VERSIONS AND FLEXIONS OF THE UTERUS.
VERSION, in the nomenclature of diseases of the womb, means that the
entire organ without any deflection in its normal axis turns, inclines
or leans either forwards, backwards or sidewards.
The prefix _ante_ is used in the sense of forwards and in composition
with _version_ we have the word _anteversion_, which in conjunction
with the term uterus, signifies that the organ is inclined forwards.
The prefix _retro_, signifies backwards, and in composition with the
word _version_ and in connection with the word uterus, it implies that
the womb is turned backwards.
The word _flexion_ differs from _version_, inasmuch as it signifies
a bending or bowing, which breaks the normal axis of the womb. The
neck or cervix of the uterus may retain its normal position, while its
_body_ is abnormally deflected or bent in any direction. The prefixes
_ante_ and _retro_ are also used in composition with the word _flexion_
as they are with _version_. These distinctions should be remembered.
ANTEVERSION OF THE UTERUS.
In anteversion the uterus has so far changed its normal shape that the
cervix of the organ is stretched out or extended in a line with the
axis of the body. This occurs when the uterus is unusually swollen
from inflammatory enlargement. The normal location of the body does
not materially change in these cases. It is a little more depressed on
the fundus of the bladder and the cervix is correspondingly elevated,
so that the latter stands considerably higher than in health. If the
bladder is empty, and the patient bears down or does anything that
increases the intra-abdominal pressure, the body of the womb is forced
down, upon the anterior vaginal wall, which prolapses into the vagina,
while the cervix is raised, so as to point upwards and backwards. When
the bladder is full, the body of the uterus is naturally raised, and
the cervix correspondingly depressed. And this is attributable to a
rigidity or stiffness about the organ, that is characteristic of a
chronic inflammatory enlargement of the uterus. Sometimes the organ is
permanently fixed by inflammatory adhesions, that lessen or prohibit
these movements.
The symptoms of anteversion are what may be expected from an enlarged
congested organ. This enlargement is due either to a subinvolution of
the uterus or to an inflammation of the intermuscular substance, a
chronic metritis. One of the most annoying symptoms of the anteverted
uterus is the feeling of looseness in the pelvic cavity. This is partly
due to the relaxed state of the surrounding tissue, and partly to the
abnormal size of the womb. The patient feels the organ roll from side
to side, as she changes her position. This causes unnatural sensations
and mental suffering that disturbs the nervous system and induces
hysterical complications. And the patient complains about something
moving in her abdomen.
The inflammatory adhesions that sometimes tie down the organ in an
anteverted position, compromise the normal expansion of the bladder;
this induces an irritation, which causes a frequent desire to urinate.
The treatment must be directed to the removal of the cause. This
disease is really only a symptom or condition of chronic corporeal
metritis or subinvolution, and as such, it is only amenable to the
measures that will cure this disease. The employment of rings and
pessaries to remedy this evil is contrary to good sense and of no
permanent value.
The intelligent employment of electricity, so as to stimulate the
absorption of the hypertrophic enlargement of the uterus and cause the
absorption of the inflammatory adhesions, will often give permanent and
positive results.
ANTEFLEXION OF THE UTERUS.
This was considered at one time the most frequent of all uterine
displacements, not because it existed formerly oftener than at present,
but because the natural or normal position of the womb was confounded
with that which was supposed to be abnormal.
The discovery that in the living subject the body of the uterus
naturally inclines forward, so as to rest on the bladder, and that the
body makes quite an angle with its cervix, altered the conception of
things very materially. To-day an actual aggravated anteflexion, that
occasions no impediment to the menstrual discharge, is not a proper
ground for treatment, although this is as yet by no means familiar to
physicians in general, for many of them have not learned to make the
distinction.
The reader should carefully study Plate II, which diagramatically
illustrates how the body bows over the bladder so as to show its
natural anteflexion. If the angle between the body and neck of the
womb becomes too sharp or acute, so that the canal of the uterus
becomes compressed at the point of flexion, in a degree that obstructs
the escape of the natural secretions of the uterine cavity, then the
anteflexion becomes a source of disease. This degree of flexion is
happily very rare, and we find it in about equal proportions due to a
congenital defect, that springs into prominence when the girl arrives
at puberty, for then the obstruction to the menstrual flow is first
realized.
