flexion, and movements of the uterus will appreciate the anatomical
differences between pathological and normal anteflexion. The degree of
flexure, the mobility or rigidity, and the size, shape, location, and
consistency of the uterus may be ascertained by conjoined manipulation.
The presence of post-uterine cellulitis is recognized by the pain
caused in dragging the uterus slightly forward and by increased
thickness and tenderness in the region of the utero-sacral ligaments,
which may be felt by vaginal or rectal touch. Anteflexion is
distinguished from a fibroid in the anterior wall of the uterus by the
probe. When the diagnosis of anteflexion is obscured by the presence of
cellulitis, it is usually better to wait for absorption of the exudate
than to subject the patient to needless danger from the probe. Should
it be necessary to pass the probe, the danger is decreased by gentle
manipulation, which is facilitated by Sims's speculum and the
latero-prone position. The common error of mistaking the normal version
and flexion of a prolapsed uterus for pathological {179} version and
flexion has been exposed in a previous paragraph. (See Etiology and
Clinical History of Descent.)
TREATMENT.--If complicating cellulitis or peritonitis exist, in the
relation of either cause or effect to the flexure, its removal becomes
the prime indication, because unless removed it is a positive
contraindication to the more direct treatment of the malposition
itself. Chronic metritis, hyperplasia, hypertrophy, and irremovable
tumors sometimes render cure impossible. Improvement of the general
health, treatment of complications, and palliation then become the only
resources.
The direct treatment of pathological anteflexion has for its object the
straightening of the uterine canal, which is usually accomplished
either by division of the cervix or by dilatation. But before
considering the treatment more specifically, it should be remembered
that surgical treatment of anteflexion in cases of dysmenorrhoea and
sterility is only justifiable when the anteflexion is pathological. To
say that most women who suffer from dysmenorrhoea and sterility have
anteflexion is only saying that in the majority of such cases the
uterus is in its normal position.
The Marion-Sims operation of dividing the cervix is open to two
objections: first, its results are apt to be only temporary, in
consequence of rapid contraction upon healing of the wound; second, it
has frequently been followed by death. Dilatation by means of tents is
also transient in its results, and dangerous to life. Both Sims's
operation and dilatation by tents have given frequent and serious
warnings in the shape of pelvic inflammations, which, if not
destructive to life, have been almost as disastrous in their influence
upon health.
The following, with some modifications, is an abstract of a valuable
contribution[10] by Goodell of Philadelphia, in which he gives positive
endorsement to rapid dilatation as proposed by Ellinger and others. The
instruments recommended are two Ellinger dilators, which are preferred
on account of the parallel action of their blades. The dilatation is
commenced with the smaller instrument and completed with the larger,
which has powerful blades that do not spring or feather. The light
instrument needs only a ratchet in the handle, but the stronger one has
a screw which forces the handles together and the blades apart. To
prevent injury to the fundus when the instrument is open, the length of
the blades is limited to two inches. The larger instrument has a
dilating power of one and a half inches, and has a graduated arc in the
handles which indicates the divergence of the blades. Goodell's
modification of Ellinger's dilators is provided with serrated blades,
to prevent them from slipping out of the canal during the process of
dilatation.
[Footnote 10: _American Journal of Obstetrics_, 1884, p. 1179.]
For dysmenorrhoea or sterility due to flexion or stenosis the method of
operation is as follows: A suppository containing a grain of the
aqueous extract of opium is introduced into the rectum, the patient
etherized, and the uterus exposed by Sims's speculum. The cervix is
held by a tenaculum, and the smaller dilator is introduced as far as it
will go. Upon gently stretching open that portion of the uterine canal
which it occupies, the stricture above so yields that when the blades
are closed they will pass higher. By repeating this manoeuvre a
cervical canal is tunnelled out which before would not admit the finest
probe. Should the os {180} externum or cervical canal be too small to
admit the instrument, a pair of pointed scissors may be substituted,
and by the same opening and closing motions the canal may be prepared
for the introduction of the smaller dilator. As soon as the cavity of
the uterus has been entered the handles are brought together. This
dilator is then withdrawn, the larger one introduced, and its handles
slowly screwed together. If the flexure be very marked, the larger
instrument after being withdrawn should be introduced with its curve in
the opposite direction to that of the flexure, and the final dilatation
made with the dilator in this position. But in reversing the curve the
operator should take care not to rotate the organ upon its own axis,
and not to mistake a twist thus made for a reversal of the flexure; the
ether is then withheld, and the instrument allowed to remain in place
until the patient begins to flinch, when it is removed. The best time
for the dilatation is midway between the monthly periods. In the
majority of cases the dilatation should be carried to about one and a
quarter inches. The infantile uterus which has failed to develop at
puberty has thin, unyielding walls, and should therefore not be dilated
more than three-fourths of an inch or an inch. In using the larger
instrument it is usually necessary to have the assistant make decided
counter-traction with the vulsella forceps to prevent the blades of the
dilator from slipping out. The cervix is sometimes lacerated, but not
sufficiently to produce unpleasant results.
