would be pathological; they do not fix the uterus; they only tend to
limit its movements to their normal range. Backward displacement of the
body is resisted by the round ligaments, backward displacement of the
cervix by the utero-vesical ligaments and by the vesico-vaginal wall.
Forward and downward displacements are resisted by the utero-sacral
ligaments, and excessive lateral motion by the broad ligaments. This
restraining power is doubtless greater in the utero-sacral than in any
of the other ligaments.
_b_. The pelvic floor, which is the chief support of the uterus, is
divided into two segments, the pubic and the sacral. The pubic
segment[4] is composed of bladder, urethra, anterior vaginal wall, and
bladder peritoneum. It is attached in front to the symphysis pubis and
laterally to the anterior bony walls of the pelvis. The sacral
segment[5] is composed of rectum, perineum, posterior vaginal wall, and
strong tendinous and muscular tissue. It is attached to the coccyx, to
the sacrum, and to the posterior wall of the bony pelvis.
[Footnote 4: Hart and Barbour's _Manual of Gynecology_.]
[Footnote 5: _Ibid._]
Permeating the pelvic floor in all directions, entering into the
composition of its single parts, binding them together, and sending its
processes to the bony pelvis, is the pelvic connective tissue, upon the
integrity of which depends the integrity of the pelvic floor as a
uterine support. Its pernicious influence as a pathological factor will
be considered hereafter. The old idea that the uterus is supported by
the vaginal walls or by the perineum or by the uterine ligaments is
obsolete; they are important parts of the pubic and sacral segments,
and as such contribute their share, but the pelvic floor as a whole
supports the uterus. The various uterine supports are to a great extent
the seat of motor influence. They consequently not only resist
excessive movement, but also serve to return the organ from its
physiological migrations.
DEFINITION AND NOMENCLATURE OF DISPLACEMENTS.--In the foregoing pages
the normal location, position, movements, and supports of the uterus
have been defined. Those conditions are pathological which induce
changes to positions or locations beyond the defined limits, or which
so fix the organ that its normal movements are prevented. The
displacements are divided into mal-locations and malpositions.
The mal-locations in which the entire uterus occupies a place outside
{151} its normal limits are as follows: ascent, retro-location,
ante-location, lateral location, descent.
The malpositions are determined by excessive change in the inclination
of the uterine axis. They are further divided into flexions, in which
the organ is bent upon itself in an abnormal degree, manner, or
direction; and versions, in which the axis of the unflexed uterus
inclines in an abnormal degree or direction. The malpositions are
retroversion, retroflexion, lateral version, lateral flexion,
anteversion, anteflexion.
SYMPTOMS AND DIAGNOSIS IN GENERAL.--Each variety of displacement may be
indicated by its own group of symptoms and physical signs. These will
be presented in the study of the special lesions. To avoid repetition,
those symptoms and signs which pertain to no special displacement, but
which belong to all alike, will be mentioned at once. They may arise
either from the displacement itself or from its possible complications,
of which the following are examples: Metritis, ovaritis, salpingitis,
atresia and stenosis, cystitis, vesical catarrh, rectitis, rectal
catarrh, peri-uterine cellulitis and peritonitis, uterine catarrh,
tumors, cicatrices, etc.
Uterine displacement may be a cause or an effect of associated
complications, or together with them it may be a concurrent result of
some common cause, or it may have had primarily no pathological
connection with them. The symptoms of displacement refer to the pelvic
organs or to the nervous system. Among the symptoms which refer to the
pelvic organs are--difficulty in walking and standing; pelvic pain,
more or less constant; dysmenorrhoea, menorrhagia, sterility, frequent
abortion, constipation, painful or difficult defecation, dysuria,
polyuria, tenesmus, etc. Among the symptoms which refer to the nervous
system are--neuralgia in various parts, paralysis, hysteria, nervous
dyspepsia, anæmia, chlorosis, spinal irritation, etc.
