A System of Midwifery Part 25

These are some of the many symptoms indicating a sudden and extensive loss of blood; others also occur, depending on the external or internal character of the haemorrhage. The want of contraction and general flaccidity of the uterus, as felt through the abdominal parietes, have been already noticed; if the blood be prevented escaping by the contracted state of the os uteri, by coagula, or the detached placenta, it begins to collect in the cavity of the uterus, which therefore swells as the acc.u.mulation continues to increase, so that it may even equal the size which it had before labour, containing many quarts of blood, and the patient may be in the most imminent danger of dying from haemorrhage, perhaps, without any blood having issued externally: this is the _internal uterine haemorrhage_, a form which is justly looked upon as peculiarly to be dreaded, from the insidious character of its attack. In most cases, the uterus fills to a certain extent only, and then, as if excited to contraction by the distention of its parietes, or any slight concussion, produced by coughing, &c. it expels a large quant.i.ty of coagula and half coagulated blood, and returning to its former state of atony, again begins to swell from fresh acc.u.mulation of blood in its cavity.

_Treatment._ So long as the inertia or atony of the uterus continues without any symptoms either of external or internal haemorrhage, we are not justified in interfering directly, either for the purpose of exciting the uterus, or still less of removing the placenta. This condition chiefly occurs where the uterus has been previously much distended, or suddenly emptied of its contents, where it has been exhausted by long and difficult parturition, and also, as Leroux has observed, "in women of a phlegmatic temperament and lax fibre, who, during pregnancy, have suffered much ill-health, by which the tone of the solids has been weakened; who have very large pelves, and a soft dilatable os uteri." (_Sur les Pertes de Sang_, 1776.)

We must therefore give the uterus time to recover from the great and sudden change which it has undergone, to collect its strength, to remodel and arrange its forces, until it is at length able, not only to resume its efforts, but to contract to that extent which shall both ensure the expulsion of the placenta and the safety of the patient. Whilst this state of inertia lasts, the patient should be kept as quiet as possible; she should be placed in a comfortable posture, take a little cool drink from time to time (as cold tea, toast and water, &c.,) in order to refresh her;[131] or, if she has been much exhausted by her labour, a gla.s.s of wine may be given with good effect. If, however, haemorrhage appears, this shows that a separation of the placenta from the uterus must have taken place: our great object should now be to excite contraction of the uterus, for by this means alone can we stop the discharge.

In ordinary cases, a little circular friction with the tips of the fingers over the fundus will generally be sufficient. If the uterus begins to swell, we may grasp it with a sudden but moderate degree of force; or we may give the fundus every now and then a smart jog with our hand. Whilst these measures are pursuing, a dose of secale cornutum (see DYSTOCIA, p.

330,) will be of great service; for even if it does not act soon enough to aid the expulsion of the placenta, it contributes greatly to ensure the contraction of the uterus afterwards. If the haemorrhage nevertheless continues profuse, it will be necessary to introduce the hand into the uterus and remove the half-separated placenta: its contractions are too feeble for that purpose of itself, and the presence of the hand in its cavity, and the artificial separation of the placenta, act as a stimulus, and rouse it to greater activity. The opinion that we only increase the danger by thus increasing the bleeding surface does not hold good, when, from the profuseness of the haemorrhage, it has become evident that the greater part of the placenta is already separated from the uterus; on the other hand, where there is but a slight discharge, the case is very different, and would not justify our having recourse to so strong a measure.

If the contraction which has been excited by the artificial removal of the placenta be but temporary, we must proceed to the use of other means for the purpose of rousing the activity of the uterus. The sudden application of cold is a most valuable means; it acts here solely by the _shock_ which it produces at the moment, and not by lowering the circulation and favouring coagulation. Thus we find that a cold wet napkin suddenly flapped upon the abdomen has an immediate effect upon the uterus; but it ought not to remain on long, and the skin should be dried with a warm towel, in order that a fresh application of the cold may produce the greater effect. A series of such _shocks_ may be produced by using another wet napkin to the v.u.l.v.a, and a third to the sacrum and loins; an a.s.sistant should remove them in the order in which they have been applied, and dry the skin, for a repet.i.tion of the remedy, if necessary.

A still more powerful mode of producing a sudden shock, and thus rousing the uterus to activity, is by a douche of cold water upon the abdomen.

