CHAPTER XIV THE DIAGNOSIS OF MALPOSITIONS OF THE UTERUS (Part 1)

CHAPTER XIV THE DIAGNOSIS OF MALPOSITIONS OF THE UTERUS General considerations, p. 215. I. Malpositions of the uterus as a whole, p. 218: 1. Ascent, p. 218. 2. Descent (prolapse), p. 218; Pathology, p. 218; Mechanism, p. 219; Symp- toms and course, p. 226; Diagnosis, p. 226; Differential diagnosis, p. 228. 3. Anteroposition, p. 229. 4. Lateroposition, p. 229. 5. Retroposition, p. 230: Retroposition with anteflexion, p. 231; Diagnosis of retroposition with anteflexion, p. 232. 6. Hernia of the uterus, p. 233. II. Abnormalities of the axis and form of the uterus, p. 234: 1. Retro- version, p. 234: Retro versio-flexion, p. 234; Diagnosis of retro versio-flexion, p. 236. 2. Anteversion, p. 238. 3. Anteflexion, p. 240. 4. Inversion, p. 240; Diagnosis, p. 240; Differential diagnosis, p. 240. 5. Torsion, p. 243. GENERAL CONSIDERATIONS In considering the subject of malpositions of the uterus it must be understood that displacement of the uterus carries with it more or less change in the position of other pelvic organs at the same time. For instance, it is manifestly impossible to place the uterus in a condition of complete4 prolapse without altering the position of the tubes, ovaries, bladder, and vagina. We shall consider in each instance the dislocation of the mosl important organ, noting the complications. The normal position of the uterus and the factors which determine its situation in the pelvis and limit its mobility under the varying conditions of health have been described in Chapter V., page 43. When pregnant or under conditions of disease the uterus is sub- ject to certain displacements as a whole, and its long axis may be turned or verted in one of several directions. Theoretically we have to do with two distinct classes of displacements. The uterus may be likened to a telescope upon a stand in a room. The tele- scope may be in the middle of the room (the pelvis), or it may be placed against the wall (retro-position), or it may be raised (ascent), or lowered (prolapse). Also it may be tilted in one of many direc- 215 216 MALPOSITIONS OF THE UTERUS tions (version) although its position as a whole with reference to the walls, floor, and ceiling of the room has not been changed. Alteration of the position of the uterus generally but not neces- sarily implies change in its axis, and often in its form. For in- stance, retroversion generally means a certain degree of retro- position and often retroflexion; prolapse presupposes retroversion Fig. 84. — Median Section of the Body of a Woman Who has Borne Children. Bladder Empty. (Schultze.) Note Ante version of Uterus. in the early stages of the descent of the uterus; inversion is a form of prolapse. The lesion that is supposed to be the important one from a pathological standpoint gives the name to the displacement, al- though— as before stated — several lesions are involved. The classification here used is a practical rather than a theoretical one. In describing the pelvic circulation, Chapter V., page 46, it has been stated that the blood-vessels of the uterus and broad liga- ments are convoluted, valveless, and capable of great distention, depending for their normal tone on absence of constricting; influ- GENERAL CONSIDERATIONS 217 ences in the way of pressure from tumors or pelvic inflammatory masses, or stretching due to malposition of the uterus. We know how much a prolapsed uterus is reduced in size after it has been replaced in a normal position in the pelvis and main- tained there for a few hours even. We know that a normal uterus, displaced downward mechanically, becomes congested. It is fair to assume that this is due to a straightening of the tortuous valve- Fig. 84a.— Longitudinal Median Section of a Pelvis with Overdistended blad- der. (Zuckerkandl.) Note Retroversion of Uterus. less veins, thus lessening the resistance of their walls to an in- creased pressure delivered by the less convoluted arteries. It is the view of the author that uterine malpositions have a direct mechanical effect on the pelvic circulation, therefore dis- placements of the uterus as ;i whole are of more importance than changes in the axis (version), or changes in form (flexions, torsions, or tumors). 218 MALPOSITIONS OF THE UTERUS I. MALPOSITIONS OF THE UTERUS AS A WHOLE 1. Ascent. 2. Descent (prolapse). 3. Antero-position. 4. Latero- position. 5. Retroposition. 6. Hernia of the uterus. 1. Ascent The uterus is in a position of ascent in the later months of preg- nancy; when it is displaced upward by a tumor developing from the lower part of the pelvis; when oversupported by a pessary; and when it has been attached to the abdominal wall by a ventral suspension or fixation operation. The diagnosis is established by bimanual palpation. The cervix uteri is far removed from the normal situation and in some cases can not be reached by the tip of the examiner's finger. The fundus may be palpated through the abdominal walls. According to our present knowledge ascent is not an important displacement. The only symptom directly traceable to ascent is an irritability of the bladder, seen occa- sionally, and thought to be due to traction on the vesical neck. Prolapse, on the other hand, is extremely important as well as of common occurrence. 