UTERUS (ABNORMAL ANATOMY). 



entire uterus, or a great oortion of it, hangs 

 forth beyond the vulva, forming there a pyri- 



Fig. 469. 



Extreme prolapsus or procidentia uteri. (Diagram.) 



form tumour of considerable size. At the 

 bottom of this is the os uteri, greatly exceed- 

 ing in dimensions in chronic cases the ordi- 

 nary condition of the part. (Fig. 472.) The 

 lips are swollen and hypertrophied, and usu- 

 ally present a sore and granular surface on 

 account of the friction to which they are con- 

 tinually exposed. The external covering of 

 this tumour, in all but its lower part, consists 

 of the inverted vagina, the horizontal ruga? of 

 which are very conspicuous anteriorly between 

 the cervix and pubic arch, where a fluctuating 

 swelling is observed, caused by the presence of 

 a portion of the displaced urinary bladder. 

 (Fig. 469.) In chronic cases the surface of the 

 inverted vagina gradually loses the character of 

 a mucous membrane, and puts on the or- 

 dinary appearance of common integument. 

 After replacement, however, an extensive 

 shedding of epidermal scales ensues, and the 

 surface resumes in time the condition of a 

 mucous membrane. 



In cases of great elongation of the cervix, 

 the latter alone may protrude, while the body 

 of the uterus remains within the pelvis. 

 Such a combination of hypertrophy with dis- 

 placement has passed with the ignorant for an 

 example of hermaphrodite formation. 



Prolapsus is the most common displace- 

 ment to which the uterus is subject. It is 

 frequent in multipart, and in women who 

 follow fatiguing occupations, especially those 

 of a relaxed habit of body ; but it also hap- 

 pens in nullipara3. In the latter, when it 

 occurs at an early period of life, it is often 

 associated with enlargement of the uterus or 

 its appendages, whereby both the weight of 

 the organ is increased, and a broader surface 

 is offered for pressure from above. 



Elevatio uteri. Dislocation upwards. This 

 is the converse displacement to the foregoing. 

 The uterus, in consequence of some eiilarge- 



685 



ment of the parts appended to it, as the ovary, 

 or on account of the formation of morbid ad- 

 hesions, may be drawn upwards to such an 

 extent that no portion of it, or only a part of 

 the cervix, is retained within the pelvic cavity. 

 This displacement is also occasionally ob- 

 served during pregnancy, and in multipart, 

 whose abdominal walls are relaxed, and permit 

 the uterus to incline forward, so that at the 

 beginning of labour the os cannot be reached 

 by the finger. 



Inversion. Eversion. The uterus, either 

 in the unimpregnated or gravid state, may 

 become partially or completely inverted. The 

 conditions which appear ordinarily to com- 

 bine in producing this displacement, are, first, 

 a distension of the uterine cavity*, as by 

 pregnancy or the presence of a tumour ; and 

 secondly, a force applied in the way of pres- 

 sure from above, or traction from below, 

 whereby the distended uterine walls become 

 folded within each other, somewhat after the 

 manner of the intestinal walls in intussuscep- 

 tion. Inversion of the uterus appears always 

 to begin at the fundus which is first depressed 

 into the uterine cavity, and then, under the 

 continued operation of the disturbing forces, 

 the part is gradually protruded through the 

 cervix and os uteri, fig. 470., until it emerges 

 in an inverted form into the vagina followed by 

 the reversed walls of the uterine body, and 

 ultimately by those of the cervix. The inver- 

 sion of the uterus is nowcomplete. The greater 

 part of the organ lies beyond the vulva as a 

 pyriform tumour, the base of which, formed by 

 the fundus, is below, while above the narrower 

 neck of the tumour consisting of the inverted 

 cervix lies in part within the vagina, the up- 

 per portion of which canal is also drawn down 

 and partly inverted. The vagina is thus ma- 

 terially shortened, and terminates in a cir- 

 cular ibid marking the point of reflexion or 

 inversion, while the usual seat of the os uteri, 

 which is necessarily obliterated, is occupied 

 by the now inverted cervix (fig. 471.). 



Inversion constitutes the highest degree of 

 displacement of which the uterus is suscep- 

 tible, for it is both prolapsed and inverted, so 

 that the 'relative situation of the entire organ 

 to surrounding structures, as well as of all its 

 parts to each other, is completely changed. 

 Inversion does not, however, always proceed 

 to the highest degree, but may stop short at 

 any of the intermediate stages just described. 



When inversion occurs to the gravid uterus, 

 the accident usually happens during the ef- 

 forts of the organ to expel the placenta. In 

 this way, inversion may occur spontaneously, 

 or it may be favoured or produced by injudi- 

 cious attempts to extract the placenta, or 

 by too much traction applied to the funis. In 

 the unimpregnated uterus, a polypus attached 

 by a stem to the fundus may by its weight 

 slowly produce the same results. That a 

 sudden and spontaneous inversion of the un- 

 impregnated uterus is possible, was proved to 



* Boyer, and some others consider that disten- 

 sion of the uterine cavity is not an essential pre- 

 liminary to inversion. 



