t'R&FFSSOR OF GYNECOLOGY, Sbieago IBedieal (Sollege. THE UNIVERSITY OF ILLINOIS LIBRARY From the collection of Julius Doerner, Chicago Purchased, 1918. Digitized by the Internet Archive in 2017 with funding from University of Illinois Urbana-Champaign Alternates https://archive.org/details/displacementsofuOOdudl DISPLACEMENTS o p THE UTERUS. BY B. C. DUDLEY, A.B., M.D., PROFESSOR OF GYNECOLOGY IN THE CHICAGO MEDICAL COLLEGE. REPRINTED FROM PEPPER’S SYSTEM OF MEDICINE. PHILADELPHIA: 1 8 90 . DISPLACEMENTS OF THE UTERUS. By E. C. DUDLEY, A. B., M. D. The title of this article is not to be taken in a restricted sense, inas- much as the uterus is anatomically so connected with adjacent organs that the displacements of the uterus cannot be intelligently considered or satis- factorily presented without at the same time incidentally taking into account the displacements, causative, resultant, or concurrent, of the ovaries, Fallopian tubes, rectum, vagina, and bladder. Normal Location and Position of the Uterus . 1 In the woiks on anatomy and gynecology which we are accustomed to consult the uterus is represented as having a straight or nearly straight canal — as lying about midway between the symphysis pubis and the hollow of the sacrum, its axis corresponding to that of the pelvic inlet. They generally agree that its position is one of slight, and only slight, ante- version ; some admit that slight anteflexion may not be injurious, but most would pronounce the organ anteverted or anteflexed to a degree that would endanger health if by conjoined manipulations its anterior wall could be felt through the anterior wall of the vagina. The classical idea of the normal position of the uterus presupposes a distended bladder and rectum occupying the anterior and the posterior thirds of the pelvic cavity. Such an arrangement would leave for the uterus only the inter- mediate space, and would constitute a condition seldom or never realized in health. Suppose a straight line coincident with the vesico- vaginal wall (Fig. 1) to be continued through the cervix to the sacrum. This line represents approximately the antero-posterior diameter of the pelvis. The length of the vesico-vaginal wall is two and a half inches, and, supposing the cervix to be just midway between the symphysis and the sacrum, the distance from its posterior wall to the sacrum must also be two and a half inches. Add to the sum of these two parts of this antero-posterior diameter one inch for the cervix, and the antero-posterior diameter of the pelvis becomes six inches instead of the normal four and one-third ; which proves that the cervix must normally be much nearer to the hollow of 1 The importance of a distinction between location and position will become apparent hereafter: by the former is meant the situation of the organ regardless of its attitude, by the latter is meant the attitude alone. To change an object from one place to another is to change its location ; to turn it over or bend it upon itself is to change its position. 147 803801 148 DISPLA CEMENTS OF THE UTERUS. the sacrum than to the symphysis. Since the length of the vesico- vaginal wall plus the diameter of the cervix measures three and one-half inches, it follows that the distance from the posterior wall of the cervix to the hollow of the sacrum must be the difference between four and one-third and three and one-half inches, or five-sixths of an inch. Again, suppose the uterus (Fig. 1) to be carried bodily upward and backward, its axis remaining the same, until the cervix reach its normal Fig. 1. position near the hollow of the sacrum ; then would the body of the uterus impinge upon the bony sacrum. It is therefore clear that the anteversion must be the normal position, because the uterus and sacrum would otherwise occupy the same space. Fig. 2 represents, according to Schultze, 1 the location and position of the virgin uterus and its surroundings, the bladder, rectum, and vagina being empty and collapsed. The angle of about 90° which the cervix forms with the vagina measures the forward inclination of the cervix, but is subject to slight variations in consequence of the physiological 1 Archiv fur Gynakologie, 1875, Band viii. p. 134, and Lageveranderungen der Gebarmutter , Berlin, 1881. Ely Van de Warker makes a full and critical study of the normal movements of the unimpregnated uterus in the N. Y. Medical Jouimal, xxi. p. 337, and of the normal posi- tion and movements of the unimpregnated uterus in the American Joumcd of Obstetrics , zi. p. 314. His conclusions substantially agree with those of Schultze. Frank P. Foster ( American Journal of Obstetrics, xiii. p. 30) presents a valuable paper giving a resum6 of the literature, with original observations, in which he takes exception? in part to the views of Schultze. NORMAL MOVEMENTS OF THE UTERUS. 149 movements of the uterus. The body is furthermore bent forward upon the cervix, so that its anterior surface rests upon the empty bladder. The angle of the normal anteflexion, according to careful measurements by Schultze, is about 48° ; Fritsch says that 90° is the physiological limit. This question will be further considered under the subject of pathological anteflexions. Normal Movements of the Uterus. Strictly, the uterus can have no absolutely normal position or location, because it has a certain normal range of movements which depend to some extent upon respiration, intra-abdominal forces, and locomotion, but more Fig. 2. The Correct Representation of the Pelvic Organs. especially upon the varying quantity of material in the rectum and bladder. Its normal position, then, varies within the limits of its normal move- ments. If the body of the uterus rest upon the bladder, it must rise as the bladder becomes distended, and, conversely, if the urine be drawn through a catheter while the woman is lying on her back, the uterus, not- withstanding the opposing influence of its own weight, immediately fol- lows the receding wall of the bladder and returns through an angle of 45°, or possibly even 90°, to its accustomed position. The dotted lines in Fig. 2 indicate the degree of version and flexion consequent upon the varying quantity of fluid in the bladder. 