CHAPTER X.

Fig. 79.—Braun’s colpeurynter.

Mechanical supports of this kind are only indicated in women in whom operation is contraindicated on account of old age or for some other reason. Perhaps the best instrument for supporting the uterus in such cases is Braun’s colpeurynter (Fig. 79). The uterus should be reduced, and the colpeurynter, well greased and containing about an ounce of water, should be introduced in the vagina and then distended with air. This instrument takes its support evenly from all parts of the vaginal outlet, and is therefore less apt to produce ulceration from pressure than the various pessaries. It should be removed at night.

As has already been said, the uterus normally lies with its anterior surface in contact with the posterior surface of the bladder, and with its long axis approximately perpendicular to the long axis of the vagina. The forward inclination of the uterus varies with the degree of distention of the bladder; it is greatest when the bladder is collapsed.

In the normal woman the long axis of the body of the uterus is inclined forward at an obtuse angle with the long axis of the cervix. In other words, the uterus is normally anteflexed. This angle is subject to rather wide variations within the limits of health. It is greater in the multiparous than in the nulliparous woman. It varies with the distention of the bladder, the position of the woman, and the intensity of intra-abdominal pressure. The axis of the uterus when removed from the body is usually straight. The anteflexion found in the organ whenin situin the living woman rarely persists. The normal or physiological anteflexion is maintained during life by the utero-sacral ligaments, which hold the cervix back, and the intra-abdominal pressure, which, acting upon the posterior aspect of the fundus, pushes the body of the uterus forward.

In the fetus and in early infancy the cervix is relatively much more developed than the body of the uterus, and there is a very marked angle of flexion between them.

Anteflexion of the uterus becomes pathological whenthe bend in the cervical canal is sufficient to impede the escape of menstrual blood or other uterine discharges.

Obstruction of this kind depends upon two factors—the degree of the flexion, and the rigidity of the uterus, which diminishes the mobility that normally exists at the angle of flexion.

No matter how sharp the angle of flexion, it should not be considered a pathological condition unless obstruction in the cervical canal is present—unless the woman presents the symptoms of dysmenorrhea and sterility.

Three varieties of anteflexion have been described:

I.Corporeal anteflexion, in which the cervix has the normal backward direction, and the body of the uterus is bent forward upon it (Fig. 80).

Fig. 80.—Corporeal anteflexion.

II.Cervical anteflexion, in which the axis of the body of the uterus is inclined forward to the normal degree, and the cervix is bent forward upon it (Fig. 81).

III.Cervico-corporeal anteflexion, when the cervix and body of the uterus are both bent forward upon each other (Fig. 82).

Anteflexion of the uterus is a disease of single and sterile married women. It is very rarely found in womenwho have borne children. The disease is congenital or is caused by imperfect development during childhood.

Fig. 81.—Cervical anteflexion.

Fig. 82.—Cervico-corporeal anteflexion.

The fetal condition of a large cervix and a small, sharply-flexed body may persist. The posterior wall of the uterus may develop while the development of the anterior wall is arrested, and thus the uterus would beflexed forward. A mark of such arrest of development is sometimes seen in the atrophied or undeveloped anterior lip of the cervix. Anteflexion is usually accompanied by a small, undeveloped condition of the whole of the uterus, and often by poorly developed vagina, tubes, and ovaries.

It is probable that improper dress and hygiene during the period of puberty have much to do with the development of anteflexion. The early menstrual history sometimes points to poor development of the sexual organs. The menses often make their appearance much later than usual—sometimes when a girl is nineteen or twenty years of age—and when established, the function is often irregular, the bleeding recurring at long intervals.

The most prominentsymptomof anteflexion of the uterus is dysmenorrhea, or painful menstruation. The dysmenorrhea is characteristic: violent pains in the center of the lower abdomen, extending down the thighs, occur for several hours before the bleeding begins. In the later years of the disease the pain extends to the whole of the pelvis and the back. The pain is caused, in all probability, by the accumulation of blood behind the obstruction in the cervical canal. When the blood begins to escape freely, the pain is relieved, and may be absent during the remainder of the menstrual period. The blood is often clotted during the first part of the flow. Nausea and vomiting may be present during the height of the pain.