The other class acquire the affection in adult life, after a once
healthy or natural menstruation has been established. Of this class
there are two species, which must be separately analyzed, so as to
avoid a confusion of ideas, that often makes this subject, _which is
the most simple_, one of the most intricate, in the text books in
gynecological practice.
One variety of the acquired affection can be described, in common
with the congenital form, to which I first referred: because the
anteflexions in both cases are due to precisely the same pathological
conditions, namely, a loss of muscular tone in the uterine walls, so
that the organ becomes flabby and weak, like a green wilted stalk,
allowing the body of the uterus to topple forwards.
The relaxation of the uterine walls is usually more pronounced at that
portion which is distinguished as the _isthmus_ of the uterus, and
corresponds to that part of the organ where the cervix goes over into
the body, forming a sort of natural hinge joint between body and neck.
If the bladder is empty, the body of the womb will naturally drop, not
necessarily forwards, for it may fall backwards, but in the majority
of cases it drops forwards, because the womb is already inclined
forwards in its natural position, so all that is necessary to induce
an excessive anteflexion, is for the body of the uterus to sink lower
than it is natural for it to be. A kink or sharp bend will cause in any
canal an occlusion. Take a small rubber tube, for instance, and bend
it sharply at right angles; the result will be at the corner of the
deflection, that the tube will be flattened, and its walls will come
together. In the case of the uterine canal, where there is an abnormal
flexion, there is precisely the same condition, and as a result
an obstruction not only to the menstrual fluid, but to the mucous
secretions, which are pent up in the uterine cavity. The retained
fluids decompose and irritate the mucous lining; and this entails a
complication of inflammatory diseases, which can never be cured, unless
the flexion is remedied.
The other variety of the acquired flexion is due to a pelvic
cellulitis. This is an inflammatory process, entirely outside of the
uterus.
The womb is surrounded by a great deal of loose cellular tissue, that
fills out the interspaces between the different ligaments and pelvic
organs. This tissue often becomes the seat of an inflammation. The
exudation from the inflammation may be of such a nature that it forms
strands of _fibrous tissue_, running from the isthmus of the uterus
backwards to the sacrum. These strands contract or shrink in the course
of time, and this draws the isthmus of the uterus backwards, and fixes
or attaches it to the posterior pelvic wall. By this contraction of the
fibrous tissue the cervix is constricted and the body falls unnaturally
forwards.
The prominent symptoms of anteflexion are painful menstruation and
sterility. Dysmenorrhœa or painful menstruation is the first sign of
the existence of anteflexion at the age of puberty. It happens that
young girls are thus tortured for days with violent uterine colic, that
is occasioned by spasmodic efforts of the uterus to force through the
constricted canal the pent-up secretion. This lasts until the menstrual
fluid has sufficiently dilated the cervical constriction to allow its
escape. These painful paroxysms of uterine colic repeat themselves at
each recurring menstrual period, and through these repetitions of pain
and suffering, the general health becomes greatly deranged. The nervous
system becomes the seat of functional disturbances, and hysterical
disorders are not uncommon.
The organ becomes involved in chronic inflammatory processes that make
the uterus exceedingly sensitive, so that the colicky pains become
aggravated and prolonged far beyond the cessation of the menses. Some
of these patients suffer for several weeks, from the time the courses
ought to begin, so that they are actually sick half the time.
Sterility is not an absolute certainty in all these cases, but it is
traced so often to an aggravated flexion, that it may be accepted as
one of its most prominent signs. Conception has taken place in extreme
flexions, because the spermatozoa can gain admittance into the uterine
cavity for several days after the uterine colic and menstrual fluid
have forced the canal open. And if the uterus has not become involved
in inflammatory processes, then conception is the means by which nature
effects a cure through her own resources.
During the menstrual period, the anteflected uterus becomes greatly
congested and swollen, and, having already grown considerably larger
from the chronic inflammatory conditions which the anteflexion has
induced, it impinges on the bladder, so as to interfere with its free
expansion. This occasions a frequent desire to void urine, and this
becomes a very distressing symptom in a certain proportion of cases.
