organ is bent backward upon itself. It usually results from, {167} and
is associated with, retroversion, but for convenience the double
displacement will be termed retroflexion. It may be caused by the great
weight of the corpus, the soft flexible state of the uterine walls
during and after involution, intra-abdominal forces, downward pressure
during defecation, tight clothing, and not commonly by the obstetric
bandage.
The ovaries, unless fixed elsewhere by adhesions, are displaced with,
and held down on either side of, the corpus, sometimes enlarged from
inflammation, often adherent, and always extremely sensitive. Chronic
metritis, cellulitis, and peritonitis, with adhesions more or less
firm, are usually present, and not infrequently as the result of
gonorrhoea, abortion, or injudicious treatment. Peritoneal adhesions
between the corpus and the cul-de-sac of Douglas sometimes make
replacement impossible. In rare cases the displacement is congenital.
[Illustration: FIG. 15. Extreme Retroflexion, with Hypertrophy of the
Corpus, which impinges upon the rectum and compresses the recto-vaginal
wall.]
SYMPTOMS AND COURSE.--Among the most pronounced symptoms are profuse
uterine catarrh, menstrual disorders, sterility, abortion, weakness,
pain in the back, painful defecation, rectal tenesmus, the symptoms of
pelvic inflammation, neurasthenia, and other nervous symptoms. The
uterine catarrh is due to an effort on the part of the engorged pelvic
organs to relieve themselves by an exaggerated secretion of mucus from
the uterus, which upon being increased in quantity becomes vitiated in
quality, and therefore pathological. Menorrhagia and abortion may also
result from congestion. Dysmenorrhoea and sterility result from the
{168} general anæmic condition and from the inflammatory complications,
and from the obstruction in the uterine canal or in the blood-vessels
at the angle of flexure. (See Pathology of Anteflexion.) The rectal
symptoms are caused by the pressure of the corpus uteri upon the
rectum, which gives the sensation to the patient of an overloaded
bowel.
Should pregnancy occur, the rapid growth of the uterus may induce
spontaneous reposition at about the fourth month, when the fundus rises
out of the pelvis, but if the corpus be incarcerated under the sacral
promontory from adhesions or from any other cause, the uterus will,
unless manually replaced, relieve itself by abortion.
Abdominal pains, nervous dyspepsia, and neuralgia in distant parts of
the body are often present; indeed, the nervous symptoms may be of the
most exaggerated character, and may comprise all that is implied by the
word hysteria in its most comprehensive signification.
DIAGNOSIS.--Digital touch discloses the cervix low in the pelvis, and
the fundus uteri is felt through the posterior vaginal wall in the
cul-de-sac of Douglas. Conjoined manipulation with the index finger of
the left hand, first in the vagina and then in the rectum, and the
right hand over the hypogastric region, will show the size, form,
consistency, and location of the uterus, the degree of the flexure, and
the difficulty of replacement. An inflammatory exudate or hæmatocele,
posterior to the uterus, or a fibroid in the posterior uterine wall,
may be mistaken for the retroflexed corpus. The probe will always
verify the diagnosis, but if there be great tenderness with fixation in
the cul-de-sac of Douglas, treatment should be directed against the
inflamed condition, and the final diagnosis made by repeated
examinations or after the disappearance of the inflammation. Great and
lasting injury is often done in the attempt to complete the diagnosis
at the first examination. The presence of a fibroid in the posterior
uterine wall with post-uterine inflammation is a serious complication
both in diagnosis and treatment. If the rectum be overloaded with fecal
matter, the diagnosis should be deferred. The displacement is
distinguished from the presence of an ovary or small ovarian tumor in
the pouch of Douglas by careful bimanual examination and by the probe.