The menstrual period may be followed by several days of great physical weakness and debility.

Unless relieved by pregnancy or by proper treatment, the anteflexion will persist during the menstrual life of the woman. The suffering increases with time. Endometritis, salpingitis, and ovaritis follow old cases of anteflexion.

Sterility usually accompanies well-marked anteflexion. This may be due to the altered direction of the cervix in case of cervical anteflexion, to the obstruction in thecervical canal that interferes with the ingress of spermatozoa, to the generally undeveloped condition of the genital organs, or to the inflammation of the mucous membrane of the cervix and the body of the uterus.

Thediagnosisof anteflexion is easily made. The character, position, and time of onset of the pain indicate some obstruction to the escape of menstrual blood. Vaginal examination reveals the sharp angle of flexion at the junction of the body and neck of the uterus.

Treatment.—If in a case of anteflexion pregnancy does occur and runs a normal course the disease will be cured. After labor the uterus does not return to the infantile shape and size. The stimulus of pregnancy brings about full permanent development of that organ. Miscarriage, however, is very apt to occur during the early months of pregnancy, especially in cases of long standing.

Various methods of treatment have been introduced for the cure of anteflexion. The object of all these methods is the straightening and enlargement of the cervical canal. Slow dilatation by graduated bougies has been successfully employed. Gradual straightening of the canal by the introduction of the uterine sound with increasing angle of flexion will also cure some cases, if seen early.

The use of the stem pessary (Fig. 83), which is worn continuously in the cervical canal, is dangerous and should not be practised.

Fig. 83.—Stem pessary.

The best method of treatment consists in rapid forcible dilatation with the uterine dilator. Various instruments have been made for this purpose. The principle of all is the same. Two blades are introduced, in contact, in the cervical canal, and are then separated. Two of these instruments should be on hand—a small and a large dilator. The Goodell dilator (Figs. 84, 85) is so made that theblades open parallel with one another, so that the whole of the cervical canal is uniformly stretched.

Fig. 84.—Goodell’s small uterine dilator.

Fig. 85.—Goodell’s large uterine dilator.

The best time to perform forcible dilatation is about one week after a menstrual period. The woman should be etherized and placed in the dorso-sacral position. The vagina should be sterilized. All aseptic precautions which one would follow in any gynecological operation should be observed here. There is always danger of producing septic inflammation of the endometrium. The cervix should be exposed through the Sims speculum, and theanterior lip should be seized with the double tenaculum. Downward traction on the cervix straightens the cervical canal and renders easier the introduction of the dilator. The smaller dilator should first be introduced. No force should be used in passing it through the cervical canal. If an obstruction which cannot be gently overcome is met, the dilator should be introduced as far as the obstruction and the blades should then be separated. Slight dilatation of this kind below the angle of flexion will usually enable the operator to pass the instrument through the cervical canal at a subsequent attempt. After the smaller instrument has been introduced to the full extent the blades should be gradually separated, for a half inch or more, until the canal becomes large and straight enough to admit the large instrument. It should always be remembered that no force should be used in the introduction of either instrument. After introduction the blades of the large dilator should be slowly separated. On the handles of the Goodell instrument is a graduated scale showing the extent of the dilatation. In no case should the dilatation be carried beyond one and a half inches. In women in whom the cervix and uterus are small an inch of dilatation is sufficient. The maximum dilatation should be reached slowly and gradually. Laceration of the cervix or of the margin of the external os should be avoided. Sometimes ten or fifteen minutes are required before full dilatation is attained. When this point is reached the handles should be held in place by the screw, and the instrument should be kept in the uterus for ten or fifteen minutes longer. The longer the dilatation, the more permanent will be the result.