Treatment for this affection is not within the sphere of the original
purpose of this work, for the efforts at home treatment must be aided
by mechanical methods of the physician. From what we are taught of the
physical cause of this affection, the fact seems self-evident that
the acute or sharp flexion must be modified to give permanent relief.
The employment of rings, pessaries, sponges or medical applications
are nonsensical, and the method of introducing a stem in the uterine
cavity, for the patient to wear for an indefinite length of time, is
not without great danger. Even though a woman cannot give herself all
the proper treatment, it must be a great satisfaction to her to be
informed of the proper methods that should be adopted.
The vagina should be thoroughly rinsed before each and every treatment
of the uterus, so as to guard against the possibility of infecting the
cavity of the uterus.
If the manipulations that are required for the purpose of carrying out
some of the mechanical or surgical treatments of uterine diseases, were
always preceded with thorough cleanliness, which implies _asepsis_, or
without putrescence, then all these operations would be shorn of their
greatest danger, namely, that of exciting inflammation and suppuration.
If a probe of the usual curve can be readily introduced into the
supposed anteflected uterine cavity, then there cannot be sufficient
flexion to constitute an obstruction, hence the flexion is not the
cause of the disease. In genuine anteflexion, the cervix and body of
the uterus are doubled up on each other, often like the letter V,
the cervix representing one line of the V, and the body the other;
bi-mammal palpation in the hands of an expert clearly establishes this
conformation.
When the diagnosis is established, the treatment should be as follows:
The patient is inclined on a table, either on her back or side, a
Sims’ speculum is introduced into the vagina and the cervix exposed.
The posterior lip of the cervix is now seized by means of a tenaculum
forceps, and gently drawn downwards and backwards, which greatly
reduces or obliterates the angle or flexion between the cervix and
the body of the womb, this greatly facilitates the introduction of a
uterine electrode. After two or three treatments, the forceps are no
longer required because the electrode can then be readily introduced
into the uterine cavity without them. The other electrode is spread
on the abdomen. (See this illustrated on Plate V.) A current of
electricity is now passed through the uterine tissues for ten minutes;
this is gauged all the way from sixty to one hundred _milliampères_.
The operation is repeated only once a week, and the cure is effected
in six weeks to three months. Great care must be exercised during the
treatment, to avoid exposure and undue exercise.
Those forms that are due to inflammatory deposits and strands outside
of the organ, should be preceded with an electrical treatment twice
a week, somewhat modified from the preceding course. This is done
by employing a _vaginal electrode_, properly protected and gently
pressed against the adhesions. The other _electrode_ is applied to
the small of the back. A current some fifty _milliampères_ stronger
is passed directly through the adhesions; when these are absorbed,
the intra-uterine electrode is employed, as in cases that are not
complicated with them.
RETROVERSION OF THE UTERUS.
This consists in a posterior inclination of the uterus, so that the
body of the womb approaches the posterior walls of the pelvis, while
the cervix of the womb is raised against the base of the bladder.
[Illustration: PLATE IV.
Retroflexion of the Uterus, or the Womb, bent backward.
This plate elucidates the womb bent or turned backward and pressing on
the rectum. This condition is generally traceable to the vicious custom
of lying on the back after confinement or during childbed. The natural
position of the organ, inclined forward and resting on the bladder, is
also shown.]
As a permanent pathological lesion, this form of displacement is very
rare, but as a forerunner of retroflexion it is of frequent occurrence.
The length of time that elapses for a version to take on a flexion
depends on the degree of induration or stiffness of the uterine walls.
The chronic inflammatory enlargement of the uterus predisposes the
organ to posterior displacement, and the displacement favors the
development of flexion. This takes place in the following order: After
the uterus is displaced backwards, and its cervix has become fixed by
inflammatory adhesions, the body of the womb gradually glides down
on the posterior pelvic wall, from gravitation and intra-abdominal
pressure. And in this very simple manner a retroversion is converted
into a retroflexion. The causes, symptoms, and complications that
characterize this variety of displacement, with its subsequent
modification into flexion, are the same as those of retroflexion, to
which the reader is referred.