150 DISPLACEMENTS OF THE UTERUS. The full rectum forces the uterus in the opposite direction, toward the symphysis, and thereby counteracts the influence of the bladder. This anterior movement is, however, somewhat limited, and is confined to the cervical portion, except when the body has been forced back into close proximity with the rectum by the over-distended bladder. Normal Supports of the Uterus. The uterus is maintained in its normal position and location by the following agents : a. The uterine ligaments ; b. The pelvic floor . 1 a. Physiologically, these ligaments are relaxed ; the state of tension 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 2 is com- posed 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 3 is composed of rectum, perineum, posterior vaginal wall, and strong tendinous and muscular tis- sue. It is attached to the coccyx, to the sacrum, and to the posterior wall of the bony pelvis. Permeating the pelvic floor in all directions, entering into the compo- sition 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 sup- ports 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 fore- going 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 1 For a description of the female pelvic floor see Hart’s Atlas. 2 Hart and Barbour’s Manual of Gynecolor/y. 3 Ibid. NORMAL MOVEMENTS OF THE UTERUS. 151 its normal limits are as follows : ascent, retro-location, ante-location, lat- eral 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, retro- flexion, lateral version, lateral flexion, anteversion, anteflexion. Symptoms and Diagnosis in General. — Each variety of displace- ment 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 displace- ment, but which belong to all alike, will be mentioned at once. They may arise either from the displacement itself or from its possible complica- tions, 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 compli- cations, 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; dysmenorrhcea, menorrhagia, sterility, frequent abortion, con- stipation, 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, anaemia, 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 phe- nomena 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 pres- ence, therefore, of the second division of the group or any part thereof, even though the first be absent, will justify, may even necessitate, a care- ful 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 ante- flexion 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 DISPLACEMENTS OF THE UTERUS. 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 use- less. 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 posi- tion ; 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 1 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 con- dition, 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. 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 im- pressed 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 1 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. LATERAL LOCATIONS OF THE UTERUS. 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 preg- nant 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 sub- ordinate 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 intract- able 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 haematocele, 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 cellu- 154 DISPLACEMENTS OF THE UTERUS. litis, 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 lacera- tion 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. Weak- ening of the supports ; III. Increased weight of the uterus ; IV. Trac- tion 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, sub- involution, hypertrophy, hyperplasia, pregnancy, fluid in the endomet- rium, 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 partu- rition. 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 . 1 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 1 The anteflexion of the multiparous uterus is less than that of the virgin. DESCENT OR PROLAPSE OF THE UTERUS. 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 peri- neum, and consequent prolapse of the recto-vaginal wall into a pouch called rectocele. In the great majority of cases of complete prolapse the posterior vaginal wall in its descent is peeled off from the rectum, leaving the Fig. 3. 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 scybalse. 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 per- itoneal 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. 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 vag- inal walls from some cause to have become relaxed and to have settled 156 DISPLACEMENTS OF THE UTERUS. 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 ante- version and anteflexion, it must occupy space which belongs to the blad- der. The vesical irritation consequent upon this mal-location has gen- erally 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 symp- toms depend upon the mal-location, not upon the anteposition. The im- portance 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. 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 Fig. 4. Showing Extreme Descent of the Uterus and of the Pelvic Floor, and the Hernial Character of the Lesion. 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 direc- tion 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 DESCENT OR PROLAPSE OF THE UTERUS. 