The final diagnosis must always depend upon direct examination of the
uterus itself. The first division of the above group of symptoms is not
likely to escape notice as indicative of displacement, but the nervous
symptoms are constantly disregarded or treated without reference to
their possible pelvic origin. The frequent dependence of these nervous
phenomena upon displacement is proved by their persistence in many
cases after ordinary treatment, by their prompt disappearance upon
permanent replacement and retention of the uterus by mechanical means,
and by their equally prompt recurrence upon removal of the support. The
presence, therefore, of the second division of the group or any part
thereof, even though the first be absent, will justify, may even
necessitate, a careful investigation into the state of the pelvic
organs.
That examination which results only in giving the name to a special
variety of displacement, and does not include the complicating lesions,
would not furnish a sufficient guide to the therapeutic indications,
and is therefore inadequate. The successful treatment, for instance, of
an anteflexion dependent upon inflammation of the utero-sacral
ligaments must include the removal of the inflammation.
An important prerequisite to examination is the absence of material in
the rectum and bladder. The full rectum distorts the vaginal walls,
deprives the examiner of the space necessary for the introduction of
the speculum, and throws the uterus out of its accustomed position.
Much more troublesome is the presence of even a small quantity of urine
in {152} the bladder, because it causes the patient to render the
abdominal muscles tense when the hand is placed over the lower portion
of the abdomen for bimanual palpation, and makes it impossible to
engage the uterus between the hand and the examining finger. The
distended bladder by pushing the uterus upward and backward makes
bimanual palpation almost useless. It is not surprising that
conflicting opinions are common, when one day the patient is examined
with rectum and bladder full, another day empty; one day in the dorsal,
another in Sims's or the knee-chest position; one day with the
cylindrical or bivalve speculum, another day with Sims's or Simon's.
For digital examination the dorsal position is preferred: the patient
should be drawn close to the edge of a bed, or preferably a table, the
thighs being flexed, the feet about fifteen inches apart, and the knees
widely separated. The examiner should stand facing the patient, never
at the side. The index finger of the left[6] hand, lubricated with
vaseline or oil, then slowly advances over the perineum into the
vagina, noting the condition of the perineum, the presence or absence
of cicatrices or of sub-involution of the vagina or perineum, the
capacity of the vagina, the condition, size, and direction of the
cervix, its distance from the sacrum and vulva, its mobility or
fixation. Now, for the first time, the right hand is pressed well down
behind the pubes, and the uterus is engaged between it and the
examining finger. (See Figs. 16 and 17.) In this way the examiner may
determine more accurately the position, location, and size of the
entire organ; may detect the possible presence of complicating tumors,
both inflammatory and non-inflammatory; may also note, if possible, the
location and condition of the ovaries, which, especially in the
posterior displacements, are liable to be prolapsed and excessively
sensitive, and to constitute, therefore, a most intractable
complication. The index finger sweeps around the cervix in search of
tender places which may be the result of former cellulitis or the
expression of some neurosis. Above all, the digital examination
requires a light, gentle, delicate touch.
[Footnote 6: The left-hand method of examination is incomparably
superior to the right. The palmar surface of the index finger is more
easily directed toward the left side of the pelvis, which is especially
subject to disease. Its tactile sense is more acute and more easily
educated. The stronger right hand should be free to palpate the surface
of the abdomen in conjoined manipulation.]
In exploring the uterine cavity to learn its position the fine
silver-wire probe of Emmet--not the sound--should be used. The uterus,
if freely movable, is liable to be thrown out of its accustomed
position by the heavier, unyielding sound. The sound also causes much
more pain and exposes the patient to great danger of cellulitis. The
frequent lighting and relighting of pelvic inflammation by injudicious
slight manipulations of the uterus doubtless led Emmet to the utterance
of a prophecy which ought to become classical: "A great advance in the
treatment of the diseases of women will be made whenever practitioners
become so impressed with the significance of cellulitis as to apprehend
its existence in every case. The successful operator in this branch of
surgery will always be on the lookout for the existence of cellulitis,
and take measures to guard against its occurrence."
When the probe or the sound is used without the speculum, the patient
{153} should be on the back and the index finger of the left hand
should be used as a guide. The bivalve and cylindrical specula are
almost useless in explorations of the interior of the uterus. The
exploration is most effectually and gently made with Sims's speculum,
the patient being in the left latero-prone position. In some cases the
probe cannot be passed by any other method.
