INVERSION OF THE UTERUS.
In inversion of the uterus this organ is turned partly or completely
inside out. The condition usually results from childbirth or from the
growth of an interstitial or polypoid tumor.
There seem to be two factors that result in the production of
inversion: a degeneration or atrophy of part of the uterine wall, and
traction, as from the drag of a uterine polyp or of the umbilical cord.
These causes may act together or independently.
If a portion of the uterine wall has lost its strength or tonicity, it
may be depressed toward the uterine cavity. The depression is increased
by the traction of a tumor or of the umbilical cord. The inversion
having been started in this way, may be rapidly increased by uterine
contractions. Emmet says that inversion usually takes place between the
birth of the child and the delivery of the placenta. A consideration
of the subject of acute inversion following labor belongs to
obstetrics. It is very important that reduction should be accomplished
immediately. The delay of a few hours greatly increases the difficulty
of replacement. Emmet says: “The uterus is generally well contracted in
twelve hours, and with many cases it would be then quite as difficult
to effect a reduction as if a year had elapsed.”
If the placenta is still attached to the inverted uterus, it should be
removed before reduction is attempted. Inversion of the uterus when
seen by the gynecologist is usually of the chronic form. It has existed
for a few weeks or for several years.
Various degrees of inversion are met with. Rarely inversion of one
horn of the uterus is seen. In the case of fibroid polyp there may be
a slight depression of part of the uterine wall, resulting from local
atrophy and traction. In other cases inversion of the fundus as far as
the internal os exists. The most usual condition is one of complete
inversion, in which the body of the uterus protrudes from the external
os into the vagina (Fig. 138). The cervix may or may not be inverted.
Sometimes the inversion is complicated by vaginal prolapse--or, rather,
by inversion of the vagina--so that the whole genital tract becomes
turned inside out and protrudes from the vulva. The exposed endometrium
becomes congested and bleeds easily. Ulceration or gangrene may result.
[Illustration: FIG. 138.--Complete inversion of the uterus.]
If the inversion is extensive, the Fallopian tubes and the ovaries are
drawn in the cup formed on the upper aspect of the uterus. Intestines
or omentum may also lie in this cup. In cases of long standing the rim
of the cup formed by the muscular cervix becomes very much contracted,
and adhesions may take place between the peritoneal surfaces. These
complications offer great, sometimes insurmountable, difficulty to
reduction in old cases.
Inversion of the uterus is not a common disease. It is very rarely seen
at the present day.
By far the most frequent form is that which follows labor; it is much
less often caused by fibroid polyp. It seems especially likely to occur
in sarcoma of the uterus.
[Illustration: FIG. 139.--Inversion of the uterus (Jeançons): _a_, mons
veneris; _c_, _c_, nymphæ; _d_, clitoris; _e_, external meatus; _g_,
anterior lip of cervix; _h_, _h_, the internal surface of the uterus.]
The symptoms of chronic inversion are hemorrhage, discharge, backache,
bearing-down pains in the pelvis, vesical disturbance, very pronounced
anemia, and general physical weakness. Menstruation is very much
increased in amount, and intermenstrual bleeding may occur after
standing or on any physical effort.
Inversion of the uterus very rarely exists without causing serious
symptoms. The majority of unrelieved cases end fatally from anemia,
septicemia, or peritonitis. A few cases of spontaneous reduction and
cure have been recorded.
The =diagnosis= of recent inversion is very easy. The body of the
uterus usually projects into the vagina, and the placenta may be found
attached to it. The abdominal hand fails to feel the rounded body of
the uterus in the normal position, but in its place is a cup-shaped
hollow.
Chronic inversion if uncomplicated by other lesion--_e. g._ a uterine
tumor--may also be readily recognized by careful examination. There
are, however, a number of cases on record in which the inverted fundus
uteri was amputated in mistake for a fibroid polyp.
The diagnosis may be made by inspection, bimanual examination, and the
uterine sound.
In complete inversion, inspection shows a round tumor filling the
vagina or protruding from the vulva. The tumor is covered with mucous
membrane, perhaps ulcerated in places, and sometimes partly covered
with stratified squamous epithelium, which has, as a result of
irritation, replaced the normal epithelium of the endometrium. It is
of a deeper red color than a pedunculated fibroid. The tumor bleeds
easily. In the only case of inversion seen by the writer the orifices
of the Fallopian tubes could be determined.
Digital examination reveals the rounded shape of the tumor and its soft
character--softer than a fibroid polyp. The tumor may be so soft that
it becomes flattened against the posterior vaginal wall.
The tumor is found to be free on all sides except at its upper
extremity, where there is a pedunculated attachment around which may be
felt the more or less attenuated cervix.
If the cervical canal be not obliterated by adhesion to the neck of the
tumor, the finger may be passed upward, and will determine that the
mucous membrane is reflected symmetrically all around on to the neck of
the tumor.
Unless the woman be fat, the abdominal hand will determine that the
uterine body is not in its normal position. In its place may be felt
the cup-shaped portion of the inverted uterus.
If the woman be fat, the rim of the cup may be felt by palpation
through the rectum, the uterus being drawn down, if necessary, by a
tape passed around the upper portion of the tumor.