157 lower extremity in consequence of rupture or subinvolution of the peri- neum. (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 inflam- matory 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 nor- mal 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 sub- ject 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 en- larged from any one or all of a variety of causes — congestion, subinvolution, hypertro- phy, and hyperplasia. Its cervix is often the seat of extreme erosion or so-called ulcer- ation. 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, espe- cially in prolapse of the second and third degrees. An explanation of this may be found in Figs. 5 and 6. Apparent elongation and disproportionate circular enlargement of the cervix are con- ditions which almost every standard author wrongly calls hypertrophic elongation and circular hypertrophy. The question of elon- gation is easily settled by placing the patient ^vag^Lfcanai^fhowin^thl Redupii in the knee-chest position. Then the uterus and°iTJ£ by its own weight falls toward the diaphragm, pears to be at x' and z[. The appar- / . p i i ii y i ent increase of length in the vaginal the vagina untolds, and the apparent utero- portion of the cervix due to the redu- vaginal attachment X' Z' (Figs. 5 and 6) &‘Ta Dd z Z ‘ Usl ”“ disappears, disclosing the actual attachment, X Z. Further, the point of the sound, passed into the bladder while the Fig. 5. 158 DISPLACEMENTS OF THE UTERUS. Fig. 6. 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) to- gether 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. Hypertrophy or hyperplasia usually causes a nearly symmetrical enlargement of the entire organ. At any rate, those cases in which the reduplication of the vaginal walls does not almost entirely explain the great elongation so called, or in which great disproportionate circular enlargement has not been caused by lace- ration of the cervix, are the rare excep- tions. The great merit of having secured general assent to the foregoing proposition, and of having given to the subject a new and right direction, must be accorded to Emmet. The cervix now is seldom am- putated except for malignant disease. Congestion of the uterus consequent upon obstruction in the stretched and dis- placed veins is often so extreme as to in- duce a state analogous to erection. Meas- urements by the probe just before and a few minutes after replacement generally show an appreciable decrease in the length of the uterine canal. If the pro- lapse has been of the third degree, the difference may amount to one or even two inches. It is important not to confound the enlargement of con- gestion with increase in the solid constituents of the organ. Symptoms and Course. — A dragging sensation and pelvic and abdom- inal pain are generally present. Rectocele and cystocele and rectal and vesical catarrh often cause painful and severe functional disturbances of the rectum and bladder. In descent of the third degree excoriations of the exposed vagina and cervix sometimes cause extreme suffering. The course is ordinarily chronic, but attacks of acute vaginitis and pelvic peritonitis are not uncommon. The peritonitis sometimes effects a spon- taneous cure by peritoneal adhesions which fasten the uterus in an ele- vated position and hold it permanently. The symptoms of descent may be so severe as to necessitate absolute rest in bed. In other cases they are often attended with very little discomfort. Descent of the Uterus, showing Excessive Cir- cular Enlargement of the Lacerated Cervix, consequent upon Reduplication of the Vag- inal Walls and Out-rolling of Intracervi- cal 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 down by the swelling and out-rolling of the mucous and submucous tissues of the cervix to point 5. The apparent os exter- num is at point 5. The utero-vaginal at- tachment X and Z seems to be at X' and Z'. The vaginal portion of the cervix there- fore appears much larger and longer than it actually is. DESCENT OB PROLAPSE OF THE UTERUS. 159 Diagnosis is by inspection, palpation, and exploration. The prolapsed uterus may be distinguished from cystocele, rectocele, inverted uterus, and fibroid tumor by the presence of the os externum. The sound may be passed through the urethra into the cystocele, and the finger through the anus into the rectocele. The length of the uterus may be determined by the sound, the size, shape, position, extent of descent, and difficulty of replacement by conjoined manipulation. Prophylaxis. — This requires such measures during labor as may be necessary to prevent long and powerful pressure upon the pelvic floor. After labor any injury to the perineum should be promptly repaired. The vagina should be kept clean by irrigations. The urine, if necessary, should be regularly drawn and the bowels moved daily without straining. If conditions be present likely to induce subinvolution — such, for exam- ple, as pelvic inflammation or laceration of the cervix — they should receive treatment at the proper time. Undue relaxation of the pelvic floor necessitates a more prolonged rest in bed, the use of astringent douches, and the application of a pessary when the patient resumes the upright position. Treatment. — The first indication is replacement, which in the first and second degree of descent is not difficult unless the uterus be held down by cicatrices or by a tumor. Complicating pelvic cellulitis and peritonitis may render replacement dangerous or impossible, and may for a time contraindicate all direct treatment. Replacement of the organs from the third degree of prolapse is accomplished in the inverse order of their descent : first, the posterior vaginal wall, then the uterus, and last the anterior vaginal wall. Not infrequently the completely prolapsed uterus and pelvic floor, hernia-like, become strangulated. Then taxis will usually suffice if supplemented by hot applications, elastic pressure, anodynes, and the knee-chest position. Should these fail anaesthesia may be required. Undue pressure from above should if possible be removed. The clothing should be loose, and the weight of the skirts supported from