INVERSION OF THE UTERUS.
With William Newham, three degrees may be recognized: 1. Simple depression. 2. Partial inversion. 3. Complete inversion.
In simple depression the fundus sinks into the cavity, but forms no tumor in the vagina. Only by combined manipulation can we recognize this variety. In partial inversion, the fundus sinks into the vagina, forming a voluminous tumor, surrounded exactly by the orifice of the cervix. (Fig. 156.) In complete inversion, the uterus projects outside of the vagina and the vulva. The organ is detected uo longer in the hypo gastrium, and the os is felt at the upper part of the tumor surrounding it like a ring. (Fig. 157.) As Courty has well said, " a combination of varied conditions are neces sary, in order that inversion may take place. Usually it occurs after labor at term, 350 times out of 400, according to Crosse, but also after miscar riage and premature labor; cases of Spaeth at five months, of Brady at five months, of Woodson at four months. It may, however, be deter mined by the presence of a fibroma or a polyp (Fig. 158), either during their spontaneous expulsion, or during efforts at removal. Inversion, however, compared with the other complications of the birth of the foetus, or the expulsion of tumors, is rare, and has doubtless, often, been mis taken for prolapse." The conditions which favor inversion are, in general, uterine inertia, sinking of the walls of the uterus, pressure on the organ from above or traction from below. Exceptionally, it muy occur spontaneously, and although Depaul doubts this, the cases of Ruysch, Corvan, Saxtorph, Radford, Simpson and West are incontestable.
In case of labor, Courty says that the inversion may occur at two differ ent periods: " 1. At the moment of the expulsion of the fcetns, through inertia of the uterus, and traction exerted by the foetus on too short s cord, the parturient being erect. 2. During the third stage, owing to utero-placental adhesions. In these instances inversion may, at the out set, be incomplete, and is rendered complete through the expulsive efforts of the woman, the pressure of the abdominal contents, etc." The majority of writers believe that there are certain factors indispen sable to the production of inversion. Rokitansky lays stress on paralysis of the organ at the placental site. This site, not participating in the
contraction of the remainder of the organ, terminates, as it were, in the uterine cavity, and palpation detects a cupping at this point. This is the first degree of inversion, and, once present, it tends to progress in part through the influence of uterine contractions, in part from the weight of the intestines, ovaries and tubes which sink into the depression_ (V. Fig. 156.) Lazati contends that not only is partial uterine inertia pre sent, but also total. Hunter insists on irregular contraction of the uterus. as the prime cause of inversion. The depressed portion becomes a foreign body in the cavity, and the uterus contracts, to get rid of it, even as hap pens in inversion of the vagina. Henkel invokes after-pains; Siebold utony of the uterus, associated with precipitate delivery. Boivin and Dues inertia of the uterus, especially if, at the time, traction is made on the cord. Tyler Smith and Radford lay stress on the same causes.
[In the American Journal of Obstetrics, October and November, 15.C5, Crampton of New York published a paper on inversion of the uterus after labor, and tabulated 120 cases of acute inversion, and 104 of chronic inversion, the line between the two classes being drawn at one month. Of the first series 87 recovered, 32 died, 1 remained unrelieved. In twelve instances, the patient was in extremis when first seen. Of the second series, 91 recovered, 7 died, 6 remained unrelieved. The average mor tality from both series is nearly 20 per cent. The conclusions the writer reached from a study of these cases are, in brief: Inversion of the uterus is preceded by paresis of some portion of the uterine muscle, not neces sarily of the placental site, the main causes being too frequent child-bear ing, tedious labor, repeated miscarriages, traumatism, emotions (especially in primipartv), precipitate labor. " It is a pure neurosis in its inception' Traction on the cord may cause prolapsus, but never alone inversion; for this to occur paresis must be present. Inversion is more likely to occur in first than in subsequent deliveries. Chronic inversion would rarely be met with if every physician adopted the custom of repeated and careful vaginal examinations after every labor within twenty-four hours.