of amputation of the uterus, that, besides its mortality, 
one quarter of all operated upon having died, those who 
survived the operation were not cured, and neither had 
they made an effort to attain perfect health, but only an 
attempt at purchasing immunity from a series of danger- 
ous and annoying symptoms at the price of the uterus. 
What is perfect health in the estimation of Dr. Thomas ? 
on the Diseases of Females, p 247. 10 
Miller, Inversion of the Uterus. 
Is not the man, who has suffered for years, with caries of 
the bones of his leg or disease of its joints, irremediable 
by therapeutics, whose sufferings have wasted his strength 
and brought him down to the brink of the grave, is not 
such a man, I ask, cured, when he has gladly submitted to 
amputation, and been restored to robust health and all 
the enjoyments of life? He purchases health by the sac- 
rifice of his limb, and the woman hers by the sacrifice of 
her womb. Neither the limb nor the womb is a vital 
component of the organism; indeed, the womb is of less 
consequence to the welfare of the individual, its function 
having reference to the species. 
There are, doubtless, multitudes of women who for 
the immunity from child-bearing, conferred by it, would 
gladly submit to amputation of the womb, provided that 
the operation could be performed, without pain or risk or 
the knowledge of their acquaintances. What physician 
can doubt this, who has been often importuned by respec- 
table married women to bring on abortion ? To them 
the most hateful of all the obligations imposed on them 
by nature and by divine revelation, is "to increase and 
multiply." 
It may still be objected by some that, though the 
ovaries are not actually removed by the amputation of 
the uterus, yet they are virtually destroyed, the utero- 
ovarian circulation and innervation being cut oft or crip- 
pled by the destruction of so much of the broad ligaments 
as was included in the uterine cavity. And there is some 
plausibility in the objection: the functional activity of 
the ovaries, under these circumstances, does seem to be 
diminished, and ovulation is probably, happily as I think, 
suspended, for were it to continue, it might cause much 
periodical suffering, as the accompanying sanguineous 
congestion could not be relieved by the flow of the 
menses. But though the ovaries may be in a state of Miller, Inversion of the Uterus. 
11 
abeyance, incapacitating them for ovulation there may 
yet remain in them sufficient activity to preserve the 
femininism, over which they are supposed to preside. I 
say "supposed to preside," for though there can be no 
doubt that the rapid development of the sexual organs 
of the female at puberty exerts a wonderful influence 
upon her, both physically and morally, which stamps her 
characteristics upon her, yet there is some reason to be- 
lieve that the stamp, once impressed, is indelible and can- 
not be effaced even by the ablation of the ovaries along 
with the uterus. 
My thoughts have been led into this train by the re- 
collection of a remarkable case, the most remarkable, 
perhaps, in the annals of midwifery. I reported it shortly 
after it happened, in the Western Journal of Medicine 
and Surgery, vol. i., for 1840. The particulars were 
given by my late lamented friend, Dr. E. Drane, who 
was my class-mate as a medical student, and whose com- 
petency and truthfulness I can vouch for. I will extract 
the report from the journal just cited, 
"Case of Forcible Removal of the Uterus and its Ap- 
pendages, after the Expulsion of the Foetus. 
"We are indebted to Dr. Drane, of this city, for the fol- 
lowing particulars of this most extraordinary case. A 
woman residing in Oldham county, in this State, was at- 
tended by a midwife in her fourth or fifth confinement. 
Shortly after the birth of the child, the midwife applied 
herself to the task of removing the placenta, and seizing 
hold of the os tincse, which was mistaken for the placenta, 
she applied such extractive force as to lacerate the vaginal 
and ligamentous attachments of the uterus and bring 
away the entire organ with the remnents of its ligaments, 
the Fallopian tubes and ovaria. Very little haemorrhage 
followed this rude operation, but the patient being alarm- 
ingly prostrated by the violence she had suffered, Dr. 
Ballard, of Westport,,Ky., was summoned to her assis- 
tance. When the doctor arrived and inquired concern- 
ing the delivery, he was informed by the midwife that 
the patient was cleared, and his attention was directed to 12 
Miller, Inversion of the Uterus. 
a vessel containing the supposed afterbirth, as evidence 
that she had performed her whole duty. He was sur- 
prised and alarmed for the safety of his patient to find, 
on examination, that it was the uterus and its appendages, 
W'hich wmre deposited in the vessel, and on making a sec- 
tion of the uterus the placenta was found enclosed in its 
cavity. 
Dr. Drane did not see the patient, nor is he informed 
as to the history of the case after the accident; he only 
knows that, without any very serious consequences, the 
woman recovered perfectly ; that she is, at this time, 
alive and in good health, and has borne no children since 
her mutilation. We had more than one opportunity of 
examining the parts, preserved by Dr. Ballard, and per- 
haps still in his possession, and he assures us unequivo- 
cally, that they comprise the uterus containing the pla- 
centa, the tubes, ovaria, and portions of the uterine lig- 
aments." 
Dr. Ballard's attention having been drawn to this 
notice of mine, he wrote me a letter confirming Dr. 
Drane's accuracy in describing the parts torn away by 
the widwife, and in the conclusion of his letter, he says: 
"In this case there was no lochial discharge, nor was 
lactation established, showing the controlling influence of 
the uterus over this important secretion. Another in- 
teresting physiological fact-inquiries instituted two 
years after the recovery of my patient convinced me, that 
the accident had not entirely deprived her of sexual pro- 
pensities ; yet both the ovaries were removed with the 
uterus." (duly, 1840.) C. G. Ballard." 
I have recently come into possession of some additional 
facts concerning the unfortunate (?) woman through Dr. 
E. D. Eoree, now of this city, but who was then prac- 
ticing medicine in her neighborhood. Dr.Eoree imforms 
me that this woman lived upwards of twenty years after 
the mutilation, in the enjoyment of good health, looking 
in every respect as she did before the injury, and that no 
differencecould b observed in the relations between her 
and her husband. Towards the latter part of her life 
she was affected with some disease of her urinary organs, Miller, Inversion of the Uterus. 
13 
which made it necessary to relieve the bladder with the 
catheter. In performing this service for her, Dr. Foree 
took the opportunity to explore the vagina by the touch, 
and found the canal amply capacious and terminating in 
a cul-de-sac, which was smooth and soft, and without 
any discoverable marks of cicatrization. He found no 
trace of the os uteri. 
Enough has been said, I trust, to dissipate all preju- 
dice against amputation of the inverted uterus, consid- 
ered merely as a surgical operation, save that which may 
remain on account of the loss of fecundity, which is nec- 
essarily involved. 
The time was, and that not remote, when amputation 
of the uterus was the only resource in cases of chronic 
inversion, threatening life by the frequency and profuse- 
ness of the hsemorrhagic and other discharges attendant 
upon them. 
It had been settled as a cannon in obstetric med- 
icine, that an inverted uterus cannot be reduced by 
any kind of manipulation, when any considerable time 
has elapsed since the displacement occurred. Few 
were bold enough to make the attempt, after the 
lapse of a week or two ; but after the lapse of months, 
when involution had restored the organ to its unim- 
pregnated size, none had the hardihood to venture 
upon such an experiment. The profession were aroused 
in this country, from servile submission to authority, by 
the publication of a case of chronic inversion of the uter- 
us of six months' duration, successfully reduced by Prof. 