Goodell's statistics include one hundred and fifty operations of full
dilatation under ether, with no fatal result and without serious
inflammatory disturbance. As precautions against cellulitis,
peritonitis, and metritis the patient should be fortified for the
operation with moderate doses of opium and full doses of quinine, and
for two or three days after the dilatation this should be continued and
supplemented by the application of an ice-bladder over the abdomen.
After forcible dilatation under ether the cervical canal rarely returns
to its previously angular or contracted condition. The cervix shortens
and widens, and the plasma thrown out thickens and stiffens the uterine
walls. In a small minority of cases the operation must be repeated.
Dysmenorrhoea or sterility, if dependent solely upon the flexure, is
cured by the dilatation. The comparative safety of forcible dilatation
in the hands of a skilful and experienced gynecologist may be
contrasted with its great danger when undertaken by an operator
unacquainted with the special requirements of uterine surgery.
Peri-uterine inflammation is a positive contraindication to the
operation.
Post-uterine inflammation, which has drawn the anteflexed or anteverted
uterus upward and backward by the contraction of the utero-sacral
ligaments, often produces traction upon the vesico-vaginal wall and
neck of the bladder, with a constant desire to micturate. For the
relief of this intractable symptom, which sometimes goes on to
cystitis, Emmet has proposed a most satisfactory remedy known as his
buttonhole operation of urethrotomy.[11] He makes a longitudinal
opening about five-eighths of an inch long through the urethro-vaginal
wall, between the meatus and the neck of the bladder, without cutting
through either. To prevent the opening from healing together, the
margins of the mucous membrane of the urethra are united with fine
catgut sutures to the {181} margins of the mucous membrane of the
vagina. According to Emmet, the operation relieves irritation due to
traction on the neck of the bladder by freeing the pelvic fascia at the
fixed point where it converges to its pubic attachment. The operation
is equally applicable for the relief of this symptom when due to
inflammation in any other part of the pelvis. The same result may be
secured, but less satisfactorily, by forcible dilatation of the
urethra.
[Footnote 11: Emmet's _Principles and Practice of Gynecology_, 3d ed.,
pp. 275 and 761.]
From personal experience the author can testify to the gratifying
effects of this operation. Vesical irritation caused by post-uterine
inflammation and consequent contraction of the utero-sacral ligaments
is often wrongly attributed to the mechanical pressure of the
anteflexed fundus uteri upon the bladder, which is manifestly
impossible, if the contracted utero-sacral supports hold the entire
uterus back away from the bladder.
The various anteflexion and anteversion pessaries which have been
devised for the purpose of propping up the corpus are almost useless.
Their false reputation depends upon the relief which they frequently
give to complicating prolapse, the symptoms of which have been wrongly
attributed to anteflexion or anteversion. The same pessaries therefore
may be applied as in descent. (See Etiology and Clinical History of
Descent.) Intra-uterine stem pessaries designed to straighten the
flexed uterus are sometimes effective, and always dangerous.
{182}
DISORDERS OF THE UTERINE FUNCTIONS.
BY J. C. REEVE, M.D.
Menstruation with its disorders is the only subject to be considered
under this head. In its monthly recurrence it is most intimately
connected with, and dependent upon, ovulation, each menstrual discharge
being the sign and evidence of the maturation and expulsion of one ovum
or more. This proposition is denied by some, but the evidence adduced
against it, while sufficient to show that the two processes may be
dissociated, and may sometimes occur independently, is not strong
enough to invalidate the truth of the general statement.
Menstruation may be entirely absent, the flow may be excessive, or it
may be accompanied by severe pain; and these derangements have been
designated from time immemorial as amenorrhoea, menorrhagia, and
dysmenorrhoea. The time is long past, however, when these affections
could be treated as distinct diseases. Each of them may be caused by
influences so various--and, above all, may depend upon pathological
conditions so different, and even dissimilar--that the name applied to
each is indefinite, and, like the term dropsy, only incites inquiry as
to some abnormal condition of which the deranged flow is the symptom. A
due appreciation of this fact is of prime importance, because treatment
cannot be instituted with expectation of success until the particular
form of each derangement has been distinguished.
The great majority of cases of uterine derangement depend upon changes
of structure. Those considered purely functional are largely in the
minority, and would be still less in number with a more intimate
knowledge of pathology or with greater skill in examination. No
argument is needed, therefore, to show that a direct and thorough
examination of the organs concerned is essential to rational treatment
of this class of affections. There are obvious difficulties in the way
of such an investigation, different from and far greater than attend
the investigation of the diseases of any other organ of the body. With
tact and proper demeanor, however, these difficulties can be generally
overcome, but in any other than trifling cases, and especially in those
continuing for any considerable time, the practitioner will do
injustice to himself as well as to his patient if he do not insist upon
this indispensable investigation.
