CHAPTER XIV THE DIAGNOSIS OF MALPOSITIONS OF THE UTERUS (Part 2)

the lower segment of the uterus, is by no means an uncommon condition. In such a case, should the utero-sacral ligaments, which ordinarily limit the amount of the descent of the uterus, prove to be strong and not susceptible of stretching, the fundus uteri may remain nearly at its normal level while the exter- nal os presents at the introitus vaginae. A typical case of true hyper- tropic elongation of the cervix was reported by Huguier ("Memoire sur les Allongements Hypertrophiques du Col de FUterus," Fig. 88a. — Hypertrophic Elongation of the Cervix in the Virgin. 1860, p. 40) as long ago as 1860. A woman twenty-three years of age, of poor general health and physique, married two years but never pregnant, presented herself for treatment because of pain- in the abdomen, dyspareunia, and a tumor in the opening of the vagina. Catamenia began at thirteen and she noticed the pro- jection at the vulva at fourteen and a half years. It came out while she was standing or straining and was reduced on lying down. Examination showed the vagina only a little shortened and occupied by the enlarged cervix; fundus uteri only a trifle below its 15 226 MALPOSITIONS OF THE UTERUS normal situation; and the uterine cavity measured five inches (13 centimeters) in depth. Prolapse is largely a disease of women who have borne children. It is most common after the menopause when the utero-sacral ligaments are prone to be fatty degenerated, the other supports of the uterus have lost their tone, and there is increased abdominal pressure due to increase in the size of the abdominal contents. It occurs infrequently in the nulliparous woman and is then com- monly due to retroversion associated with chronic diarrhea or a long standing cough; or to increase of abdominal pressure from ascites or a tumor. It is probable that stretching of the utero- sacral ligaments and a consequent carrying forward of the cervix may result from chronic fecal impaction of the rectum. Symptoms and Course of Prolapse. — The usual symptoms of pro- lapse are: Dragging pains in the pelvic region and difficulty in walking; frequency of micturition and vesical tenesmus; inability to empty the rectum; leucorrhea, irritation, and pain from vaginitis or an ulcerated vagina ; and sterility. It may be necessary for the patient to stay in bed in severe cases — often all hard labor has to be given up. The course of the disease is chronic as a rule, though not infrequently complicated by attacks of acute vaginitis. Occa- sionally an attack of peritonitis, by making adhesions and thus fixing the uterus, has been known to effect a cure. Diagnosis of Prolapse. — In establishing the diagnosis of prolapse we consider the clinical history, and, in a less degree, the symptoms. The woman is generally at the menopause or has passed it, is the mother of one or more children, and belongs to the working classes. There is ordinarily a history of a preceding uterine malposition, such as retroversion. The appearance of a protrusion at the vulva on straining at stool or on other exertion is often a sudden affair and may be the first abnormality noticed. The cervix is distinguished from rectocele, cystocele, cysts of the vagina, a fibroid polyp, or inverted uterus by the presence of the os externum. When the prolapse is established, the patient complains of pelvic pains, dysuria or frequent micturition, difficult locomotion, and, if the rectum is involved in the descent, of inability to evacuate the bowel without assistance from the hand. There may be inconti- nence of urine from overdistention of the bladder, and the pro- lapsed mass may become ulcerated from attrition — in this case DESCENT OR PROLAPSE 227 soreness and a more or less offensive discharge will claim the pa- tient's attention. As has been stated already, prolapse is usually of gradual develop- ment. In some cases, however, it is acute, in which case reposition will more often result in a permanent cure than in the chronic cases. The patient should be examined first in the dorsal position. v Fig. 89.— Partial Prolapse of the l't ems and Vagina. The Light Spot Shows the Situation of the Tip of a Sound in (he Bladder, Marking (he Lowest Poinl of the Bladder. (Kelly.) If the1 prolapse is only partial an examination in the standing position should be made also, the patient bearing down so as bo drive out the hernia to its bill extent. There is seldom much difficulty in making the diagnosis. The important points are to determine the extent of the downward dislocation of the uterus; the exact size, position, :m<l shape of this organ; the situation 228 MALPOSITIONS OF THE UTERUS of bladder, urethra, and rectum — also the ovaries and tubes — and the amount of prolapse and the condition of the vagina. In most cases of prolapse the vagina becomes thickened to a marked degree and takes on the characteristic of skin, and ulceration may develop in its structures. These items are to be noted carefully because upon them depends the form of treatment employed and its success. A conjoined recto-abclominal examination determines the situ- ation of the fundus uteri. A sound passed into the uterine cavity shows its depth, size, and shape, and whether or not any polypi are situated there. The cleansed sound passed into the urethra shows the direction of the canal and whether any portion of it is dislo- cated downward and, if so, how much. It also shows the limits of the bladder in the prolapsed mass by noting the situation of the point of the sound on the vagina both by sight and touch. (See high light in Fig. 89, marking tip of sound in bladder.) A finger hooked through the anus shows whether the rectum has been dis- located downward. It may be possible to palpate the whole of the uterus outside the vulva through the walls of the inverted