This may easily be effected by a teapot or kettle held at some height above, and slowly emptied upon the lower part of the abdomen; the uterus will seldom refuse to obey such a stimulus as this, however great may be the inertia into which it has fallen. The inefficiency of a prolonged application of cold to the abdomen, however severe, and the efficiency of the contrary practice, is admirably expressed by Dr. Gooch, in his description of a dangerous case of haemorrhage:--"Finding the ice so inefficient, I swept it off, and taking an ewer of cold water, I let its contents fall from a height of several feet upon the belly: the effect was instantaneous; the uterus, which, the moment before, had been so soft and indistinct as not to be felt within the abdomen, became small and hard; the bleeding stopped, and the faintness ceased--a striking proof of the important principle that cold applied with a shock is a more powerful means of producing contraction of the uterus than a greater degree of cold without the shock." (_An Account of some of the more important Diseases belonging to women_, by Robert Gooch, M. D.)

Another mode of applying cold to induce uterine contraction, and little, if at all, inferior to that above-mentioned, is the injection of cold water into the uterus itself: this can only be effectually employed after the removal of the placenta and membranes, and frequently proves of the greatest a.s.sistance, being capable of rousing the uterus when many other means have failed. If, from the sultriness of the weather, water cannot be procured of sufficient coldness, or if the case be very urgent, vinegar and water in equal parts may be used; but the injections of spirit and water, which some have recommended, can scarcely be considered as a safe proceeding.

These various means frequently require to be repeated several times before the contraction of the uterus becomes permanent, nor must we be discouraged by finding the uterus becoming soft again in a minute or two after ceasing to use them; for we may feel a.s.sured, with few exceptions, that if we can only keep the uterus, by this means, in a state of tolerable contraction for half an hour, it will ultimately become permanent, and remain so of itself.[132]

It is, in these cases, where pressure is of so much importance, not for the purpose of producing uterine contraction, as of maintaining it when once excited. By pressure applied at this moment, we may frequently keep the enfeebled uterus in a state of contraction, which, but for this support, would have yielded to the general force of the circulation, and have again expanded. For the same reason, whenever the uterus begins to swell again from internal haemorrhage, and by the renewal of the above remedies, it becomes hard, but does not diminish in size: this shows that the contraction has not been powerful enough to expel the blood, which, in all probability, has already begun to coagulate in its cavity: where this is the case, the hand, or at least two fingers, should be pa.s.sed, to dislodge the clots, and a.s.sist in their expulsion; after which, a cloth folded into a thick compress should be placed over the fundus, and firmly bandaged upon the abdomen by a broad towel.

Where every means has failed to induce a sufficient or permanent degree of contraction, we believe that the only certain means which remains, is putting the child to its mother's breast. Under no circ.u.mstances do we see the sympathy between the uterus and the breast so beautifully displayed as here, and we may most truly affirm that we have never known it fail where the mother was sufficiently conscious to know that it was her own child.

To a by-stander, ignorant of what was taking place, the sudden gush of blood mixed with coagula, which follows the application of the child, would be nothing less than a sign of renewed danger, while, in fact, it is a proof that the uterus is beginning to contract and expel its contents.

If the pulse has been seriously reduced by the loss of blood which the patient has sustained, a gla.s.s of wine, or a spoonful or two of brandy, will be of great service in rousing the vital powers; and this must be repeated or increased, according to the urgency of the circ.u.mstances; a little weak beef-tea, given from time to time, frequently appears to rouse the system, even more than the brandy, and is more refres.h.i.+ng to the patient; it can also be taken in larger quant.i.ties, for when the exhaustion is very great, stimuli appear to excite vomiting, which is by all means to be avoided. Where, however, it occurs spontaneously, it need not be looked upon in so formidable a light: thus Dr. Denman observes, "when patients have suffered much from loss of blood, a vomiting is often brought on, and sometimes under circ.u.mstances of such extreme debility that I have shrunk with apprehension lest they should have been destroyed by a return or increase of the haemorrhage, which I concluded was inevitable, after so violent an effort: but there is no reason for this apprehension; for, though vomiting may be considered as a proof of the injury which the const.i.tution has suffered by the haemorrhage, yet the action of vomiting contributes to its suppression, perhaps by some revulsion, and certainly by exciting a more vigorous action of the remaining powers of the const.i.tution, as is proved by the amendment of the pulse, and of all other appearances immediately after the vomiting."

When a slight trickling of blood continues, although the uterus is tolerably hard and contracted, it will be desirable to make an examination, for we shall frequently find a long slender coagulum hanging through the os uteri into the v.a.g.i.n.a, upon the removal of which, the discharge will cease.

