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INVERSION OF THE UTERUS. 
BY 
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540 <£■ 551 Broadway, yew York. INVERSION OF THE UTERUS. 
BY 
H. P. C. WILSON, M. IX, 
BALTIMORE, MARYLAND, 
VICE-PRESIDENT OF THE AMERICAN GYNAECOLOGICAL SOCIETY, SURGEON 
IN CHARGE OF THE WOMAN’S DEPARTMENT OF THE 
UNION PROTESTANT INFIRMARY, ETC. 
\REI‘RINTED FROM THE NEW YORK MEDICAL JOURNAL, FEB., 1879.] 
NEW YORK: 
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549 & 551 BEOADVVAY. 
1879. . INVERSION OF THE UTERUS.* 
I desire to place upon record the following case of' inver- 
sion of the uterus as a tribute to the statistics of this impor- 
tant subject. This misplacement is rare, is often overlooked, 
when discovered is frequently neglected as beyond the power 
of the practitioner to rectify, and is sometimes included in 
the term “ falling of the womb,” which, under the ignorance 
of the past or inattention or thoughtlessness of the present, 
embraces all forms of malposition of the uterus. 
Mrs. E. B. was nineteen years old in April, and married in 
December, 1875 ; was confined with her first child September 
15, 1876, after five hours of natural labor. The child -was 
living and healthy, but died three months after birth. She 
conceived again in February, 1877, two months after the death 
of her child ; and was delivered of her second child Novem- 
ber 7, 1877, after seven hours of natural labor. She nursed 
this child two months after delivery, and then weaned him 
because of her great debility. She is of very fair complexion, 
lax muscular fibre, light hair, and blue eyes. 
Her physician was one of the most eminent practitioners 
of the Eastern Shore of Maryland. He told me that he never 
attended a more natural or easier labor. A few minutes after 
the child was born, he placed one hand on the abdomen, and 
* Read before the Baltimore Academy of Medicine December 3, 1878. 4 
made very moderate pressure on the uterus, while he tight- 
ened the cord gently with the other hand. 
The after-birth came away with a sudden splash, and a 
mass (which he took to be a procidented uterus) protruded at 
the same moment about two inches from the vulva. He 
pushed it back at once. It reentered the pelvis without any 
difficulty, and he saw, heard, and thought no more of it. 
I saw Mrs. B. for the first time May 3, 1878. She was 
then perfectly anaemic, and so feeble that she was obliged to 
be on the bed almost constantly. Her countenance wras de- 
jected, and she was spiritless and hopeless. Since the birth 
of her child (six months ago) she has been losing blood from the 
uterus constantly, and at times profusely, with dragging sen- 
sations about the hips, back, and lower abdomen ; yet no 
vaginal examination had been made to discover the condition 
of the uterus, and she was sent to Baltimore on a visit to 
friends with the expectation that change of scene, air, diet, 
and association would overcome these symptoms, and restore 
her to health and strength. 
It was the day after she arrived that I first saw her ; and 
a few miriutes’ conversation satisfied me that there was some- 
thing radically wrong about the uterus, yet she stoutly re- 
sisted my making a vaginal examination, being convinced 
in her mind that there was nothing wrong in that quarter, 
and insisting she was only weak ; and it was not until I was 
about leaving the room with the announcement, “ I had 
rather give up the case than prescribe without knowing what 
was the matter,” that she very reluctantly consented to a digi- 
tal examination only. 
The index-finger of the left hand on entering the va- 
gina came in contact with a tumor, the lower end of which 
was just within the vulva, and the upper end apparently pro- 
jecting from a dilated os uteri by a neck or pedicle. The 
tumor was about two and three fourths inches in its long 
diameter, and one and a half inch in its greatest transverse 
diameter. It was dense, and in every particular resembled a 
fibroid polypus coming from the cavity of the uterus. The 
pedicle was completely encircled by a dilated os, and in a mo- 
ment after my finger was inserted into the vagina I was on 5 
the point of announcing the presence of a pediculated fibroid 
tumor of the cavity of the uterus. 
