INVERSION OF THE UTERUS.

The uterus is liable, although rarely, to a peculiar displacement called inversion, where the fundus is forced down into the cavity of the uterus, and so through the os uteri into the vagina; or where the whole uterus is turned wrong side outwards, the fundus appearing at the os externum, the former being the partial, the latter the complete inversion: in the latter it is not only the entire uterus which is inverted, but it is also the vagina, so that the whole mass which the uterus forms at the os externum is attached to the inverted vagina as by a hollow pedicle, and is encircled by the os uteri close to the labia; the external surface of the mass is the inner surface of the uterus.

As it is impossible for the fundus to descend through the os uteri when this is not dilated and open, it is evident that, except in certain cases of polypus, inversion of the uterus can only take place immediately after delivery. If, at this moment, especially when the uterus has been too suddenly emptied of its contents, any force be applied to the fundus, it may be easily pushed down into the cavity, or, by the continued action of that force, the fundus may be carried through the os uteri or even through the os externum.

Causes. Where this force has been applied externally, it may be produced by violent straining during the last pains, violent efforts, as coughing, vomiting, sneezing, &c., or by sudden attempts to rise in bed, by which the abdominal muscles are put into powerful action. Where, on the other hand, it has been applied from within, it may arise from improper attempts to extract the placenta before the uterus was sufficiently contracted; where the cord has been unusually short, or twisted round the child, or where the patient has been suddenly surprised with violent pains, and the child dashed upon the floor before she could reach her bed, by which means the cord has received a violent jerk, or has been even broken.

It has been very much the habit to attribute inversion almost solely to these latter causes, and that, except where it takes place from the shortness of the cord, or the sudden expulsion of the child whilst the mother is in the erect posture, it must almost necessarily be a result of improper pulling at the cord on the part of the practitioner: the cases on record, however, go to prove that, in by far the majority of instances, no force of this sort had been applied to the fundus; and in those instances where the child has been dashed upon the floor and the cord broken (some six or seven of which have at different times occurred under our own notice,) the fundus has not once been pulled down, although the force applied to it must have been very considerable, since the very cord which had thus given way to the weight of the child resisted afterwards, on more than one occasion, a considerable effort which we made to break it. In by far the majority of these cases, the cord has given way nearly at the same spot, viz. about three inches distance from the umbilicus, apparently justifying the inference, that it was weaker here than elsewhere. Another reason why the fundus should not have been pulled down by the weight of the child might be stated, viz. that the placenta being at that moment above the brim of the pelvis, the direction in which the strain was made upon the cord (viz. in that of the outlet, or downwards and forwards,) was not much calculated to affect the fundus.

“The practice of pulling too early and violently at the cord,” says Dr. Radford, “after the expulsion of the child, before the uterus has contracted, so as to detach and expel the placenta, has been generally considered as the cause of inversion; but we know that the accident happens before any force has been applied to the funis. In case fourth, the descent was so rapid and forcible through the os externum, that it would have been quite impossible to have resisted the unnatural action by which the organ was carried down. It has occurred when the patient was delivered of a dead child, the funis so putrid as to break with a slight effort. It has been found before the cord was separated, and the child given to the nurse. In the practice of Ruysch, this circumstance took place after he had extracted a dead child.”[133]

Still, however, it is not the less important to recommend caution, especially to young beginners, against pulling at the cord with too much force, in their hurry to bring the placenta away; the condition of the uterus at this moment is highly favourable if in a state of inertia.

Diagnosis and Symptoms. In cases of partial inversion of the uterus, we distinguish the disease by the absence of the hard spherical tumour of the fundus above the pubes, and by the presence of a globular fleshy body in the os uteri, which is sensible to the touch. This tumour will be found broader at the base than at its extremity; and surrounded by the os and cervix uteri, forming, as it were, a tight ring round it. The patient complains of a sense of dragging amounting to severe pain in the groins and lumbar region, and which compelling her to strain violently, often forces the uterus farther down, and sometimes induces complete inversion; hÆmorrhage more or less considerable accompanies it; the pain is more acute in this than in the complete inversion, and the hÆmorrhage more violent; the patient suffers under an oppressive sense of sinking, with nausea or vomiting, cold clammy sweats, feeble fluttering or nearly extinct pulse, faintings or even convulsions.