James P. White, of Buffalo. Dr. White accompanied 
his report of the case with remarks on reduction in 
chronic inversion, illustrated by four wood-cuts, making 
the manipulation, by which he succeeded, easy to be un- 
derstood. 
*The American Journal of the Medical Sciences, for July, 1858. 14 
Miller, Inversion of the Uterus. 
It is necessary to my purpose that the method of ma- 
nipulation, pursued by Dr. White, and the various modi- 
fications of it, which other operators have adopted, 
should be described. Before I proceed to do this, how- 
ever, it is meet that I should pay a tribute of honor to 
our countryman, Prof. James P. White, who has not 
received the credit he so well deserves, for his leader- 
ship in the revolution of gynaecological practice, which 
he inaugurated. Even a superficial reading of his report 
must satisfy any one that he regarded himself as a pio- 
neer in his attempt to reduce, by the taxis, chronic in- 
version of the uterus; and that he was wholly uncon- 
scious that such a surgical feat had been performed 
either at home or abroad. Keither had it been so much 
as thought of at home, much less performed, nor had it 
been performed abroad in such a way as to attract pro- 
fessional attention or inspire confidence in it, until Dr. 
Tyler Smith, of London, published a case of twelve years' 
duration in the London Medical Times and Gazette, April 
24th, 1838, which of course could not have been known 
to Dr. White, whose case was successfully treated on the 
12th of March, immediately preceding, though not pub- 
lished until July following, the earliest time that it could 
be published in a quarterly journal. 
According to the method of manipulation practiced by 
Dr. White, the patient was placed upon an elevated, firm 
bed, "with the hips brought quite to its edge, the knees 
separated, the feet resting in the laps of assistants, with 
directions to each to support a knee and hand of the pa- 
tient, and prevent her from moving about." She was 
brought moderately under the influence of chloroform. 
Having placed himself upon his knees between the limbs 
of the patient, the operator introduced his right hand 
completely into the vagina and forcibly grasped the en- 
tire body and neck of the uterus; and at the same time Miller, Inversion of the Uterus. 
15 
a large rectum bougie was carried up and received into 
the palm of the hand and held firmly in contact with the 
fundus ot the uterus. "Continuous, gentle pressure was 
now made upon the external extremity of the bougie 
with the left hand, whilst the right compressed the uter- 
ine tumor and kept the upper extremity of the instru- 
ment directly upon the fundus; and with the dorsum of 
the hand in the concavity of the sacrum, directed the 
force in the axis of the pelvic cavity, putting the vagina 
completely upon the stretch. This pressure was exerted 
and this position unintermittingly maintained, although 
the force was not to such a degree as to endanger lacera- 
tion of the utero-vaginal connection, until my strength 
was nearly exhausted from continuity of effort. At 
length, and when about to relinquish the task, the uterine 
tumor began to shorten at its neck, and the mouth of the 
organ to push upon the upper surface of the hand. No 
depression or dimpling of the fundus was at any time 
perceptible. Ascending more and more rapidly as the 
neck diminished in length, the fundus finally passed out 
of the hand, and was easily pushed by the bougie through 
the mouth and neck of the organ up to its proper posi- 
tion." 
The method of manipulation contrived by Dr. Tyler 
Smith, in his case, consisted in passing the right hand 
into the vagina, night and morning, and with it squeez- 
ing and moulding the uterus for about ten minutes at a 
time. In the intervals between these manipulations, the 
vagina was distended and firm pressure exerted up- 
wards by a large air pessary. These means gradually 
dilated the os uteri to such an extent as to allow of the 
partial return of the uterus, and on the eighth day from 
the commencement complete reinversion took place. 
It will be observed, that although the force in Dr. 
White's method was made to bear specially on the fun- 16 
Miller, Inversion of the Uterus. 
dus, by the rectum bougie, yet he distinctly says that 
there was no dimpling or depression of the fundus, but 
the uterine tumor began to shorten at its neck. The cer- 
vical resistance was then overcome by the pressure ex- 
erted upon it by the manipulations of the fundus, and 
the parts which last escaped were first returned. It has 
been doubted whether or not the fundus uteri, in chronic 
cases, can be indented; but another method, that of Dr. 
Noeggerath, proceeds upon the assumption that it can 
be. This method, as we learn from Dr. Thomas, who 
highly approves it, "consists in compressing the uterine 
body, opposite to each horn, so as to indent one of these 
and thus offer to the cervical canal a wedge which passes 
up and is followed rapidly by the other horn and the 
whole body." 
There is yet another method, which has been success- 
fully practiced by the ingenious and skillful surgeon of 
the Mew York Woman's Hospital, Dr. Thomas Addis 
Emmet As described by him, "it consists in passing the 
hand within the vagina, and while the fundus rests in 
the palm, the five fingers are made to encircle the por- 
tion within the cervix, as near as possible to the seat of 
inversion. While this portion is thus firmly grasped, it 
is pushed upward, and the fingers are immediately after- 
ward expanded to their utmost. 
When the reduction is so far advanced that the fingers 
cannot be passed fully up to the seat of inversion, steady 
pressure is applied to the fundus, by means of the tips 
joined together, while an increased effort is made with 
the other hand to roll out the parts above, by sliding the 
the abdominal parietes over the edge of the ring near 
the seat of the inversion." 
Yet another method has been proposed by Dr. Thomas, 
which is not so much a distinct method of manipulation 
as it is a manoeuvre-a strategic movement-which seems Miller, Inversion of the Uterus. 
17 
to be designed to take the stricture by surprise. Taking 
the fundus in his fingers, he draws it down outside of the 
vulva and rapidly pushes it up to'the highest point possi- 
ble in the pelvis. This manoeuvre is only available, as 
the Doctor informs us, after the uterus is partially re- 
placed by other manipulations. 
We are now prepared to institute a comparison be- 
tween the treatment of chronic inversion of the uterus 
by amputation and by manipulation. Before we pro- 
ceed to do so, however, I think it proper to caution the 
reader not to allow his predilections to bias his judgment 
inj favor of manipulation. In the investigation of all 
subjects, we need to be on our guard against the warping 
influence of our predilections as well as our prejudices. 
It is so much more gratifying to our feelings to save than 
to destroy-to restore a distorted organ to its pristine 
shape than to lopp it off-that we may be tempted to 
undue and unsafe perseverance in our manipulatory 
efforts. Moreover we may be led to prefer manipula- 
tion where, under all the circumstances of the case, am- 
putation ought to be performed. 
This being premised, I will now compare amputation 
and manipulation in the following points of view: 1. 
Their respective mortality and success, so far as the 
attainment of the object of the operation is concerned. 
2. The validity of the cures effected by them respectively. 
3. Their respective range of applicability and success, so 
far as regards the attainment of their object. 
1. The respective mortality of amputation of the inverted' 
uterus and replacement by manipulation. 
The mortality from amputation of the uterus, m cases 
where the inversion succceeded to parturition, is stated by 
Dr. West* to be fifteen out of fifty-nine cases, or nearly 
one in every four. To show the results obtained by the 
♦Lectures on the Diseases of Women, third American edition, p. 197 18 
Miller, Inversion of the Uterus. 
different modes of operating in these fifty-nine case, he 
has compiled the following table: 
• 
Recov'd. 
Operatdns 
Died, abandoned. 