Ascent of the Uterus.
This mal-location may result from traction above or from pressure
below. The organ may be drawn upward and backward by shortening of the
utero-sacral ligaments, which results from inflammation and which
usually induces a troublesome form of anteflexion. The enlarged
pregnant uterus sometimes becomes attached by adhesive inflammation to
a portion of the peritoneum in one of the higher zones of the pelvis or
in the abdomen, and the organ may consequently remain fixed in its
elevated position after involution. A tumor connected with the uterus
or its appendages which has grown too large to be retained in the
pelvis may, upon rising into the abdomen, drag the uterus with it.
Pressure below may come from excessive distension of the rectum or
bladder, or from a large accumulation of menstrual fluid in the vagina,
or from a tumor originating in any portion of the pelvis below the
level of the uterus. In diagnosis, prognosis, and treatment this
displacement is wholly subordinate to the more significant lesions of
which it is only the incidental result.
Retro-location of the Uterus.
The uterus may be forced back into a post-normal location by the
presence of a tumor in front or by the distended bladder, or it may be
drawn back and fixed by peritoneal adhesions. Retro-location is liable
to induce vesical irritation by putting the vesico-vaginal wall on the
stretch and thereby dragging on the neck of the bladder. This
intractable symptom is sometimes relieved by Emmet's buttonhole
operation of urethrotomy, for an account of which see section on
Anteflexion. This operation would obviously be applicable also for the
relief of the same symptom when caused by ascent of the uterus.
Ante-location of the Uterus.
The causes of this displacement are similar to those which produce
retro-location; they are--distension of the rectum, post-uterine
hæmatocele, post-uterine tumors, and peritoneal adhesions.
Ante-location often causes vesical irritation, consequent upon the
invasion by the uterus of that space which belongs to the bladder.
Lateral Locations of the Uterus.
The entire uterus is often displaced to the right or the left by a
tumor or by an inflammatory exudate. The latter occurs as a product of
{154} cellulitis, usually in the left broad ligament, and crowds the
organ toward the opposite side of the pelvis. After resolution the
ligament, shortened by inflammatory contraction, draws the uterus to
the affected side and fixes it there. Lateral displacement from this
cause often accompanies laceration of the cervix, the cellulitis having
occurred on the side corresponding to the laceration.
Descent or Prolapse of the Uterus.
The nature of this displacement is clearly indicated by its name. It is
convenient to distinguish three degrees of descent: In the first the
organ is displaced downward and forward until sufficient space has been
gained between the cervix and the sacrum to permit the body to turn
back into extreme retroversion; in the second the cervix descends to
the vulva; in the third the uterus protrudes partially or wholly
through the vulva, constituting a condition sometimes called
procidentia.
ETIOLOGY AND CLINICAL HISTORY.--Descent may be the result of any or all
of the following causes: I. Pressure from above; II. Weakening of the
supports; III. Increased weight of the uterus; IV. Traction from below.
Either of the above conditions being the primary cause, the others
singly or combined may result.
I. Pressure from above may depend upon the presence of a pelvic or
abdominal tumor, ascites, fecal accumulations, tight or heavy clothing,
etc.
II. The uterine supports may be weakened and relaxed in consequence of
subinvolution, senile atrophy, abnormally large pelvis, increased
weight of the uterus, pressure from above, traction from below, etc.
III. Increased weight of the uterus may be caused by congestion,
subinvolution, hypertrophy, hyperplasia, pregnancy, fluid in the
endometrium, uterine tumors, etc.
IV. Traction from below may be due to vaginal cicatrices, abnormally
short vagina, falling of the pelvic floor, etc.
Obviously, descent of the vesico- and recto-vaginal walls, or, more
comprehensively, the sacral and pubic segments of the pelvic floor,
involves also concurrent descent of the uterus. Descent of the vagina,
therefore, must be studied in connection with the descent of the
uterus. Excessive descent of the vaginal walls usually originates with
parturition.