In the complete form we have neither the hÆmorrhage nor that frightful train of symptoms produced by the strangulated condition of the inverted uterus; for now that it is fairly turned inside out, it is just, or nearly as capable of contracting as in its natural state, which it is prevented from doing when only partially inverted: complete inversion, however, is not the less to be dreaded, for death may suddenly follow from the shock which the nervous system has sustained, or from dangerous fainting in consequence of the sudden evacuation of the abdominal cavity; this latter circumstance will be aggravated by the inversion of the vagina which is apt to accompany the complete form, and thus give rise to considerable displacement of the intestine.

Treatment. The sooner we endeavour to return the uterus the better, for we shall seldom experience much difficulty in effecting our object, if done immediately upon the occurrence of the accident; indeed, we know of a case where, under these circumstances, it was successfully returned by a midwife. If, on the other hand, some hours are permitted to elapse before the attempt at reduction is made, it will be attended with great difficulty, or even prove entirely abortive; the os uteri contracts powerfully, the uterus swells from the obstructed return of the circulation, inflammation rapidly follows, and diminishes still farther our chances of success. Dr. Denman says, “The impossibility of replacing it, if not done soon after the accident, has been proved in several instances, to which I have been called so early as within four hours, and the difficulty will be increased at the expiration of a longer time.” Still, however, we must not despair of success, for numerous cases have been recorded by different authors where the reduction has been effected after a much longer period.

There has been a considerable discrepancy of opinion as to the management of those cases where the placenta is still adhering to the uterus, viz. whether it is not safer to reduce the fundus with the placenta, and excite the uterus to throw it off afterwards in the usual way, or whether we ought not to separate the placenta before making the attempt at reduction. Mr. Newnham, the author of almost the only monograph upon this subject, recommends the former mode of practice. “It has been recommended by several respectable authorities to remove first the placenta, in order to diminish the bulk of the inverted fundus, and thus facilitate the reduction. But it is surely impossible that this proceeding can be attended with any beneficial consequences, whilst the irritation of the uterus will necessarily tend to bring on those bearing down efforts, which would present a material obstacle to its reduction; and would increase the hÆmorrhage at a period when every ounce of blood is of infinite importance, besides returning the placenta while it remains attached to the uterus; and its subsequent judicious treatment as a simply retained placenta will have a good effect in bringing on that regular and natural uterine contraction, which is the hope of the practitioner and the safety of the patient.” (Essay on the Symptoms, Causes, and Treatment of Inversion of the Uterus, by W. Newnham, Esq. p. 14.)

On the other hand, many authorities, especially of modern times, advocate a very opposite practice, and recommend that the placenta should be removed before attempting to reduce the fundus; as by so doing it will pass back much more easily than where the bulk of the placenta is added to it. There can be no doubt that this practice is correct in cases of complete inversion, where, as we have already observed, there is little or no danger from hÆmorrhage, and where it is of the greatest importance to avail ourselves of every advantage by lessening the size of the inverted uterus as much as possible: where, however, it is a case of partial inversion, it is generally accompanied with hÆmorrhage; and here, therefore, it becomes a question how far we are justified in detaching the placenta, and therefore increasing the flooding, either before we are certain that we are able to reduce the fundus, or before we have placed the uterus in a condition in which it is capable of contracting. In Mr. Mann’s case, quoted by Dr. Radford (op. cit.,) the inversion was evidently complete, for the uterus was found to have “passed externally from the vagina, and the placenta attached to it.” “I first peeled the placenta from the fundus uteri, and then grasping the extruded part with my hand, I did not find it very difficult to re-introduce it into the vagina, and to carry it through the os uteri. I followed with my hand, or rather pushed it forward, when I observed it suddenly start from me as a piece of India rubber would.”

Dr. Merriman, who candidly owns that he has altered his opinion on this point, since the last edition of his work on difficult parturition, in favour of removing the placenta, distinctly proves that the presence of this mass was the chief cause of the difficulty. “I tried,” says he, “to effect the reduction without removing the placenta, but could, by no possibility, accomplish it till I had first separated the placenta: this being effected, I succeeded to my entire satisfaction in re-inverting the fundus.” (Synopsis of Difficult Parturition.)

