INVERSION OF THE UTERUS. ' 5gi 



in this operation ; the round end is applied to the fundus of the uterus, 

 and the pressure is made at the other end of the instrument by the chest 

 or abdomen of the operator, whose hands are thus at liberty to direct the 

 viscus into the vulva and vagina. 



Seco7id Method. — If the uterine tumor is voluminous, and hangs — a 

 heavy mass — as low as the hocks, then the first method is dangerous, if 

 not impracticable, and must not be attempted. The best method now 

 undoubtedly is to return, first, the parts of the organ nearest the vulva, and 

 not act directly on the fundus of the uterus until the greater portion has 

 been replaced in the pelvis. 



In order to accomplish this, the assistants on each side of the croup 

 raise the uterus in the manner already described, so as to bring it near 

 the vulva, and opposite the axis of the pelvis. Then the operator gently 

 presses with open hands on eacli side on the parts close to the vulvar 

 opening, in order to force them gradually into it. By acting in this w^ay 

 with care and patience, and preventing, as well as he can, the expulsion 

 of those portions he has already reduced, the tumor by degrees becomes 

 diminished, and may even be entirely returned. But it is not necessary 

 to continue the method after two-thirds or three-fourths of the total mass 

 has been conveyed into the pelvic cavity ; for it is then more expeditious, 

 and quite as safe, to apply the closed fist to the extremity of the tumor, 

 and push it directly into the vagina and abdomen. In some instances it 

 will be found that, towards the termination of reduction, the organ itself 

 returns to its normal position, and often quite suddenly, as if it had been 

 thrown back by a spring. 



Sometimes a combination of the first and second methods is most useful : 

 an assistant pressing; on the extremity of the tumor, while the operator 

 manipulates near the vulva. 



Third Afethod. — This method was first brought to notice by Coculet 

 i^Jounial dcs Vet. dii Midi, 1862), who, finding the previous methods long 

 and laborious, set himself the task of improving it. 



This he has succeeded in doing by an ingenious procedure, which is 

 described as follows. A dry and clean piece of linen, about a yard in 

 length, and twenty-eight to thirty inches wide, is passed beneath the 

 inverted uterus, and close up to the vulva ; its lower border is then lifted 

 over the organ, one of the ends folded over it, and then the other end 

 over this, so as to envelop the entire uterus — the four corners of the 

 wrapper being uppermost. Tepid w^ater is now kept incessantly applied 

 to this cloth, which is gradually tightened every minute, by placing the 

 open hand beneath the mass, and with the other hand pulling at the 

 upper end of the wrapper. 



This equable, gentle, and sustained pressure over the entire organ, soon 

 (fifteen to twenty minutes) brings about a marked diminution in its size, 

 and renders its reduction easier. 



The method has been most successfully employed on several occasions ; 

 though some practitioners prefer immersing the protruded uterus in cold 

 water at once, as being a quicker plan for reducing it, while also effecting 

 the necessary cleansing process. 



Certainly cold water might frequently be substituted for tepid, and 

 compression might commence at the lower extremity of the organ, par- 

 ticularly if the bandage is elastic, on the Esmarch principle ; this would 

 greatly expedite the operation, and would prevent injury to the uterus. 



Jensen (Hering's Repcrtorium, 1874, p. 183) describes a similar 

 method to that of Coculet. 