vagina, but in most cases, for the purposes of diagnosis, it is best to reduce the prolapse. This is done by covering it with muco- lubricans and making gentle upward pressure, at the same time squeezing the mass a little, and in some cases it may be necessary to place the patient in the knee-chest position before resorting to this measure. When the mass has been reduced a bimanual ex- amination is made with the patient in the dorsal position and the size and shape of the uterus mapped out anew. It is now possible to determine true hypertrophic elongation of the lower segment of the uterus, fibroid nodules, the location of the ovaries, etc. If the vaginal walls are much thickened the tactile sense of the ex- aminer's finger will be blunted. In this event a recto-abdominal examination will prove to be more satisfactory. Differential Diagnosis of Prolapse. — An inverted uterus may be mistaken for a prolapse. The absence of a distinct ring having a sharp edge completely surrounding the prolapsed mass-, and the fact that at no point can a sound be passed into the tumor, serve to distinguish the two. If the abdominal walls happen to .be ex- tremely thin a cup-shaped depression in the abdominal aspect of an inverted uterus may be made out by bimanual touch. LATEROPOSITION 229 True hypertrophic elongation of the lower uterine segment (Fig. 88a) has been spoken of as a part of prolapse. It is diagnosed by dis- tinguishing unusual length of the lower part of the uterus by bi- manual touch, by finding a fundus placed relatively high in the pelvis, and increased length of the cervical canal, as disclosed by measuring the sound passed only to the internal os, — the point where the tip meets an obstruction. When the patient is placed in the knee-chest position the cervix is not obliterated, as under normal conditions. True hypertrophic elongation occurs only in sterile women; false hypertrophic elongation, occurring in the parous, is described in the chapter on laceration of the cervix, page 209. A pedunculated fibroid or polypus is sometimes mistaken for a prolapse. In this case a sound can be swept about in the uterine cavity at any point in the circumference of the collar of the cervix except at the side where the polypus is attached to the uterine wall. There is no cavity in the polypus, and recto-abdominal touch re- veals the presence of the fundus uteri in its normal position. 3. Anteroposttion- Anteroposition of the uterus, or a uterus placed as a whole too near the symphysis pubis, is due to retro-uterine tumors, such as a pelvic hematocele, dermoid ovarian tumor, or tumor of the rectum, or even an overloaded rectum. As far as we know, this position of the uterus is of no significance from a pathological or clinical point of view. The diagnosis is established by the bimanual touch; noting that the uterus is not in its normal sit nation but close against the pubic arch. 4. LATEROPOSITION The uterus may be displaced to the right side or to the lefl side by a tumor or an inflammatory mass, the uterus being pushed fco the opposite side of the pelvis to thai occupied by the tumor mass. Cicatricial contraction following an effusion in one broad ligament may draw the uterus to that side of the pelvis. Such a malposi- tion is to be noted for the purpose of removing its cause and has significance only because of the pathological condition pro- ducing it. 230 MALPOSITIONS OF THE UTERUS 5. Retroposition This is an important malposition which is almost always attended by dysmenorrhea. It is often spoken of as retroversion and also as anteflexion. Dissimilar as these abnormalities appear to be, there are comparatively few cases of retroversion or anteflexion that do not have a certain amount of retroposition. The placing of the uterus backward near the sacrum seems to be the important Fig. 90. — Anteflexion in the Little Girl. (Schultze.) factor in the causation of symptoms. The immobility of the uterus in this position is undoubtedly the chief factor in the causation of a large class of cases of anteflexion, and the fixity of the organ close to the hollow of the sacrum, rather than its anteflexion, is the deter- mining element in the production of the symptoms from which patients with these abnormalities suffer. The retropositions asso- ciated with retroversion will be taken up under the head of retro- version. Here we will discuss the very common uterine disease, retroposition with anteflexion. RETROPOSITION 231 Retroposition with Anteflexion. — By reference to the figure taken from B. S. Shultze's ''Displacements of the Uterus," Fig. 90, it will be noted that in the little girl — the bladder and rectum being empty — the uterus is normally in a state of anteflexion; that the vagina is relatively long; the long axis of the cervix — also long with reference to the length of the corpus — is nearly in the axis of the vagina; the intravaginal anterior lip of the cervix is short; and o a C7Q Fig. 91. — Pathological Anteflexion Arising from Contraction of the Utero- sacral Ligaments, (a) Direction of the Pull of the Ligaments. (6) Direction of the Intra-abdominal Pressure. (Schultze.) the region of the internal os is high up, because the entire uterus is in the false pelvis, and is near the sacrum. The uterus is not fixed, however, in this position. This condition, then, is normal to the growing girl before puberty. Fig. 91 shows retroposition with anteflexion, the old so- called "pathological anteflexion." The similarity of the two conditions is striking, and it seems fair to draw the inference that retroposition with anteflexion is a persistence of the puerile state, 232 MALPOSITIONS OF THE UTERUS with the addition, in the case of retroposition with anteflexion, of adhesions limiting the mobility of the uterus. Anteflexion may be acquired, however, as in the case of a uterus with