A System of Midwifery

by Edward Rigby

INVERSION OF THE UTERUS.

Partial and complete.—Causes.—Diagnosis and symptoms.—Treatment.—Chronic inversion.—Extirpation of the uterus.

The uterus is liable, although rarely, to a peculiar displacement called inversion, where the fundus is forced down into the cavity of the uterus, and so through the os uteri into the vagina; or where the whole uterus is turned wrong side outwards, the fundus appearing at the os externum, the former being the partial, the latter the complete inversion: in the latter it is not only the entire uterus which is inverted, but it is also the vagina, so that the whole mass which the uterus forms at the os externum is attached to the inverted vagina as by a hollow pedicle, and is encircled by the os uteri close to the labia; the external surface of the mass is the inner surface of the uterus.

As it is impossible for the fundus to descend through the os uteri when this is not dilated and open, it is evident that, except in certain cases of polypus, inversion of the uterus can only take place immediately after delivery. If, at this moment, especially when the uterus has been too suddenly emptied of its contents, any force be applied to the fundus, it may be easily pushed down into the cavity, or, by the continued action of that force, the fundus may be carried through the os uteri or even through the os externum.

Causes. Where this force has been applied externally, it may be produced by violent straining during the last pains, violent efforts, as coughing, vomiting, sneezing, &c., or by sudden attempts to rise in bed, by which the abdominal muscles are put into powerful action. Where, on the other hand, it has been applied from within, it may arise from improper attempts to extract the placenta before the uterus was sufficiently contracted; where the cord has been unusually short, or twisted round the child, or where the patient has been suddenly surprised with violent pains, and the child dashed upon the floor before she could reach her bed, by which means the cord has received a violent jerk, or has been even broken.

It has been very much the habit to attribute inversion almost solely to these latter causes, and that, except where it takes place from the shortness of the cord, or the sudden expulsion of the child whilst the mother is in the erect posture, it must almost necessarily be a result of improper pulling at the cord on the part of the practitioner: the cases on record, however, go to prove that, in by far the majority of instances, no force of this sort had been applied to the fundus; and in those instances where the child has been dashed upon the floor and the cord broken (some six or seven of which have at different times occurred under our own notice,) the fundus has not once been pulled down, although the force applied to it must have been very considerable, since the very cord which had thus given way to the weight of the child resisted afterwards, on more than one occasion, a considerable effort which we made to break it. In by far the majority of these cases, the cord has given way nearly at the same spot, viz. about three inches distance from the umbilicus, apparently justifying the inference, that it was weaker here than elsewhere. Another reason why the fundus should not have been pulled down by the weight of the child might be stated, viz. that the placenta being at that moment above the brim of the pelvis, the direction in which the strain was made upon the cord (viz. in that of the outlet, or downwards and forwards,) was not much calculated to affect the fundus.

“The practice of pulling too early and violently at the cord,” says Dr. Radford, “after the expulsion of the child, before the uterus has contracted, so as to detach and expel the placenta, has been generally considered as the cause of inversion; but we know that the accident happens before any force has been applied to the funis. In case fourth, the descent was so rapid and forcible through the os externum, that it would have been quite impossible to have resisted the unnatural action by which the organ was carried down. It has occurred when the patient was delivered of a dead child, the funis so putrid as to break with a slight effort. It has been found before the cord was separated, and the child given to the nurse. In the practice of Ruysch, this circumstance took place after he had extracted a dead child.”[133]

Still, however, it is not the less important to recommend caution, especially to young beginners, against pulling at the cord with too much force, in their hurry to bring the placenta away; the condition of the uterus at this moment is highly favourable if in a state of inertia.

Diagnosis and Symptoms. In cases of partial inversion of the uterus, we distinguish the disease by the absence of the hard spherical tumour of the fundus above the pubes, and by the presence of a globular fleshy body in the os uteri, which is sensible to the touch. This tumour will be found broader at the base than at its extremity; and surrounded by the os and cervix uteri, forming, as it were, a tight ring round it. The patient complains of a sense of dragging amounting to severe pain in the groins and lumbar region, and which compelling her to strain violently, often forces the uterus farther down, and sometimes induces complete inversion; hæmorrhage more or less considerable accompanies it; the pain is more acute in this than in the complete inversion, and the hæmorrhage more violent; the patient suffers under an oppressive sense of sinking, with nausea or vomiting, cold clammy sweats, feeble fluttering or nearly extinct pulse, faintings or even convulsions.

In the complete form we have neither the hæmorrhage nor that frightful train of symptoms produced by the strangulated condition of the inverted uterus; for now that it is fairly turned inside out, it is just, or nearly as capable of contracting as in its natural state, which it is prevented from doing when only partially inverted: complete inversion, however, is not the less to be dreaded, for death may suddenly follow from the shock which the nervous system has sustained, or from dangerous fainting in consequence of the sudden evacuation of the abdominal cavity; this latter circumstance will be aggravated by the inversion of the vagina which is apt to accompany the complete form, and thus give rise to considerable displacement of the intestine.