The circumstances attending parturition, as I have been able to collect them from the attendants, the midwife, and the attending physician, are as follow, viz. That she was taken in labour in the night of the 8th of May, that a female practitioner attended in the first instance, but that the pains being severe, the woman restless, disobedient, and as it was thought a little deranged, it was concluded to call in a neighbouring physician, who came and succeeded in the delivery of the child early the next morning. It appears that the inversion of the uterus accompanied the attempt to extract the placenta: the physician informed the midwife of the accident at the time, and expressed a certain conviction of the fatality of the case; at the same time he appears to have succeeded in reducing it within the os externum, and upon leaving her ordered strict confinement to a supine posture; which order, although perfectly judicious, was far from being strictly adhered to by the disorderly patient.

I did not meet the attending accoucheur at the house of the patient, yet I afterwards saw him and received from him some further particulars respecting this very interesting case. He informed me, that after the birth of the child, with which no extraordinary circumstance occurred, he made a gentle effort at the cord to extract the placenta, but finding that it did not advance, after a second trial, and after waiting eight or ten minutes, that he introduced his hand to feel whether there was any separation of the cake or not; but finding it still to adhere by its whole surface, he withdrew his hand and pulled at the cord; but with no more force, and he thinks not so much as he had used, without any ill effects, on other occasions; when something came forward which he supposed to be a placenta unusually large; but upon further examination, he found it to be the uterus with the placenta still adhering to the fundus with its whole surface; which he then separated; when some hæmorrhage followed, not more, however, in his opinion, than from two to three pints: then with his hand flattened he restored the uterus, as he supposed, to its right position and place, and enjoined rest; but left her, as he candidly acknowledged, without any idea of her long surviving the accident.

As this practitioner declined again visiting the patient, although subsequently called on when the protrusion again happened (which was on the same day in which he had left her,) another gentleman of considerable eminence in the obstetric art was applied to, who came a day or two after the accident, and who found her, as I was informed, much in the same situation in which I now saw her. His opinion was, however, equally strong as that of the other gentleman with regard to the fatality of the case, and he left her without prescribing any thing.

At the time I was called, besides the appearance of the inverted uterus, and the discharge therefrom, which have been already mentioned, she was labouring under nervous affections of the most violent and distressing kind; so that she supposed herself immediately in the hour of dissolution, which idea could not be chased from her mind, but appeared to be perpetually present; and I was assured that she had scarcely slept at all since her delivery.

My prognosis under all these circumstances could not be otherwise than unfavourable. I however determined not to abandon the patient without attempting something for her relief.

An attempt to revert the uterus I did not then think justifiable, after the abandonment of the patient by two practitioners older than myself; its probable utter impossibility, and especially after the assertion of an author so celebrated as Dr. Denman, that he had never been able to revert an inverted uterus, even in so short a time as four hours after the accident. Only two indications, therefore, from this view of the case, remained to be fulfilled. The first, to check the progress of the threatened, or perhaps, already begun gangrene of the uterus; and the second, to quiet the extreme nervous irritability, and thus procure sleep for the distressed patient.

Having previously experienced the powerful antiseptic effects of the wild indigo, (Sophora Tinctoria) of Linnæus, and believing it superior in this respect to the Peruvian bark itself, strips, wrung out of a strong decoction of this indigenous plant, were ordered to be applied to the inverted uterus; at the same time the cinchona was not omitted to be given internally. To fulfil the second intention, opiates in sufficient quantity to allay

the inordinate commotion of the nervous system, and to procure sleep, were administered.

In a case so apparently desperate, these circumstances wore a more favourable aspect; her pulse was regular, her voice strong, and her appetite good.

By perseverance in the remedies prescribed for the first seven days, the black colour of the inverted uterus was nearly gone, the smell was less offensive and the bulk much diminished; but the serous discharge still remained, and the extreme despondency and depression of spirits were not much abated, although the opiates administered had the desired effect of procuring sleep.

At this period the cerussa acetata was added to the decoction of wild indigo, principally with a view of lessening the discharge of serous matter; and I had reason to be satisfied with the effects of these remedies, in the rapid amendment afterwards experienced: of which I had frequent information, although the patient, being several miles distant, and in a very retired situation (more than a mile from any road whatever) was not so frequently the subject of my visits as I could have wished, for the purpose of making more particular observations upon the phenomena of so novel a case.