softened tissues having a fibroid in the anterior wall of the fundus. Excessive straining at stool tends to bend the cervix forward and at the same time to fold the fundus and bod}' of the uterus forward and downward, provided the forward excursion of the region of the internal os is limited. Thus a flexed uterus becomes more flexed. The uterine canal is obstructed mechan- ically at the internal os by excessive flexure, therefore we should expect these patients to suffer with blood stasis and endometritis, the results of a damming up and decomposition of the uterine dis- charges, and this is usually the case. Vesical symptoms are due to the backward traction of the cervix on the vesical neck and to the interference offered by the forward flexed fundus uteri to the filling of the bladder. Of the two the former is the more important cause. I have previously called attention to the frequency of retro- position with anteflexion (" Division of the Utero-Sacral Liga- ments and Suspensio Uteri for Immobile Retroposition with Ante- flexion," Amer. Gyn. and Obstet. Jour., Jan., 1898, and " Further Experience with the Operative Treatment of Anteflexion/' Amer. Gyn. and Obstet. Jour., Jan., 1900). The condition has not been recognized generally by the profession, having been classed broadly as retroversion. Diagnosis of Retroposition with Anteflexion. — The diagnosis is made by finding the uterus as a whole in the extreme back part of the pelvis. This is done by practising the bimanual vagino- abdominal or recto-abdominal touch. The cervix is in the axis of the vagina, the anterior lip is flattened and short, the crown of the cervix being in extreme cases practically continuous with the front wall of the vagina. The cervix, in the axis of the vagina, is not so long, as a rule, as in the case of the puerile cervix, but it is long as compared with the fundus, representing two-thirds of the entire length of the uterus. Its tissues are generally indurated and more or less tender; there is a cervical discharge from a pin- hole os. The fundus is flexed forward and may be grasped be- tween the forefinger in the vagina and the fingers of the hand on the abdomen. It may be enlarged or it may not, and tenderness HERNIA OF THE UTERUS 233 on pressure and induration are not necessarily present. Shortened utero-sacral ligaments or extraligamentous adhesions — these latter rarely present — limit the forward excursion of the uterus as de- termined by making forward traction with the examining hands. Rigidity of the tissues at the angle of flexion is determined by manipulating the uterus. Downward pressure on the fundus by the hand on the abdomen moves the cervix backward, and up- ward pressure on the fundus by the finger in the vagina moves the cervix forward. It is impossible to change the relation of cervix and fundus to each other by separating two fingers placed between them in the vagina. As a rule it is not necessary to pass the sound in order to verify the diagnosis. In fat women, however, with thick and rigid abdominal walls, this procedure may be necessary. Select a flex- ible sound of small caliber. This is better and safer than a probe, the tip of which will catch in pockets of the lining mucous mem- brane. Bend the sound so that it corresponds to the bent uterine canal as determined by palpation; fix the cervix with a tenaculum and make gentle traction, thus straightening the uterine canal as much as possible. Pass the sound tentatively, withdraw and rebend, until the tip will slip through the internal os. Note the point of sensitiveness in the uterine canal, if any, the distance of the internal os from the external os, and the total depth of the uterine cavity. Note thus the relation that the length of the cervical canal bears to the length of the uterine cavity proper; also consider the tightness of the internal os, the capacity of the uterine cavity, and the amount and character of the discharge. If blood follows the gentle passing of the sound and tenderness is present, one may diagnose endometritis. 6. Hernia of the Uteris Hernia of the uterus through the inguinal or the crural canal is a rare anomaly. The diagnosis is established by determining the absence of the uterus from its normal situation and Its presence in the hernial sac. The latter is a most difficull matter and most of these eases have been operated on for strangulated hernia, when the diagnosis was made. Congestion or tumefaction of the hernial tumor containing a uterus should be looked for at the time oi 234 MALPOSITIONS OF THE UTERUS menstruation. If the displaced uterus becomes pregnant — as it has in a few cases reported in the literature — the tumor becomes progressively larger as pregnancy advances and the symptoms and signs of pregnancy are present. II. ABNORMALITIES OF THE AXIS AND FORM OF THE UTERUS 1. Retroversion; Retroversio-flexion. 2. Anteversion. 3. Ante- flexion. 4. Inversion. 5. Torsion. 1. Retroversion Retroversion is that abnormal position of the uterus in which the long axis of the organ is tilted backward to or beyond the long axis of the vagina. Retroflexion signifies the bending backward of the fundus and body alone — a flexing of the uterus — and there- fore a change only in form. Retroversion and retroflexion are commonly associated. They present similar pathological condi- tions both as regards the tissues of the uterus itself and the sur- rounding organs; their symptoms are the same; therefore, they will be considered together. Retroversio-flexion. — This is one of the commonest uterine mal- positions. As has been pointed out in describing the mechanics of prolapse, in order that the uterus may be retroverted it is neces- sary for the cervix to leave its normal position — it must move forward — for with the cervix normally situated there is not suffi- cient room for the fundus and body