2. Descent or Prolapse The extent of the descent varies from a slight " falling of the womb" to the complete escape of the uterus through the vulvar orifice. When the uterus remains within the body the displacement is spoken of as an incomplete prolapse, or descensus uteri; when it is outside the body it is known as complete prolapse, or procidentia. This form of displacement is generally of slow development — a matter of months and years. Acute prolapse, due to violence or sudden straining when the uterus is large and heavy, the ligaments weak, and the retentive power of the abdominal walls diminished — as after labor — has been observed as a rarity. Pathology. — The pathology of prolapse includes the morbid anatomy of all the pelvic organs involved. The circulation is obstructed by traction on the vessels and all the displaced organs DESCENT OR PROLAPSE 219 become congested; the nerves also are stretched or even sundered. The displaced vagina becomes swollen and congested and may be ulcerated; there may be hernia of the cul-de-sac of Douglas, and the rectum may occasionally send an offshoot into the hernia; the bladder is frequently displaced and is subject to catarrh; and the endometrium is the seat of endometritis — the uterus being, as a rule, much congested. Mechanism. — To understand the mechanism of the production of prolapse one must consider three factors, (a) The pelvic floor. (6) The uterine ligaments and attachments of the uterus to sur- rounding structures, (c) The varia- tions of pressure exerted by the abdominal contents. (a) The pelvic floor is a muscular and tendinous diaphragm closing the outlet of the pelvis. Through this diaphragm runs the vagina trans- versely and obliquely as a slit. In the erect woman the vagina is at an angle of about 60° with the horizon, terminating above at the neck of the womb, which in turn has its long axis placed at a right angle to the long axis of the vagina. The vagina in its course from the cervix to the introitus vaginae shows an S-shaped curve when seen in a median longitudinal section of the body, the forward bulging portion of the S being in its lower portion opposite the under edge of the symphysis pubis. (See Fig. 85.) This prominent portion of the vagina is made by the presence at this point of the chief muscle masses of the levator ani and smaller muscles and fasciae making up the pelvic floor. It is the so-called "perineal body" of the older gynecologists. By reference to the diagram (Fig. 84) it will be seen that this key-stone to the arch of the pelvic diaphragm lies about midway between the lower border of the symphysis and the coccyx. Injury to the muscles here naturally destroys the sigmoid curve of the vagina, opens its outlet, and diminishes the support to the structures lying above. The vagina, instead of being a flattened ribbon-like canal with walls in apposi- Fig. 85. — S-shaped Curve and Inclination of Vagina. Note that the Walls Are in Apposition. (Skene.) 220 MALPOSITIONS OF THE UTERUS tion and running almost transversely from the cervix to the hymen, now becomes a straighter open tube, leading almost directly down- ward from the cervix to the introitus. The pelvic floor, according to Hart and Barbour, may be divided up into an anterior and a posterior segment. The anterior seg- ment is a relatively movable one, the posterior is relatively fixed. The anterior or pubic segment consists of anterior vaginal wall, urethra, and bladder, all attached loosely to the symphysis pubis by retropubic deposits of fat. The posterior or sacral segment is made up of posterior vaginal wall, the muscles and fasciae of the perineum, and the rectum, all firmly bound to the sacrum and coccyx. During labor the anterior segment is drawn up; the posterior segment is driven down. In the formation of prolapse the anterior segment, because of the injury of the posterior seg- ment, swings downward and backward — the retropubic fat giving way with consequent dislocation of bladder and urethra. It is plain that a tipping back of the uterus on its axis, so that it may get into the same axis as the vagina, is a requisite to the descent of that organ, and that this tipping backward is made possible by injury of the posterior segment of the pelvic floor and dislocation of the anterior segment, so that the cervix — not stayed from be- hind and having no firm tissue in front of it — swings forward until its long axis coincides with the long axis of the vagina. This subject will be made clearer when we consider the different direc- tions in which under varying conditions the intra-abdominal pressure is applied to the fundus uteri. (6) The uterine ligaments and the attachments of the uterus to the surrounding structures. The ligaments, described in Chapter V, page 44, consist of three pairs of ligaments proper — the broad, the round, and the utero-sacral ; and the attachments are — the utero- vesical connec- tive tissue, the vagina, and the retro-uterine cellular tissue. In considering the causation of prolapse we must think of the woman being in the erect position, because it is in this attitude that the great strain is brought to bear that causes sacro-pubic hernia. By reference to the diagram (Fig. 84) on page 216 it will be seen that the origins and insertions of all the ligaments lie in nearly the same plane. As a matter of fact, the pubic ends of the round ligaments are a little lower than their insertions into the horns of DESCENT OR PROLAPSE 221 the uterus, therefore the round ligaments can not support the uterus except in cases of extreme prolapse. On the other hand, the attachments of the utero-sacral ligaments to the pelvic wall near the second piece of the sacrum are a trifle higher than their insertions into the uterus at the level of the internal os. They are normally firm and strong and act as true supports. The broad ligaments check lateral motion and limit the uterine 12th rib ThrieTal -ppritiyjeu/n oq slanting' shelf Crest of ihu/rj fkneTai periTonevni. -5>- 7n6 Fig. 86. — Right Side of Abdominal Wall Has Been Removed, Showing Tun- nel Shape of Abdominal Cavity, which Is Wide Above and Narrow Below, also the Slanting Shelf which Gives Partial Support to the Viscera. (After Corning.) movements largely to forward and backward excursions. The intra-abdominal pressure is exerted on the posterior aspect of their broad surfaces and thereby they assisl either in retaining