The periodical hæmorrhages, with profuse leucorrhœa during the intervals are too common, both to chronic partial inversion and to polypus, to afford any certain means of diagnosis; and the gradually increasing debility, from the constant drain upon the system and ultimate breaking up of the general health, may be as much the result of the one as of the other. The rugged uneven surface of the inverted uterus, the smoothness of a polypus, are distinctions not of long continuance; for, after awhile, the uterus gradually becomes smoother, whereas, a polypus rarely continues long in the vagina without its surface becoming irregular from ulceration.
It might be a question whether it would not be possible to detect the menstrual fluid at the catamenial periods oozing from the surface of the inverted uterus: that this is quite possible in cases of complete inversion, is a well-known fact, but how far it can be detected in the partial form is not so certain, as the position of the tumour pretty high up in the vagina would prevent our ascertaining it, especially when there is more or less hæmorrhage going on. In most cases, the history of the case, and our not being able to pass up a catheter far beyond the os uteri, which completely surrounds the neck of the tumour without adhering to it, are the chief points upon which we must found our diagnosis.
“Whilst the inverted uterus remains in the vagina, the discharge (excepting at the periods of menstruation) will be of a mucous kind; but if the uterus falls lower, so as to protrude beyond the external parts, the exposure of that surface, which in a natural state lined the cavity, to air, as well as to occasional injuries, may induce inflammation and ulceration over a part or the whole of its surface; and the mucous discharge may be changed to one of a purulent kind, so considerable in quantity as to debilitate the constitution, and to cause all the common symptoms of weakness.” (Sir C. M. Clarke, on the Diseases of Females, part i. p. 155.)
Although such a length of time has elapsed since the inversion, that it has become of the chronic kind, still we are not justified in giving up all hopes as to the possibility of returning it. Dr. Churchill has given an interesting summary of cases where many days, and in one case even twelve weeks, had intervened, and yet, nevertheless, where the reduction was successfully effected. (On the Principal Diseases of Females, p. 331.) We may also add two very remarkable cases related by Boyer (quoted by Kilian,) viz. where the uterus had resisted every endeavour to reduce the inversion, which in one case had remained fourteen days, in the other more than eight years, and where, in consequence of a sudden and violent fall upon the nates, reduction followed spontaneously and permanently.
Extirpation of the uterus. Where, however, the powers of the system are rapidly breaking, from the profuse hæmorrhages at each menstrual period, and not less profuse discharge during the intervals, the only means of saving the patient is by treating the case as one of polypus, or in other words, removing the uterus by ligature. Numerous cases are on record where this has succeeded perfectly, although during the process the patient suffered from several attacks of pain and even inflammation, occasionally requiring the ligature to be loosened for awhile. In the case recorded by Mr. Newnham, rather more than three weeks were required before the separation of the tumour was effected. When once this source of irritation is removed, the hæmorrhage and other discharges which had so greatly reduced the patient cease, and, as in cases of polypus, a most striking and favourable change is produced, the health and strength return, and the recovery of the patient is complete.
CHAPTER VIII.
ENCYSTED PLACENTA.
Situation in the uterus.—Adherent placenta.—Prognosis and treatment.—Placenta left in the uterus.—Absorption of retained placenta.