afterwards, they retract out of it. In long-standing cases, the rim of the peritoneal cup is contracted by the muscular fibre of the cervix so as Inversion of uterus+inversion of vagina, occasioned by a small sub-mucous fibroid (M'Clintock). Sm F, sub-mucous fibroid. Other letters as before. scarcely to admit a finger (fig. 223). In a case of six months standing, in which A. R. Simpson performed Thomas' operation before having recourse to amputation, the contracted ring just admitted the finger; an Ovary was caught within it. Adhesions rarely form between the peritoneal surfaces; this is an interesting fact and is of importance in regard to replacement. We might have expected detachment of the peritoneal lining or tearing of it by the sudden dislocation; the previous stretching of it during pregnancy is perhaps the reason why this has not been noticed. Fritsch says that the lifting up of the fornices by the tumour in the vagina, diminishes the strain on the peritoneum. The bladder, from its relation to the cervix (v. Chap. III.), is not altered in position unless there is prolapsus. When the latter occurs, there is Inversion of uterus (Crosse). The inverted uterus (U) lying in the vagina (V) is cut open to show the peritoneal sac which does not contain the ovaries (0); bristles are passed into uterine orifices of tubes. cystocele (v. fig. 222). We may therefore contrast the two types of inversion as follows: Inversion of uterus, cervix and bladder normal in position; Inversion of uterus + prolapsus (ie., inversion of vagina), cervix inverted and cystocele. ETIOLOGY AND FREQUENCY. Inversion arises under two different conditions. 1. In the puerperium-puerperal inversion; 2. Secondary to intra-uterine tumours growing from the fundus. Inversion has also occurred independent of the puerperal condition and of tumour growth; this is quite exceptional. 1. Puerperal inversion. This is by far the most frequent form; out of 400 cases, 350 occurred in the puerperal uterus (Crosse). Its frequency was formerly due to improper management of the third stage of labour. When the uterus was flabby and not contracting and the placenta not coming away, the removal of the latter by traction on the cord drew down the part of the wall to which it was attached and thus inverted the uterus. This accident was favoured by the situation of the placenta over the fundus (Hennig). Since the removal of the placenta by compression (which is best done by the Credé methodwith the thumbs of both hands well down behind the fundus so that the uterus may be firmly compressed antero-posteriorly) has been enforced, this accident has become rarer. A dilated condition of the uterus (distension by blood clots) or a flaccid condition of the walls favours inversion. 2. Inversion secondary to uterine tumours is much rarer. Of 400 cases, only forty (ten per cent) arose in this way (Crosse). It has been observed with pediculated fibromata (fig. 222), and will be referred to again when we treat of them (v. Chap. XXXVI). It is peculiarly frequent in sarcoma (v. Chap. XLI). We know of no case where it has followed on carcinoma uteri; Barnes describes a specimen in which both conditions were present, but does not say which was the primary lesion. SYMPTOMS. The symptoms produced by inversion at the time of its occurrence, concern the obstetrician rather than the gynecologist. There is the feeling of something giving way in the pelvis, accompanied with pain, hæmorrhage, and sometimes collapse. With complete inversion, there is retention of urine. It often occurs, or at least becomes so marked as to attract the patient's notice, when she has made a straining effort. The cases where the patient says that it first came down several days after labour, are to be explained by supposing that partial inversion occurred after labour but only the final stage attracted attention. If the uterus be not replaced at the time, the case becomes one of chronic inversion. The symptoms of chronic inversion are Hæmorrhage, Pain in the pelvis of a bearing-down character, Hæmorrhage is the most dangerous symptom. The menstruation is always profuse, as may be easily understood from the fact that the mucous membrane is extended in its area and lies exposed in the cervical canal and vagina. There is also inter-menstrual hemorrhage, which comes on unprovoked or on straining. The bearing-down pain in the pelvis resembles that felt in prolapsus uteri. It varies indefinitely in intensity; sometimes it is very acute, rarely is it so slight that the patient becomes reconciled to her discomfort and is able for work. The anaemia and weakness may be so marked as to cause suspicion of malignant disease. DIAGNOSIS. The diagnosis of recent inversion is easy. If the placenta has not yet been expelled, the hands laid on the fundus to expel it by the Credé method find that the rounded fundus is replaced by a cup-shaped hollow. The cervix is sometimes lifted up by the inverted uterus, so as to be “high above the pubes, even near the umbilicus" (Crosse). On passing the hand into the vagina to remove the placenta, care is required to recognise what is placenta and what is inverted uterus, and not to increase the inversion in detaching the placenta. If the placenta is already expelled, the hand on the abdomen recognises the same condition; while a large soft body, varying in size according to the extent of the inversion, fills the vagina. Chronic Inversion. Before the sound and the Bimanual came to the gynecologist's aid in diagnosis, it was impossible to diagnose this condition with certainty. Mistakes were committed by the most eminent surgeons, just because they had not the means of examination which we now possess. Even now-a-days mistakes occur through the hasty making of a diagnosis before all the means of examination have been employed. We therefore describe fully the routine examination. 1. Pass the fingers into the vagina; a rounded and firm or flattened and soft tumour, which bleeds easily, is felt in the vaginal cavity. Sweep the fingers round it, and recognise that it is free on all sides except at its upper extremity. Round this extremity is felt the cervix, the lips and fornices being recognised; or the cervix is thinned out to a ring and the fornices obliterated. If the cervical canal be obliterated by adhesions, the finger will not pass farther up; if it be patulous, it will pass for one-and-a-half to two inches and find that the cervical mucous membrane is reflected equally all round on to the neck of the tumour. 2. With one finger in front of the tumour and the other behind it, lift it up towards the abdominal wall which is depressed with the external hand till the fingers in the vagina are in contact with it. The external hand feels, in the place of the fundus uteri, a truncated body with a depression in the centre (see fig. 226). 3. Now pass one finger into the rectum, which first comes on the body in the vagina: drag this body downwards with the noose represented at fig. 224, as the volsella causes hæmorrhage; the finger in the rectum, reaching the upper border of the body, can thus feel that it ends abruptly and can pass into the cup-shaped end. Now depress the |