After the instrument is withdrawn the cervical canal and the vagina should be washed out with a 1:2000 solution of bichloride of mercury, and a light gauze pack should be introduced into the vagina. The pack should be removed at the end of forty-eight hours, and a daily douche of 1:4000 bichloride solution should be administered for the following week. The patient should remainin bed for two weeks, or longer if there is any pelvic pain. Pain, however, does not follow this operation if we avoid operating upon those cases in which there is inflammatory disease of the tubes and ovaries. The too early resumption of the erect position may cause the failure of the operation. The abdominal pressure exerted upon the fundus uteri, before the organ has become fixed in its altered shape, may bring about a recurrence of the anteflexion. In case the external os be very small—too small to admit the dilators—it may be incised by small crucial incisions or reamed out with the closed blades of the scissors.

Dilatation of this kind usually produces a permanent broadening and shortening of the cervix. The cervical canal is rendered straighter and larger.

The good effects of the operation are not always apparent at the menstrual period immediately following the operation, because the results of the traumatism to the mucous membrane and the structures of the cervix are still present. At the periods after this, however, the dysmenorrhea is absent or is very much relieved. The benefit usually derived from this operation is a strong proof of the truth of the obstructive theory of the dysmenorrhea. If, after dilatation, conception takes place, the woman may look forward to perfect cure. In some cases the dilatation does not seem to be sufficient to produce a permanent open condition of the cervical canal, and the signs of obstruction (dysmenorrhea) return. In such a case the dilatation should be repeated. The more thoroughly the dilatation is performed the first time the less often will the second operation be necessary.

Retroversionof the uterus means a turning back or a backward rotation of that organ. The shape of the uterus may not be altered. The fundus, instead of lying forward upon the bladder, is directed backward, and sometimes lies in the hollow of the sacrum (Fig. 86).

Fig. 86.—Retroversion of the uterus.

Retroflexionmeans a bending backward of the uterine axis. The axis of the body of the uterus is normally inclined forward at an obtuse angle with the axis of the cervix. When the axis of the body of the uterus is inclinedbackward at an angle with the axis of the cervix, retroflexion exists. Retroflexion may vary in extent from an angle very little less than 180 degrees to an angle considerably less than 90 degrees (Fig. 87).

Fig. 87.—Retroflexion of the uterus.

Retroflexion and retroversion usually coexist. The conditions are due to similar causes. They may originate simultaneously, or one condition, occurring primarily, may induce the other.

An infinite number of degrees of retroversion may exist. For convenience of clinical description three degrees have been described. In the first degree the fundus uteri is directed upward approximately toward the promontory of the sacrum. In the second degree the uterus lies transversely across the pelvis, the fundus and the cervix being at about the same level. In the third degree the retroversion is extreme, and the fundus lies below the level of the cervix (Fig. 88).

Retroversion of the uterus is progressive. It usually proceeds from bad to worse. As soon as the downwardabdominal pressure begins to act upon the anterior face of the uterus there is a continuous force increasing the retroversion.

There are many causes of retroversion and retroflexion.

Fig. 88.—Diagram of the degrees of retroversion of the uterus.

The disease may be congenital. Extreme retroflexion has been found in the uterus of the new-born infant. Congenital retroversion and retroflexion may be due to imperfect development, and resulting imperfect invagination of the cervix. The condition may also be caused by arrest of development of the posterior wall of the uterus; the anterior wall thus outgrowing the posterior.

Many cases of retroversion undoubtedly originate during girlhood as a result of falls, blows, distortion of the body, or sudden efforts at lifting. The origin of the symptoms may be traced in many cases directly to some such cause.

The uterus may be considered to be balanced upon an axis running transversely. Anything that turns the uterus backward, so that the intra-abdominal pressure may act upon the anterior wall, will produce retroversion.It is probable that an over-distended bladder occasionally acts as a cause of retroversion.

Retroversion is not at all rare in single women. It is very often discovered soon after the establishment of the menstrual function, the symptoms of the retroversion, which probably occurred during girlhood, first appearing at this time. Retroflexion, on the other hand, except to the slight extent caused by the retroversion, is unusual in single women.

Parturition is probably the most frequent cause of retroversion and retroflexion of the uterus. If the woman leaves her bed or goes to work too soon after miscarriage or labor, many conditions are present that favor retrodisplacement of the uterus. The uterus is larger and heavier than normal, as a result of imperfect involution: the uterine ligaments are lax; the vagina and the vaginal orifice are relaxed, and the support of the pelvic floor is consequently deficient; the abdominal walls are relaxed and the retentive power of the abdomen is diminished. It will be remembered that these are the causes that favor prolapse of the uterus; in fact, a slight degree of uterine prolapse usually accompanies such cases of retrodisplacement. A certain amount of retroversion must always exist before the uterus can pass along the vagina. It must turn backward, so that its axis becomes parallel to the axis of the vagina.