RETROFLEXION OF THE UTERUS.
This form of uterine displacement exists when the body of the womb is
bent towards the posterior wall of the pelvis, which is in an opposite
direction to that where it naturally belongs. I have already pointed
out, in speaking of the normal position of the uterus, that the body
is directed forwards and rests on the bladder, while its cervix points
downwards into the pelvic cavity. I now refer you to Plate IV, in which
I plainly show the uterus in a directly opposite position to that in
health, namely, turned back, resting on and depressing the rectum.
In retroflexion the cervix of the uterus continues to point downwards,
into the pelvic cavity, in almost the same direction as in the natural
position, while the body is directed backwards, or backwards and
downwards. We seldom, if ever, find this condition as a congenital
affection, but as an acquired displacement it is undoubtedly more
frequently met with in gynecological practice than all other
displacements combined. The round ligaments of the uterus were at one
time, and are even yet by some, supposed to be the means that retain
the womb in its normal anteflected position. Upon this theory a new
surgical operation sprung into prominence for the relief of this class
of cases. It was reasoned, that if the round ligaments actually tied
the uterus down, and retained it in its natural anteflected position,
that to shorten these ligaments by opening the inguinal canal in the
groin, and drawing them out, would remedy a displacement of the womb,
whether a prolapsus or a retroflexion. This operation was performed,
it was claimed successfully, and if the view that the round ligaments
retain and support the uterus were a correct one, it must be admitted
that the operation would have been _ideal_. I convinced myself,
however, of the utter fallacy of this position, in dissections on the
cadaver, where in several instances the round ligaments could not be
reached without opening the abdominal cavity, and even then it was
impossible to trace them. These views were expressed in an article
in the _American Journal of Obstetrics and Diseases of Women and
Children_, and as the operation fell shortly afterwards into merited
disrepute, I partly claim the credit of having been instrumental in
bringing that about. I said:
“That this ligament has nothing to do in fixing the uterus in its
normal anteverted position, is proven from many facts which occur in
daily practice. The insertion or origin, whichever one chooses to call
it, of these cords at the groin, is somewhat irregular and sometimes
so rudimentary that it cannot be found upon a most careful and tedious
dissection. It may be found divided into a number of processes, one
being connected with Poupart’s ligament in the inguinal canal, the
other being lost in the labia majora, and another may be traced to the
sheath of the rectus muscle.
“If these cords were so important as the advocates of the
Alexander-Adams operation try to make us believe, in binding the
uterus forward, and, as we are recently informed, have a strength
equal to support four and one-half pounds weight, a great deal of
uneasiness, if not actual pain, would be felt and located along the
inguinal canal, following this structure to its points of insertion,
in sudden dislocations of the uterus backwards. This is, however, not
the case; when sudden painful symptoms arise, they are invariably
referred to the sacral region. In sudden retroversions or flexions, as
in the pregnant uterus, occurring accidentally or those retroverted or
flexed uteri which are so often met with in a state of subinvolution
after confinements, there are no symptoms pointing to a tension of
these cords at all, but all symptoms point to uterine pressure on the
posterior pelvic wall, which can be precisely located. And these pains
disappear as soon as the offending member is put right.”
There is no doubt that the uterus retains its abnormal retroflected
position by the same forces that keep it in a normal or anteflected
state; these are (1) intra-abdominal pressure, and (2) the force of
gravitation of its own weight.
In some women there are certain predispositions to the occurrence
of a retroflexion. If the walls of the uterus are weak and relaxed,
especially that portion where the cervix unites with the body of the
womb, then the body may fall in any direction, and, as the bladder is
liable to be distended, and thus raise the body of the uterus upwards,
folds of intestine are likely to intervene, so that the organ is
inclined backwards, and the abdominal pressure, now falling on the
anterior surface of the body, presses the womb backwards and downwards
into a flexion.