In a large experience in diseases of women for twenty- 
eight years I had never before seen a case of inversion of the 
uterus (either acute or chronic), and so perfectly did the tu- 
mor before me simulate a fibroid that I was within an ace of 
being misled in my diagnosis, and of advising an operation 
for the removal of a fibroid. These mistakes have often been 
committed in similar cases, and the uterus removed by mis- 
take ; but they ought never to occur, when all the means of 
diagnosis are employed, and we are careful not to jump at 
conclusions. 
The impression of a fibroid tumor had scarcely flashed 
across my mind, when it was replaced by the recollection that 
this lady was in perfect health up to the time of her last con- 
finement, and had not had a well day since ; so that her pres- 
ent condition must in some way be connected with that occa- 
sion. I began to feel by bi-palpation for the body of the 
uterus. It could nowhere be found, either per rectum ox per 
vaginam, and T decided at once that the tumor before me must 
be the uterus. To make my diagnosis certain, 1 placed my 
patient in Sims’s left lateral position, introduced the specu- 
lum, and attempted to pass the sound by the side of the ap- 
parent tumor, through the dilated os, into the cavity of the 
uterus; but all my efforts failed. These digital and probing 
examinations settled me in my opinion, and I at once an- 
nounced to the patient that she had inversion of the uterus, 
and would require an operation for its restoration. I desired 
her to write at once to her physician of my diagnosis, and to 
ask that he would be present at the operation. 
The time for the return of her menses was at hand. They 
were just coming on, and I advised a return to her home on 
the Eastern Shore, where, with her husband, child, and friends, 
she would have less of the terrors of an operation hanging 
over her than by remaining in Baltimore. This she did, and 
came back to me, with her physician, four or five days after 
menstruation had ceased. 
I may remark here in passing that I saw in this case what 
I have never seen before, and shall probably never see again 6 
—the process of menstruation going on from the surface of 
the uterus turned inside out. It gave the impression of a 
sweating of blood from the surface of an engorged mucous 
membrane, just like the sweating of perspiration from the 
surface of the skin over an excited capillary circulation. 
On the 17th of May, thirteen days after I first saw her, 
and five days after menstruation had ceased, after she had 
been examined by her physician and my diagnosis verified, 
she was given a liberal drink of whisky and then chloroformed 
to complete relaxation by Dr. Gardner. Lying on a table in 
the dorsal position, with thighs flexed on abdomen and legs 
flexed on thighs, one knee steadied by Dr. Bayley and the 
other by a nurse, having first pared closely my finger-nails, I 
proceeded to the reduction of the inversion. 
One hand was passed completely into the vagina, and, the 
fundus uteri resting in its palm, the neck was encircled by 
the fingers, and steady upward pressure was made against 
that portion of the uterus which last emerged from the exter- 
nal os, while the other hand made steady counter-pressure 
above the pubis. The fingers were separated as far as possi- 
ble from time to time to expand the encircling os, and allow 
the neck and body to return more easily. My plan was to 
return first the portion last inverted, until the fundus should 
disappear through the internal os. 
At the end of half an hour of steady pressure, first with 
one hand and then with the other, I had succeeded in reduc- 
tion to the point of bringing the lower end of the fundus 
within the external os, but all efforts to carry the body 
through the internal os were unavailing for some time longer. 
My fingers became so cramped, and my hands and arms so 
powerless, that I was obliged to desist from time to time, and 
replace my hands with those of Dr. Gardner, who rendered 
me most valuable assistance in every step of this operation. 
When I had reached that point in reduction where the 
fundus had entered the external os, and all efforts to advance 
it through the internal os were unavailing, I changed my plan 
of attack. I indented the fundus uteri with the index-finger 
of one hand, and made counter-pressure with the index- 
finger of the other hand, pressing firmly down into the in- 7 
ternal os from above the pubis; but all efforts in this direction 
failed. 
I then attempted by indenting first one horn of the uterus 
and then the other, while the same counter-pressure was made 
as above, but with no more success. I then returned to my 
first manipulation, of grasping the fundus with my hand, and 
the cervix with my fingers, and making steady pressure up- 
ward against steady pressure downward from above the pubis, 
and at the end of one hour and ten minutes from the com- 
mencement of the operation we were rewarded with com- 
plete reduction of the inverted uterus. 