Uterus removed by ligature, 
45 
33 
10 2 
" " " knife or 
ecraseur, : : : : : 
Uterus removed by knife or 
5 
3 
2 
ecraseur and ligature : 
9 
6 
3 
59 
42 
15 2 
With these results exhibited by Dr. West, in cases 
where the inversion followed parturition, it will be profita- 
ble to compare other cases where the inversion was compli- 
cated with, and, caused by polypus of the uterus, for such 
•complication cannot be regarded as insignificant and un- 
worthy of our attention. In the American Journal of 
Obstetrics, etc., for August, 1868, there is a "Record of 
removal of the inverted uterus by ligation, excision, and 
by both combined," translated from Beitraege zur Geburts, 
Kunde und Gynackologie, which Dr. Thomas copied into 
his paper for no other purpose, so far as it appears, than 
to show the increased rate of mortality from amputation 
of the uterus, eigthteen out of the fifty-eight-nearly one- 
third-dying from the operation. I will not swell my 
pages by copying this record, but endeavor rather to ex- 
tract some useful lessons from it that may serve to throw 
light upon the often obscure pathway of our practice. 
The first lesson taught us by this German record is, 
that polypus is a more frequent complication of inversion 
of the uterus than has been generally supposed. Accord- 
ing to the statistics of Mr. Crosse, it occurs once in every 
eight cases, the remaining seven being sequelae of partu- 
rition. But from the record before us, it appears that it 
was met with fourteen times in fifty-eight cases, being 
once in every four and one-seventh. 
The second lesson is, that amputation of the uterus, by Miller, Inversion of the Uterus. 
19 
all the inodes of operation, issued more unfavorably 
where polypus complicated the inversion. The opera- 
tion was successful in nine out of the fourteen cases and 
fatal in five, rather more than one-third of the number 
submitted to it. This is, perhaps, no more than we 
might have anticipated, the uterus being diseased as well 
as displaced. 
The third lesson is, that the operation by excision is 
less successful than by the ligature, or the ligature and 
excision combined. Of eight patients treated by ex- 
cision six died, while of twenty-three treated by the lig- 
ature, sixteen were saved and seven were lost; and of 
twenty-seven treated by ligation and excision, twenty-two re- 
covered and five died-i. e., one death in five and two fifths 
cases. Shall we not profit by such a lesson as this ? 
Even if we had not been taught by experience, speaking 
through this "record," the fatality of excision, we ought 
to have dreaded it on account of the haemorrhage that 
must unavoidably accompany it, and over which we can 
have but little control. I shall never forget my first and 
only case of excision, which happened many years ago, 
before I had thought much about the operation, or con- 
sulted many authors concerning it. The patient was a 
poor, wasted creature, who was ansemiated by profuse 
losses of blood, and whose sufferings made her pray for 
death. She was most anxious to submit to any opera- 
tion, that promised either to cure her or to release her 
from the bonds of life, apparently indifferent whether 
she lived or died. After a consultation with my friend, 
Dr. S. D. Gross, who was at the time my colleague in the 
University of Louisville, it was concluded to amputate 
the uterus with a bistoury, which was made for the pur- 
pose. The operation was easily performed, with the able 
assistance of my friend; alarming haemorrhage immedi- 
ately ensued; a speculum was introduced in the hope 20 
Miller, Inversion of the Uterus. 
that the bleeding vessel might be secured. But to my 
great surprise, on bringing the cut surface to view, there 
was a great circular ring, into which the tips of two or 
three fingers might have been inserted, and through 
which the intestine could be seen. It was plain that 
haemorrhage was going on apace, but it was equally plain 
that the bleeding vessel could not be ligatured, and that 
there was no haemostatic, which could staunch the flow 
The patient sank rapidly and in a few hours died. 
If amputation by excision endangers the lite of the pa- 
tient by haemorrhage, ligation may destroy it by septicae- 
mia, arising from the putrefactive decomposition of the 
strangulated portion of the organ. From fifteen to 
thirty days after the application of the ligature, this de- 
composition is going on, and the parts are immersed in 
acrid and fetid discharges, -which undermine the strength 
and poison the blood. We are not surprised, therefore, 
that ligation, though it yields better results than excision, 
is yet not so favorable as ligation and excision combined; 
for, by this method, haemorrhage is avoided on the one 
hand and septicemia on the other, together with most of 
the discomfort arising from the nauseous odor of the dis- 
charges. 
It should be a rule of practice to allow the ligature to 
remain on a sufficient time for the strangulated portion 
to begin to putrify, as evinced by some odor from the 
genitals, before excision is made. Within this period, in- 
flammation will have been set up above the ligature, by 
which adhesion of the parts involved in the inflammatory 
process will be secured, and there will no longer be dan- 
ger of haemorrhage. What interval there should be be 
tween the ligation and excision has not been settled, and to 
me it seems that the rule adoptod by Dr. M'Chntock,* after 
consultation with Dr. Johnson, is a safe one, namely, 
*0p. cit, p. 89. Miller, Inversion of the Uterus. 
21 
that the ligature should not be removed and ex- 
cision practiced under forty-eight hours. Dr. M'Clin- 
tock relates two cases in which he amputated the inverted 
uterus, by the ligature and ecraseur with the most satis- 
factory results. His practice was to apply a ligature of 
silk fishing-line, prepared in oil, round the neck of the 
uterus, by means of a Gooch's canula, and to tighten it as 
often as necessary, and after the lapse of forty-eight hours, 
to draw down the uterus with a vulsellum until it ap- 
peared between the labia, just enough to permit of carry- 
ing the chain of the ecraseur around it; "the chain hav- 
ing been securely lodged in the sulcus made by the liga- 
ture, this and the canula were withdrawn : the ecraseur 
was worked very slowly, and eight minutes passed over 
before the uterus was severed." 
If, by the combination of ligation and excision, the 
mortality was reduced to one in five and two-fifths cases, 
there is reason to hope that, under more skillful surgery 
and improved after treatment, the mortality will become 
still less. We are encouraged in this hope by the inform- 
ation, communicated by Dr. M'Clintock, that the opera- 
tion has been performed eight times in Dublin-five times 
by Dr. Charles Johnson, once by Dr. Joseph Clarke and 
twice by himself, the first two using the ligature only- 
and in all of them with complete success. 
What has been said leads me to inquire whether or 
not any other capital operation in surgery can boast of a 
less rate of mortality than amputation of the uterus ? 
Sir James Simpson,* pleading for the recognition of 
ovariotomy as a legitimate surgical operation, (such re- 
cognition having been persistently flouted), proved by 
the irresistible logic of figures that ovariotomy is less 
fatal than some of the other capital operations in surgery, 
Lectures on disceases of women, Amer, edit., 1863, p. 378. 22 
Miller, Inversion of the Uterus. 
and but slightly more formidable and dangerous than 
others. 
The mortality from various capital operations "which," 
as Sir James says, "are not only considered as legitimate, 
but which surgeons count it a glory to perform," is set 
forth in tabular form, showing the results, as they have 
been reported by different surgeons, or as occurring in 
different hospitals. It is not necessary for my purpose to 
copy this table in full: I shall merely name the different 
operations and affix to them severally the rates of their 
mortality, appending to those included in Sir James' 
table, amputation of the uterus: 
Ovariotomy, one in three and one-fifth; amputation at 
hip-joint for chronic diseases, one in one and one-third; 
herniotomy, one in two and one-sixth; amputation of 
limbs, one in two and one-half; ligature of innominate 
artery, all died ; amautation of thigh, one in one and three- 
fifths ; ligature of subclavian, one in two and seven- 
tenths; amputation of the aterus for chronic inversion, one 
in five and two-fifths; ligature of other large arteries, one 
in three. 