Retroflexion occurring after miscarriage or labor is sometimes the result of unequal involution in the uterine walls. If the involution takes place more completely in the posterior than in the anterior wall of the uterus, a bending back, or a retroflexion, will occur. Such inequality of involution may result from inflammation about the site of the placenta.

Retroflexion is a disease of the parous woman, as anteflexion is a disease of the single and the sterile woman.

Retroversion may be a direct result of laceration of the perineum. When the pelvic floor is destroyed and the posterior vaginal wall begins to prolapse, it dragsupon the posterior wall of the cervix, and may in this way turn the uterus backward.

Retroversion also results from traction of inflammatory adhesions in the pelvis. Cases of chronic inflammation of the Fallopian tubes accompanied by inflammation of the pelvic peritoneum present adhesions between the posterior wall of the uterus and the hollow of the sacrum; these adhesions drag the uterus backward (Fig. 89).

Fig. 89.—Retroversion of the uterus, with adhesions binding it to the anterior wall of the rectum and the hollow of the sacrum.

In cases of retroversion and retroflexion of the uterus serious derangement of the circulation results. A state of passive congestion follows interference with the venous supply. This congestion produces some enlargement of the uterus and chronic congestion or inflammation of the endometrium. Consequently, in all old cases of retrodisplacement endometritis is an accompaniment.

Retroversion of the uterus causes traction on the vesico-uterine connection, and the neck of the bladder is dragged upon; for this reason irritability of the bladder, characterized by frequent and perhaps painful micturition, is often present in cases of retroversion. It is not uncommon to see women who have received treatment directed to the bladder for conditions of this kind that disappear immediately when the uterus is restored to the normal position.

The pressure of the displaced fundus upon the rectum may also give trouble. Women in this condition often complain of a feeling of obstruction in the rectum. Pressure upon the hemorrhoidal veins results in hemorrhoids.

There usually accompanies retroversions of the uterus a backward and downward displacement of the ovaries—in other words, a prolapse of the ovaries.

Thesymptomsof retrodisplacement are numerous, and may be referred directly to the altered position of the uterus and the accompanying conditions. There are backache situated in the upper part of the sacrum, and headache situated on the top of the head or in the occiput. These may be considered the two constant symptoms. There is a feeling of weight and dragging in the pelvis, extending down the thighs. Physical weakness, or inability to walk or stand for more than a short time, is often very marked, and seems to be out of all proportion to the lesion of the uterus. The manner in which such weakness of the legs is produced is not very evident. That it is caused directly by the displacement of the uterus, however, is proved by the fact that it disappears as soon as the uterus is restored to its normal position.

The accompanying prolapse of the ovaries produces symptoms referable to these organs, the chief symptom being pain in each ovarian region.

The irritability of the bladder has already been spoken of. Menorrhagia and leucorrhea may be present as a resultof the congestion and the chronic inflammation of the endometrium. Menstruation is usually painful. At the menstrual period the backache, headache, ovarian pain, and vesical disturbance are increased. Dysmenorrhea due to obstruction is unusual in cases of retroflexion. Retroflexion usually occurs in parous women, in whom the cervical canal is large, and the flexion therefore does not cause sufficient obstruction to impede the escape of menstrual blood. All the symptoms arising from retroversion of the uterus are ameliorated by the recumbent posture.

Thediagnosisof retroversion and retroflexion of the uterus is very easily made by bimanual examination. The abdominal hand fails to find the fundus in the normal position. The vaginal finger feels the cervix uteri directed not backward toward the coccyx, but forward in the direction of the vaginal axis or toward the symphysis pubis. The posterior wall of the cervix and the body of the uterus may be plainly felt inclined backward. In case of retroflexion the angle of flexion may be felt by the vaginal finger.