the shoulders either by straps or preferably by buttoning them upon a waist made for the purpose. This waist is a good substitute for the corset, which under all circumstances and in all its forms is injurious. Increased uterine weight from subinvolution or congestion is to be overcome by appropriate means. Enlargement of the uterus when due to hypertrophy or hyperplasia is generally incurable. Amputation of the cervix for what was formerly considered circular hypertrophy and hypertrophic elongation is now seldom or never required for the purpose of decreasing uterine weight. Amputation except for malignant disease has given place to the operation of trachelorraphy. Tumors exerting pressure above or traction below should if possible be removed. Regulation of the bowels and general tonics are usually necessary. The knee-chest position assumed several times a day causes the uterus to gravitate toward the diaphragm, and thereby gives temporary rest to the overburdened sup- ports. While in this position the patient should separate the labia, so that the air may rush in and the vagina become expanded. The measures enumerated above, together with rigid care of the diet and of such other hygienic requirements as the individual case may demand, are essential as adjuvants to the more special treatment which almost every case requires. 160 DISPLACEMENTS OF THE UTERUS. In exceptional cases of sudden descent, even to the third degree, replacement alone is sometimes followed by permanent relief ; but if the descent has been gradual it always recurs immediately after replacement. Measures are therefore required for the maintenance of the uterus in its normal location and position. This indication is fulfilled by pessaries and by operations. Pessaries. — The function of the pessary is not only to maintain the uterus on the health level in its normal location, but also, if possible, in its normal position, which requires the cervix to be about one inch from the sacrum. The cervix being thus placed, the organ cannot turn back into retroversion, because in so doing the fundus would encoun- ter the sacrum. The direction of least resistance would then be for- ward into the normal anterior position. The application of the pessary is then based upon the general proposition that if the cervix be normally placed the body of the uterus will in the absence of complications take care of itself. Since the vagina at its upper extremity is attached to the cervix, displacement of the latter is clearly impossible if the upper ex- tremity of the vagina be sustained in its normal location. The pessary restores and maintains the relations of the relaxed vaginal walls by crowding the posterior vaginal cul-de-sac backward into the hollow of the sacrum. It thereby also holds the attached cervix within a proper distance of the sacrum. The Hodge pessary or some modifications there- of fulfils this purpose in ordinary cases more satisfactorily than any other. The curves of the pessary demand careful attention in its application. When the uterus is below the normal level, the broad ligaments are necessarily rendered more tense than natural, and the blood-vessels, more especially the veins, which are looped one upon the other, and which traverse these ligaments to and from the uterus, are made to collapse. This causes venous congestion and consequent increase in weight of the uterus — a condition favorable to malposition, uterine catarrh, and patho- logical changes in structure. A pessary which will raise the uterus to the health level clearly fulfils an indication. A pessary which raises it above the health level renders the broad ligaments tense and reproduces a condition which it was designed to relieve. Maintenance of the uterus upon the health level depends largely upon the curves of the pessary. The accompanying cuts illustrate the shape and curve of the Hodge pessary as modified by Emmet and Albert Smith. Fig. 7 represents the curve of Emmet, and Fig. 8 that of Albert Smith. For convenience let us characterize that curve which rests in the posterior vaginal cul-de- sac as the uterine curve, and that which occupies that part of the vagina DESCENT OB PROLAPSE OF THE UTERUS. 161 adjacent to the pubis the pubic curve. The acuteness and length of the uterine curve determine the height to which the pessary will lift the uterus. The longer and more acute the curve, the higher the uterus will be lifted, and vice versa. The smaller curve of the Emmet modification will answer the average indication more nearly than the sharper curve of the Albert Smith modification, which may lift the uterus too high. The pubic should generally be proportioned to the uterine curve; that is, the greater the uterine, the greater the pubic curve. A pessary properly adjusted in all other respects may, by pressure upon the urethra and neck of the bladder, create vesical tenesmus and urethral irritatiou. This calls for increase in the pubic curve. The pubic curve may, however, be so great that the lower part of the pessary occupies the centre of the vulva, where it may create irritation. For this condition lessening of the pubic curve is the remedy. The pessary should not be so wide as to distend the vagina. Its length should be measured by the distance from the lower extremity of the symphysis pubis to the posterior vaginal cul-de- sac, less the thickness of the finger. If properly adjusted it should sustain the pelvic floor in its normal relations and the uterus in stable equilibrium. The uterus in the first and second degrees of descent is usually either retroverted or retroflexed. The reader is therefore referred to the remarks on the application of pessaries in the treatment of these dis- placements. In advance prolapse dependent upon extensive injuries to the perineum and other parts of the pelvic floor, and usually associated with extreme subinvolution of all the pelvic organs, the axis of the vagina is often