A due appreciation of the influence of uterine disorders and diseases
upon other and remote parts of the body is necessary to a correct
estimate of their importance, and often of great practical value in
treatment. Through the sympathetic nervous system pathological
conditions of the uterus modify the processes of organic life, and by
direct or reflex action {183} affect the cerebro-spinal system in its
centre or at any point of its terminal ramifications. That the stomach
responds readily to uterine excitations is shown in pregnancy, and
uterine disease often causes disorders of the digestive organs the
origin of which may not be suspected. Eructations, vomiting, and the
various forms of indigestion are not uncommon. The bowels are irregular
in action, constipation alternating with diarrhoea, and flatulent
distension may occur even to a degree demanding special treatment.
Failure of general nutrition and impoverished blood are the
consequences of this disturbed digestion; without good blood there is
no sound innervation, and the nervous system is soon in such a
condition as to respond unduly to even insignificant impressions.
Normal menstruation is marked by a nervous erethism which shows itself
by irritability, fits of despondency, and exhibitions of temper. There
are therefore abundant reasons why nervous diseases should be very
frequently seen as a remote effect of uterine disorders.
A very large proportion of these reflex diseases first occur at the
period of puberty, many present striking exacerbations at every
menstrual period, and some are so closely associated with this function
as to be cured only by remedies addressed to it. Headache, neuralgia,
hysteria in its varied forms, chorea, catalepsy, epilepsy, and even
mania, have been repeatedly shown to have their origin in the sexual
organs. The reproach often directed at gynecologists, of a disposition
to magnify their specialty, falls pointless before such important
facts; and since it is not uncommon for diseases of organs in close
proximity to the uterus, as those of the urethra, bladder, and rectum,
to be mistaken for or confounded with diseases of the uterus itself,
there is abundant warrant for urging the closest scrutiny as to a
possible uterine origin of remote diseases, especially those of a
nervous character.
Amenorrhoea.
The term amenorrhoea signifies the absence of menstruation. It occurs
in two different forms: First, those cases in which menstruation has
never occurred--emansio mensium; second, those in which it has
disappeared after having been established--suppressio mensium.
The following pathological schedule may assist in the study of the
subject. It need scarcely be said that it is not presented as correct
in every particular, nor with the idea that the dividing-lines between
physiological and pathological conditions can be always determined, but
as a convenient guide to follow in the study of the subject:
A. Amenorrhoea (absent menstruation) from
_a_, anatomical conditions: want of development of organs,
atresia of passages;
_b_, physiological influences: delayed puberty, idiopathic;
_c_, pathological causes: constitutional diseases, disease of the
sexual organs, the cachexiæ.
B. Amenorrhoea (secondary or suppressed menstruation):
_a_, anatomo-pathological: atresia of passages, atrophy of
organs;
_b_, physiological: pregnancy, nursing, premature change of life;
_c_, pathological: besides those given above--A-_c_--are
psychical influences and exposure or taking cold during
menstruation.
{184} Absence or want of due development of some of the sexual organs
is not of very infrequent occurrence. The ovaries are very rarely found
wanting; they are more often checked in development and present the
characteristics of early life. This condition may be the cause of
delayed, irregular, or scanty menstruation, making a more or less near
approach to amenorrhoea. Absence of the uterus is often combined with
absence or with an undeveloped condition of the vagina, but this canal
may be perfect and no change of the external organs be present to
indicate that the uterus is wanting. It may also exist in a rudimentary
form, and may be found corresponding in size and shape to the uterus of
any period of early life.
Absence of the ovaries not only causes amenorrhoea, but checks the
progress of the bodily development and prevents the sexual changes of
puberty. When the ovaries are wanting there is almost always absence of
the Fallopian tubes, uterus, and vagina. The symptomatology of absence
of the uterus is not generally striking, the lack of menstruation being
the principal sign; exceptionally, however, it is otherwise. In some
cases where the ovaries are present and the uterus wanting, the most
aggravated affections of the nervous system show themselves.