The accompanying prolapse of the ovaries is usually very easily demonstrated by vaginal touch.

Treatment.—As retroflexion does not usually cause obstruction of the menstrual flow, the treatment need not be directed toward rendering patulous the cervical canal, as in the case of anteflexion. Retroflexion is always associated with retroversion, and the methods that correct the retroversion place the uterus in such a position that the intra-abdominal pressure acts on the posterior face of the uterus and gradually reduces the flexion. Therefore the treatment of retroflexion and of retroversion may be considered together.

Retroversion is treated by the vaginal pessary and by operation.

The vaginal pessaryis an instrument to be worn in the vagina, and designed to retain the uterus in its normal position. A great many different kinds of pessaries havebeen invented. The large number of different-shaped instruments proves the inefficacy of the pessary as a means of treatment in many cases of retroversion.

The best pessaries for retroversion are the Hodge (Fig. 90,A), the Smith (Fig. 90,B), and the Thomas (Fig. 90,C). These instruments are made of hard rubber. They consist of an upper and a lower transverse bar joined by two lateral bars. They are so shaped that when introduced into the vagina they correspond very closely to the curvature of the vaginal slit.

Fig. 90.—Pessaries for retroversion:A, Hodge pessary;B, Smith pessary;C, Thomas pessary.

Fig. 91shows a side view of a pessary in position, and it will be observed that the curves of the instrument are closely adapted to the curves of the posterior vaginal wall, upon which it lies.

The vaginal pessary retains the uterus in place by raising the posterior vaginal fornix and keeping tense the posterior vaginal wall. It will be observed that the posterior wall of the vagina runs over the upper transverse bar of the pessary like a rope over a pulley; therefore there is maintained a continuous traction in an upward and backward direction upon the cervix, and a resulting continuous tendency to throw the fundus uteri in a forward position (Fig. 91). The tension of the posteriorvaginal wall and the traction upon the cervix vary with the position and occupation of the woman, and are increased by anything that increases the intra-abdominal pressure.

The vaginal pessary does not maintain the uterus in place by pressure upon the body of the uterus, nor does the vaginal pessary correct a retrodisplacement. The uterus should be restored to its normal position as nearly as possible before the pessary is introduced.

Fig. 91.—The retroversion pessary in position. The arrow shows the direction of the traction of the posterior vaginal wall upon the cervix.

Replacement of the uterus may be effected in one of two ways: by bimanual reposition while the woman is in the dorsal position; or by instrumental reposition while the woman is in the knee-chest position.

In bimanual reposition the uterus is manipulated between the vaginal finger or fingers and the abdominal hand until the organ is brought to its normal position of anteversion (Fig. 92). Sometimes this may be more easily accomplished by introducing one or two fingers into the rectum.

After bimanual reposition the pessary should be introducedin the vagina, and the upper bar of the instrument should be carried behind the cervix by manipulation with the vaginal finger.

Bimanual reposition is often difficult or impossible in fat women and in those with rigid abdominal walls.

Fig. 92.—Bimanual reposition of the retroflexed uterus.

Instrumental reposition in the knee-chest position, however, is applicable to all cases in which a pessary is indicated. As this method is the one that should in general be followed, it will be described in detail.

Fig. 93.—Uterine repositor.

The woman should be placed in the knee-chest position. The perineum should be retracted and the cervix exposed with a Sims speculum. It will be observed that the cervix is directed forward toward the symphysis pubis. The uterine repositor (Fig. 93) is then introduced, and pressure is made in the posterior vaginalfornix upon the displaced fundus. The fundus may be felt with the repositor in this position. Sometimes, by grasping the cervix with a tenaculum and drawing it downward, the repositor may be applied with better effect (Fig. 94). It will often be observed that under this pressure the fundus immediately drops forward, while the cervix is turned backward through an angle of 90° or perhaps 180°, so that the external os looks no longer toward the symphysis pubis, but toward the hollow of the sacrum. The direction of the cervix shows plainly when the uterus is in the normal position. Instead of the uterine repositor we may use a small firm ball of cotton held in long forceps.

Fig. 94.—Replacement of retrodisplaced uterus by means of the uterine repositor, with patient in the knee-chest position (Baldy).