changed from its forward oblique to the vertical direction. (See Fig. 3.) The downward traction of the prolapsing cystocele and rectocele upon the fornix of the vagina may then be so great that the pessary is inade- quate to maintain in place the upper extremity of the vagina. The cervix then moves forward, the corpus turns back, and the whole uterus easily descends in a vertical direction along the prolapsing walls of the vagina to the second or third degree of prolapse. In this condition pessaries which disappear within the vagina are liable to be forced out with the prolapsing pelvic floor, or if retained seldom maintain the uterus in posi- tion. In such cases the various cup pessaries which are supplied with external attachments and abdominal belts are often used, but they are inadequate, because they either so fix the uterus as to prevent its normal movements, or they hold it in such unstable equilibrium that it may assume any one of the various malpositions, anterior, posterior, or lateral ; and they are open to the further serious objection of constantly reminding the patient of their presence. As an expedient the uterus may sometimes be held within the pelvis by means of a large Albert Smith pessary with extreme uterine and pubic curves. The rational treatment, however, requires first an operation on the anterior vaginal wall to restore the fornix of the vagina to its normal place in the hollow of the sacrum, and with it the attached cervix ; and second, an operation at the vaginal out- let to bring the posterior wall in contact with the anterior, and thereby to restore the lower extremity of the vagina to its normal place under the pubis. Anterior Elytrorrhaphy. — N umerous operations on the vaginal lr OL. iv .— 1 1 162 DISPLACEMENTS OF THE UTERUS. walls have been devised for the purpose of narrowing the vagina, and thus preventing descent along the vaginal canal, but they are temporary in their results, because, as long as the direction of the vagina remains vertical, its walls again become dilated by the prolapsing uterus and the former condition is re-established. The operation to be effective is per- formed as follows : A Sims’s speculum of long blade, perforated at its extreme end, to which the cervix has been attached by a piece of silver wire, passing through the perforation and the posterior lip, is intro- duced, the patient being in Sims’s position. The cervix is thereby drawn by the point of the speculum far back into the hollow of the sacrum. The author finds this preferable to the method described by Emmet, who has the cervix held back by a sponge probang in the hand of an assistant. The space in the anterior part of the pelvis is now so increased that the uterus readily falls forward into decided ante- version. While the uterus is thus held in position by its attachment to the blade of the speculum, the operator with two uterine tenacula finds in the loose vagi- Fig. 10. nal tissue on either side of the cervix two points which can be brought together in front of the cervix. Then at each of the two lateral points a surface is denuded with the curved scissors about one-half Fig. 9. The First Suture before Twisting in Emmet’s Operation for Folds on the Anterior Vaginal Wall Procidentia (Emmet). formed after Twisting the First Su- ture (Emmet). inch square, and in front of the cervix a surface an inch long by half an inch wide across the anterior vaginal wall close to the uterine attachment. A No. 26 silver-wire suture is then passed, as shown in Fig. 9, and twisted as shown in Fig. 10, so as to secure the lateral denuded surfaces in contact with the larger surface in front of the cervix. Inasmuch as the operation often fails at the point of the first suture, the author has usually introduced two or three of this kind instead of one. Two longitudinal folds are now formed on the anterior vaginal wall, which serve as guides for denuding and turning in the remaining redundant tissue by a line of sutures, which should extend forward along the centre of the vesico-vaginal wall until the folds are lost in the vaginal surface near the neck of the bladder. Sometimes the redundant tissue about the urethra cannot be disposed of by turning it in from side to side. Then it is desirable to make a crescentic denudation across the lower portion of the vagina, its concavity being on the uterine side, and DESCENT OB PROLAPSE OF THE UTERUS. 163 to unite the margins below to those above by means of a curved line of sutures. The completed operation is shown in Fig. 11. The after-treatment requires the self-retaining Sims’s sigmoid catheter in the urethra for a week or frequent catheterization, absolute rest in bed, hot-water vaginal douches, regulation of the bowels, and the removal of Fig. 11. the sutures on the twelfth day. After the completion of the operation the cervix is maintained near the hollow of the sacrum, and the organ remains normally anteverted and anteflexed, making an acute angle with the vesico- vaginal wall, which has now been restored to its normal direc- tion and length. Unfortunately, it is not unusual to abandon the patient after this operation, in the vain hope that the uterus and anterior vaginal wall will maintain their normal relations without the support of the perineum and posterior vaginal wall. This is a great mistake, because the cystocele and procidentia almost always completely reappear within a few months. Anterior elytrorrhaphy, therefore, is simply one of the steps in the treatment. Perineorrhaphy. — This is the name usually applied to the repair of the ruptured perineum, but the scope of the operation has been extended to include also the surgical treatment of rectocele and relaxation of the posterior vaginal wall. The most scientific operation yet devised is the one proposed by Emmet, 1 which is performed as follows : The patient being etherized and in the lithotomy position, the operator seizes with a tenaculum