COOPER MEDICAL COLLEGE, SAN FRANCISCO, CAL and is not to be removed from the Library Room by any person or under any pretext whaterer. 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, Mathews-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 cupshaped 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 hemorrhage (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). Mathews 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 occurrence. Slight inversion of the uterine wall, at the base of a polypoidal 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 peritoneum, 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 hemorrhage) 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, 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. 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 develop 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 in 'Crosse figures one preparation in which the cervix was inverted although there was no prolapsus. verted 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; after Inversion of uterus+ inversion of vagina, occasioned by a small sub-mucous fibroid (M'Clintock). Sm F, sub-mucous fibroid. Other letters as before. wards, 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 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 in teresting 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 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. in position unless there is prolapsus. When the latter occurs, there is 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 (i.e., 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. |