TREATMENT OF RETROVERSION AND RETROFLEXION.--The objects of treatment
are replacement and retention of the uterus. The obstacles to
replacement are cellulitis, peritonitis, and fixation of the uterus,
and these complications often require weeks, and in severe cases
months, of treatment preparatory to replacement. Some of the general
therapeutic suggestions under the subject of descent are also
applicable to the retro-positions. Rest, massage, careful regulation of
the bowels, feeding, and general tonics are essential. For the
inflammation small blisters over the inguinal regions frequently
repeated, and the daily application of the cotton and glycerin plug to
the cervix, and dry cupping over the sacrum, are most efficacious. The
glycerin may be combined with alum, tannin, chloral hydrate, or
iodoform. Thymoline in small quantities partially destroys the
disagreeable iodoform odor. The most useful and essential topical
application is the hot-water vaginal douche, but its use will be
followed by failure and disappointment if it be applied in the ordinary
way. The following is quoted from a paper by the author which was
published in the _Chicago Medical Gazette_, Jan. 1, 1880: {169}
"_Ordinary Method of Application_. | "_Proper Method of Application_.
|
"I. Ordinarily, the douche is | "I. It should invariably be
applied with the patient in the | given with the patient lying on
sitting posture, so that the | the back, with the shoulders
injected water cannot fill the | low, the knees drawn up, and the
vagina and bathe the cervix uteri, | hips elevated on a bed-pan, so
but, on the contrary, returns | that the outlet of the vagina
along the tube of the syringe as | may be above every other part of
fast as it flows in. | it. Then the vagina will be kept
| continually overflowing while
| the douche is being given.
|
"II. The patient is seldom | "II. It should be given at least
impressed with the importance of | twice every day, morning and
regularity in its administration. | evening, and generally the
| length of each application
| should not be less than twenty
| minutes.
|
"III. The temperature is | "III. The temperature should be
ordinarily not specified or | as high as the patient can
heeded. | endure without distress. It may
| be increased from day to day,
| from 100° or 105° to 115° or
| 120° Fahr.
|
"IV. Ordinarily, the patient | "IV. Its use, in the majority of
abandons its use after a short | cases, should be continued for
time." | months at least, and sometimes
| for two or three years.
| Perseverance is of prime
| importance."
"A satisfactory substitute for the bed-pan may be made as follows:
Place two chairs at the side of an ordinary bed with space enough
between them to admit a bucket; place a large pillow at the extreme
side of the bed nearest the chairs; spread an ordinary rubber sheet
over the pillow, so that one end of the sheet may fall into the bucket
below in the form of a trough. The douche may then be given with the
patient's hips drawn well out over the edge of the bed and resting on
the pillow, and with one foot on each chair; the water will then find
its way along the rubber trough into the bucket below." The Davidson
syringe, which has an interrupted current, is preferable to any of the
fountain syringes.
As the tenderness disappears the cotton plugs may be increased in
quantity, and thereby made to serve as temporary support for the uterus
until a more permanent pessary can be substituted. The sluggish
circulation in the pelvis and torpid condition of the bowels may be
much relieved by the daily application of the wet pack. A small flannel
sheet folded lengthwise to the width of two feet, dipped in very hot
water, and dried by passing it through a wringer, is wound about the
hips and covered by another dry one. At the end of a half hour, during
which time the patient maintains the recumbent position, the sheets are
removed. When the tenderness has been sufficiently reduced, gentle
attempts at replacement may be made every day or two by conjoined
manipulation. The patient's tolerance of manipulation may thus be
observed and the way prepared for complete replacement and permanent
retention after the subsidence of the inflammation.
In retroversion and retroflexion always replace the uterus before
adjusting the pessary, otherwise the instrument will press upon the
sensitive uterus, when one of three unfortunate results must occur: (1)
The pessary may not be tolerated on account of pain; (2) the pessary
may be forced down by pressure from above so near to the vulva that it
will fail to do the least good; (3) the uterus, finding it impossible
to hold its position against the pessary, instead of taking its proper
position will often be bent over it in exaggerated retroflexion, with
the cervix between {170} the pessary and the pubes and the body between
the pessary and the sacrum, or the whole organ may slip off to one side
of the instrument into a malposition more serious than the one for
which relief is sought. The safest and most effective method of
replacement is by conjoined manipulation, as represented in Figs. 16
and 17. The dotted lines in the former indicate the gradual elevation
of the corpus out of the hollow of the sacrum to the pelvic brim, where
it may be anteverted by the fingers of the right hand pressed well down
behind its posterior wall. During the process of anteversion the index
finger of the left hand in the anterior fornix of the vagina presses
the cervix back to its place in the hollow of the sacrum, as in Fig.
17. Efficient reposition of the uterus is very often impossible without
anæsthesia.