the crest of the rectocele or posterior vaginal wall at a point which can be drawn forward without undue traction — point a. With another tenaculum the lowest caruncle or vestige of the hymen (point 6), 1 Trans. Am. Gynaecological Society , 1883 ; Principles and Practice of Gynecology , 3d ed. 164 DISPLACEMENTS OF THE UTERUS. and with another the posterior commissure of the vulva (point c), are hooked up. The triangle included between these points defines one-half of the surface to be denuded. The three tenacula are now placed in the hands of assistants, the sides of the triangle are made tense by traction, and the included surface denuded. The tenaculum at c is then removed, and the middle point of the line a 6 is caught and drawn toward the interior of the vagina in the direction of the vaginal sulcus on that side, and the sutures are introduced, as in Fig. 13. The same thing is then repeated on the other side, and the sutures are all tightened, forming a line of union running back into each sulcus, as shown in Fig. 14. The essential part of the operation inside the vagina almost always succeeds, but the external part of the rupture at the posterior commissure Fig. 12. a is at the crest oi the rectocele; b at the caruncle just within the labium ; and c at the posterior com- missure. The cut represents that half of the surface to be denuded which is on the operator’s right. The dotted lines represent the other half, on the left. often fails to unite; furthermore, the operation as described by Emmet does not overcome the patulous condition of the introitus vaginfe in case of great relaxation of the vagina. The author has sought to obviate the first of these difficulties by the use of deep silver sutures instead of the superficial ones described by Emmet. They should be introduced before tightening the vaginal sutures, and should be passed far around in the posterior vaginal wall, their points of entrance and exit being the same as for the three lower unsecured superficial external sutures in Fig. 14. The second difficulty may be overcome by further denuding a triangular surface in the vaginal sulcus on each side, the base of the triangle corresponding RETROVERSION. 165 to the line a b, Fig. 12, and its apex being in the vaginal sulcus at a dis- tance corresponding to the degree of relaxation. This increases the lengtn of the lines of union running into the sulci represented by d 6 and ef, Fig. 14. In the vaginal portion of the wound silk or catgut is prefer- able to silver, the latter being difficult to remove. Fig. 13. Fig. 14. Fig. 13. The Sutures in Place. When secured they will unite ad with b d , and lift the perineum up in contact with the anterior vaginal wall. Fig. 14. All the Vaginal Sutures Twisted. One suture, including the crest of the rcctocele and the labium majus on either side, and three superficial external sutures, are yet to be secured. The lines a d and d b, Fig. 13, have been brought into coincidence by means of the sutures, and now form the line of union db. The tissues between the lines ac and cb, Fig. 13, have been so lifted up and are so held under the line of union db that the line c 6, Fig. 13, has been reduced to c b , Fig. 14, which makes the exter- nal portion of the wound insignificant in extent. Emmet is entitled to great credit for having given to the profession an operation which brings the posterior vaginal walls up against the anterior more perfectly than any other, and which, being mostly inside of the vagina, is therefore followed by very little of the pain during convales- cence which formerly rendered perineorrhaphy one of the most trying operations in gynecology. The operation furthermore has demonstrated the former teachings relative to the direction of perineal rupture 1 and the tissues involved to be incorrect, or at least inadequate. Retroversion. Retroversion is that position of the uterus in which the fundus is pos- terior to the axis of the pelvic inlet. If the cervix be in its normal place near the sacrum, retroversion is scarcely possible, because it is prevented by the proximity of the over-arching sacrum. (See Fig. 2.) The first degree of prolapse must therefore precede any considerable backward turning of the uterus. When the cervix has been displaced downward 1 At the meeting of the American Medical Association in June, 1883, the author pre- sented a paper describing the transverse laceration of the perineum and its operative treatment, which was published with illustrations in the transactions by the journal of the Association, Dec. 22, 1883. This communication referred only to the recent rupture and the immediate operation. 166 DISPLACEMENTS OF THE UTERUS. and forward so far that its distance from the sacrum is equal to or greatei than the length of the uterus, retroversion to any extent becomes pos- sible. (See Figs. 3 and 16.) Etiology and History. — From the above it follows that the causes of commencing retroversion must be identical with the causes of the first degree of prolapse. After the puerperium the relaxation of the supports and the weight of the organ may persist, and spontaneous replacement may be prevented by the pressure and weight of the intes- tines upon the anterior surface. Every act of defecation forces the cervix forward and downward, and the uterus, being in the axis of the vagina, and having therefore little support below, must depend upon the sub- involuted peritoneal suspensory ligaments and pelvic fascia, which are inadequate. This condition is very often induced by abortions, with resulting increased weight and relaxation of the vaginal walls. Local peritonitis and cellulitis may permanently fix the corpus in its retro- verted position by cicatricial bands and adhesions. Symptoms and Course. — The displacement and its complications usually cause bearing-down sensations, a feeling of heaviness in the pelvis, exhaustion upon walking and standing, especially the