Some of the reports in the table are omitted, as they 
relate to amputations in different hospitals and they co- 
incide very neary with those retained. It will be seen 
from the above list that amputation of the uterus has 
been attended with less mortality than any of the other 
operations, not excepting ovariotomy. 
I do not find, however, that the operation has taken a 
place among other amputations, in any of our treatises 
on surgery, or that it is so much as noticed, except inci- 
dentally, in any of them 'except in Dr. Gross' System of 
Surgery, where it is dismissed upon short notice. He 
says: "When the tumor is hopelessly irreducible, it is 
not only a source of mechanical inconvenience, but of 
almost incessant haemorrhage, draining the system of Miller, Inversion of the Uterus. 
23 
blood and keeping the woman constantly at death's 
door. Under such circumstances, as a dernier resort, 
amputation is occasionally practiced. The operation, 
however, is generally fatal, the patient dying from shock, 
haemorrhage, peritonitis, or pyaemia. In a case in my 
hands, some years ago, death occurred in less than forty- 
eight hours from inflammation ; and in another, in which 
I assisted Prof. Miller, the woman perished from haemor- 
rhage in less than three hours. From the results of these 
two cases, I should certainly have no desire to repeat the 
operation."* 
When, according to the author's statement, the patient 
is at death's door, or rather before she reaches so near 
her goal, why not give her a reasonable hope of escape 
by an operation, which, as I have shown, is less fatal 
than any of the operations which he is in the daily habit 
of performing? Is it a less boon to snatch the poor 
woman from death by the sacrifice of her womb, than it 
would be to rescue her from the same fate by the ampu- 
tation of her limb at the hip-joint? 
Dr. Marion Sims (op cit.) has as little desire, as Dr. 
Gross, to repeat the operation. He too has performed 
it only once, and then by excision, the ecraseur alone 
having been made use of instead of the knife. The con- 
sequence was that the most fearful haemorrhage he ever 
encountered took place, and in an instant the vagina was 
filled with arterial blood. "Fortunately," he tells us, 
"the bleeding was from that part of the broad ligament 
still adherent to the severed uterus," and the undivided 
portion of it, with the artery was tied. Had the broad 
ligament been severed with the rest of the uterus, his 
patient must have bled to death. This case is but an- 
other warning against excision, whether by the knife or 
ecraseur, for experience has abundantly shown that the 
♦System of Surgery, Second Edition, Vol. 11., p. 902. 24 
Miller, Inversion of the Uterus. 
ecraseur is no sure guarantee against haemorrhage after 
any surgical operation. Had Dr. Sims, Dr. Gross and 
myself operated as Dr. McClintock did in his case, the 
result might have been different: at least there would 
have been no haemorrhage. 
I will now inquire into the mortality and success of 
manipulations practiced with a view to the replacement of 
the uterus, in cases of chronic inversion. Previously to 
doing so, however, it is necessary to define the meaning 
of the term "chronic" in this relation. I shall apply it 
only to cases of three months' duration and upwards, 
which is not an arbitrary distinction founded on time 
only, but on the period that must elapse after parturition 
before the involution of the uterus is probably complete. 
Boivin and Duges affirm (1) as I think, truly that the re- 
duction of the uterus, after parturition, to the volume 
and density natural to it in one who has borne children, 
does not take place in less than about two months, and I 
think it fair to allow an additional month for the retard- 
ing influence exerted by the displacement upon the pro- 
cess of involution. No case of inversion ought, there- 
fore, to be considered as chronic, which has not existed 
at least three months, and not even then, if the uterus be 
found larger and softer than it should be at that period 
after parturition. In such a case, reinversion might be 
comparatively easily effected by manipulation, whereas 
had involution been complete, the operation would have 
been difficult, if not impossible. On these grounds I 
reject from the category of chronic cases not only all 
such as were only of a few week's duration, but also such 
as were of longer continuance, when we are told by the 
reporter that the uterus was not completely involuted 
Thus, in Dr. Belcombe's case, (2) the womb was found, 12 
1 Traite Practique des Maladies de 1'uterus. Tome 1, p. 35. 
2 Med. Gaz., 1841, Vol. VII., p. 783, quoted by Dr. West. Miller, Inversion of the Uterus. 
25 
weeks after delivery, a large spherical pouch, and in Dr. 
Miller's patient, (3) at the end of three months, it like 
wise admitted readily the introduction of two fingers into 
its cavity. 
The cases of chronic inversion of the uterus, in which 
manipulations have been tried, are not numerous : still I 
have collected a sufficient number to enable us to form 
an approximate estimate of the danger, if any, and the 
success or failure of the practice. 
Experience has taught us that Dr. Tyler Smith was 
over-sanguine when he declared, in his paper reporting 
a case of nearly twelve years' duration successfully 
treated, that while no amount of force will suddenly 
reduce a case of chronic inversion, yet by air or fluid 
pressure, so as to convert the fundus and body of the 
uterus into a wedge, the os uteri maybe slowly enlarged, 
in any case, so as to admit of reinversion. We shall 
presently see whether or not this prediction has been ver- 
ified. 
The following is a list of cases of chronic inversion, 
which I have collected : 
M. Valentine's case of 16J months standing. 
Mr. Barrier's case of 15 months. 
M. Canney's case of 5 months. (4) 
Dr. James P. White, of Buffalo, 6 months. (5) 
Dr. James P. White, 15 years standing. (6) 
Dr. Tyler Smith, nearly 12 years. (7) 
Mr. T. P. Teale, Jr., of Leeds, 2| years. (8) 
Dr. Charles West, nearly 12 months. 
Dr. Charles West, 7J months. (9) 
3 Ed. Monthly Journal, Dec. 1851, quoted also by Dr. West. 
4 For these I am indebted to Dr. Churchill's Diseases of Women, 
New Amer, edit., revised by the author, 1857. 
5 American Journal of the Medical Sciences for July, 1858. 
6 Amer. Jour. Med. Sciences, for Jan., 1859. 
7 Med. Times and Gazette, April 24th, 1858. 
8 Med. Times, Aug. 20, 1859, quoted by Dr. West. 
9 Lectures on Diseases of Women, p. 195. 26 
Miller, Inversion of the Uterus. 
M. Brockenthal, 6 years. (10) 
M. Aran, duration not stated, but doubtless chronic, as 
evinced by the intractableness of the inversion. (11) 
Dr. Noeggerath, of New York, 13 years. (12) 
Dr. McClintock, 14 months' standing. (13) 
Dr. Thomas Addis Emmet, 7 months. 
Dr. Thomas Addis Emmet, 8 months. 
Dr. Thomas Addis Emmet, 18 months. (14) 
Dr. Thomas Addis Emmet, 14 months. (15) 
Dr. T. Gaillard Thomas, nearly 2 years. 
Dr. T. Gaillard Thomas, 10 months. (16) 
Dr. Joseph Worster, nearly 4 years. (17) 
Dr. Marion Sims, 9 months. 
Dr. Marion Sims, 12 months. 