[Illustration: FIG. 16. Commencing Reposition of the Retroverted or
Retroflexed Uterus by Conjoined Manipulation (modified from Schultze).]
[Illustration: FIG. 17. Completed Reposition of the Retroverted or
Retroflexed Uterus by Conjoined Manipulation (modified from Schultze).]
The replacement is not usually accomplished by drawing the fundus
forward and pushing the cervix back directly in the median line. In
most cases the fundus sweeps around the arc of a circle on the left
side of the pelvis, and the cervix on the right. This is owing to the
greater frequency of cellulitis on the left side, and consequent
shortening of the left broad ligament. After replacement the organ is
to be held in position by a suitable pessary.
Bimanual replacement has two great advantages over the more familiar
methods of the sound or repositor: first, it is more effective and more
{171} permanent; second, the lever action of the sound or repositor, by
which the operator may unwittingly use an undue and dangerous amount of
force, is avoided in the use of the hands, through which the operation
is not only constantly under his control, but also within his
appreciation.
Inasmuch as the pessary fulfils its indications by sustaining the
pelvic floor, and thereby holding the cervix in the hollow of the
sacrum, the same general principles, and in fact the same pessaries,
which are applicable to prolapse apply also to retroversion and
retroflexion. Indeed, the first step in the genesis of the
retro-positions has been shown to be prolapse. The student is therefore
referred to the general remarks on the adjustment of pessaries for
prolapse.
The operations of elytrorraphy and perineorraphy, especially the
latter, already described in the treatment of descent, are often of the
utmost importance in the treatment of the posterior displacements, and
should therefore be carefully studied in this connection.
In the adjustment of the pessary it is desirable, if possible, to avoid
direct pressure upon any part of the uterus. Pessaries designed to prop
up the body of the uterus by pressure upon the posterior wall to
correct the posterior malpositions, and upon the anterior wall to
correct the anterior malpositions, are very liable to induce metritis
and perimetritis, and are therefore generally unsafe. In certain cases,
however, the vaginal walls, {172} especially the posterior, may be so
relaxed from subinvolution and other causes that the instrument, though
very long, fails to maintain the cervix in its normal place. Under such
conditions a pessary may be required to act directly upon the uterus.
The Schultze's sleigh pessary represented in Fig. 19 fulfils this
indication. Schultze's figure-of-eight pessary, or a long Albert Smith
pessary with its uterine curve made so extreme as to bring the upper
part of the instrument in front of the cervix instead of behind,
answers the same purpose.
[Illustration: FIG. 18. Showing the Pelvic Organs sustained by the
Emmet Pessary alter reposition of the prolapsed, retroverted or
retroflexed uterus.]
Thomas's retroflexion pessary, with its bulbous upper extremity, is a
long narrow instrument of extreme uterine curve. It lifts the uterus
very high, and is specially applicable in cases of great relaxation of
the pelvic floor and of complicating prolapse of the ovaries (Fig. 21).
The bulbous portion is sometimes made of soft rubber.
A properly-adjusted pessary gives to the patient no consciousness of
its presence. If the instrument cause pain it should be removed and
search made for the tender places; it should then, if possible, be
remoulded into such shape that it will not exert pressure upon them.
Often a slight indentation at some point will enable the patient to
wear it with comfort.
Sometimes when the corpus has been firmly bound back by peritoneal
adhesions they may be broken up by very forcible conjoined manipulation
under ether, but the operation is dangerous, and should therefore be
{173} undertaken only by an expert operator. In place of this operation
Lawson Tait has proposed to open the abdomen, break the adhesions, and
stitch the fundus uteri to the abdominal wound. This operation in the
hands of such an operator as Tait is probably not more dangerous than
breaking up firm adhesions by forcible conjoined manipulation.
[Illustration: FIG. 19. Schultze's Sleigh Pessary in place, as adjusted
for prolapse, retroversion, or retroflexion with great relaxation of
the vaginal walls (after Schultze).]
In certain cases in which replacement is impracticable or impossible on
account of inflammation or adhesions a soft rubber ring may be
inserted, and will often give decided relief by lifting the uterus and
pelvic floor nearer to the health level. In the treatment of all
displacements coition should be forbidden or permitted only with great
moderation, and the pessary should be kept clean by copious daily
applications of the vaginal douche. Every three or four weeks the
instrument should be removed and the pelvic organs carefully examined.