A fall backwards or a violent push or jump may cause retroflexion
any time during life. Retroflexions of this nature are not as a rule
injurious, and if the circulation is not compromised, nor the uterine
canal obstructed, women may go through life without feeling any the
worse because their womb occupies an abnormal position. It is only when
the organ is congested and swollen, so that its own tissue is painfully
sensitive, and the surrounding tissues are compressed by the foreign
body, that it requires measures for relief.
In those women who have borne children, and those who have gone through
a miscarriage, retroflexion is frequently met. A little reflection
will make this clear, for when we remember how the pregnant uterus at
any time from conception to final delivery becomes congested and the
seat of a corresponding growth of its own tissue to accommodate the
growing fetus, we at once perceive that either after an abortion or on
delivery at full term, the enlarged and congested uterus is in the best
possible condition, to lose its normal place and sink backwards. The
pernicious custom in vogue in most countries, of keeping a woman on the
flat of her back after delivery, has never been as vehemently opposed
by the intelligent members of the profession, as the gravity of the
subject demands. Some women have an idea that the longer and quieter
they remain on their backs, the surer they are to make an excellent
recovery from the lying-in chamber. American and English practitioners
are inclined to recommend this as the most proper way to lie, but there
is no doubt that this not only favors the occurrence of retroflexion,
but that it actually causes it.
The woman who rests on her back gives to the heavy body of the womb an
opportunity to sink backwards, after the distended bladder has pushed
the organ high enough up so that its own weight may throw it over,
until it finds resistance on the posterior wall of the pelvic cavity.
Many nurses insist on the dorsal position for days, and never permit
the patient the privilege of lying upon one or the other side. Aside
from the injurious effect that this has on the position of the uterus,
it is exceedingly tiresome to be compelled to remain for several days
in one position. Women should be allowed to lie on all sides, after
delivery, and no longer on one side than on another. And to insure
against a retroversion or flexion, she must also lie on the abdomen a
certain length of time during each twenty-four hours.
Tight bandaging after delivery, for “preserving the figure,” greatly
aggravates the displacement; the binder should be so applied that it
feels comfortable but not too tight, its purpose being to offer a
gentle support to the suddenly relaxed abdominal muscles, and thus
stimulate them to contract to their normal form.
The symptoms of retroflexion are greatly varied by the pathological
conditions that affect the uterus, or by the complications that may
have caused the flexion.
It is indisputable that the uterus may be retroflected for an
indefinite length of time without causing any inconvenience. From this
it may be inferred that the retroflection itself does not constitute
the disease, but the inflammatory processes, in which the organ is
involved, or the relaxation of the adjacent structures, as we find
them immediately after confinement, constitute the actual diseased
conditions.
One of the most constant symptoms is pain in the back, and this is
severe in proportion to the swelling and sensitiveness of the organ,
when it presses on the sacral nerves and rectum.
As a result of the flexion, the circulation in the organ is interfered
with, so that the congested uterus feels heavy, and there is a
sensation of fullness and bearing down, that greatly hinders walking.
Uterine catarrh and hyperæmia place the organ in such an irritable
state that prolonged and excessive menstruation is the rule. This may
last for fourteen days, so that the patients become anæmic and greatly
debilitated from the excessive loss of blood. The menstruation is
always more painful, especially at the beginning of the flow; this
pain may be interrupted or spasmodic, so that it assumes the form of a
uterine colic; the lower abdominal region becomes painful and the pain
radiates towards the groins. The degree of suffering is very seldom as
great as that which characterizes anteflexion, because the obstruction
in the latter flexions are much greater than in retroflexions.
Those women who have borne children suffer less pain during
menstruation than those who have never been pregnant. It may be
presumed that, in the latter class, the flexion was congenital
or acquired in early childhood, which makes the obstruction or
constriction more complete and obstinate, and for that reason it
induces sterility. With those who have once borne and afterwards
acquired the flexion, the possibility of conception is much greater.
When the enlarged and swollen body of the uterus is pushed backwards
and downwards, it presses on the sacral plexus of nerves; this is a
bundle of nerves that supplies branches to the legs, and from this
pressure the lower extremities become lame or paralyzed either on
one or both sides. The paralysis subsides after the removal of the
offending body. There is quite a number of other neurotic affections
that can often be traced to a retroflected uterus. These are all of
a functional nature, and appear in the form of hysteria, epilepsy,
St. Vitus’ dance and neuralgias of almost any part of the body. Dr.