In reducing the fundus, we must not thrust our fingers collected into a cone against the tumour, as has been recommended by most authors; for, by so doing, we only produce a depression in it, and, as it were, re-invert or double the uterus upon itself, and thus add considerably to the bulk of the mass, and the difficulty of the reduction. We should grasp the tumour firmly, and push it bodily upwards in the direction of the pelvic outlet: at first little or no change is produced, until it has ascended so far, that the vagina which had been dragged down is returned again to its natural situation; the hand must follow the tumour, and now that the lower part of the uterus is fixed, by the vagina being put upon the stretch, the pressure which is applied to the fundus will act with so much greater effect. We should endeavour to “return, first, that portion of the uterus which was expelled last from the os uteri.” (Newnham, op. cit. p. 616.) As the hand rises into the cavity of the pelvis, and is no longer able to grasp the tumour, so far from contracting the points of our fingers into a cone, it will be desirable to spread them at equal distances round it, and thus apply the pressure over a larger space: it was to attain this object that Leroux recommended the application of a cloth to the fundus, as by this means the force applied to it was more equally divided. (Sur les Pertes de Sang, § 218.) The hand, however, will be far preferable. We must gradually alter the direction in which we press up the tumour as it ascends, guiding our hand in the axis of the pelvic cavity, and lastly bringing it upwards and forwards in that of the superior aperture. When once the fundus has repassed the os uteri, it usually recedes suddenly from the hand, as already described in Mr. Mann’s case: if we feel the uterus through the abdominal parietes well contracted, there will be no need of passing the hand into its cavity; but if it be still flaccid and soft, the hand should be introduced, not only for the purpose of guarding against any return of the inversion, but of exciting more active contractions by its presence. The patient should avoid making any sudden efforts to raise herself, or to cough, strain, or by any means excite the abdominal muscles to exert pressure upon the fundus, for it is occasionally observed, that the disposition to inversion continues some time after the reduction has been effected.

Where some little time has elapsed before any attempt is made to reduce the fundus, the inverted portion begins to swell from obstruction to the return of blood, especially where the inversion is partial, and, therefore, tightly girded by the os uteri; the passages grow hot and dry, and the chances of reducing the tumour diminish in proportion. “Is it not reasonable,” as Mr. Newnham observes, “to suppose that the first effect of the accident will be to bring on inflammatory action and tension of the parts, and this very state will in itself be a sufficient obstacle to success.” (Op. cit. p. 18.) If, under these circumstances, we find that the attempts at reduction is attended with considerable difficulty, or is evidently impossible, it will be necessary to wait until the excitement of the circulation, and the congestion and swelling of the parts are reduced, and the passages duly relaxed by bleeding; besides this, the external parts should be well fomented, the patient should use the warm hip bath, or sit over the steam of hot water, and throw up emollient and sedative enemata as recommended in our treatment of inflammation of the uterus; the operation, which was during the state of inflammation and feverish excitement in which the patient was, strongly contra-indicated, now becomes practicable and safe, and the difficulties, which before would have rendered it nearly or quite impossible, are now in a great measure removed.

Wherever the uterus is completely inverted, and there is reason to expect considerable difficulty in reducing it, we shall find great benefit in adopting the mode of practice recommended by Mr. C. White, of Manchester, viz. of firmly grasping the tumour until we have succeeded in considerably diminishing its size, and thus removing the chief obstacle to its reduction. “I grasped the body of it in my hand,” says Mr. W., “and held it there for some time, in order to lessen its bulk by compression. As I soon perceived that it began to diminish, I persevered, and soon after made another attempt to reduce it, by thrusting at its fundus; it began to give way. I continued the force till I had perfectly returned it, and had insinuated my hand into its body: it was no sooner reduced, than the pulse in her wrist began to beat: she recovered as fast as we could wish.” (White, on Lying-in Women, case, 19. Appendix, p. 429, 2d edit.)

Where the fundus is partially inverted, and the os uteri girds it very tightly, so as not only to produce very frightful symptoms arising from the strangulated condition of the organ, but also to render its reduction a matter of great difficulty, or even impossibility, Dr. Dewees has advised that, so far from attempting to push up the fundus, we should rather try to bring it down, and thus render the inversion complete; by this means, the “pain, faintness, vomiting, delirium, cold sweats, convulsions, extinct pulse,” &c. will not only be relieved, but the farther danger from hÆmorrhage prevented.

“The propriety and safety of this plan is, it must be confessed, predicated upon the happy result of a solitary case, but, from its entire and speedy success in this instance, it is rendered more than probable that it will be of equal advantage if employed in others; “all reasoning upon the subject” is certainly in its favour; and experience, so far as a single case may be entitled such, is equally so. The patient is to be placed upon her back near the edge of the bed, and have her legs supported by proper assistants; the hand is to be introduced along the interior part of the vagina, but sufficiently high to seize the uterus pretty firmly; it is then to be drawn gently and steadily downward and outward, until the inversion is completed: this will be known by a kind of jerk, announcing the passing of the confined part through the stricture. Traction should now cease, and the part be carefully examined; if the inversion be complete, the mouth of the uterus will no longer be felt, and there will be an immediate cessation of pain and other distressing sensations.” (Dewees, Compendious System of Midwifery, § 1318.)