The application of the child to the breast is not less valuable for preventing any return of the haemorrhage than for stopping it in the first instance: we are _never_ perfectly secure against haemorrhage coming on during the first few hours after delivery, even where every thing has turned out as favourably as possible: the exhaustion from the length or severity of the labour, the warmth of the bed, and in some cases, it would even seem, the relaxing effects of deep sleep, are all liable to be followed by inertia uteri and haemorrhage. In no way can we ensure our patient so completely against this kind of danger as by putting the child to the breast; the uterine contraction which it excites is not only powerful, but permanent; nor do we consider that a pract.i.tioner is justified in leaving a patient in whom the uterus has shown a disposition to inertia without having ensured her safety by this simple but effectual safeguard.

There is a form of haemorrhage after the birth of the child, which seems to depend upon an over-distended state of the circulation, and where its activity appears too great for the contractile power of the uterus; so that, in spite of the uterus being tolerably firm and hard, a profuse haemorrhage is almost sure to follow the separation of the placenta. This condition has been described by the late Dr. Gooch, and still more recently by Professor Michaelis, of Kiel; to the former, especially, we are indebted, not only for having first pointed out this important fact, but for having placed it before us in the simplest and clearest light. "I had now witnessed," says Dr. Gooch, "two labours in the same person, in which, though the uterus contracted in the ordinary degree, profuse haemorrhage had nevertheless occurred: let me be understood--after the birth of the child, I laid my hand on the abdomen, and felt the uterus within, of that size and hardness, which is generally unattended by, and precludes haemorrhage; in both instances, the labour had been attended by an excessively full and rapid circulation. I could easily understand that a contraction of the uterus, which would preclude haemorrhage in the ordinary state of circulation, might be insufficient to prevent it, during this violent action of the blood-vessels; and the inference I drew was, that, in this case, the haemorrhage depended not on a want of contraction of the uterus, but on a want of tranquillity of the circulation; and that if ever she became pregnant again, a mode of treatment which would cause her to fall in labour with a cool skin and a quiet pulse, would be the best means of preventing a recurrence of the accident." This will be effected by an occasional venesection during the last weeks of pregnancy, by the use of saline laxatives; and if there be still much disposition to heat the surface, and excitement of circulation, by doses of nitre three times a day, and by strict antiphlogistic regimen.

CHAPTER VII.

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 v.a.g.i.n.a; 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 v.a.g.i.n.a, so that the whole ma.s.s which the uterus forms at the os externum is attached to the inverted v.a.g.i.n.a as by a hollow pedicle, and is encircled by the os uteri close to the l.a.b.i.a; the external surface of the ma.s.s 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 pract.i.tioner: 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 circ.u.mstance 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 p.u.b.es, 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; haemorrhage more or less considerable accompanies it; the pain is more acute in this than in the complete inversion, and the haemorrhage 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 haemorrhage 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 circ.u.mstance will be aggravated by the inversion of the v.a.g.i.n.a which is apt to accompany the complete form, and thus give rise to considerable displacement of the intestine.

_Treatment._ The sooner we endeavour to return the uterus the better, for we shall seldom experience much difficulty in effecting our object, if done immediately upon the occurrence of the accident; indeed, we know of a case where, under these circ.u.mstances, it was successfully returned by a midwife. If, on the other hand, some hours are permitted to elapse before the attempt at reduction is made, it will be attended with great difficulty, or even prove entirely abortive; the os uteri contracts powerfully, the uterus swells from the obstructed return of the circulation, inflammation rapidly follows, and diminishes still farther our chances of success. Dr. Denman says, "The impossibility of replacing it, if not done soon after the accident, has been proved in several instances, to which I have been called so early as within four hours, and the difficulty will be increased at the expiration of a longer time."

Still, however, we must not despair of success, for numerous cases have been recorded by different authors where the reduction has been effected after a much longer period.

There has been a considerable discrepancy of opinion as to the management of those cases where the placenta is still adhering to the uterus, viz.

whether it is not safer to reduce the fundus _with_ the placenta, and excite the uterus to throw it off afterwards in the usual way, or whether we ought not to separate the placenta before making the attempt at reduction. Mr. Newnham, the author of almost the only monograph upon this subject, recommends the former mode of practice. "It has been recommended by several respectable authorities to remove first the placenta, in order to diminish the bulk of the inverted fundus, and thus facilitate the reduction. But it is surely impossible that this proceeding can be attended with any beneficial consequences, whilst the irritation of the uterus will necessarily tend to bring on those bearing down efforts, which would present a material obstacle to its reduction; and would increase the haemorrhage at a period when every ounce of blood is of infinite importance, besides returning the placenta while it remains attached to the uterus; and its subsequent _judicious_ treatment as a simply retained placenta will have a good effect in bringing on that regular and natural uterine contraction, which is the hope of the pract.i.tioner and the safety of the patient." (_Essay on the Symptoms, Causes, and Treatment of Inversion of the Uterus_, by W. Newnham, Esq. p. 14.)