Dr. Prothero Smith, 13 months. (18) 
The late Prof. John Hardin, several years. (19) 
I will now analyze these twenty-four cases to ascertain 
the results of manipulatory treatment of chronic inver- 
sion of the uterus. And, in the first place, it is to be 
remarked that two of the patients died: one of Dr. West's, 
and one ot Dr. White's. In the former, replacement was 
not accomplished, in the latter it was; but peritonitis 
supervened in both cases, which proved fatal. It is 
worthy of remark that different methods of reposition 
were practiced in these cases ; Dr. White used the rectum 
bougie and greater manual force than did Dr. West, who 
employed the air pessary, as recommended by Dr. Tyler 
Smith, which has been supposed to be milder and safer 
in its operation, but yet it was not less lethean in its 
10 Zeitschr. f. Gebcrtskunde, Vol. XV., p. 313. quoted by Dr. West. 
11 Quoted by Dr. West. 
12 Amer. Med. Times, 1862, p. 230. 
13 Clinical Memoires, p. 85. 
14 Amer. Jour. Med. Scieuces, for Jan. and April, 1866, and Jan., 1868. 
15 Amer. Jour, of obstetrics, for Aug., 1869. 
16 Amer. Jour, of obstetrics, &c., for Nov. 1869. 
17 Amer. Jour. Med. Sciences, for Oct. 1867. 
18 Transactions of the London Obstetrical Society, Vol. X. 
19 This case has never been published, but I saw it in consultation. Miller, Inversion of the Uterus. 
27 
effects, in the hands of Dr. West. Dr. West's account 
of this case is instructive and may serve to abate the con- 
fidence with which wTe might assail an inverted uterus, in 
full assurance of success. lie had replaced the organ, in 
his first case, in four days, notwithstanding that it had 
been inverted nearly twelve months: in his second case 
the pressure of the air pessary continued for twelve days, 
"while it failed to replace the womb, gave rise to peri- 
tonitis, of which the patient died, four days after the 
pessary had been removed. The instrument had pro- 
duced complete dilatation of the os uteri, but had had no 
influence on its fundus, the uterine tissue at the point of 
inversion being hard and puckered, so that the little 
finger could with difficulty be pressed into the cul-de-sac 
formed by it." 
In Dr. Aran's case the presence of the pessary in the 
vagina produced abdominal pain, shivering and febrile 
symptoms, and the operation was abandoned. Of his 
case Dr. McClintock* says : "Having entertained san- 
guine expectation of success, in consequence of the re- 
laxed condition of the os uteri, it was with much reluc- 
tance I abandoned the attempt to restore the organ to its 
natural position. But after giving the taxis what ap- 
peared to be a fair trial, I felt it was quite needless, if not 
highly dangerous to persevere any longer." 
In Dr. Marion Sims' case, notwithstanding that he had 
just said that reinversion is "quite practicable," after 
steady efforts of four hours continuance, the uterus was 
only partially replaced, i. e. the fundus was pushed up 
within the os uteri, but it could not be passed farther- 
On examining a day or two afterwards he says that he 
was horrified to discover that the vagina, particularly at 
its posterior cul-de-sac, had an ecchymosed appearance, 
*0p. cit. 28 
Miller, Inversion of the Uterus. 
as if it had been stretched almost to the verge of being 
ruptured. About eighteen days afterwards another effort 
of an hour's time was fruitlessly made, and yet another 
after a proper interval, and all hope of replacing the 
organ was abandoned. "After this," we are told, "she 
and her husband begged to have the organ removed, as 
we promised to do it with the ecraseur without pain." 
Of the operation I shall speak further on. 
In one of Dr. Emmet's cases the operation was not ac- 
complished, except partially, and after a peculiar fashion, 
of which I shall speak more anon. Dr. Thomas failed to 
reinvert the uterus by ordinary manipulations in one of 
his two cases, and the late Dr. Hardin failed in his case, 
and by the usual progress of the disease, the patient died. 
The comparison between amputation and manipulation 
brings out, therefore, this result, namely, amputation, 
when performed by the best method, is attended with a 
mortality of in 5 2-5 cases, but it never fails to accom- 
plish its object-the ablation of the uterus. Manipulation 
shows a mortality of 1 in 12 cases, and it fails to attain 
its object-the restoration of the uterus-in seven cases, 
while in three out of the seven, it had to be abandoned 
on account of the alarming symptoms to which it gave 
rise. 
2. We have to inquire, into the validity of the cures 
effected by amputation and manipulation respectively. 
It is to be regretted that, in respect to these operations 
as to all others in surgery, there is a deplorable lack of 
information touching their sequences. After the opera- 
tions, satisfactorily and, it may be, brilliantly performed, 
surgeons are too apt to lose sight of their patients and 
cease to take much interest in them. Perhaps they are 
not to be blamed: the daily pressure upon them of new 
cases absorbs all their time, and they cannot pursue the 
patients, whom they have dismissed. Be this as it may, Miller, Inversion of the Uterus. 
29 
they hear but little, and that only of a few, whom they 
have lost sight of. 
Of the sanitary condition of a few women, who have 
been submitted to amputation of the uterus, I have al- 
ready given an account, and that account is satisfactory 
in the highest degree. Their health was good, even 
robust, and in no respect did they differ from what they 
were, save that they were incapacitated for child-bearing. 
How is it with the women, who have had their •wombs 
restored to their rightful position ? In a few cases, the 
gestative function has been resumed. Dr. Tyler Smith 
tells us that since the presentation of his paper, he has 
been informed that his patient was in the fifth month of 
pregnancy. Equally gratifying information was con- 
veyed to Dr. Emmet by the husband of one of his patients, 
and Dr. Worster says of his patient that she returned 
home "with a complete aptitude for conception." 
The joyful news of prospective children was sure to 
find its way to the cars of the happy operators: 
but what became of the remaining twenty-one or 
twenty-two ? Indeed, should Dr. Worster's confident 
prediction be not fulfilled, of whom we hear nothing. 
In the absence of information, we cannot refrain from 
speculation. 
Knowing, as we do, the proneness of the uterus to all 
manner of disease, we are slow to hope that, after having 
gone so far astray as to be turned inside out, and then be 
violently pushed back to its place, it will settle down in 
a healthy condition. If not diseased previous to its in- 
version, as it is, where polypus exists and has caused the 
displacement, is it not extremely liable to become so after 
what it has undergone? 
And ought we not to expect that congestion, inflam- 
mation, or ulceration, or some other kind of displacement, 30 
Miller, Inversion of the Uterus. 
such as flexion, or version, or prolapsus may invade it? 
We know too well how difficult such diseases are to cure, 
how chronic they are, how they embitter the lives of 
multitudes of women, so that they might gladly purchase 
immunity from them, even by the loss of their wombs, 
provided that the price could be paid without suffering 
or risk. 
3. The range of applicability of amputation and ma- 
nipulation respectively. 
It scarcely needs to be said that amputation is applica- 
ble to all cases of chronic inversion of the uterus, where 
it is judged to be the proper remedy. It is conceivable 
that the organ might be found to be in such a disceased 
condition that it would be the height of imprudence to 
attempt to restore it or to save it. In such a case, there 
could be no hesitation in removing it by the proper opera- 
tion. Then again, manipulation, however perseveringly 
tried, may fail, as we have shown that it has failed in 
nearly one-third of the cases in which it has been 
practiced, and then amputation is, or at least, has hitherto 
been, our only alternative, and it is applicable here, just 
as it is in cases where it is called for on account of 
disease of the uterus accompanying inversion. 