It should be urged that no man can safely apply the pessary until he
has fully appreciated its indications and contraindications. Few
practitioners possess naturally the mechanical skill necessary to its
proper adjustment. Of this thousands of unfortunate women bear witness.
Its dangers in inefficient hands are in striking contrast with its
usefulness when judiciously employed.
Many cases of displacement, both anterior and posterior, are so
complicated by prolapsed and adherent ovaries, by advanced disease of
the ovaries and Fallopian tubes, and by peritoneal adhesions, that not
only {174} replacement, but even palliation, is impossible; then, as a
final resort, the activity of the pelvic organs, both physiologically
and pathologically, may be put at rest by the removal of the ovaries
and Fallopian tubes.
[Illustration: FIG. 20. Front View of Schultze's Figure-of-Eight
Pessary. The upper opening is intended to hold the cervix. This pessary
has the uterine and pubic curves, as in Figs. 7 and 8.]
[Illustration: FIG. 21. Thomas's Retroflexion Pessary.]
William Alexander of Liverpool has devised an ingenious operation of
shortening the round ligaments for the radical cure of descent and of
the posterior displacements. He reports twenty-two cases of the
operation in his own practice and several more in the practice of other
surgeons, with almost uniform success in completely curing the
displacements. The operation, although new, gives promise of a
brilliant and successful future.
Lateral Versions and Flexions.
The lateral malpositions which often complicate retroversion and
retroflexion are usually the result of inflammation in a broad ligament
or in the uterus itself, or in both. Their treatment is that of the
causative inflammation, and follows the general principles which have
been laid down for the treatment of other versions and flexions.
Pathological Anteversion.
Sometimes the physiological angle of flexure becomes obliterated in
consequence of chronic metritis, resulting in permanent straightening
of the uterus, and the cervix becomes elevated and fixed above, or the
corpus depressed and fixed below, the normal level. This constitutes
pathological anteversion (Fig. 22).
[Illustration: FIG. 22. Pathological Anteversion.]
ETIOLOGY.--The exaggerated anteversion of early pregnancy is
physiological, the exaggerated anteversion of the uterus in chronic
metritis is pathological. Elevation of the cervix and depression of the
corpus may be induced by peritoneal adhesions. Increased weight from a
mural fibroid may also depress the corpus.
{175} The SYMPTOMS are due to the pelvic inflammations already
mentioned and other complications. The increased weight of the uterus,
which is usually hypertrophied from metritis, generally causes a
dragging sensation, especially if the organ be also prolapsed. The
enlarged corpus occupying the territory of the bladder often induces
persistent vesical irritation or even cystitis. Menorrhagia, when
present, is the result of the metritis or a fibroid rather than of the
displacement per se.
DIAGNOSIS AND PROGNOSIS.--The displacement is recognized by digital
touch, which discloses the anterior wall of the uterus parallel to the
anterior wall of the vagina, with the fundus close to the symphysis and
the cervix elevated. Conjoined examination will show the size, shape,
hardness, and degree of fixation. Exaggerated anteversion of the
healthy uterus is not necessarily pathological in its results. This is
illustrated by the anteversion of early pregnancy. The prognosis is
therefore good if the causes can be removed.
TREATMENT.--Inasmuch as exaggerated anteversion is the position taken
by the uterus in chronic metritis, it follows that the treatment is
often that of chronic metritis. For the treatment of metritis,
perimetritis, fibroids, menorrhagia, etc. the reader is referred to the
special literature of those subjects. Irritable bladder, which is often
a mechanical result of the displacement and enlargement, may sometimes
be relieved by means of an Albert Smith or Hodge pessary, which lifts
the organ to a higher level away from the bladder. In thus elevating
the uterus the {176} anteversion may be rather increased than
diminished, which proves that the symptoms were dependent not upon the
anteposition, but rather upon descent and antelocation. Should the
parts be too sensitive to tolerate the hard-rubber pessary or a
flexible rubber ring, the daily application of medicated pledgets of
cotton will give support to the uterus and decrease the tenderness
until the more permanent instrument can be worn. The numerous
anteversion pessaries designed to elevate the corpus by direct pressure
on the anterior wall of the uterus generally irritate the organ, and
thereby aggravate the inflammatory complications. They are therefore to
be used with extreme caution.