On the other hand, many authorities, especially of modern times, advocate a very opposite practice, and recommend that the placenta should be removed _before_ attempting to reduce the fundus; as by so doing it will pa.s.s back much more easily than where the bulk of the placenta is added to it. There can be no doubt that this practice is correct in cases of complete inversion, where, as we have already observed, there is little or no danger from haemorrhage, and where it is of the greatest importance to avail ourselves of every advantage by lessening the size of the inverted uterus as much as possible: where, however, it is a case of partial inversion, it is generally accompanied with haemorrhage; and here, therefore, it becomes a question how far we are justified in detaching the placenta, and therefore increasing the flooding, either before we are certain that we are able to reduce the fundus, or before we have placed the uterus in a condition in which it is capable of contracting. In Mr.

Mann's case, quoted by Dr. Radford (_op. cit._,) the inversion was evidently complete, for the uterus was found to have "pa.s.sed externally from the v.a.g.i.n.a, and the placenta attached to it." "I first peeled the placenta from the fundus uteri, and then grasping the extruded part with my hand, I did not find it very difficult to re-introduce it into the v.a.g.i.n.a, and to carry it through the os uteri. I followed with my hand, or rather pushed it forward, when I observed it suddenly start from me as a piece of India rubber would."

Dr. Merriman, who candidly owns that he has altered his opinion on this point, since the last edition of his work on difficult parturition, in favour of removing the placenta, distinctly proves that the presence of this ma.s.s was the chief cause of the difficulty. "I tried," says he, "to effect the reduction without removing the placenta, but could, by no possibility, accomplish it till I had first separated the placenta: this being effected, I succeeded to my entire satisfaction in re-inverting the fundus." (_Synopsis of Difficult Parturition._)

In reducing the fundus, we must not thrust our fingers collected into a cone against the tumour, as has been recommended by most authors; for, by so doing, we only produce a depression in it, and, as it were, re-invert or double the uterus upon itself, and thus add considerably to the bulk of the ma.s.s, and the difficulty of the reduction. We should grasp the tumour firmly, and push it bodily upwards in the direction of the pelvic outlet: at first little or no change is produced, until it has ascended so far, that the v.a.g.i.n.a which had been dragged down is returned again to its natural situation; the hand must follow the tumour, and now that the lower part of the uterus is fixed, by the v.a.g.i.n.a being put upon the stretch, the pressure which is applied to the fundus will act with so much greater effect. We should endeavour to "return, first, that portion of the uterus which was expelled last from the os uteri." (Newnham, _op. cit._ p. 616.) As the hand rises into the cavity of the pelvis, and is no longer able to grasp the tumour, so far from contracting the points of our fingers into a cone, it will be desirable to spread them at equal distances round it, and thus apply the pressure over a larger s.p.a.ce: it was to attain this object that Leroux recommended the application of a cloth to the fundus, as by this means the force applied to it was more equally divided. (_Sur les Pertes de Sang_, -- 218.) The hand, however, will be far preferable. We must gradually alter the direction in which we press up the tumour as it ascends, guiding our hand in the axis of the pelvic cavity, and lastly bringing it upwards and forwards in that of the superior aperture. When once the fundus has repa.s.sed the os uteri, it usually recedes suddenly from the hand, as already described in Mr. Mann's case: if we feel the uterus through the abdominal parietes well contracted, there will be no need of pa.s.sing the hand into its cavity; but if it be still flaccid and soft, the hand should be introduced, not only for the purpose of guarding against any return of the inversion, but of exciting more active contractions by its presence. The patient should avoid making any sudden efforts to raise herself, or to cough, strain, or by any means excite the abdominal muscles to exert pressure upon the fundus, for it is occasionally observed, that the disposition to inversion continues some time after the reduction has been effected.

Where some little time has elapsed before any attempt is made to reduce the fundus, the inverted portion begins to swell from obstruction to the return of blood, especially where the inversion is partial, and, therefore, tightly girded by the os uteri; the pa.s.sages grow hot and dry, and the chances of reducing the tumour diminish in proportion. "Is it not reasonable," as Mr. Newnham observes, "to suppose that the first effect of the accident will be to bring on inflammatory action and tension of the parts, and this very state will in itself be a sufficient obstacle to success." (_Op. cit._ p. 18.) If, under these circ.u.mstances, we find that the attempts at reduction is attended with considerable difficulty, or is evidently impossible, it will be necessary to wait until the excitement of the circulation, and the congestion and swelling of the parts are reduced, and the pa.s.sages duly relaxed by bleeding; besides this, the external parts should be well fomented, the patient should use the warm hip bath, or sit over the steam of hot water, and throw up emollient and sedative enemata as recommended in our treatment of inflammation of the uterus; the operation, which was during the state of inflammation and feverish excitement in which the patient was, strongly contra-indicated, now becomes practicable and safe, and the difficulties, which before would have rendered it nearly or quite impossible, are now in a great measure removed.