Chrobak, of Vienna, reported a case of asthma that had resisted all the
treatments that could be suggested, until it was finally traced to a
retroflected uterus; that being rectified, the asthma subsided.
Irritability of the bladder is not so frequent a symptom of this
variety of displacement as of others; should there be inflammation
complicating the bladder, then, of course, there would be considerable
annoyance from this source.
Habitual constipation is often very prominent and in some of the cases
it is the only sign that leads to an examination, which reveals the
retroflexion. Hemorrhoids or piles, due to a compression of the veins
of the rectum, are another complication included in the signs of this
displacement.
TREATMENT.
There is a small proportion of cases in which the system has become
accustomed to the retroflected position of the womb, and if the
abnormal condition is rectified, a great many painful symptoms spring
into prominence, that are attributable to the interference. This is
particularly the case in women who are in those years that we term
“change of life,” and for this reason they should be let severely
alone.
Excluding the above class of cases, the question arises in other cases
whether the uterus can be replaced without violence, or whether it is
fixed or grown to its surroundings by inflammatory adhesions. It is
not always an easy matter to dispose of this question at once, because
the enlarged and congested body is often so firmly wedged down between
the posterior pelvic wall and the vagina, that any attempt to dislodge
it is accompanied with such acute pain that one feels constrained
to desist for a time. When there is great pain or sensitiveness,
the patient should take to bed, so as to give the pelvic organs
every chance to get rid of the inflammatory irritability. Hot-water
compresses should be applied to the lower abdominal or pelvic region,
and hot vaginal irrigations thrown into the vagina; these should be
copious, no less than a gallon of water at once, at a temperature of
107 to 110° Fahr., repeated twice daily. The bowels should be kept
loose, say several operations each day, for three or four days; after
that once a day will be sufficient.
In the course of several weeks the congestion will have subsided,
so that, in the great majority of cases, reposition can be readily
accomplished. If the resistance of the womb still persists, then it is
reasonable to infer that the organ is tied down by old inflammatory
adhesions; these, then, should be treated with galvanism, after the
manner described for removing adhesions in anteflexions.
The statistics show that, out of every five women who are suffering
from female diseases, one has a posterior displacement, either a
retroflexion or retroversion. The greatest number of these are
traceable to their last confinement. All these displacements, as
well as those that are accidental or induced by a fall, jumps or the
like, should be replaced as soon as possible, otherwise inflammatory
adhesions may complicate and greatly obstruct the replacement.
The reposition or replacement of the womb may be accomplished through
natural agencies, that can be employed by the patient herself. These
are, in a great measure, the same forces to which the womb’s posterior
displacements are to be attributed, namely, intra-abdominal pressure
and gravitation. To employ these for the purpose of remedying the evil,
the so-called knee-chest position must be assumed by the patient. The
first step towards assuming this position is to get down on the bended
knee, the thighs in a vertical position, then the body is gradually
inclined forwards until one or the other shoulder touches the floor or
level of the knee. If this position is retained for ten minutes it will
alone replace the organ forwards, sometimes suddenly, at other times
gradually, provided the organ is moveable and not squeezed into the
pelvis or adhered by inflammatory exudation.
Dr. Henry F. Campbell, of Georgia, introduced this natural therapeutic
agent into the profession, but it appears to be very little known or
understood by the profession, perhaps because it is so very simple.
Dr. Mundé, in an article on “Uterine Displacement and Its Curability,”
in the _American Journal of Obstetrics_, indorses the knee-chest
or knee-shoulder position in the following language: “A moment’s
thought will demonstrate the utility of this combined _vis a fronte_
(gravitation of the abdominal viscera towards the diaphragm) and
_vis a tergo_ (air suction into the vagina and pressure against the
vaginal roof). This position is to be assumed several times daily, and
maintained each time as long as the patient can bear it, continued for
months, if necessary; the best time is at night at retiring, when the
lateral position is to be taken for the night.”