In labor the anterior wall of the vagina is so depressed, stretched,
and shortened by the advancing head that during and after the second
stage the anterior lip of the cervix may be seen behind the urethra. If
the puerperium progress favorably, with prompt involution of the
uterus, vagina, perineum, and peritoneum, the relaxation of the
vesico-vaginal wall and of the utero-sacral supports disappears and the
uterus resumes its normal multiparous location and position.[7] But if
the enlarged uterus remain in the long axis of the vagina, with its
fundus incarcerated in the hollow of the sacrum between the
utero-sacral ligaments, and with its sacral supports so stretched that
they cannot recover their contractile power, and with involution of all
the pelvic organs arrested, the descent {155} may not only persist, but
may even progress with constantly increasing cystocele to the third
degree of prolapse. The downward influence of the above conditions may
be materially increased by rupture of the perineum, and consequent
prolapse of the recto-vaginal wall into a pouch called rectocele.
[Footnote 7: The anteflexion of the multiparous uterus is less than
that of the virgin.]
In the great majority of cases of complete prolapse the posterior
vaginal wall in its descent is peeled off from the rectum, leaving the
latter in its normal position. In rare instances the lower portion of
the rectum is also found to have extruded in extreme rectocele, making
a pouch below and in front of the anus, where fecal matter may
accumulate and remain in hard scybalæ.
Obviously, complete prolapse of the uterus is only an incident to the
prolapse of the pelvic floor. The whole mechanism is in all respects
analogous to that of hernia. The extruded mass drags after it a
peritoneal sac, which, hernia-like, contains small intestine. This sac
forces its way to the pelvic outlet and extrudes through the vulva,
having the inverted vagina for its covering.
[Illustration: FIG. 3. First Degree of Prolapse of the Post-partum
Uterus. The posterior vaginal wall has been changed from its normal
forward direction to a vertical direction by perineal rupture and
anterior displacement of the cervix; the vesico-vaginal wall descends
in cystocele, becomes hypertrophied, and drags the heavy uterus after
it. The descending uterus carries with it a reduplication of the
vaginal walls.]
In descent of the first degree the location of the uterus is either
changed to a lower level, the position remaining normal, or, as is more
common, the cervix having moved nearer to the symphysis and the organ
turns back into retroversion. In a given case suppose the vaginal walls
from some cause to have become relaxed and to have settled {156} to a
lower level in the pelvis. As an associated fact the uterus to which
these walls are attached must then also occupy a place correspondingly
nearer to the vulva--_i.e._ the location of the uterus has changed, so
that space enough intervenes between it and the hollow of the sacrum
for the former to turn back into the position of retroversion or
retroflexion. If, on the contrary, the descending uterus still
maintains its normal anteversion and anteflexion, it must occupy space
which belongs to the bladder. The vesical irritation consequent upon
this mal-location has generally been ascribed to the anteversion and
anteflexion, which are therefore oftentimes wrongly pronounced
pathological. The prompt relief which follows permanent replacement of
the organ in the normal location, even though in so doing its
anteposition be exaggerated, proves that the symptoms depend upon the
mal-location, not upon the anteposition. The importance of a clear
distinction, therefore, between location and position becomes apparent.
Vesical irritation, moreover, is sometimes caused by the dragging of
the uterus upon the neck of the bladder. This traction occurs not only
in ascent, but also when the organ descends below a certain level.
[Illustration: FIG. 4. Showing Extreme Descent of the Uterus and of the
Pelvic Floor, and the Hernial Character of the Lesion.]
In the foregoing paragraphs traction due to the falling pelvic floor
has been discussed as a cause of descent. The impairment of the uterine
supports may, however, be such that instead of falling and dragging the
uterus after them, they simply permit it to descend along the vaginal
canal by the force of its own weight, and to carry with it the
reduplicated vaginal walls. This influence is generally enforced by the
increased weight of the diseased organ. The vagina more readily becomes
a track for the descending uterus when from any cause the normal
forward direction of the vaginal canal changes toward the vertical:
this change may occur either as the result of a forward displacement of
its upper extremity, involving anteposition of the cervix, or of a
retro-displacement of its {157} lower extremity in consequence of
rupture or subinvolution of the perineum. (See Fig. 3.) Descent in the
track of the vagina is obviously combined with some degree of
retroversion, because the axes of the uterus and vagina then
correspond.