Sometimes it is not possible to make the entire correction of the displacement at one time. The uterus may perhaps be reduced from retroversion of the third degree to that of the first degree, and at a subsequent attempt it may be reduced still more, until finally it is brought to its normal position. In some cases the difficulty of producing complete reduction at one time is due to the factthat the woman is unaccustomed to the position and the manipulations, and is constantly straining and involuntarily resisting. Complete relaxation of the abdominal walls is necessary.

If the uterus can be reduced to the normal position, the pessary may be immediately introduced. If the reduction is not complete, it is best to pack the vagina with cotton to maintain the degree of reduction that has been attained, and to repeat the attempt the next day, continuing in this way until the uterus has been brought approximately to its normal position, when the pessary should be introduced. The cotton should be packed into the vagina in the form of balls or pledgets about one and a half inches in diameter, which should be introduced with the forceps (Fig. 95) and carefully and tightly packed into the posterior vaginal fornix. Other pieces should then be packed against the anterior aspect of the cervix, and then the rest of the vagina should be rather loosely filled.

Fig. 95.—Uterine forceps.

The pessary should be introduced with the woman in the knee-chest position. A number of pessaries, of various sizes and shapes, should be at hand, in order to have a suitable assortment for choice. The pessary must be of the proper length, breadth, and shape; these requirements differ in various cases. The length of the pessary should be such that when the upper transverse bar lies in the posterior vaginal fornix the lower transverse bar is over the position of the internal urinary meatus. The course of the urethra is marked by small transverse folds of mucous membraneon the middle of the anterior vaginal wall, and the internal urinary meatus is situated approximately where these small transverse folds cease and become merged into the larger oblique folds of the vaginal walls. This distance may be measured upon the uterine repositor or it may be estimated with the eye.

It should be remembered that all the dimensions of the vagina are exaggerated in the knee-chest position, as the vaginal canal is distended by atmospheric pressure. The width of the pessary should be such that there is no lateral tension put upon the vaginal walls.

The curvature of the pessary should be such that the upper transverse bar does not press upon the posterior aspect of the cervix, but is so placed that the posterior vaginal fornix is drawn upward and backward.

The curvature of the pessary may be altered to suit any case by dipping the instrument in oil and gently heating it over the flame of a spirit-lamp. In this way the rubber is softened and may be pressed into any shape. While soft and under pressure it should be plunged into cold water to set it in the altered form.

The pessary may be introduced while the perineum is retracted with the speculum; or it may be passed into the vagina first, the speculum then being introduced and the pessary moved into the proper position. The pessary should be greased, the lower transverse bar should be grasped with the thumb and the index finger, and the instrument should be introduced in such a direction that one lateral bar lies in the vaginal sulcus. The upper transverse bar may readily be placed behind the cervix, by manipulation with the finger or the forceps, when the perineum is retracted with the speculum.

The speculum should be removed, and the woman should assume the Sims posture for a few minutes. She may then get up from the table, and the examination may be made in the erect posture, for in this position, better than in any other, the fit and the action of the pessary may be determined. It will be found that thelower bar of the pessary is in relation with the anterior vaginal wall at the position of the internal urinary meatus. It should not protrude from the ostium vaginæ. It should be possible to pass the finger readily between the vaginal walls and the lateral and lower bars of the pessary. The cervix should be felt directed backward through the upper portion of the ring of the pessary. It will be felt that the pessary is retained in the vagina not by any pressure against the vaginal walls, but by a suction—in other words, by the retentive power of the abdomen.

A vaginal douche of warm water should be administered once a day while the pessary is worn.

The woman should be directed to return for examination three days after the introduction of the pessary, or sooner if any discomfort is experienced. Sometimes the uterus becomes retroverted while the pessary is in position, and becomes flexed over the upper bar of the instrument, considerable pain resulting. In other cases, where the vagina is patulous and too small an instrument is used, the pessary becomes turned so that the long axis lies transversely. It is well to advise the woman to remove the instrument herself if it makes her very uncomfortable.

