In extreme prolapsus or procidentia, the entire uterus, or a great portion of it, hangs forth beyond the vulva, forming there a pyri form tumour of considerable size. At the bottom of this is the os uteri, greatly exceed ing in dimensions in chronic cases the ordi nary condition of the part. (Fig. 472.) The lips are swollen and hypertrophied, and usu ally present a sore and granular surface on account of the friction to which they are con tinually exposed. The external covering of this tumour, in all but its lower part, consists of the inverted vagina, the horizontal rugx of which are very conspicuous anteriorly between the cervix and pubic arch, where a fluctuating swelling is observed, caused by the presence of a portion of the displaced urinary- bladder. (Fig. 469.) In chronic cases the surface of the inverted vagina gradually loses the character of a raucous membrane, and puts on the or dinary appearance of common integument. After replacement, however, an extensive shedding of epidermal scales ensues, and the surface resumes in time the condition of a mucous membrane.
In cases of great elongation of the cervix, the latter alone may protrude, while the body of the uterus remains within the peh is. Such a combination of hypertrophy with dis placement has passed with the ignorant for an example of hermaphrodite formation.
Prolapsus is the most common displace ment to which the uterus is subject. It is frequent in multiparx, and in women who follow fatir,uing occupations, especially those of a relaxed habit of body • but it also hap pens in nulliparae. In the latter, when it occurs at an early period of life, it is often associated with enlargement of the uterus or its appendages, whereby both the weight of the organ is increased, and a broader surface is offered for pressure from above.
Elevatio uteri. Dislocation upwards.—This is the converse displacement to the foregoing. The uterus, in consequence of some enlarge ment or the parts appended to it, as the ovary, or on account of the formation of morbid ad hesions, may be drawn upwards to such an extent that no portion of it, or only a part of the cervix, is retained within the pelvic cavity. This displacement is also occasionally ob served during pregnancy, and in multiparx, whose abdominal walls are relaxed, and permit the uterus to incline forward, so that at the beginning of labour the os cannot be reached by the finger.
Inversion. Eversion.— The uterus, either in the unimpregnated or gravid state, may becotne partially or completely inverted. The conditions which appear ordinarily to coni bine in producing this displacement, are, first, a distension of the uterine cavity*, as by pregnancy or the presence of a tumour ; and secondly, a force applied in the way of pres sure from above, or traction from below, whereby the distended uterine walls become folded within each other, somewhat after the manner of the intestinal walls in intussuscep tion. Inversion of the uterus appears always
to begin at the fundus which is first depressed into the uterine cavity, and then, under the continued operation of the disturbing forces, the part is gradually protruded through the cervix and os uteri,fig. 470., until it emerges in an inverted form into the vagina followed by the reversed walls of the uterine body, and ultimately by those of the cervix. The inver sion of the uterus is now complete. The greater part of the organ lies beyond the vulva as a pyriform tumour, the base of which, formed by• the fundus, is below, while above the narrower neck of the tumour consisting of the inverted cervix lies in part within the vagina, the up per portion of which canal is also drawn down and partly inverted. The vagina is thus ma terially shortened, and terminates in a cir cular fold marking the point of reflexion or inversion, while the usual seat of the os uteri, which is necessarily obliterated, is occupied by the now inverted cervix (fig. 471.).
Inversion constitutes the highest degree of displacement of which the uterus is suscep tible, for it is both prolapsed and inverted, so that the relative situation of the entire organ to surrounding structures, as well as of all its parts to each other, is completely changed. Inversion does not, however, always proceed to the highest degree, but may stop short at any of the intermediate stages just described.
When inversion occurs to the gravid uterus, the accident usually happens during the ef forts of the organ to expel the placenta. In this way, inversion may occur spontaneously, or it may be favoured or produced by injudi cious attempts to extract the placenta, or by too much traction applied to the funis. In the unimpregnated uterus, a polypus attached by a stem to the fundus may by its weight slowly produce the same results. That a sudden and spontaneous inversion of the un impregnated uterus is possible, was proved to me in a 'case which I witnessed of an aged woman whose uterus became completely in verted during a convulsion. In this instance, the only apparent predisposing cause was the dilatation of the uterine cavity by a tumour the size of a flattened apricot, which was pelled at the moment when the uterus came down completely inverted, —the violent ac tion of the abdominal muscles and diaphragm probably here producing or aiding the ever slon.