Is manipulation equally applicable to all cases of in- 
version? This is a question which I propose to discuss 
for a few moments. In cases of inversion, complicated 
with polypus of the uterus, and we have seen that they 
are not infrequent, my own opinion is, that an attempt 
to restore the uterus to its normal position by manipula- 
tion is not admissible, because it is in a diseased state, 
and, if restored, would most likely prove to be a plague 
rather than a blessing. 
I cannot but sanction the course pursued by Dr. 
McClintock, in such a case as this, in the person of Mary 
O'Hara, aged 66, a charwoman, who was never married, Miller, Inversion of the Uterus. 
31 
and her changes had ceased fifteen years before there was 
complete procidentia and inversion of the uterus, with a 
polypus growing from the fundus. Says Dr. McClintock. 
"The completeness of the inversion, and the patient's ex- 
treme intolerance of any squeezing or manipulation of 
the tumor, altogether excluded the hope of doing any 
good by attempts at reposition." And I admire the good 
sense as well as the pluck of the poor woman, who, when 
informed that the womb must be extirpated, plainly told 
her medical advisers "to whip it oft* as soon as they 
liked." The extirpation was performed, and the patient 
recovered, being one of the eight in Dublin, all of whom 
were saved by the operation. What use had she for the 
womb, and why should she care to have it put back, 
supposing that it could have been done, only to give her 
trouble in future? This case is, judging from the figures 
representing them, the counterpart of Dr. Emmet's 
fourth case.* 
His patient, Mrs. Conklin, was 54 years of age, had 
been married but was sterile,the uterus was found inverted 
with a fibro-cystic tumor at the fundus, which presented 
just within the labia. "The tumor was as large as a 
pigeon's egg, but had evidently undergone a reduction in 
size from cystic degeneration," and on the right side of 
the uterus, the shrivelled remains of a mucous polypus 
existed. Dr. Emmet further stated, in the discussion 
which followed the reading of his paper before the New 
York Obstetrical Society, that there had existed quite a 
number of glandular cysts in the uterus itself, some of 
which he had emptied out by pressure after the removal 
of the tumor. Dr. Emmet's treatment of this case con- 
sisted in the removal of the tumor by the 6craseur, and 
then attempting the reposition of the uterus. With 
*Amer. Jour. ®f Obstetrics, &c., for Aug., 1869. 32 
Miller, Inversion of the Uterus. 
much skill and ingenuity he succeeded in pushing the 
fundus within the os uteri and up to the plane of the 
vaginal junction, so that a sound could be passed within 
the cavity a little over an inch. It was found impossible 
to make any further advance, and recourse was had to 
a devise which Dr. Emmet had found to succeed 
in a previous case, viz: the introduction of three silver 
sutures into the cervix, without denuding it of its mu- 
cous membrane; the steady pressure thus maintained 
against the fundus would, it was hoped, overcome 
the resistance and complete the reposition. The patient 
was sent home but returned in six weeks, when it being 
found that the partial inversion still continued, a portion 
of the inner face of the os uteri was denuded, and three 
deep interrupted silver sutures brought the sides to- 
gether in the centre, leaving the line open at each ex- 
tremity. "The sutures were removed on the eighth day, 
the union was found perfect, and shortly afterwards, she 
was discharged from the hospital." 
In this case, as it appears to me, amputation was more 
clearly indicated than in Dr. McClintock's case. The 
patient had as little use fora womb as Mary O'Hara, and 
certainly Mrs. Conklin's was the most diseased, for be- 
sides the polypus of the fundus there was extensive 
disease of the utricular glands of the mucous membrane 
of the uterus. The renowned Surgeon-in-chief of the 
New York State Woman's hospital, I must think, dis- 
played the qualities of the ingenious and skillful opera- 
tor more than those of the profound pathologist. Why 
should a uterus, rioting in disease, be stored away in a 
receptacle, specially provided for it? Filled wTith the 
germs of disease, as it seemed to be, is there not reason 
to fear that these will multiply, as in a hot bed, and 
bring forth fruit unto death? Time alone can give a sat- 
isfactory answer to these questions. Millfr, Inversion of the Uterus. 
33 
These "Thoughts" have been scattered over a wider 
expanse than I had intended, and must now be concen- 
trated upon the substitute for amputation of the uterus, 
proposed and practiced by Dr. Thomas. His substitute, 
as we have seen, is a grave surgical operation, supple- 
mental to manipulations, by which their deficiency may 
be made up, and so the much-dreaded amputation be al- 
together dispensed with. 
We will now let Dr. Thomas introduce his patient: 
"I found Mrs. B. to be a delicate, fragile blonde, weighing 
about ninety pounds, very pale and exsanguinated from 
profuse menorrhagia, which had occurred at intervals 
for twenty-one months. Taxis had been tried fourteen 
times, some efforts lasting from five to six hours, and 
only one less than an hour. The constriction which re- 
sisted reduction had been cut at infinite risk, and all had 
failed. The only recognized operation which now offered 
Itself was amputation, and at the thought of this the 
patient revolted." Having had a steel dilator, made on 
the principle of a glove-stretcher, fabricated for the oc- 
casion, Dr. Thomas was ready for the novel operation, 
which he shall describe. "The patient having been put 
under the influence of ether, Dr. Metcalfe introduced his 
hand into the vagina, and lifted the uterus so that I could 
detect the cervical ring against the abdominal wall. I 
then slowly cut down upon the median line, as for an 
exploratory incision in ovariotomy, and leaving the 
wound exposed to the air until all oozing had ceased, 
cut into the peritoneum. I then inserted my finger into 
the uterine sac, and found no adhesion whatever to exist. 
Replacing Dr. Metcalfe's hand by my left hand, I now 
inserted the steel dilator, and dilated the stricture. The 
dilatation urns exceeding easy and rapid* but I found that 
as I withdrew the dilator, the tissue of the organ would 
at once contract. After dilating the stricture fully, I 
partially returned the uterus after some effort. Drawing 
it down to the vulva, I rapidly pushed it up, and was 
gratified at finding that it was nearly replaced. Drawing 
it down again, time outside of the body, to my dismay, 
I discovered that the artery, cut one week before, was 
spouting freely. I now saw that success must be attained 
•The italics are mine. 34 
Miller, Inversion of the Uterus. 
at once, or that it would elude my grasp when just within 
it. Actuated by this feeling, I rapidly returned the organ, 
and was delighted to find one horn rise into its place. 
But the additional force employed was a little more than the 
vagina could bear, and one finger passed through between the 
uterus and bladder. One horn was still inverted. Passing 
the dilator into this, I stretched it open, and instantly 
the uterus resumed its normal position." 
Nothing can excel the graphic description of the ope- 
ration contained in this extract, while perfect truth- 
fulness and candor are conspicuous in every line of it. 
Whether or not the operation will eventually establish its 
claim to be a substitute for amputation, experience alone 
can decide; but in the mean while it is allowable for us 
to judge between them according to all the collateral 
light that can be made to shine upon them, so that gynae- 
cologists may be encouraged to repeat the operation or 
to avoid it, according as their verdict may be favorable 
or unfavorable to it. 