The PATHOLOGICAL ANATOMY may involve all the displaced organs. The
circulation throughout the pelvis is impeded by traction upon the
vessels, and the entire pelvic contents therefore become the subject of
venous congestion, with consequences disastrous to local innervation
and nutrition.
The ovaries may suffer concurrent displacement, with resulting
inflammatory and cystic enlargement. The peritoneum which enters into
the formation of the uterine ligaments and of the pelvic floor is
dragged along with the uterus.
The vagina is hypertrophied and swollen. Its mucous membrane becomes
the seat of acute vaginitis and chronic catarrh. In the third degree of
descent the exposed vagina, no longer lubricated by the normal
secretions of the uterus, becomes dry, parchment-like, oedematous,
eroded, and ulcerated. Sometimes the cul-de-sac of Douglas is distended
by downward pressure of the intestines, by a small tumor, or by ascitic
fluid, and a consequent hernial sac may protrude into the vagina
through some portion of the posterior vaginal fornix. The anterior
fornix is subject to a similar accident. These conditions are
designated enterocele vaginalis, anterior and posterior.
The rectum and bladder are subject to inflammation and chronic catarrh,
and the bladder especially to concurrent descent. The uterus may be
enlarged from any one or all of a variety of causes--congestion,
subinvolution, hypertrophy, and hyperplasia. Its cervix is often the
seat of extreme erosion or so-called ulceration. The endometrium, in
order to relieve the organ of its surplus blood, gives forth an
excessive secretion of mucus, which upon being increased in quantity
becomes vitiated in quality. This is termed uterine catarrh. The
enlargement of the uterus often pertains more to the cervix than to the
body, especially in prolapse of the second and third degrees. An
explanation of this may be found in Figs. 5 and 6.
[Illustration: FIG. 5. Descent of the Virgin Uterus into the Vaginal
Canal, showing the Reduplicated Vaginal Walls. The utero-vaginal
attachment, points _X_ and _Z_, appears to be at _X'_ and _Z'_. The
apparent increase of length in the vaginal portion of the cervix due to
the reduplication is measured by the distance from _X_ and _Z_ to _X'_
and _Z'_.]
[Illustration: FIG. 6. Descent of the Uterus, showing Excessive
Circular Enlargement of the Lacerated Cervix, consequent upon
Reduplication of the Vaginal Walls and Out-rolling of Intracervical
Tissues. The divided fragments of the os externum are at _a_ and _b_.
The curved lines forming the angles 1, 2, 3, 4, and 5 indicate the
gradual process of the eversion. The angle of the laceration at point 1
has been forced by the swelling and out-rolling of the mucous and
submucous tissues of the cervix to point 5. The apparent os externum is
at point 5. The utero-vaginal attachment _X_ and _Z_ seems to be at
_X'_ and _Z'_. The vaginal portion of the cervix therefore appears much
larger and longer than it actually is.]
Apparent elongation and disproportionate circular enlargement of the
cervix are conditions which almost every standard author wrongly calls
hypertrophic elongation and circular hypertrophy. The question of
elongation is easily settled by placing the patient in the knee-chest
position. Then the uterus by its own weight falls toward the diaphragm,
the vagina unfolds, and the apparent utero-vaginal attachment _X'_ _Z'_
(Figs. 5 and 6) disappears, disclosing the actual attachment, _X_ _Z_.
Further, the point of the sound, passed into the bladder while the
{158} cervix is exposed by Sims's speculum, may be placed against the
anterior wall of the cervix at _Z_, which would be impossible if the
attachment were at _Z'_.
The comparatively small amount of hypertrophy in disproportionate
circular enlargement is proved by the operation of trachelorraphy or by
bringing the points _a_ and _b_ (Fig. 6) together with uterine
tenacula, the organ being exposed by Sims's speculum. Then the
out-rolled intracervical mucous tissues are rolled back, the proper
diameter of the cervix is restored, and a laceration on one or both
sides, extending past the vaginal attachment, becomes apparent.