ANTEFLEXION OF THE UTERUS.
As has already been said, the uterus normally lies with its anterior
surface in contact with the posterior surface of the bladder, and with
its long axis approximately perpendicular to the long axis of the
vagina. The forward inclination of the uterus varies with the degree of
distention of the bladder; it is greatest when the bladder is collapsed.
In the normal woman the long axis of the body of the uterus is inclined
forward at an obtuse angle with the long axis of the cervix. In other
words, the uterus is normally anteflexed. This angle is subject to
rather wide variations within the limits of health. It is greater in
the multiparous than in the nulliparous woman. It varies with the
distention of the bladder, the position of the woman, and the intensity
of intra-abdominal pressure. The axis of the uterus when removed from
the body is usually straight. The anteflexion found in the organ
when _in situ_ in the living woman rarely persists. The normal or
physiological anteflexion is maintained during life by the utero-sacral
ligaments, which hold the cervix back, and the intra-abdominal
pressure, which, acting upon the posterior aspect of the fundus, pushes
the body of the uterus forward.
In the fetus and in early infancy the cervix is relatively much more
developed than the body of the uterus, and there is a very marked angle
of flexion between them.
Anteflexion of the uterus becomes pathological when the bend in the
cervical canal is sufficient to impede the escape of menstrual blood or
other uterine discharges.
Obstruction of this kind depends upon two factors--the degree of the
flexion, and the rigidity of the uterus, which diminishes the mobility
that normally exists at the angle of flexion.
No matter how sharp the angle of flexion, it should not be considered
a pathological condition unless obstruction in the cervical canal is
present--unless the woman presents the symptoms of dysmenorrhea and
sterility.
Three varieties of anteflexion have been described:
I. _Corporeal anteflexion_, in which the cervix has the normal backward
direction, and the body of the uterus is bent forward upon it (Fig. 80).
[Illustration: FIG. 80.--Corporeal anteflexion.]
II. _Cervical anteflexion_, in which the axis of the body of the uterus
is inclined forward to the normal degree, and the cervix is bent
forward upon it (Fig. 81).
III. _Cervico-corporeal anteflexion_, when the cervix and body of the
uterus are both bent forward upon each other (Fig. 82).
Anteflexion of the uterus is a disease of single and sterile married
women. It is very rarely found in women who have borne children. The
disease is congenital or is caused by imperfect development during
childhood.
[Illustration: FIG. 81.--Cervical anteflexion.]
[Illustration: FIG. 82.--Cervico-corporeal anteflexion.]
The fetal condition of a large cervix and a small, sharply-flexed body
may persist. The posterior wall of the uterus may develop while the
development of the anterior wall is arrested, and thus the uterus would
be flexed forward. A mark of such arrest of development is sometimes
seen in the atrophied or undeveloped anterior lip of the cervix.
Anteflexion is usually accompanied by a small, undeveloped condition of
the whole of the uterus, and often by poorly developed vagina, tubes,
and ovaries.
It is probable that improper dress and hygiene during the period of
puberty have much to do with the development of anteflexion. The
early menstrual history sometimes points to poor development of the
sexual organs. The menses often make their appearance much later than
usual--sometimes when a girl is nineteen or twenty years of age--and
when established, the function is often irregular, the bleeding
recurring at long intervals.
The most prominent =symptom= of anteflexion of the uterus is
dysmenorrhea, or painful menstruation. The dysmenorrhea is
characteristic: violent pains in the center of the lower abdomen,
extending down the thighs, occur for several hours before the bleeding
begins. In the later years of the disease the pain extends to the whole
of the pelvis and the back. The pain is caused, in all probability, by
the accumulation of blood behind the obstruction in the cervical canal.
When the blood begins to escape freely, the pain is relieved, and may
be absent during the remainder of the menstrual period. The blood is
often clotted during the first part of the flow. Nausea and vomiting
may be present during the height of the pain.
The menstrual period may be followed by several days of great physical
weakness and debility.
Unless relieved by pregnancy or by proper treatment, the anteflexion
will persist during the menstrual life of the woman. The suffering
increases with time. Endometritis, salpingitis, and ovaritis follow old
cases of anteflexion.
Sterility usually accompanies well-marked anteflexion. This may be due
to the altered direction of the cervix in case of cervical anteflexion,
to the obstruction in the cervical canal that interferes with the
ingress of spermatozoa, to the generally undeveloped condition of the
genital organs, or to the inflammation of the mucous membrane of the
cervix and the body of the uterus.
The =diagnosis= of anteflexion is easily made. The character, position,
and time of onset of the pain indicate some obstruction to the escape
of menstrual blood. Vaginal examination reveals the sharp angle of
flexion at the junction of the body and neck of the uterus.
