INVERSION OF THE UTERUS.
_Partial and complete.--Causes.--Diagnosis and symptoms.--Treatment.--
Chronic inversion.--Extirpation 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.