To express my thoughts fully, beforehand, on the im- 
portant question, which has just been referred to the 
arbitrament of experience for its final decision, I shall 
have to explain the nature of inversion of the uterus, 
and what is involved in it. This is a rather intricate 
subject, which is but poorly illustrated by drawings or 
models, and which can be clearly comprehended only by 
fixing the attention upon it and getting it (delineated, as 
it were, in the mind. Few, I apprehend, take the trouble 
to get it thus mentally mapped out, and yet unless this is 
done, 1 shall fail to make myself understood. 
To proceed with my explanation. 
Inversion is the turning of the uterus inside out, by the 
falling of the fundus into its cavity and its descent until 
it reaches the os uteri, through which it passes into the 
vagina and thence escapes at the vulva, appearing out- 
wardly as a red, vascular and bleeding tumor between the 
thighs of the patient. Such is the lapsus of the uterus Miller, Inversion of the Uterus. 
35 
and such its appearance, in recent cases, when it occurs 
as a sequela of parturition. If only the fundus and body 
have escaped through the os uteri, it is incomplete inver- 
sion, and the part that last escaped will be found encir- 
cled by the os uteri, and at the point above the os where 
the inversion was arrested, there will be a ring formed 
by the folding of the lapsed wall of the uterus upon the 
stationary wall, which is the outermost. This ring I 
shall call the "parietal duplicature," and it is an impor- 
tant point to be noted. This duplicature may take 
place at the internal os of the cervix, or above or below 
it, and it becomes the bottom of the cul-de-sac into which 
the cervix is converted, whose depth, measured from the 
os uteri, varies according as the parietal duplicature is 
near or remote from the os uteri. It is a mere assump- 
tion to limit this parietal duplicature to the os internum 
of the cervix, for in the recently emptied gravid uterus, 
the cervix is quite expanded, and no cause can be assigned 
why the duplicature of the uterus should be opposite to 
what will be the os internum, when the division into 
body and neck is restored by the tonic contraction of the 
organ. 
If not only the fundus and body, but also the cervix, 
have become inverted, the inversion is complete', then 
there is no parietal duplicature, and the os uteri is the 
summit of the uterine tumor, and the cervix, in being 
inverted, draws the upper portion of the vagina along 
with it, the vagina being then attached, funnel-shaped, to 
the inside of the inverted cervix. The os uteri is now 
continuous with the vagina, and its orifice cannot be 
reached, for it opens upwardly into the cavity of the ab- 
domen. 
This displacement necessarily produces a cul-de-sac or 
pouch of peritoneum above the entrance to the abnormal 
cavity of the womb. 36 
Miller, Inversion of the Uterus. 
It has been disputed whether complete inversion of the 
uterus ever occurs, and certainly it is rare, much rarer 
than the perusal of cases narrated by incompetent and 
careless observers might lead us to believe. Nothing is 
more common, especially if the uterus should protrude 
through the vulva, than for such an observer to say that 
it is completely inverted, mistaking the size of the uterus 
and the degree of protrusion for completeness of inver- 
sion. Then again, the inversion may be arrested just at 
the os uteri, (the third degree of the displacement of 
Boivin and Duges*) and without a very caretui examina- 
tion by a practiced touch, the os uteri might not be felt. 
It is, nevertheless, true that complete inversion does 
sometimes, though rarely, take place, as the well-authen- 
ticated cases, cited by the authors just quoted, fully attest. 
When complete inversion happens at the time ot par- 
turition, the tumor formed by the uterus is larger than 
it should be at such time, for it is distended by portions 
of intestine lodged in it as well as by the ovaries and 
Fallopian tubes. In the cases referred to, this was 
proved by post-mortem examinations. In the first of 
these cases, by Stalpart Van der Wiel, the intestines were 
brought to view by an incision of the tumor hanging 
between the thighs of the patient. Not to refer to others, 
a case, by the celebrated Levret, shows that the sac, 
formed by the inverted uterus and vagina, was filled with 
a portion of the rectum, the bladder, the small intestines 
and the tubes and ovaries: the patient, in this case was 
seventy years of age, and of course the inversion was 
chronic. 
Observe now that, when inversion takes place, it is by 
a movement of the uterine walls inwardly, and when 
reinversion occurs spontaneously, if it ever does, or is 
effected by art, it is by an opposite movement. The 
*Traite des Maladies de I'Uterus, tome 1, p. 220. Miller, Inversion of the Uterus. 
37 
morphological changes that arise from inversion are 
curious and worthy of notice. If the inversion be in- 
complete, the cavity formed by the inverted portion of 
the uterus is a preternatural one, lined by serous, and 
covered by mucus membrane, and it has a preternatural 
mouth, looking upwardly towards, and communicating 
with the cavity of the abdomen. This mouth is formed 
by the parietal duplicature, and might be called the os 
prceternaturale. Beneath this cavity is the natural cavity, 
or so much as remains of it, of the cervix, lined of course 
by mucous membrane, and it continues to communicate 
with the vagina by the os uteri which is now only the 
mouth of the cervix. In becoming, whether completely 
or incompletely inverted, the uterus probably draws along 
with it not only portions of the broad ligaments, but also 
the Fallopian tubes and ovaries; and likewise portions 
of small intestines; for the womb is so large and its 
walls so flaccid, that there is ample room for their re- 
ception. 
So much for a brief description of the changes the 
uterus undergoes, in recent parturient inversion. But 
when the inversion has become chronic, the uterus has 
returned to its non-gravid state: it has retreated within 
the vagina, its walls have resumed their previous density; 
its cavity has contracted down to the small size, which it 
had, before parturition seriously distorted it. In this 
process of involution, the ovaries, etc,, are ejected from 
the uterine cavity and lodged above the uterus in the per- 
itoneal pouch.* 
* Note on the Operation of Amputation of the Inverted Uterus.-The 
admitted fact that loops of the small intestine are contained in the 
recently inverted parturient uterus, taken in connection with Lev- 
ret's case, where these were found, in a case of chronic inversion, in 
a woman aged seventy years, may be regarded by the timid as 
counter-indicating the operation of amputation. But Levret's case 
is an unique one: I know not that a parallel one can be found on 
record. It must have been produced by a paralysis of involution, for 
certain it is, that when that restorative process is duly performed, the 38 
Miller, Inversion of the Uterus. 
In other words, the uterus has become, as it was in '■s 
non-gravid state, a thick-walled and small-cavitied organ, 
the walls possessing but little flexibility, and stubbornly 
refusing to yield to any force that tends to indent them 
or to change their shape. To such an extent is this true 
of the unimpregnated uterus, that it is generally admit- 
ted by authors, that it cannot be inverted, by any force 
that can be brought to bear upon it. The late Professor 
Charles D. Meigs expresses his convictions very strongly 
on this point, when he says,* speaking of a case ot 
chronic inversion ot six month's duration-"It was in- 
verted at the time of her confinement, six months ago. 