latter, and constipation. After the puerperium the extreme engorgement of the pelvic organs often produces uterine hemorrhage, which should not be confounded with the returning menstruation. Especially after abortion the hemorrhage often persists for a long time unless cured by treatment. Gradual or sudden replacement may occur spontaneously, or the causes may continue active, and even be enforced by cystocele and rectocele. The displacement may also be complicated by disease and displacement of the ovaries. Organic disease of the uterine walls may induce a super- added retroflexion. The heavy organ may descend along the relaxed subinvoluted vaginal walls even to complete procidentia. Diagnosis and Prognosis. — The symptoms outlined in the preceding paragraph indicate the probability of displacement, but the diagnosis depends upon direct examination of the uterus. Conjoined manipulation and the probe will usually show the retroverted organ with the cervix displaced toward the pubes and with the corpus in the hollow of the sacrum. The introduction of the probe is contraindicated by cellulitis and peritonitis. In certain cases of anteflexion, as represented in Fig. 23, the cervix is bent forward in the vaginal axis as in retroversion. The condition is in reality one of retroversion of the cervix with high anteflexion of the corpus, which may usually be detected by careful con- joined examination. The prognosis with treatment is generally favor- able both for speedy relief and ultimate recovery. Treatment. — As in descent, the treatment consists in removing cellu- litis, peritonitis, and other complications, in the use of pessaries, and in operations on the anterior and posterior vaginal walls if needed. Inas- much as the treatment corresponds to that of retroflexion, it will be pre- sented under that subject. Retroflexion. Etiology and Pathology. — Retroflexion is that displacement iD which the organ is bent backward upon itself. It usually results from, RETROFLEXION 167 and is associated with, retroversion, but for convenience the double dis- placement 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, abor- tion, or injudicious treatment. Peritoneal adhesions between the corpus Fig. 15. Extreme Retroflexion, with Hypertrophy of the CorpuSj which impinges upon the rectum and com- presses the recto-vaginal wall. and the cul-de-sac of Douglas sometimes make replacement impossible. In rare cases the displacement is congenital. 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 gen- 168 DISPLACEMENTS OF THE UTERUS. eral anaemic 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 symp- toms 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 loca- tion of the uterus, the degree of the flexure, and the difficulty of replace- ment. An inflammatory exudate or hsematocele, posterior to the uterus, or a fibroid in the posterior uterine wall, may be mistaken for the retro- flexed 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 inflam- mation. Great and lasting injury is often done in the attempt to com- plete 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 over- loaded with fecal matter, the diagnosis should be deferred. The displace- ment 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 cot- ton 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 whicli was published in the Chicago Medical Gazette , Jan. 1, 1880: RETROFLEXION. 1(59 “ Ordinary Method of Application. “ I. Ordinarily, the douche is applied with the patient in the sitting posture, so that the injected water cannot fill the vagina and bathe the cervix uteri, but, on the contrary, returns along the tube of the syringe as fast as it flows in. “ II. The patient is seldom impressed with the importance of regularity in its administration. “ III. The temperature is ordinarily not specified or heeded. “ IV. Ordinarily, the patient aban- dons its use after a short time.” “ Proper Method of Application. “ I. It should invariably be given with the patient lying on the back, with the shoulders low, the knees drawn up, and the hips elevated on a bed-pan, so that the outlet of the vagina may be above every other part of it. Then the vagina will be kept continually overflowing while the douche is being given. “II. It should be given at least twice every day, morning and evening, and generally the length of each application should not be less than twenty minutes. “ III. The temperature should be as high as the patient can endure without distress. It may be increased from day to day, from 100° or 105° to 115° or 120° Fahr. “ IY. Its use, in the majority of cases, should be continued for 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 circu- lation 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 cov- ered 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 leplacement 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 adjust- ing the pessary, otherwise the instrument will press upon the sensitive uterus, when one of three unfortunate results must occur : (1) The pes- sary 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 DISPLACEMENTS OF THE UTERUS. 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 anaesthesia. Fio. 16. Comweuciug Reposition of the Retroverted or Retrofiexed Uterus by Conjoined Manipulation (modilied 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 posi- tion 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 RETROFLEXION. 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 appre- ciation. Fig. 17. Completed Reposition of the Retroverted or Retroflexed Uterus by Conjoined Manipulation (modified from Schultze). 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 applic- able 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 adjust- ment 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 DISPLACEMENTS OF THE UTERUS . 