In a certain proportion of cases the knee-chest position alone will
not dislodge the retroflected uterus, so that manual aid is required
to effect that purpose. There is a number of methods that have been
suggested from time to time, but none are so good as that in which the
knee-chest position is combined with the manipulation of the operator.
Reposition may occur spontaneously, and it undoubtedly does in a large
proportion of cases, in which the retroflected organ becomes pregnant.
When the retroflected organ occasions symptoms of retention of urine,
the bladder should first be emptied with a soft No. 8 catheter, then
the patient is directed to kneel on both of her knees, her thighs
remaining perpendicular, while her body inclines forward until one
or the other shoulder touches the floor or level of her knees. The
operator may then gradually lift the womb and elevate the body
sufficiently so that it will fall forward into its natural place. When
there is no bladder trouble from compression, and the womb resists even
mild force to replace it, I have accomplished gradual reposition by
keeping the woman in bed for three or four weeks, with the instructions
that she resume the knee-shoulder position two or three times a day,
and from five to ten minutes, also that she shall lie on her side and
chest and never on her back. In this manner I have accomplished in time
and without force what could not have been accomplished with forcible
attempts without inducing an abortion.
It curiously happens that there are cases of retroflection which are
never suspected nor recognized until the patient has become pregnant.
After the woman is about three months gone, the growth of the
pregnant uterus can no longer be accommodated in the pelvis, because
the direction of its growth is in the direction of the retroflected
organ, namely, backwards and downwards (see Plate IV) which makes it a
physical impossibility to escape from or grow out of the bony pelvis.
The symptoms are retention of urine or a constant dribbling of urine
and a straining at stool or pain in the rectum or pelvis, and, of
course, the absence of the menses since the commencement of pregnancy.
Retroflection may be also acquired during the first three or four
months of normal pregnancy, from a jump or fall on the back, in which
all the symptoms that indicate this condition are suddenly manifested.
In pregnancy, the course that is to be pursued, in order to rectify
the displacement, must be obviously different from that pursued when
the woman is not pregnant. The pregnant uterus is a “touch me not;” it
permits of no tampering without running the fearful risk of inducing an
abortion, and no one but a tyro or an ignoramus will ever meddle with
the pregnant womb.
The replacement of the retroflected uterus, that is positively not
pregnant, and there must be no question about it either, will admit of
introducing a sound into its cavity. This sound is used as a lever upon
which the organ may be lifted out of its abnormal position and inclined
over the bladder in an anteflected position, which is its natural one.
The sound which I employ, and which is my own invention, for replacing
the uterus is screwed into a thimble, and from two and one-half to
three inches long. The object of this is to artificially elongate the
finger so that it can be introduced into the womb. The force which one
employs by using this instrument is keenly appreciated by the operator,
hence there can be no undue strain, that otherwise might be exerted
on adhesions which are too strong to be safely lacerated or even
stretched, while slight and recent adhesions might be torn without any
bad results. Truax, of Chicago, manufactures my repositor.
Before introducing any sound into the uterine cavity, it is absolutely
necessary that the vagina should be thoroughly cleansed with borax
water.
The inflammatory enlargements of the womb, subinvolutions, uterine
catarrhs, and any of the complications that may exist at the time that
the organ is replaced, should be treated on the same principles that
have been laid down in the respective chapters on these diseases; in
fact, these complications constitute part of the after treatment for
retroversion or flexion. The other treatment is to be directed toward
retaining the womb where it naturally belongs. The daily exercise in
the knee-chest position should never be neglected, and in cases in
which this is insufficient, it is very probable that the pelvic floor
or natural support of the uterus has been injured or lacerated during
confinement, and this may require a plastic operation as a preliminary
to a cure. In obstinate cases there is no cure so effectual as
pregnancy and a full-time delivery, provided precautions are taken so
that the mother will not acquire a new retroflexion during her lying-in
period, from the cause that has been already detailed. The patient
must accustom herself to sleep either on the chest with face turned to
one or the other side, or in a semi-prone position on either the right
or left side. Perseverance in sleeping in this manner for a few weeks
cultivates the habit that gives more refreshing sleep than lying on the
back, which most persons are inclined to do.