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ward of any part of the uterine structure. Had the slightest contraction taken place, the parietes would liave assumed a more dense and firm condition. In the instance of Coesa- rean section I performed just previous to the death of the mother, the parietes would scarcely have measured one-sixth of an inch, while afterward the uterus was fully half an inch thick, if not more. I do not perceive, with all I have advanced, how the views of Duncan can be substantiated, that " it is necessary to show that paralysis or complete inertia of the higher parts of the uterus may occur, while the lower parts (the cervix) are in a state of contraction." The three Nizagara Online im- portant points of the advocates for the production of inver- sion of the uterus, by commencing with the indentation of the fundus, viz., through contraction of that part, the impulse of the intestines, the abdominal nisus and local paralysis, have very little if any influence in effecting the object, as these observa- tions show. Is it not possible to Order Nizagara believe, therefore, that inver- h^ ACTIVE UTEETNE INVERSIOIS^ 477 eion may commence, contrary to tlie opinions advanced, at the neck? If so, I will now ask, in return, if there is any positive evidence of a case of spontaneous active inversion taking place, in which the fundus was recognized by the hand over the pubes and abdomen, as depressed before the inversion took place or occurred, except that based on the result ? The result of the act or mechanism is certainly not the proof that the fundus was in- dented first. Sometimes the uterus is inverted, and the cervix is felt high above the pubes, even near the umbilicus. Depression may exist in a part of the uterus not accessible to the touch exercised through the abdominal parietes. Instances have oc- curred where a surgeon of eminence had given assurance of his having felt the contracted uterus above the pubes, and satisfied himself that all was right, when the organ at that time was totally inverted, the fundus being in the vagina, and the os uteri uppermost. Reversely, the case of Ingleby, as cited, shows that the fundus was felt round, firm, and globular, while the uterus was partially inverted from the cervix upward. This strong evidence, more than the mere ipse dixit of this or that authority, shows how mistaken the tactile examination over the pubes is, in the diagnosis of inversion of the fundus. It teaches us that there is no positive proof that the advocates of the depression theory have to present, except the result to which they appeal, nor " that the human family are the excep- tion to the general law of inversion of the uterus," which I think is not proven. Independent of the pathological views of local paralysis, and the other points alluded to, we must not forget that a physiological one should not be ignored, of how the uterus may be prevented from inversion except by its own contrac- tion. John Bell, on the nature of wounds of the abdomen, holds that the abdomen should* be considered not as a mere closed cavity, but that it has other and more important objects to perform tlian the mechanical agency, which may be less or greater according to Buy Nizagara Online circumstances. "We all know that it has been demonstrated with much simplicity of thought and much power, and which we must admit as true, that all the viscera are moved, by the diaphragm and the abdominal muscles, up- 478 THE MECHANISM OF SPOJSTTANEOUS ward and Nizagara Tablets downward with an equable, continued pressure which has no interval. When the bowels are forced down by the diaphragm, the abdominal muscles recede; when the bowels are pushed back again, it is the reaction of the ab- dominal muscles that forces them back and follows them. There is never an instant of interruption of this pressure — never a moment in which the bowels do not press against the peritonaeum, Buy Nizagara nor is there the smallest reason to doubt that the same points in each are essentially opposed. How, then, with- out this equable, universal, and constant pressure, could the viscera be supported ? How, without this uniform pressure, could the viscera fail to give way and burst ? There is, then, not only a uniform pressure, by which the intestines are retained in their place, and have their inherent mechanism, but there is implied also a conservative principle which the abdomen has, and without which important principle or power in the abdomen the uterus would prolapse. Two diflferent anatomical views appear to pervade the minds of the profession — those of Charles Bell, and those of Deville, Kolliker, and other anatomists. In the anatomical as well as in the mechanism of parturition they are entirely different. Anticipating the explanation I have to advance on the mechanism of inversion, it will be necessary for me to make some reference to these views. Bell is of opinion that there are no circular muscular fibres in the cervix uteri or os tincse, corresponding in place or office with the sphincter of other hollow organs. He has " no hesitation in saying that toward the fundus the circular fibres prevail, that toward the cervix the longitudinal fibres are most apparent, and that, on the whole, the most general course of the fibres is from the fundus toward the orifice. This prevalence of the longitudinal fibres is undoubtedly a provision for diminishing the length of the uterus, or drawing the fundus toward the orifice, at the same time. The longitudinal fibres must dilate the orifice, and draw the lower part of the womb over the head of the child." By this muscular action it must be apparent, according to

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