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 repre- sented in Fig. 19 fulfils this indication. Schultze’s figure-of-eight pes- sary, 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. Fig. 18 . Showing the Pelvic Organs sustained by the Emmet Pessary after reposition of the prolapsed, retro- verted or retrod exed 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 re- moulded 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 under- RETROFLEXION. 173 taken 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. 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 Fig. 19. Schultze’s Sleigh Pessary iu place, as adjusted for prolapse, retroversion, or retroflexion with great relaxation of the vaginal walls (after Schultze). 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 prac- titioners 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 useful- ness when judiciously employed. Many cases of displacement, both anterior and posterior, are so com- plicated by prolapsed and adherent ovaries, by advanced disease of the ovaries and Fallopian tubes, and by peritoneal adhesions, that not only 174 DISPLACEMENTS OF THE UTERUS. 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. William Alexander of Liverpool has devised an ingenious operation of shortening the round ligaments for the radical cure of descent and Fig. 20. Front View of Schultze’s Figure-of Eight Pessary. The upper open- ing is intended to hold the cervix. This pessary has the uterine and pubic curves, as in Figs. 7 and 8. Fig. 21. Thomas’s Retroflexion Pessary. 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 dis- placements. 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 causa- tive 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 pathologi- cal anteversion (Fig. 22). Etiology.— The exaggerated anteversion of early pregnancy is phys- iological, 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. PATHOLOGICAL AETEVERS10E. 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 sensa- tion, 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 wail 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, Fig. 22. hardness, and degree of fixation. Exaggerated anteversiou 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 tJhose 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 ante- 176 DISPLACEMENTS OE THE UTERUS. version 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 ante version 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, Fig. 23. Congenital Anteflexion. Both cervix and body are flexed forward. does not disappear upon filling the bladder, but remains constant undei all conditions, the rigidity makes the flexure pathological. Anteflexion is therefore pathological if the mobility at the angle of flexure is increased nr diminished or absent. PATHOLOGICAL ANTEFLEXION. 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.) Acquired anteflexion may be simply an exaggeration of the normal flexure, due either to increased weight of the corpus from the presence Fig. 24. 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 dis- couraging complication. Sometimes the inflamed ligaments contract and drag the anteflexed uterus upward and backward, where it may be per- manently fixed by peritoneal adhesions. (See Fig. 24.) 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 Vol. IV.— 12 178 DISPLACEMENTS OF THE UTERUS. peri-uterine inflammations, having the relation either of cause or effect of the flexure, often bind the pelvic organs together in a mass of exu • date, with resulting failure of nutrition, nerve-irritation, and con- stant pain, which sometimes render the patient’s life miserable and useless. Symptoms and Course. — The numerous symptoms due to the inflam- matory 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 con- sequent irritable condition of the muscular tissue of the uterus. Some- times upon the establishment of the flow the uterine canal becomes temporarily straightened ; this removes the cause of the vascular obstruc- tion, 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 fol- lowed 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. Diagnosis. — The educated touch which distinguishes the normal ver- sion, 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 con- sistency 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 PATHOLOGICAL ANTEFLEXION. 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 contraindica- tion 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 treat- ment of anteflexion in cases of dysmenorrhoea and sterility is only justi- fiable 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 dis- astrous in their influence upon health. The following, with some modifiations, is an abstract of a valuable contribution 1 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 com- menced 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 Elliuger’s dilators is provided with serrated blades, to prevent them from slipping out of the canal during the process of dilatation. 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 tenac- ulum, 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 1 American Journal of Obstetrics , 1884, p. 1179. 180 DISPLACEMENTS OF THE UTERUS. 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. I n 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 lace- rated, but not sufficiently to produce unpleasant results. GoodelPs statistics include one hundred and fifty operations of full dilatation under ether,' with no fatal result and without serious inflam- matory 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 applica- tion 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 ante- verted 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 button- hole operation of urethrotomy . 1 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 mar- 1 Emmet’s Principles and Practice of Gynecology , 3d ed., pp. 275 and 761. PATHOLOGICAL ANTEFLEXION. 181 gins 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. 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.