[Reprinted from the New York Journal of Gynecology and Obstetrics 
for August, 1894. 
A CASE OF COMPLETE INVERSION AND PROLAPSUS 
OF THE UTERUS. 
By J. W. Pickel, A. B., M. D., Crystal City, Mo. 
On June 13, 1893, I was called at 8.30 a. m. to see Mrs. R. in 
labor. She was a German, stout of build, married five years. She 
had had two miscarriages and one stillbirth ; last child is living, 
healthy, aged nineteen months. Patient has suffered for the last few 
years with prolapsus uteri. Digital examination showed the os well 
dilated ; presentation V. R. O. A. Pains were irregular, infrequent, 
and inefficient. At 9 a. m. I gave eight grains of quinine. This was 
all the medicine she had until after the child was born. In half an 
hour the pains were stronger and more frequent. The child was born 
at 12.15 p- M- As the head was passing through the vulva there came 
a powerful expulsive pain which sent the child swiftly through my 
hands, and it lay in bed as far away as the cord would let it go. The 
child was of medium size and well developed. 
Pains to expel placenta began promptly. With my hand placed 
gently across the abdomen I noticed that the fundus uteri was un- 
commonly broad and at each contraction it became smaller unusually 
fast, but I still suspected nothing uncommon. The placenta could 
now be felt in the vagina and, as I made a gentle traction on the cord 
to lift it out, there came a strong expulsive contraction and the uterus 
inside of the placenta lay fully six inches outside of the vulva. I rap- 
idly stripped off the placenta and membranes and attempted to replace 
the womb ; but as the patient’s suffering was so terrible, having no 
help but the husband, I wrapped the uterus in a clean towel and gave 
a hypodermic of morphine. By this time the inverted uterus was too 
large to pass back through the vulva, but with firm and continued J. W. Pickel, M. D. 
2 
pressure with my hands the size was reduced so that it went back 
easily into the vagina. It being too tender for further manipulation, 
I had to send three miles and a half for an assistant. 
The loss of blood was small, the suffering intense, but the shock 
not great; pulse 96, breathing rapid, swimming in the head. 
The assistant arrived about 2 p. m. Chloroform anaesthesia. A 
hand was introduced into the vagina, the uterus firmly grasped and 
pushed with counter-pressure by the other hand against the cervix, 
which could be felt through the abdominal wall as a hard ring about 
one inch and a half in diameter. This accomplished nothing. Then 
lateral taxis was made. This also did no good. I then folded my fin- 
gers into a cone and made steady pressure on the inverted fundus, at 
the same time using the other hand in the same manner ; thus pushing 
the abdominal wall into the os and dilating it. The right hand in this 
way readily carried the fundus through the cervix, and the entire 
uterus to its normal position. My hand was left in the uterus until a 
hypodermic of normal liquid ergot was given and firm contraction 
obtained. An intra-uterine douche of boiled water and bichloride 
1 to 4,000, as warm as could be borne, was given with the Jamison 
irrigator. These douches were repeated daily for the three following 
days. 
Patient made an excellent recovery and suffered less, she said, than 
during her previous confinements. Her temperature rose to ioi° F. 
on the third day with some delirium, which readily gave way to purga- 
tives and quinine. Since her confinement the prolapsed uterus has 
been kept up and she has been quite comfortable with a Hodge pes- 
sary. 
It may seem that this trouble should have been discovered and 
prevented but, as I had never met with such an accident in over five 
hundred confinements, and as it is said to occur only once in a hun- 
dred and forty thousand deliveries, coming on so suddenly it caught 
me off my guard. 
Here the cause of inversion was plainly the sudden jerk on the 
cord given by the rapid expulsion of the child. It will also be no- 
ticed that stripping off the placenta and membranes did not cause 
haemorrhage. The three methods usually recommended to restore 
the inverted uterus were tried, with results in favor of replacing the 
fundus first.