Her amendment was not however entirely uninterrupted, as on the fifteenth of June, (thirty-seven days after the accident) I was requested to visit her on account of her being more unwell. At this time the serous discharge, which had nearly ceased some time before, became more copious, the appearance of the inverted uterus was more red and spongy, its bulk was also somewhat larger, and it was not so much retracted within the os externum as when I had seen it last. She had also a slight cough, and quick pulse, for which I at this time prescribed a solution of tartarised antimony, combined with the camphorated tincture of opium. A solution of acetas plumbi was ordered to be continued, made with vinegar and water, for as the gangrenous appearances had changed for a pale healthy red, the indication for continuing the sophora no longer existed. From about this period her amendmeat became more perceptible, so that by the second day of July (fifty-four days after the accident) the inverted uterus was diminished to the size, and was much of the shape, of a large pear; and by the

twelfth of the same month, I was assured that it sometimes disappeared entirely by retraction within the os externum.

At what period menstruation recommenced I am not now precisely able to ascertain; but it was some time anterior to this period; and as the uterus in its appearance, and the symptoms at the time of menstruation, were much like those which I have noticed when I was called to her on the fifteenth of June, I am impressed with the idea that she menstruated about that time: it probably beginning thus early because she did not nurse her child; which her situation in the first weeks rendered her unable to do. This natural evacuation of the menses, however, when once restored, continued regularly at the usual periods from the inverted uterus, as I was assured upon very particular and repeated enquiries, both by the woman herself, and by her sister with whom she lived; the latter being a woman of more than common stability and understanding for one of her rank in society.

Some time after this period, and as I recollect, after the woman had gotten about, and was able to attend to some business, an irregular bred practitioner obtained some credit in this case, and as I conclude induced the woman and her friends to believe that he had reverted the uterus and restored it to its natural situation; but as I was informed by the woman herself that he applied a plaister to her external parts, and by her sister that the uterus at the periods of menstruation sometimes came partially to view,* I am disposed to think that his only merit consisted in pushing the uterus somewhat further into the vagina, and applying a plaister in such a manner as to diminish the capacity of the os externum, and thus retain it there, after having made fruitless and violent attempts at reversion.

A period of seven years and six months has now elapsed since the accident; in which period (until within the last year) I have frequently seen her and made enquiries respecting her situation. I have learned that menstruation has been regular,

* I have before observed that the uterus some time before this period disappeared entirely by retraction within the os externum. Of the appearances at the periods of menstruation, I made many and very particular enquiries; the result was, that the uterus came into view at these times; that it looked larger and redder, and that blood might be seen exuding from its inverted surface.

and that she has enjoyed good health, and been able to do the work of females usually required in the kitchen, and even, in the dairy season of the year, to make the cheese of a large farm, which in that abundant country of dairies is a frequent source of employment, and is considered harder than other kinds of work, usually performed by females.

In conclusion, I may observe, that I consider the management of the placenta as the most delicate part of practice in the obstetric art, but submit any practical deductions which this case might suggest to yourself.

I must beg that nothing contained in this account be construed as designed to throw any censure upon the other professional gentlemen who were concerned in it; the probability is, I think, very great, that there was a predisposition in the uterus to invert, or else, that the slight pulling at the cord, which the gentleman who attended represented his having used, would not have produced that effect.

As to the remedy used in this case to stop the progress of gangrene (sophora tinctoria) I am disposed to consider it a very powerful antiseptic; having, besides the above, used it in a great many other cases wherein mortification was threatened, or actually present, with the most decided benefit, both externally and internally. But on this head I need not further expatiate, as in Dr. Thacher's very valuable Dispensatory (edition of 1813) it is directed to be kept in the shops, and therefore (as it respects New England at least) may be considered as a legitimate article of the Materia Medica.

I am, sir, with very great respect,

Your most obedient servant,

THOMAS C. JAMES, M. D.

JOSEPH COMSTOCK.

* Since writing the foregoing account, I have observed that Dr. Thacher has not given the dose of this article. I have known many practitioners use it, without much care in this respect, as it is pretty uniformly procured in a recent state from the fields and pastures of New England, where it grows in great abundance. When used externally, this is not of so much consequence; but for internal use, half an ounce of the bark of the root, (which is the most active part of the plant) to a pound of water, boiled 15 or 20 minutes, and given from one to two table spoonsful once in from two to four hours, I consider as medium doses.