The pessary should be examined digitally in the dorsal or the erect position, or visually in the knee-chest position. If it is found that the retroversion has returned, the uterus should be replaced and a pessary better suited in size and shape should be introduced. It is always desirable to use as small an instrument as practicable. The intervals between examinations may be gradually lengthened to two weeks or a month. A woman using a pessary should always be under the supervision of a physician. The retroversion pessary does not interfere with sexual connection.

The bowels should be carefully regulated. The clothing should be supported from the shoulders, not from the waist, and heavy lifting should be avoided as much as possible.

After a woman has worn a pessary for three or four months, and it is found that the uterus remains in the normal position, the instrument should be removed and the result carefully watched.

If the uterus continues in its normal position of anteversion, a cure has been accomplished and the pessary may be discarded. If the retroversion returns, as it very often does, the pessary should be introduced again, and an unfavorable prognosis of cure by this means should be made. The patient must then choose between the use of the pessary for an indefinite period, under medical supervision, and cure by means of an operation.

The Smith pessary is better adapted to the shape of the vagina, which normally narrows from above downward, than is the Hodge instrument. The Thomas pessary, in which the upper bar is made very broad, is applicable to cases of sharp retroflexion with retroversion, in which the upper bar may become fixed in the angle of flexion in case the retroversion returns. The upper bar is made so broad that the angle of flexion would be spanned by it in case of such an accident.

The action of the pessary depends upon the integrity of the vagina and the pelvic floor. The retroversion pessary, therefore, cannot be used when there is a laceration of the perineum. In such a case the perineum must always be closed as a preliminary step.

The pessary should not be used when there is a laceration of the cervix uteri, for traction upon the posterior lip of the cervix increases the eversion.

The pessary is contraindicated in all cases in which there are pelvic adhesions restraining the uterus, in those cases in which there is inflammatory disease of the Fallopian tubes, and in cases where there is prolapse of the ovary, which may be pressed upon by the upper bar of the pessary.

Before making any attempt to replace a displaced uterus the physician should always make a careful bimanual examination to determine the existence of anyacute or chronic inflammation of the Fallopian tubes or the ovaries. Such inflammation is a contraindication to the use of the pessary and to any of the manipulations for replacement of the uterus that have already been described.

If the uterus is adherent, the pessary should not be used. Cure of the retroversion by it is practically impossible, and operative treatment is safer and more certain.

Operative Means of Treating Retrodisplacement of the Uterus.—A great many kinds of operation have been introduced for curing retrodisplacement of the uterus. The fundus has been attached to the anterior abdominal wall by passing a needle and a suture into the uterus and thrusting it through the uterine wall and the anterior abdominal wall; the uterine cornua have been sutured to the anterior parietes; the round ligaments have been shortened by folding each upon itself, and fixed in this position by suture; the round ligaments have been drawn back through openings made in the broad ligaments and attached by suture to each other and to the posterior surface of the uterus; the utero-sacral ligaments have been shortened; the uterus has been held forward by sutures applied through the anterior vaginal fornix.

The two operations that have deservedly met with the greatest favor are ventro-suspension of the uterus, in which the abdomen is opened and the fundus is sutured directly to the anterior abdominal wall, and Alexander’s operation, in which the uterine displacement is corrected by shortening the round ligaments as they emerge from the inguinal rings. The latter operation is designed to be extra-peritoneal. The following is the method of performing Alexander’s operation:

The uterus should first be replaced as already described, and held in position by a gauze or cotton pack. A two-inch incision is made from the pubic spine in the direction of the inguinal canal. The external inguinal ring is opened without wounding the pillars. The thin layer of fascia over the ring is divided, the fat is separated, and the round ligament is sought with a blunt hook. Ifthe ligament is not found here, the canal may be opened to the internal ring. When one ligament has been found, it is secured with forceps and the wound is protected while the other ligament is secured in a similar way. The ligaments are then gently drawn out until they become tense. If the inguinal canal has been opened, it should be repaired by a catgut suture.

The ligament should be sutured to the pillars of the ring by two or three sutures. The excess of the ligament, sometimes amounting to two or three inches, should be cut off. The incision should then be closed.

