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conservative principle is deficient, then the uterus in Buy Nortriptyline Online the unim- pregnated state, or in gestation, or after its reinversion, would have no support but from the subjacent parts. After resurveying the principal points I have referred to, as tending, besides the contraction Nortriptyline 10 Mg of the uterus itself, to es- tablish an inversion, viz., the abdominal nisus, the impulse or pressure of the intestines, the functional or true paralysis of the fundus uteri, I think I have opened the subject to show that these have but little Cheap Nortriptyline influence in producing inversion in the spontaneous active form independent of the muscular action of the organ itself. If we consider the physiological mechanism of labor, and the natural physiological condition the uterus passes through 484 THE MECHANISM OF SPONTANEOUS to accomplish the delivery of the infant and the placenta, it is my decided conviction that the spontaneous active inversion of the uterus rests upon the prolonged natural and energetic ac- l^on of the body and fundus ; the cervix, the lower part, yield- ing first, is then rolled out, or everted, or doubled up, as there is no obstruction from the contractility of the cervix, which is at rest, or functionally paralyzed ; the body is gradually, some- times instantaneously, forced lower and lower, or inverted, and, as the fundus continues its action, and the contraction yields, the fundus is Order Nortriptyline Online flapped out, or falls through, and the uterus is then either partially or wholly inverted, the fundus presenting. Should the conservative principle and the elevating forces of the abdomen be rejected as having no important bearing, there is no reasonable way to account for the replacement of the uterus in cases of inversion or procidentia, or after they have been returned. The usual expressions which are so frequently made use of by the operator for reinversion of the uterus, when the displacement is about being accomplished, is, that the organ went back with a bound — a snap — a spring into its place, testify to some inherent principle existing physi- ologically in the abdomen, which could not well be explained in any other way. June 6, 1869. — I was requested to visit Mrs. "W., in con- sultation with Drs. N. C. Husted and Bliss, for an inversion of the uterus. Primipara, aged twenty-five years. After the delivery of the child, in a few moments, the physician in attendance introduced liis hand to remove the placenta. Through strong efforts, he succeeded in inverting the uterus, the placenta still attached. He peeled off the Buy Nortriptyline placenta and tried to replace the uterus, but could not. Dr. I^T. C. Husted was sent for. I saw the patient a few hours Generic Nortriptyline afterward. The opinion of Dr. Husted was confirmed. The appearance of the tumor was large, soft, and flabby, and, when pressed, would contract. There was no hsemorrhage at that time. The tumor was sensitive to the touch. Patient was anaesthetized. Dorsal position observed. I attempted to reinvert the uterus, after re- turning it into the vagina. Grasping the fundus and body in my right hand, with the left placed directly above the pubes. ACTIVE UTEKINE INVERSION. 485 and expanding the upper part of the vagina with the fingers, I proceeded to make direct pressure on the cer\dx, as well as I could by the lingers of the Nortriptyline 25 Mg left hand, and made direct and Nortriptyline 25mg steady pressure upward in the axis of the superior strait, but without success. I then withdrew the uterus from the vagina, and, placing my index and middle fingers in the rectum, intro- duced them into the cervix uteri, and raising the body of the uterus, thus forming a point cVappui, instead of the abdomen ; then, grasping the fundus and body of the uterus, I pressed firmly with the right hand against the fingers near the cervix. Having introduced the uterus into the vagina, I made steady and firm pressure downward and backward on the two fingers, which also assisted the stretching of the cervix. By persever- ance, I could feel the organ begin to unfold at the cervix, and diminishing in length, when, shortly afterward, continuing efibrts on the remaining part of the fundus, and removing the fingers from the rectum, the fundus passed through, and the uterus was restored to its normal position. On examination by Drs. Husted and Bliss, the fundus was felt firm and well contracted above the pubes. In this case I had the opportunity of noticing and feeling Nortriptyline 25 the contraction and relaxation of the uterus, the same as we realize after delivery through after-pains. Meigs was the first, I think, if not the only authority at that time, to refer to this circumstance, and he Nortriptyline Mg counsels that no effort .should be made during the contraction, but to wait till the spasmodic action has ceased, and then resume the pressure when relaxation takes place. Adopting the suggestion in this instance, I must say I did not feel any contraction Nortriptyline 10mg of the cervix when the fundus and body were in action, verifying the natural action of the uterus during labor. In a short time the uterus was restored perfectly. I was not aware, when I had accomplished the object of restoration by this method, that I had been anticipated by Prof. Courty, of Montpellier. He is therefore entitled to the credit. I had frequently thought and spoken of it as possibly useful expedient to adopt in some cases. In chronic cases it is also applicable. Courty's case was of ten months' duration, the patient having incessant and free haemorrhages, with ex- 486 THE MECHANISM OF SPONTANEOUS

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