M.y fingers, hands, and arms were almost powerless at the 
end of the operation, and I should have failed in the reduction 
at this first attempt, but for the aid given me by Dr. Gardner. 
The extent of this paralysis may be appreciated, when I state 
that I was unable to use my pen or perform any delicate 
manipulation for several days. I have never experienced 
such paralysis of the hand or arm in any previous operation 
within the pelvis. 
The chloroform in this case was most skillfully adminis- 
tered. She took in all eight ounces, and was kept perfectly 
relaxed from beginning to end. 
After the reduction the uterus was mopped out with 
Monsell’s solution of sub-sulphate of iron and glycerine as an 
antiseptic. A pledget of cotton soaked in glycerine was 
placed in the vagina against the os, and the patient lifted into 
bed. She received no other treatment but plenty of milk and 
a liberal diet, was kept in bed for four or five days, and had 
her uterus mopped out every other day for ten days, first 
with the above solution of iron and glycerine, and then with 
Churchill’s caustic iodine. At the end of this time she was 
allowed to return to her home with no other directions than 
to live liberalljT, drink plenty of milk, and wash out the va- 
gina once daily with very hot water. She returned to see 
me in six weeks, looking well, healthy, happy, and full of 
life and gratitude. 
Just before she left for home, I noticed that the uterus 
was inclined to fall backward, and in her relaxed, anaemic 
state, with all its natural supports exhausted, and stretched 8 
to their fullest capacity, I deemed it best to insert a small 
Hodge’s pessary, rather than run the risk of complete retrover- 
sion. This was done with great comfort to the patient. 
As stated in the commencement of this paper, this is the 
first case of inversion of the uterus I have ever seen ; and, 
to give some idea of how rarely it occurs, it was “observed at 
the Rotunda Hospital but once in upward of 190,800 deliv- 
eries,” in a period of over thirty years. It most commonly 
occurs immediately after labor by pulling on the cord while 
the placenta is still attached to the walls of the uterus; and 
when it thus occurs, if recognized at once, it is very easily re- 
duced by pressing it immediately back through the relaxed 
and dilated os uteri. Every day, month, or year that it re- 
mains unreduced, its reduction becomes more difficult, and 
after great length of time often impossible. 
Inversion of the uterus is sometimes produced immediately 
on expulsion of the child, wdiere there has existed an unusu- 
ally short funis, and this wrapped several times around the 
child’s neck. The weight of the child under such circum- 
stances may pull the fundus through the external os, by drag- 
ging on an lengthy cord. It is as easily reduced 
as in the previous case, if discovered at once. Or inversion 
of the uterus may occur immediately after labor, where there 
has been no pulling on the cord, by the weight of an attached 
placenta dragging the uterus through the dilated os. It is as 
easily rectified in this as in the previous cases, if observed and 
undertaken at once. 
Inversion of the uterus may also occur soon after labor, 
where the placenta has neither been pulled upon nor has its 
weight dragged the body of the uterus through the dilated os 
It may take place in an anaemic woman of lax muscular 
fiber, where there are irregular and partial contractions of the 
body of the uterus, by which the semi-paralyzed seat of pla- 
cental attachment is forced through the dilated os by other 
portions of the uterus contracting around it. Inversion oc- 
curring from these causes is not susceptible of as easy reduc- 
tion as in the previous cases mentioned ; but, if promptly 
undertaken, and, if necessary, calling in the aid of chloroform, 
there is usually no great difficulty in replacing the uterus. 9 
To this class of cases belongs the verv remarkable one 
recently reported by my friend Dr. Bvrne, of Brooklyn, in the 
“New York Medical Journal ” for October, 1878, and which 
he styles “unavoidable or spontaneous” inversion. In this 
ease the hand carried into the cavity of the uterus immediately 
after the delivery of the placenta (which was found in the 
vagina) encountered a partially inverted fundus. This inver- 
sion was readily reduced by upward pressure with the fingers, 
but invariably returned on withdrawal of the hand ; and, as he 
states there was “no active haemorrhage,” in all probability 
the uterus was well contracted around this semi-paralyzed 
fundus (no doubt the recent seat of placental attachment), 
and thus the fundus was forced into “ unavoidable inversion.” 