Chronic inversion. Where some time has already elapsed since the occurrence of the accident, and the more distressing symptoms have subsided, the inversion now passes into a chronic state, which, although not immediately dangerous to life, will ultimately be not less fatal. The form of the tumour gradually alters; it assumes a more polypoid shape, from the increasing contraction of its mouth narrowing the upper part of it; and now the diagnosis from polypus sometimes becomes exceedingly difficult, the more so as the pressure produced by the os uteri diminishes the sensibility of the fundus. Hence, as Mr. Newnham observes, we may conclude, “that it is always difficult and sometimes impossible, with our present knowledge, to distinguish partial and chronic inversion of the uterus from polypus; since, in both diseases, the os uteri will be found encircling the summit of the tumour, and, in either case, the finger may be passed readily around it. And if, in order to remove this uncertainty, the entire hand be introduced into the vagina, so as to allow the finger to pass by the side of the tumour to the extremity of the space remaining between it and the os uteri; and if we find that the finger soon arrives at this point, it will be impossible to ascertain whether it rests against a portion of the uterus which has been inverted in the usual way, or by the long-continued dragging of the polypus upon its fundus. And if, under these embarrassing circumstances, we call to our assistance our ideas concerning the form of polypus, its enlarged base and narrow peduncle, we must also recollect the abundant evidence to prove that the neck of such a tumour is often as large, and sometimes larger, than its inferior extremity, and we shall still be left in inexplicable uncertainty.”

The periodical hÆmorrhages, with profuse leucorrhoea during the intervals are too common, both to chronic partial inversion and to polypus, to afford any certain means of diagnosis; and the gradually increasing debility, from the constant drain upon the system and ultimate breaking up of the general health, may be as much the result of the one as of the other. The rugged uneven surface of the inverted uterus, the smoothness of a polypus, are distinctions not of long continuance; for, after awhile, the uterus gradually becomes smoother, whereas, a polypus rarely continues long in the vagina without its surface becoming irregular from ulceration.

It might be a question whether it would not be possible to detect the menstrual fluid at the catamenial periods oozing from the surface of the inverted uterus: that this is quite possible in cases of complete inversion, is a well-known fact, but how far it can be detected in the partial form is not so certain, as the position of the tumour pretty high up in the vagina would prevent our ascertaining it, especially when there is more or less hÆmorrhage going on. In most cases, the history of the case, and our not being able to pass up a catheter far beyond the os uteri, which completely surrounds the neck of the tumour without adhering to it, are the chief points upon which we must found our diagnosis.

“Whilst the inverted uterus remains in the vagina, the discharge (excepting at the periods of menstruation) will be of a mucous kind; but if the uterus falls lower, so as to protrude beyond the external parts, the exposure of that surface, which in a natural state lined the cavity, to air, as well as to occasional injuries, may induce inflammation and ulceration over a part or the whole of its surface; and the mucous discharge may be changed to one of a purulent kind, so considerable in quantity as to debilitate the constitution, and to cause all the common symptoms of weakness.” (Sir C. M. Clarke, on the Diseases of Females, part i. p. 155.)

Although such a length of time has elapsed since the inversion, that it has become of the chronic kind, still we are not justified in giving up all hopes as to the possibility of returning it. Dr. Churchill has given an interesting summary of cases where many days, and in one case even twelve weeks, had intervened, and yet, nevertheless, where the reduction was successfully effected. (On the Principal Diseases of Females, p. 331.) We may also add two very remarkable cases related by Boyer (quoted by Kilian,) viz. where the uterus had resisted every endeavour to reduce the inversion, which in one case had remained fourteen days, in the other more than eight years, and where, in consequence of a sudden and violent fall upon the nates, reduction followed spontaneously and permanently.

Extirpation of the uterus. Where, however, the powers of the system are rapidly breaking, from the profuse hÆmorrhages at each menstrual period, and not less profuse discharge during the intervals, the only means of saving the patient is by treating the case as one of polypus, or in other words, removing the uterus by ligature. Numerous cases are on record where this has succeeded perfectly, although during the process the patient suffered from several attacks of pain and even inflammation, occasionally requiring the ligature to be loosened for awhile. In the case recorded by Mr. Newnham, rather more than three weeks were required before the separation of the tumour was effected. When once this source of irritation is removed, the hÆmorrhage and other discharges which had so greatly reduced the patient cease, and, as in cases of polypus, a most striking and favourable change is produced, the health and strength return, and the recovery of the patient is complete.