Bidder, whose observations concern more especially the changes in form and in situation of the uterus, shows that flexions and versions are very frequent during the puerperium.
The following table gives the percentages found by Horwitz, Winckel, Schroeder, and Bidder: These deviations do not depend directly on labor, but usually on an inflammation or hypertrophy of the uterus during pregnancy. We un derstand readily, therefore, how these deviations may persist after labor, and become the cause of further disease.
Let us see now what the modifications are which the uterus undergoes after labor, and how the organ returns to the normal. These modifica tions have received the name of involution. Immediately after the birth of the foetus the uterus retracts, its body becomes more consistent, its form more spherical, but the cervix does not close at once, and the finger in the vagina determines that the cervix, soft and relaxed, floats, as it were, in the upper part of the vagina. The external os, widely open, may be distended with the greatest ease. The internal os has partially closed, but it is soft, dilatable, and the resistance it offers is insignificant.
The placenta once delivered, the cervix becomes firmer and more re sisting. Its length has diminished notably, although beyond the normal, and it is still permeable to the finger. At the end of a few hours, the cervix has acquired more tonicity; in appearance it is more normal, the internal os is closed—whence the difficulty sometimes met with when it is necessary to extract a retained placenta. This difficulty is as nothing, in general, compared to that resulting from placental adhesions, but it is still a serious matter. At the end of two or three days, the cervix has usually regained its shape. During the few days after delivery, the exter nal os is gaping, the cervical canal, in both primiparte and multiparte, allows the passage of the finger to the internal os, which is open, but difficult to pass. The lips of the cervix are swollen, unequal, and soft, easily depressed, and bleeding at the touch of the finger.. From this time forth, the cervix progressively resumes its shape, consistency, and original dimensions.
We have had occasion, as is noted further on, to examine eighty-three women with the speculum, about fourteen days after delivery, and we have been struck by the difference existing between primiparm and multipare3 as regards the changes in the cervix. We do not speak of the outside of the cervix, because, although we have attempted to measure the exterior of the vaginal portion, we have not bequ able to obtain any reliable results.
When the speculum is inserted into the vagina of a woman delivered about fifteen days previously, the first thing noticed is that its color is more or less deepened, that it is as yet more or less relaxed, and, at the bottom, and issuing from the cervix there is mucus, colored dirty brown, at times as much as a teaspoonful. When this mucus is wiped off with cotton, the cervix is seen. In multipara3 it is bluer, firmer, and more compact than in primiparte, and does not seem so narrow. In primipane, on the other hand, the cervix is larger, softer, and bleeds more readily to the touch, but what is particularly noteworthy is the external os. It is larger than in multiparre, light red, and granular, the lips projecting considerably, and the mucus membrane, protruding, forms a true ectropion, which Nieberding so well described in 1879, an ectropion which tends to disappear during the puerperium, but which we may find traces of even at the return of menstruation.
At the thirtieth or fortieth day, the cervix has usually regained its nor mal length, although it is still much larger. The lips are more distinct, less relaxed. We do not, hence, agree with Depaul in the statement that in multiparie the cervix returns less rapidly to the normal, and that it remains longer soft and permeable. We believe that Depaul thought so because he only made a digital examination, and that the multiparous cervix, being shorter than the primiparous, is more depressible and easier to pass. However, Depaul himself admits that there are many variations, and he attributes to ergot a marked effect in the retro gression of the cervix.