the uterus in anteversion, or, if the axis of the uterus has been changed from anteversion to retroversion, the pressure being on their posterior aspects, they assist in keeping the womb in that position and in aiding prolapse. The thick bases of the broad ligaments 222 MALPOSITIONS OF THE UTERUS intimately joined with the uterus form strong connecting and supporting structures between the uterus and pelvic walls. Pro- lapse can not occur unless the attachments of the ligaments or the ligaments themselves are severed or stretched. The utero-vesical connective tissue, when torn asunder by labor or when weakened by the atrophy of the triangular mass of subpubic fat, promotes retroversion and also prolapse by lessening the resisting power of the structures connecting the uterus with the symphysis and indirectly diminishing the distance between the cervix and the pubes. One of the common results of a difficult labor is to loosen the attachments of the vagina to the cervix. As seen through a speculum with the patient in the Sims or knee-chest position, there appears to be little or no intra-vaginal portion to the cervix. In these cases the mobility of the uterus is increased and, other things being equal, descensus is favored. The attachments of the vagina to the cervix serve to steady the uterus and keep it in its proper relation to the pelvic floor. The retro-uterine cellular tissue has probably very little influ- ence on the position of the uterus unless it is the seat of inflamma- tory thickening; in which case it fixes the organ. It sometimes happens that women who are the subjects of pelvic inflammation are relieved of preexisting prolapse only to suffer with it again when the exudate has been absorbed. (c) The variations of pressure exerted by the abdominal con- tents. The reader is referred to Chapter V., page 45, for a partial exposition of this subject. Here it is sufficient to say that we have to do with (1) downward pressure exerted by (a) increased weight of the uterus itself, (b) the weight of the intestines filled with a varying amount of solid, fluid, or gaseous matter, and (c) the weight of dislocated organs, such as the stomach or kidneys, or the weight of a tumor; and (2) additional pressure transmitted to the abdominal contents by the walls of the abdomen and by the diaphragm in coughing, laughing, straining, jumping, and riding. The downward pressure spends itself under normal conditions mostly on the lower anterior wall of the abdomen. By consulting Fig. 6, page 44, it is apparent that the long axis of the abdominal cavity falls at nearly a right angle to the long axis of the pelvic cavity, and that the pelvic viscera are protected in a measure from DESCENT OR PROLAPSE 9.93 pressure directed downward from above by the forward lumbar curve of the spine, which, in the normal standing posture of the individual, must take some of the weight of the contents of the abdomen. A transverse section of the body of the adult virgin through the fifth lumbar vertebra shows that at this situation the depth of the abdominal cavity from before back is very much less than it is in the upper portion of the abdomen. For instance, it rep- resents only a little over a third of the entire thickness of the body if measured in the median line from the anterior face of the lumbar ver- tebra to the skin surfaces of the front and back of the body. At the level of the twelfth dorsal ver- tebra, on the other hand, the abdominal cavity takes up over a half of the thickness of the trunk if measured in the same way and occupies a major part of the cubic contents of the body at this point. When the back is flattened and the forward lumbar curve is more or less obliterated — as happens in the case of the flat-chested, slouchy body posture so often ^evn in women — more of the weight of the viscera will fall on the inlet of the pelvis. Under normal condition- there IS present a thrust directed forward the slanting surface- of the brim of the false pelvis (60° with the horizon) that throws the abdominal pressure on to not only the lower abdominal wall, but also on to the posterior surface of the anteverted uterus and the backs of the wide expanses of the broad ligaments. Thus is the uterus maintained normally with its long axis at a right angle a1 leasl with the long axis of the vagina. As has been stated previously, the axis of the uterus must be changed to retroversion before prolapse can occur. Such a change in axis is brought about by relaxation of the uterine ligaments, by Fig. 87. — Complete Prolapse or Procidentia. (After Euguier.) inward, and downward from 224 MALPOSITIONS OF THE UTERUS chronic distention of the urinary bladder, chronic fulness of the rectum, sudden jar, etc. (see Retroversion, page 234). When once the axis has been changed, the intra-abdominal pressure is ex- erted against the anterior face of the uterus and the broad liga- ments, and increased pressure accentuates the retroversion, and at the same time pushes down the uterus, now in the same axis as the vagina. Factors which make for greater downward pressure, such as a persistent cough or violent straining because of chronic Fig. 88. — Prolapse of the Vagina and Cervix, with Elongation of the Supra- vaginal Cervix. diarrhea, tend to cause descensus uteri. Constant straining is an important factor in the causation of prolapse ; therefore prolapse is found most frequently among women of the working classes. These women are apt to get up and begin work soon after con- finement when the uterus is large and heavy and retroverted. Inversion of the vagina may take place without actual descent of the uterus because of the elasticity of the vagina, and, prolapse may be simulated by elongation of the lower uterine segment. DESCENT OR PROLAPSE 225 True hypertrophic elongation of the cervix, a lengthening of the cervix and