Wherever the uterus is completely inverted, and there is reason to expect considerable difficulty in reducing it, we shall find great benefit in adopting the mode of practice recommended by Mr. C. White, of Manchester, viz. of firmly grasping the tumour until we have succeeded in considerably diminis.h.i.+ng its size, and thus removing the chief obstacle to its reduction. "I grasped the body of it in my hand," says Mr. W., "and held it there for some time, in order to lessen its bulk by compression. As I soon perceived that it began to diminish, I persevered, and soon after made another attempt to reduce it, by thrusting at its fundus; it began to give way. I continued the force till I had perfectly returned it, and had insinuated my hand into its body: it was no sooner reduced, than the pulse in her wrist began to beat: she recovered as fast as we could wish."

(White, _on Lying-in Women_, case, 19. Appendix, p. 429, 2d edit.)

Where the fundus is partially inverted, and the os uteri girds it very tightly, so as not only to produce very frightful symptoms arising from the strangulated condition of the organ, but also to render its reduction a matter of great difficulty, or even impossibility, Dr. Dewees has advised that, so far from attempting to push up the fundus, we should rather try to bring it down, and thus render the inversion complete; by this means, the "pain, faintness, vomiting, delirium, cold sweats, convulsions, extinct pulse," &c. will not only be relieved, but the farther danger from haemorrhage prevented.

"The propriety and safety of this plan is, it must be confessed, predicated upon the happy result of a solitary case, but, from its entire and speedy success in this instance, it is rendered more than probable that it will be of equal advantage if employed in others; "all reasoning upon the subject" is certainly in its favour; and experience, so far as a single case may be ent.i.tled such, is equally so. The patient is to be placed upon her back near the edge of the bed, and have her legs supported by proper a.s.sistants; the hand is to be introduced along the interior part of the v.a.g.i.n.a, but sufficiently high to seize the uterus pretty firmly; it is then to be drawn gently and steadily downward and outward, until the inversion is completed: this will be known by a kind of jerk, announcing the pa.s.sing of the confined part through the stricture.

Traction should now cease, and the part be carefully examined; if the inversion be complete, the mouth of the uterus will no longer be felt, and there will be an immediate cessation of pain and other distressing sensations." (Dewees, _Compendious System of Midwifery_, -- 1318.)

_Chronic inversion._ Where some time has already elapsed since the occurrence of the accident, and the more distressing symptoms have subsided, the inversion now pa.s.ses into a chronic state, which, although not immediately dangerous to life, will ultimately be not less fatal. The form of the tumour gradually alters; it a.s.sumes a more polypoid shape, from the increasing contraction of its mouth narrowing the upper part of it; and now the diagnosis from polypus sometimes becomes exceedingly difficult, the more so as the pressure produced by the os uteri diminishes the sensibility of the fundus. Hence, as Mr. Newnham observes, we may conclude, "that it is _always difficult_ and _sometimes impossible_, with our present knowledge, to distinguish _partial and chronic inversion of the uterus from polypus_; since, in both diseases, the os uteri will be found encircling the summit of the tumour, and, in either case, the finger may be pa.s.sed readily around it. And if, in order to remove this uncertainty, the entire hand be introduced into the v.a.g.i.n.a, so as to allow the finger to pa.s.s by the side of the tumour to the extremity of the s.p.a.ce remaining between it and the os uteri; and if we find that the finger _soon arrives_ at this point, it will be impossible to ascertain whether it rests against a portion of the uterus which has been inverted in the _usual way_, or by the long-continued dragging of the polypus upon its fundus. And if, under these embarra.s.sing circ.u.mstances, we call to our a.s.sistance our ideas concerning the _form of polypus_, its enlarged base and narrow peduncle, we must also recollect the abundant evidence to prove that the neck of such a tumour is often as large, and sometimes larger, than its inferior extremity, and we shall still be left in inexplicable uncertainty."

The periodical haemorrhages, with profuse leucorrhoea 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 v.a.g.i.n.a 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 v.a.g.i.n.a would prevent our ascertaining it, especially when there is more or less haemorrhage going on. In most cases, the history of the case, and our not being able to pa.s.s 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 v.a.g.i.n.a, 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 quant.i.ty as to debilitate the const.i.tution, 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 Princ.i.p.al 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 haemorrhages 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 haemorrhage 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.