posterior vaginal wall. This necessarily pulls the cervix back, and thus the fundus is kept forward (see fig. 66). In other words, if the cervix be thus kept back by the tension of the finger in the posterior fornix, the uterus cannot become retroverted although the fundus may become retroflexed. Now if a Hodge pessary be passed into position and held by the hand, it will act just as the finger does. It does not require to be held, however, as it rests on the oblique sacral segment and is pressed against it by the pubic segment and abdominal viscera. Note that the pressure on the Hodge is at right angles to the posterior vaginal wall; there is no side to side pressure on the instrument, and thus it does not require to extend from side to side of the vaginal walls. The after-watching of the case is important. The patient should be instructed to return in two days to see that the instrument is in place, and to return at once if it causes pain. After this she should report herself occasionally, say at intervals of a month, when examination is made to ascertain that the uterus keeps its place. If she uses hot water injections occasionally, it is not necessary to remove the instrument to clean it more frequently than this. After the pessary has been worn for some months, it may be removed to see if the uterus remains in position without it. Sometimes we find that the uterus falls back again into its abnormal position as soon as the instrument is withdrawn; in such a case, it must be introduced again and may have to be worn for years. Should conception occur, the pessary may be worn till the fourth month, after which the uterus rises above the brim and there is no longer reason to fear displacement. In some cases the uterine tissue is flaccid at the angle of flexion, and the body falls to the back or front as if it were jointed to the cervix. Here the Hodge, which acts on the body through the cervix, does no good; the intra-uterine stem, along with a Hodge which has transverse bars, does good in some of these cases. good form of pessary on this principle. Wynn Williams has devised a From what has been said on the action of the Hodge pessary, it is evident that in the treatment of Retroversion + Retroflexion the version alone is affected by the pessary. Whether the flexion is remedied will depend on the state of the uterine walls and the effect of intra abdominal pressure upon them. CHAPTER XXXII. INVERSION OF UTERUS. LITERATURE. Atthill-Inversion of uterus due to fibroid tumour: Dublin Medical Journal, Feb. 1879. Barnes-Op. cit., p. 721; and Med. Chir. Trans., 1869. Crosse-An Essay, literary and practical, on Inversio Uteri: Trans. Provincial Med. and Sur. Assoc., London 1845. Duncan, Matthews-On the Production of inverted uterus: Edin. Med. Jour., May 1867. Emmet-Principles and Practice of Gynecology: Churchill, London 1880, p. 410. Fritsch-Die Lageveränderungen der Gebärmutter: Billroth's Handbuch für Frauenkrankheiten: Stuttgart 1881. M'Clintock-Diseases of Women: Dublin 1863, p. 76. Macdonald-Two cases of chronic inversion of the uterus: Edin. Obst. Trans., vol. VI., p. 170. Spiegelberg-Archiv. f. Gyn., IV. S. 350, and V. S. 118. Thomas-Op. cit., p. 453. The essay by Crosse gives the fullest anatomical description of inversion, and contains a series of lithographic plates of specimens. The literature up to 1879 is fully given by Fritsch. Other references are given as foot-notes. PATHOLOGY. In inversion the uterus is turned inside out, so as to form a polypoidal projection into the vagina; its peritoneal surface is converted into a cup-shaped hollow; its mucous membrane becomes everted so as to lie exposed on all sides in the vagina. The mechanism by which this condition is brought about is the following. 1. A portion of the muscular wall of the uterus having lost its tone, becomes depressed towards the uterine cavity. In the puerperal condition this is usually that portion of the wall to which the placenta has been attached, and the condition has been described by Rokitansky as "paralysis of the placental seat;" this partial inversion will be frequently found on abdominal palpation in cases of post-partum hæmorrhage (Fritsch). In cases of tumour growth, fatty degeneration (Scanzoni) or malignant infiltration (A. R. Simpson) weakens the wall of the uterus round the base of the polypoidal growth, and thus produces an analogous condition. 2. Muscular contractions of the non-depressed portion of the uterus, combined with intra abdominal pressure, carry the depressed portion further into the uterine cavity, until the fundus uteri reaches the os internum (fig. 229). In the puerperal condition, muscular contractions are present of themselves or are produced by the presence of the placenta; in the case of a polypoidal tumour, they are due to the presence of the foreign body. Traction from below, such as the pulling away of the placenta or the tension of the pedicle of a polypus which is being extruded, also produces inversion. 3. The fundus of the uterus, by continuation of the same process, dilates the cervical canal and is born' into the vagina (fig. 226). In some cases inversion seems to take place from below upwards with a mechanism similar to that of prolapsus uteri, the lower part of the body of the uterus becomes inverted into the cervical canal (Taylor). Matthews Duncan, whose paper was a valuable contribution towards establishing the correct theory of inversion, distinguishes between active and passive inversion. The active is that described above; the passive is produced by inertia of the whole uterus, in which the organ is driven down entirely by intra-abdominal pressure or by traction from below-and not by uterine contractions. It is evident that the process may become arrested at any of these stages and persist as a permanent condition. When it has persisted for a few weeks, it constitutes "chronic inversion;" this is found in the following forms. (1.) Inversion of one horn only is a rare occurSlight inversion of the uterine wall, at the base of a polypoidal rence. Inversion of uterus (half-size, Barnes from Crosse's essay). The fundus lies in the vagina; the cervix is not inverted; the lips are flattened out to a swelling seen below the angle of inversion. The ovaries (seen from behind) are not in the peritoneal sac. fibroid, has been more frequently observed. (2.) Partial inversion, when the fundus has descended as far as the os internum, is also found as a chronic condition. (3.) Complete inversion is the condition most frequently met with. An exact knowledge of the relation of parts in complete inversion is necessary for diagnosis and treatment. This can only be gained by studying the inverted uterus as seen in section (fig. 221). We must study the position of— The body of the uterus, The cervix uteri, The Fallopian tubes and ovaries, The bladder. The body of the uterus. The inversion extends, in simple uncomplicated cases (see below), as far as the os internum but no further. The uterus lies partly in the vagina, partly in the cervical canal. Its neck is embraced by the os externum, which may lie loosely on it (favouring hæmorrhage) or constrict it firmly (favouring gangrene). After involution takes place, it becomes small, rounded and of firm consistence, closely resembling a pediculated fibroid tumour; and it has been amputated by mistake for such. It has a rounded form, is of a softer consistence and deeper red colour than a pediculated fibroid, and has a smooth and slippery surface which bleeds freely when handled. The softness may be so marked that the uterus moulds itself to the vaginal cavity and, becoming flattened against the posterior vaginal wall, takes on a mushroom-like form (Freund). The mucous membrane of the uterus may undergo all the changes of any tumour with a constricted base and exposed surface. It is usually congested and bleeds easily; it may become ulcerated and even gangrenous, or may be hypertrophied with polypoidal formations; it may lose its single layer of cubical epithelium and develope a stratified squamous epithelium. The occurrence of these changes has an important bearing on the desirability of replacing the organ. The cervix uteri. This is rarely* displaced in simple uncomplicated inversion; it forms a broad ring embracing the neck of the tumour. Sometimes the inversion is complicated with prolapsus, or, more properly, the vagina also becomes inverted and the inverted uterus caps the inverted vagina (fig. 222). When this occurs, the cervix uteri is also more or less inverted; a part remains just above the os externum, as a depressed ring which also disappears on making traction on the uterus (Fritsch). The Fallopian tubes and ovaries, with some coils of small intestine, may (at first) lie within the inverted cup, which is lined with peritoneum ; * Crosse figures one preparation in which the cervix was inverted although there was no prolapsus. |