Pathological Anteflexion.
DEFINITION.--The normal forward bending of the corpus upon the cervix
uteri when the bladder is empty makes an angle of which the approximate
physiological limits are between 45° and 90°: the flexure would
generally be pathological if less than 45° or more than 90°.
Furthermore, if the flexure, whether it be normal or abnormal in
extent, does not disappear upon filling the bladder, but remains
constant under all conditions, the rigidity makes the flexure
pathological. Anteflexion is therefore pathological if the mobility at
the angle of flexure is increased or diminished or absent.
{177} ETIOLOGY AND PATHOLOGY.--Anteflexion may be congenital or
acquired. By congenital is meant not defective foetal development, but
failure of the immature child uterus to develop at puberty, a failure
which usually pertains alike to the uterus, Fallopian tubes, ovaries,
and vagina. In congenital anteflexion the uterus is bent upon itself
almost double, the body and cervix both pointing in the direction of
the pelvic outlet, with the cervix somewhat elongated and situated in
the long axis of the vagina. (See Fig. 23.)
[Illustration: FIG. 23. Congenital Anteflexion. Both cervix and body
are flexed forward.]
Acquired anteflexion may be simply an exaggeration of the normal
flexure, due either to increased weight of the corpus from the presence
of the uterine fibroid near the fundus or to unequal growth of the
uterine walls or to unequal involution. A very frequent cause of
anteflexion is thickening of the posterior wall of the uterus from the
products of inflammation, and a corresponding atrophy of the anterior
wall from prolonged pressure at the angle of flexure. Post-uterine
cellulitis and peritonitis involving the utero-sacral ligaments is a
frequent and discouraging complication. Sometimes the inflamed
ligaments contract and drag the anteflexed uterus upward and backward,
where it may be permanently fixed by peritoneal adhesions. (See Fig.
24.)
[Illustration: FIG. 24. Anteflexion with Post-uterine Fixation.]
A constriction of the uterine canal at the point of flexure may, by
confining the secretions above, produce inflammation in the body of the
uterus, Fallopian tubes, and ovaries analogous to the cystitis,
ureteritis, pyelitis, and nephritis which follow stricture of the male
urethra. The {178} peri-uterine inflammations, having the relation
either of cause or effect of the flexure, often bind the pelvic organs
together in a mass of exudate, with resulting failure of nutrition,
nerve-irritation, and constant pain, which sometimes render the
patient's life miserable and useless.
SYMPTOMS AND COURSE.--The numerous symptoms due to the inflammatory and
other complications should not be confounded with those of the
displacement. The symptoms of anteflexion are polyuria and dysuria,
dysmenorrhoea and sterility.
The vesical symptoms are produced either by the rigidity of the uterine
tissue at the angle of flexure, which prevents the body from rising out
of the way of the filling bladder, or by the inflammatory shortening of
the utero-sacral ligaments, which, by drawing the uterus upward and
backward, put the vesico-vaginal wall on the stretch, thereby causing
traction upon the neck of the bladder.
The dysmenorrhoea may depend upon the presence of constriction of the
uterine canal at the angle of flexure. This causes the blood to
accumulate and to coagulate in the body of the uterus, from which it is
expelled at intervals by uterine contractions simulating labor-pains.
The pain when due to this cause is therefore always very severe just
before the passage of a clot. Furthermore, the dysmenorrhoea may be
caused by obstruction in the veins at the angle of flexure, which
causes intense venous congestion of the entire body of the uterus; pain
is then due to the pressure of the swollen vessels upon the
nerve-filaments and to a consequent irritable condition of the muscular
tissue of the uterus. Sometimes upon the establishment of the flow the
uterine canal becomes temporarily straightened; this removes the cause
of the vascular obstruction, and together with the flow gives relief.
Sterility is very commonly associated with anteflexion. The fact that
dilatation and incision of the constricted canal have frequently been
followed by conception has been accepted as proof that the sterility is
due to the constrictive obstruction. This mechanical theory is
questioned by many, who say that the dilatation cures sterility by
straightening the uterus and thereby removing the venous obstruction
and the consequent congestion.