Notwithstanding the skillful manipulation of this distinguished 
gynaecologist, he was unable to prevent this partial inversion 
from becoming a complete one. The entire body of the uterus 
passed through the cervix into the vagina, and all justifiable 
manipulation failed in its replacement till nine days after its 
occurrence. 
This is an exception to the general rule that these cases 
are easily reduced if promptly discovered. I refer the reader 
to Dr. Byrne’s paper for this interesting case of inversion as 
well as for the ingenious instrument invented to replace it. 
Sometimes inversion of the uterus is produced by a fibroid 
tumor in its cavity dilating the cervical canal, and then by 
its weight, dragging the body of the uterus through the exter- 
nal os into the vagina. The tumor should be removed and 
the reduction undertaken at once. 
To this class of cases belongs the interesting one reported 
by Dr. T. Gaillard Thomas, in the October number of the 
“ American Journal of Obstetrics ” for 1878, in which a fibroid 
tumor was the cause of complete inversion of both uterus and 
vagina. Tumor, uterus, and vagina appeared as one mass 
without the vulva. The woman had not been pregnant for 
thirteen years, and the condition in which he found her had 
existed for three or four years. 
Another cause of inversion of the uterus is too great 
pressure through the abdominal walls on the fundus of a re- 
laxed uterus. In this way the fundus may be indented, and 10 
very little irregular uterine contractions may be sufficient to 
carry on the work, till the fundus emerges through the ex- 
ternal os. 
In this, as in all other cases, inversion of the uterus is 
usually reduced with ease, if recognized early and undertaken 
at once. Those of months’ and years’ standing are the ones 
that give the practitioner so much trouble, and sometimes 
prove entirely beyond his control; and hence the importance 
of seeing, immediately after every labor, that the uterus is in 
proper place and condition. 
Injudicious pulling on the funis by the accoucheur is the 
cause of more cases of inversion of the uterus than all other 
causes combined. It has been my habit in obstetrical practice, 
for many years, never to tighten the cord, unless an exami- 
nation with the index-finger discovered the placenta in the 
vagina. Then there is no objection to pulling it away by the 
cord. But, if the placenta remains in the uterus after the cord 
has been tied and the child handed to the nurse, I immedi- 
ately grease my hand and pass it into the uterus. If the 
placenta is detached, 1 turn it out with the hand, just as I 
would turn out a mass of clotted blood; if it is attached, I 
peel it off with the finger-nails, turn it out, and manipulate 
the uterine cavity till contractions expel my hand. I thus 
secure firm contraction of the uterus, seldom encounter post- 
partum haemorrhage, and diminish the chances of septicaemia, 
by more effectually closing the mouths of all open vessels, and 
more thoroughly cleansing the cavity of the uterus. I also 
secure the patient against inversion of the uterus, and lessen 
many of the other dangers to which parturient women are 
liable. 
I am aware that at least one of my most distinguished 
friends, Dr. Fordvce Barker (whose teachings I delight to 
treasure, and whose warnings should never go unheeded), cau- 
tions against the introduction of the hand into the cavity of 
the uterus after labor, and thinks it is fraught with the dan- 
ger of lacerating the cervix; but I cannot see how the cervix 
uteri can escape laceration while the head and shoulders of a 
child are passing through it, and meet with it by the introduc- 
tion of the hand immediately after delivery. 11 
It must l>e a very large hand, and very rough manipulation, 
that could produce such a result immediately after the expul- 
sion of the child; and, when laceration has followed such a 
manual exploration, I would think it due rather to the egress 
of the child than the ingress of the hand. 
I consider this use of the hand free from all danger. We 
gain thereby perfect intelligence of the condition of the cavity 
of the uterus, and secure, as by no other means, "firm and 
permanent contraction of the same. We are cognizant at 
once of threatened inversion, threatened haemorrhage, threat- 
ened hour-glass contraction, adherent placenta, and any re- 
maining deciduae, and thus have the knowledge of any im- 
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New York Medical Journal, 
Edited by JAMES B. HUNTER, M.D., 
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Critical and Impartial Reviews of all New Medical Books. 
Proceedings of Medical Societies. 
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