Mrs. Lucina inverted it by pulling at the cord before the 
placenta was detached, and either did, or did not know 
what she had done. The haemorrhage was terrible. The 
woman ceased to bleed, and did not die, because she 
fainted so badly that the vascular injection by the heart 
was too feeble to kill her by haemorrhage. She slowly 
recovered, in a measure, but bleeds still upon the smallest 
excess of exercise or labor. Well now, my young friend, 
you have made your diagnostic. What are you to do 
for your patient? Will you reposit or reinstate this 
womb ? You can't. You might as well try to invertone of 
the non-gravid uteri on my lecture-room table as to reposit 
uterus is contracted down to something like its non gravid size and 
condition, and such contraction excludes the ovaries and intestine 
from its cavity and lodges them in the peritoneal pouch above. It is 
barely possible that, in cases of complete inversion, the pressure of 
the bowels upon the os uteri might prevent its firm closure and allow 
a slight insinuation of a knuckle of in estine a short distance within 
the cervix But this, should it occur, will not add to the danger of 
the operation, unless the ligature should be applied to the base of the 
tumor, which never ought to be done. In cases of incomplete inver- 
sion, the ligature must needs be applied to the inferior part of the 
body of the uterus, at or just below the os uteri, and only the body 
is severed by the ligature, aided by the gcraseur. The body is the 
source of all the hsemorrh igic and other exhausting discharges, and 
therefore only it need be extirpate 1. And so in complete inversion, 
only the body should be extirpated, and it will prove a good and safe 
rule of practice to apply the ligature about two inches above he 
fundus, which will leave the cervix intact. If this rule be observed, 
there can be no risk of including the inverted vagina or peritoneal 
pouch in the ligature. 
*Letters to his Class, pp. 231 and 232. Miller, Inversion of the Uterus. 
39 
this one.* The time is gone by. You have no art or skill 
nor no power equal to the performance of such a miracle of 
surgery as that." The miracle in the case of the inverted 
uterus, has, nevertheless, been performed, but with ex- 
ceeding great labor, and the attempt to perform it has 
been frustrated in nearly one-third of the cases, while in 
two it proved fatal. 
Now, whence all this difficulty? Dr. Thomas and 
others tell us that it arises from a stricture at the os in- 
ternum. But when the abdomen was opened and the 
dilator was inserted in this so-called stricture, did it resist 
like a veritable stricture? Dr. Thomas answers, "the 
dilatation was exceedingly easy and rapid." Then we 
may reasonably inquire, is this the way that other stric- 
tures behave-strictures of the oesophagus, of the ure- 
thra, of a hernial sac, for examples? One of the marks 
of a stricture, as I understand it, is, that being overcome 
by the knife ora dilator, all resistance ceases and the ob- 
struction is removed. The stricture in hernia, for instance, 
being cut, the strangulated intestine can easily be re- 
turned into the abdomen. After fully dilating his 
so-called stricture, as he says he did, did Dr. Thomas 
easily reposit the womb? No, but on the contrary, so 
great was the difficulty yet to be overcome, that he had 
to resort to his favorite but, I must think, violent manceu- 
vre, and draw down the uterus once and again, the last 
time, outside of the body, and pushing it up again with 
a force that sent one of his fingers, tearing its way 
through the vagina, and into the space between the uterus 
and the bladder. 
Do surgeons have to use so much force in the opera- 
tion for strangulated hernia? Or after dividing the 
stricture, is the intestine easily replaced in the abdominal 
cavity? The difference in the two cases is readily ex- 
*The italics are mine. 40 
Miller, Inversion of the Uterus. 
plained. The stricture being divided, in the case of her- 
nia, the thin-walled intestine may have the gas, that in- 
flates it, pressed out of it and its walls, being thin and 
yielding, it can be moulded to the aperture through 
which it is to pass. Not so with the uterus: it is, in a 
great degree, inflexible and insusceptible of being 
moulded. Besides, the problem for the gymecologist to 
solve is, not to make an aperture through which the 
uterus may be pushed bodily, but to start the process of 
reinversion, by first unfolding the parietal duplicature- 
the os proeternaturale-and when that is done, the body 
and fundus follow with their outward movement, and so 
they resume, though slowly and stubbornly, their proper 
places. The difficulty, I repeat, consists not in a stric- 
ture, formed by the os internum, but in the inflexibility 
of the parietes of the uterus and the smallness of its 
cavity, and therefore if we could dilate the so-called 
stricture ever so widely, we shall still have the intracta- 
ble walls of the uterus to deal with. There are, and, I 
doubt not, there ever will be cases where there is so great 
rigidity of these walls that nothing short of a miracle 
can reinvert them. This was the trouble in Dr. Emmet's 
case, as I regard it, and not adhesions of the broad liga- 
ment, which have never been proved to exist, and which, 
if they existed, could not hinder the reposition of the 
organ by any mode of action that I can imagine. 
To express my views a little more fully here, I should 
say that the difficulty, amounting to impossibility, in 
some cases, of reinverting the uterus, depends upon per- 
fect involution of the organ after parturition. We know 
that a variety of causes may impede involution, and 
among them we may reasonably reckon so serious a dis- 
turbance of the uterus, as inversion must give rise to. If 
there be imperfect involution of the uterus, superadded 
to its inversion, then its parietes will be more succulent Miller, Inversion of the Uterus. 
41 
and pliable, and its cavity larger, and its mouth more 
patulous, than in the normal non-gravid state. It must 
then be much easier to reinvert it than when its walls 
are compact, and its cavity small. If I am right in this 
opinion, I have satisfactorily accounted for the total fail- 
ure ot the most eminent and skillful operators to replace 
the inverted uterus, in the cases which I hav e cited. 
From the considerations which have now been pre- 
sented, the deduction appears to be warranted, that Dr. 
Thomas' substitute will not prove to be a trust-worthy 
supplement to manipulation, in the treatment of chronic 
inversion of the uterus, and that it will not, therefore, 
abolish the necessity of amputation in certain cases. 
I shall endeavor finally, to estimate, as well as I can, 
what additional mortality will ensue from gastrotomy 
and the dilatation of the so-called stricture of the uterus, 
as helps to manipulation. Here we have to deal with 
probability only, wThile nothing is more certain than that 
there must be increased mortality, except it be true that 
the abdomen may be opened, and the serous membrane 
of the uterus irritated with impunity. All surgical 
writers agree that penetrating wounds of the abdomen, 
even though none of the viscera may be implicated, are 
attended with danger. The peritoneum is ever ready 
to take on inflammation, and this, when kindled, spreads 
with alarming rapidity, and is often fatal in its termina- 
tion. Besides these causes of inflammation-the wound 
and the irritation of the uterus-there must be nearly as 
much handling of the payts contiguous to the uterus as 
in the operation of ovariotomy, unattended with complica- 
tions, such as adhesions, &c. Peritonitis must, therefore, 
come in for its share of victims, in all operations per- 
formed within the cavity of the abdomen. Whether or 
not the increased rate of mortality from manipulatory 
treatment, caused by gastrotomy, will make the operation 42 
Miller, Inversion of the Uterus. 
more or less fatal than amputation of the uterus, cannot 
be predicted. In view of the whole drift ot this discus- 
sion, I will venture, however, to assume this position : 
Should it be proved by experience that manipulation, 
surmounted by gastrotomy, is more fatal than amputation, 
it ought to be altogether rejected, because it is of far 
more consequence to save lives than wombs. Better that 
a score of women should lose their wombs, with the 
chances of saving their lives, than that one should die, 
when the life of that one might have been saved by a 
different surgical proceedure. I do not expect that Dr. 
Thomas will concur with me in this sentiment, because 
his opinion is widely different from mine, in respect to 
the defeminizing consequences of ablation of the uterus. 
Could I believe with him that the loss of the womb un- 
sexes a woman, and makes her a mockery, a caricature 
of her former self, I should turn from so degrading an 
operation, as I would from the mutilating processes of the 
comprachicos, who, as Victer Hugo says, made monsters of 
hapless children for the amusement of the happy.