The sound passed around the neck of the tumor will show the diminished
depth of the uterine cavity and the symmetrical reflection of the
cervix on to the neck of the tumor.
If the inversion be partial, the fundus lying still above the internal
os, the difficulty of diagnosis becomes much greater. Examination under
anesthesia may be necessary, when the cup-shaped depression on the top
of the uterus may be detected, and dilatation of the cervix will enable
the examiner to palpate the intra-uterine tumor.
The differential diagnosis between inversion and uterine polyp is made
by determining, in the latter condition, that the body of the uterus
lies in its normal relationship to the cervix, and that the upper
surface is not cupped.
The sound usually passes to unequal distances around the neck of a
fibroid polyp, unless it be situated symmetrically in the centre of the
fundus. The depth of the uterus in the case of uterine polyp is usually
greater than two and a half inches, as a result of the hypertrophy that
accompanies polypi.
It is said that if the sound passes to a less depth than two and a half
inches in the case of uterine polyp, accompanying partial inversion of
the uterus should be suspected.
=Treatment.=--As I have already said, an inverted uterus should be
reduced immediately after the accident occurs. If this is not done,
the difficulties of reduction become very great. Until about fifty
years ago, reduction in chronic cases was considered to be impossible.
A considerable variety of methods of reduction have been recommended.
Some operators advocate reduction by the hands alone; others advise
the assistance of instruments; and others, again, the employment of
continuous elastic pressure.
The woman should be kept in bed for a few days before the operation.
Saline laxatives should be administered. The parts should be prepared
by vaginal injections of hot water in large quantity, administered
three times a day. A large Barnes bag or colpeurynter filled with air
or water should be placed in the vagina for two or three days before
the operation, in order to distend the genital tract sufficiently to
admit the hand. In some cases the pressure of such a bag, applied for
from one to eleven days, has itself effected reduction. At the time of
operation an anesthetic should be administered and the woman should be
placed in the lithotomy position. The bladder should be emptied.
[Illustration: FIG. 140.--White’s repositor for inversion of the
uterus.]
The hand should be greased before introduction into the vagina. Emmet
describes the method of reduction as follows: “My hand was passed into
the vagina, and, with the fingers and thumb encircling the portion of
the body close to the seat of inversion, the fundus was allowed to rest
in the palm of the hand. This portion of the body was firmly grasped,
pushed upward, and the fingers were then immediately separated to their
utmost; at the same time the other hand was employed over the abdomen
in the attempt to roll out the parts forming the ring, by sliding
the abdominal parietes over its edge. This manœuver was repeated and
continued. At length, as the diameter of the uterine cervix and os was
increased by lateral dilatation with the outspread fingers, the long
diameter of the body of the uterus became shortened, and the degree of
inversion proportionally lessened. After the body had advanced well
within the cervix, steady upward pressure upon the fundus was applied
by the tips of all the fingers brought together.”
The reduction may be aided by the use of White’s repositor (Fig. 140).
This instrument consists of an india-rubber cup set on a curved iron
staff which has at its other end a stout spiral spring. The cup is
placed against the inverted fundus, and the spring against the body
of the operator, who is thus enabled to maintain continuous pressure
during the manipulations of his fingers.
[Illustration: FIG. 141.--Emmet’s method of retaining partially reduced
inversion.]
Reduction of chronic inversion by manual methods is a long and
exhausting process, requiring sometimes three or four hours for its
accomplishment. It is advisable to have several assistants for mutual
relief. It may be necessary to desist, and to repeat the operation when
the condition of the patient permits it. In case the reduction can
be but partially accomplished, or when, from any cause, the attempt
at reduction has to be temporarily abandoned, the result of the work
done may be preserved by a method of Emmet’s of temporarily closing
the cervix by suture (Fig. 141). This procedure not only prevents
the complete inversion from returning, but the traction produced by
stretching the cervix over the fundus itself favors reduction.
_Reduction by Continuous Elastic Pressure._--This method is employed
after the manual method has failed, or it may be used primarily. As
has been said, the gradual pressure of a colpeurynter has in several
instances accomplished reduction.
The most efficient instrument for maintaining continuous pressure
consists of a wooden cup set on a stem that extends out of the vagina.
Pressure is made by firm elastic bands attached to the stem; these
bands pass, two in front and two behind, to a broad abdominal bandage.
The elastic pressure is maintained for from one to three weeks.
The parts must be carefully watched for sloughing. The rim of the cup
of the repositor should be covered with lint saturated with carbolized
oil. The instrument should be removed and reapplied every day.
The direction of pressure may be regulated by the tension of the
elastic bands.
Splitting the posterior lip of the cervix is sometimes a useful
procedure in cases that have resisted other treatment. The cervix is
split in the median line posteriorly; the body and fundus are replaced
by taxis, and the incision is then closed by suture.
If inversion accompany a uterine polyp, the tumor should be removed;
and if the inversion is not spontaneously corrected, it must be reduced.
If, after careful trial of conservative methods, reduction of an
inverted uterus is found to be impossible, the physician may be
compelled to amputate the inverted portion or perform hysterectomy.