Congenital atresia of the genital canal may occur in any part of its
course. Imperforate hymen is the most frequent as it is the least
dangerous form, being more than twice as common as atresia of the
vagina and three times as frequent as that of the cervix uteri. The
vagina may be extremely small in calibre, closed in part or the whole
of its course, or only a fibrous cord indicate where it should be. The
uterus may be closed at the internal or external os; the latter is the
more frequent. An occlusion at one point does not preclude the
existence of other closures higher up. The effect of a closed canal
with a recurring secretion above is evident, and gives rise to a
well-marked class of cases. The organs above become distended, and the
distension increases until an opening is made by art or the retained
fluid bursts a passage for escape. This may occur outwardly with
immediate relief and cure, or into the peritoneal cavity, causing
speedy death. The time at which the uterus may be expected to give way
under such distension cannot be stated, as the power of resistance of
the organ differs and the amount of secretion each month may vary
widely. Scanzoni in one case evacuated eight pounds of blood, the
result of seven months' accumulation, and found the uterine wall as
thin as paper. Bernutz states that the average time before interference
is necessary is three or four years, and gives a case first operated
upon in the tenth year of its course.
Menstrual retention is not at first indicated by pronounced symptoms.
Suspicion of the nature of the case may be first excited by the
severity of those symptoms which at every period announce the approach
of menstruation and known as the menstrual molimen. As distension
increases these become extreme, with rectal and vesical tenesmus and
severe uterine colic. The nervous system sympathizes, as with all
menstrual derangements, and there may be rigor, fainting, or even
convulsions.
Whenever a patient presents such symptoms an examination should be
insisted upon. It will generally reveal a smooth, soft, and fluctuating
tumor, projecting externally if the case be one of imperforate hymen,
or higher up if the vagina be occluded. If the uterus has become
distended, {185} there will be a round, smooth, elastic tumor above the
pubes. Diagnosis will be more or less difficult according to the seat
of the obstruction. Cases of imperforate hymen may be readily diagnosed
by sight, if touch and the history are not sufficient. When the
occlusion is deeper, the patient should be placed under the influence
of an anæsthetic. By one finger in the rectum and the thumb in the
vagina, and a sound in the bladder, the seat and extent of the
obstruction may be determined. Should it be necessary, the urethra may
be dilated and a finger passed into the bladder in order to make a
diagnosis. Rectal exploration is of great assistance in discovering the
uterine enlargement and its character. Scanzoni calls attention to the
difference in the cervix when the atresia is at the internal or
external os. In the latter case the cervix will be obliterated; in the
former, it will be unchanged. With a perfect vagina and a cervix of
this character retention may be taken for an early pregnancy,
especially as it is not uncommon for sympathetic mammary symptoms and
gastric troubles to be present. Time will demonstrate the nature of the
case if a diagnosis cannot be made at once.
The age at which the menstrual flow is established varies greatly. The
average age of puberty in this country, as appears from Emmet's tables
made up of 2330 cases, is 14.23 years, and these are believed to be the
only American statistics. A close correspondence may be noted between
this and the statistics of the four largest cities of France, which
give 14.26 as the average. But that it is not unusual for the
appearance of menstruation to be delayed is shown by the fact that of
the above 2330 cases, 288 only menstruated at sixteen years and 254
more between that age and twenty-three. The circumstances which may
influence, within physiological limits, the appearance of menstruation
should be considered in connection with cases of this kind. Climate and
social position are the principal ones. The epoch of puberty descends
in the scale of age in proportion to the average height of the
temperature of various countries, and vice versâ. Social position and
city life show a marked effect in hastening puberty as compared with
the simpler manners and plainer life of rural populations. It amounts
to an average of something over a year, and is explained by the
influence of enervating and luxurious habits, of light reading and the
drama, the chief subject of both being the grand passion, but
especially of a freer intercourse between, and the co-education of, the
sexes, and the greater extent to which music is cultivated and enjoyed.
Among pathological conditions giving rise to amenorrhoea it would seem
that disease of the ovaries should occupy the first rank in frequency
and importance. The reverse is the truth. The ovaries are rarely
inflamed, and when so amenorrhoea is not always the result. They are
frequently the seat of cystic degeneration, producing tumors of large
size, yet so long as but a small portion of one of the organs remains
unaffected Graäfian vesicles may still be furnished and menstruation
continue. It is by the influence of remote pathological conditions that
the menstrual flow is most frequently restrained, and especially by
those general affections known as cachexiæ, all of which exhibit marked
depression and low grade of vital power and activity, if not more
pronounced pathological processes. Chlorosis, the relations of which to
menstruation are intimate, and which seems to be sometimes the
offspring of {186} amenorrhoea, exerts a marked retarding influence,
amounting to an average of one year and a half. The scrofulous cachexia
is still more potent: Scanzoni states that of 31 well-marked cases, in
19 menstruation did not occur until the twenty-first year.
Amenorrhoea which is the result of pulmonary tubercular disease comes
frequently under observation. It may occur at a very early period of
the disease, before there is any great amount of deposit in the lungs,
when it is rather the expression of want of vital force than of the
exhausting effect of the disease. Under these circumstances it is only
to the laity a subject of serious consideration; to the physician it is
but a symptom.