More often the onset is gradual and hemorrhage is more or less continuous and abundant. Leucorrhcea and met rorrhagia, with the symptoms of metritis, anemia, and nervous exhaustion, con stitute the chief subjective evidences of the disease.
An inverted uterus may be differen tiated from a fibroid polypus by the fol lowing signs:— The inverted uterus in recent cases is darker, softer, and more sensitive, and the cervix is represented by a shallow depression all the way around. A fibroid can be twisted slightly without carrying the cervical rim with it. The cervical rim can, in some cases, be made to dis appear by means of traction exerted upon the fundus, completely inverting the en tire organ. The orifices of the Fallo pian can sometimes be detected and the relations of the parts be thus determined.
Binianual recta-abdominal examina tion demonstrates the absence of the fundus from the pelvis, the presence of a cup-shaped depression, and in old cases the presence of the ovaries at the edges of the depression.
When the uterus is completely inverted by a polypus, the deviation of the poly pus from the size, symmetry, and even ness of surface of the uterine body, and a depression at the level of the attach ment may aid us in discovering the character of the tissues. A shallow in cision, which can be quickly sutured, will reveal the structure of the tumor and the existence of a capsule.
Anatomy and Pathology.—The fundus may be (1) merely indented, or (2) the entire corpus may project through the cervix, or (3) the cervix and corpus may be completely inverted, like a bag turned inside out. The first and third condi tions exist, as a rule, only temporarily and while traction upon the corpus is being made; hence the second one con stitutes the type.
Before involution has taken place the peritoneal cup within the cervix is large. and contains the Fallopian tubes and ovaries. Right after labor the fundus projects into the vagina as a large, soft, purplish, spongy mass. This gradually becomes smaller and harder and smoother as involution progresses. The discharge, at first bloody, soon becomes a bloody mucus, and the membrane assumes the characteristics of hyperplasia.
After involution the body becomes. hard and pear-shaped, and the ovaries and tubes are no longer contained in the peritoneal cup. The mucous membranes. undergo atrophy, although in places glandular pockets dip into the mucous membrane. Gangrene of the fundus is a possible, although extremely rare, oc currence.
Prognosis. — lamorrhage, local dis cOmfort, leucorrhcea, etc., may lead to profound anemia and depression, and finally to exhaustion. In the puerperal state immediate death from hemorrhage or inflammation, or perhaps death later from sepsis, may take place.
Treatment.—Immcdiately after labor the knuckles should be pushed steadily against the projecting mass until it re cedes through the relaxed cervix. Then (but not until then) measures should be used to contract the uterus, such as ergot hypodermically, judicious massage over the fundus, or—if necessary—a hot in trauterine douche or antiseptic gauze packing.
In recent cases beyond the puerpe rium taxis may suffice. Prolonged trac tion upon the cervix with a vulsellum combined with attempts to enlarge the cervical ring by eccentrical pressure, and compression of the corpus uteri with the hands or padded forceps may be followed by an attempt to indent one of the horns by the fingers formed into a cone, while the traction is being kept up.
Counter-pressure by means of the in dex fingers introduced into the bladder and rectum, respectively, while the thumbs in the vagina press against the fundus, has proved successful in two or three cases.
In older cases the gradual method is the best. The fundus is pushed back toward the sacrum, and a rubber bag is intro duced between it and the coccyx and sa crum, and inflated. Elastic continuous pressure is thus made toward the pelvic brim and the resistance of the uterine tissue is gradually overcome. The vagina is thoroughly douched before each in troduction of the bag, which is taken out and cleaned every forty-eight hours. Two or three days or as many weeks may be required for the reduction.