=Treatment.=--If in a case of anteflexion pregnancy does occur and runs
a normal course the disease will be cured. After labor the uterus does
not return to the infantile shape and size. The stimulus of pregnancy
brings about full permanent development of that organ. Miscarriage,
however, is very apt to occur during the early months of pregnancy,
especially in cases of long standing.
Various methods of treatment have been introduced for the cure of
anteflexion. The object of all these methods is the straightening and
enlargement of the cervical canal. Slow dilatation by graduated bougies
has been successfully employed. Gradual straightening of the canal by
the introduction of the uterine sound with increasing angle of flexion
will also cure some cases, if seen early.
The use of the stem pessary (Fig. 83), which is worn continuously in
the cervical canal, is dangerous and should not be practised.
[Illustration: FIG. 83.--Stem pessary.]
The best method of treatment consists in rapid forcible dilatation
with the uterine dilator. Various instruments have been made for this
purpose. The principle of all is the same. Two blades are introduced,
in contact, in the cervical canal, and are then separated. Two of these
instruments should be on hand--a small and a large dilator. The Goodell
dilator (Figs. 84, 85) is so made that the blades open parallel with
one another, so that the whole of the cervical canal is uniformly
stretched.
[Illustration: FIG. 84.--Goodell’s small uterine dilator.]
[Illustration: FIG. 85.--Goodell’s large uterine dilator.]
The best time to perform forcible dilatation is about one week after
a menstrual period. The woman should be etherized and placed in the
dorso-sacral position. The vagina should be sterilized. All aseptic
precautions which one would follow in any gynecological operation
should be observed here. There is always danger of producing septic
inflammation of the endometrium. The cervix should be exposed through
the Sims speculum, and the anterior lip should be seized with the
double tenaculum. Downward traction on the cervix straightens the
cervical canal and renders easier the introduction of the dilator. The
smaller dilator should first be introduced. No force should be used in
passing it through the cervical canal. If an obstruction which cannot
be gently overcome is met, the dilator should be introduced as far
as the obstruction and the blades should then be separated. Slight
dilatation of this kind below the angle of flexion will usually enable
the operator to pass the instrument through the cervical canal at a
subsequent attempt. After the smaller instrument has been introduced
to the full extent the blades should be gradually separated, for a
half inch or more, until the canal becomes large and straight enough
to admit the large instrument. It should always be remembered that
no force should be used in the introduction of either instrument.
After introduction the blades of the large dilator should be slowly
separated. On the handles of the Goodell instrument is a graduated
scale showing the extent of the dilatation. In no case should the
dilatation be carried beyond one and a half inches. In women in whom
the cervix and uterus are small an inch of dilatation is sufficient.
The maximum dilatation should be reached slowly and gradually.
Laceration of the cervix or of the margin of the external os should
be avoided. Sometimes ten or fifteen minutes are required before full
dilatation is attained. When this point is reached the handles should
be held in place by the screw, and the instrument should be kept in the
uterus for ten or fifteen minutes longer. The longer the dilatation,
the more permanent will be the result.
After the instrument is withdrawn the cervical canal and the vagina
should be washed out with a 1:2000 solution of bichloride of mercury,
and a light gauze pack should be introduced into the vagina. The pack
should be removed at the end of forty-eight hours, and a daily douche
of 1:4000 bichloride solution should be administered for the following
week. The patient should remain in bed for two weeks, or longer if
there is any pelvic pain. Pain, however, does not follow this operation
if we avoid operating upon those cases in which there is inflammatory
disease of the tubes and ovaries. The too early resumption of the erect
position may cause the failure of the operation. The abdominal pressure
exerted upon the fundus uteri, before the organ has become fixed in its
altered shape, may bring about a recurrence of the anteflexion. In case
the external os be very small--too small to admit the dilators--it may
be incised by small crucial incisions or reamed out with the closed
blades of the scissors.
Dilatation of this kind usually produces a permanent broadening and
shortening of the cervix. The cervical canal is rendered straighter and
larger.
The good effects of the operation are not always apparent at the
menstrual period immediately following the operation, because the
results of the traumatism to the mucous membrane and the structures
of the cervix are still present. At the periods after this, however,
the dysmenorrhea is absent or is very much relieved. The benefit
usually derived from this operation is a strong proof of the truth
of the obstructive theory of the dysmenorrhea. If, after dilatation,
conception takes place, the woman may look forward to perfect cure. In
some cases the dilatation does not seem to be sufficient to produce
a permanent open condition of the cervical canal, and the signs of
obstruction (dysmenorrhea) return. In such a case the dilatation should
be repeated. The more thoroughly the dilatation is performed the first
time the less often will the second operation be necessary.