The field of this operation is very limited. It is not applicable when there are adhesions nor when there is disease of the tubes or ovaries requiring operative treatment.

Many of the cases of retroversion of the uterus that require operative treatment are complicated by salpingitis and pelvic adhesions, though these extra-uterine conditions are very often not recognized by bimanual examination before the abdomen is opened.

The operation that at present seems to possess most advantages for the cure of those cases of retroversion of the uterus that cannot be cured by the pessary is the operation of ventro-suspension of the uterus (Fig. 96). It is performed as follows:

An incision, one and a half to three inches in length, is made in the median line of the anterior abdominal wall, immediately above the pubis. Two fingers are introduced into the abdominal cavity, and the fundus uteri is lifted forward. The plane of the abdominal incision is exposed, and a curved needle carrying a medium-sized silk suture is passed through a few fibers of the rectus muscle and the peritoneum on one side, immediately above the lower angle of the incision. The needle is then passed through the tissue of the fundus uteri on the line joining the uterine cornua or a little posterior to this line. The amount of uterine tissue included in the suture is about one-quarter of an inch broad and one-eighth to one-quarter of an inch deep. The needle isthen passed through the peritoneum and a few fibers of the rectus muscle on the side of the abdominal incision opposite the point of entrance. The fascia of the rectus should not be included. A similar suture is passed about one-third of an inch above this, traversing the uterine wall on a line about one-third of an inch posterior to the first suture. While the fundus is held forward by the finger of an assistant these sutures are tied, so that the fundus uteri is brought into contact with the anterior abdominal wall. The ends of the sutures are cut short. The abdominal incision is then closed by three layers of sutures—silk for the peritoneum, catgut for the muscle and fascia, and the intra-cutaneous suture for the skin. Accompanying disease of the tubes and ovaries may be treated directly by this operation, and any adhesions may readily be broken.

Fig. 96.—Position of the sutures in ventro-suspension of the uterus.

In performing this operation it should be remembered that we do not wish to make a fixation of the uterus tothe anterior abdominal wall. The inclusion of a broad mass of uterine tissue in the suture, and scarification of the anterior face of the uterus, which is sometimes practised, may result in a broad, unyielding adhesion which will interfere with the normal mobility of the uterus and with the course of pregnancy and labor.

Fig. 97.—The suspensory ligament two years after the operation of ventro-suspension. The ligament measured three inches in length.

After this operation of ventro-suspension the fundus uteri does not remain permanently in contact with the anterior abdominal wall. In time it drops somewhat backward and downward. The silk sutures drag out a ribbon-shaped fold of tissue consisting of peritoneum and a little muscle-fiber from the anterior abdominal wall,and a similar fold of peritoneum and perhaps some muscular fibers from the uterus, so that in time the uterus becomes attached by a slight pliable ligament from one to three inches in length (Fig. 97). Bimanual examination of the uterus one year after this operation shows that the uterus has about the normal range of mobility. If this operation is properly performed, the course of subsequent pregnancies and labors seems to be in no way impeded.

The operation of ventro-suspension should always be accompanied by perineorrhaphy in case there has been laceration of the perineum. The two operations may be done at the same time.

The treatment of retrodisplacement of the uterus may be briefly summarized as follows:

The cases of retrodisplacement of the uterus suitable for treatment by the pessary are those in which there are no adhesions and in which there is no disease of the Fallopian tubes or the ovaries. If a prolapsed ovary returns to its normal position when the displacement of the uterus is corrected, it will of course not be pressed upon by the bar of the pessary. But in some cases the ovarian prolapse continues even though the uterus is in its normal position, and under such circumstances a pessary usually cannot be tolerated.

The cases that offer the best prospect of cure by the pessary are those cases of retroversion, occurring as the result of labor, in which the perineum is intact, and which are seen within one or two years after the occurrence of the lesion. The prognosis becomes more unfavorable the longer the condition has existed before treatment.

Cases of congenital retroversion, or those occurring in young unmarried women, are very difficult to cure with the pessary. This instrument should always be tried for a few months, however, before operative measures are advised. In such cases the uterus has been so long in an abnormal position that its natural supports have becomepermanently altered, and some continuous additional aid is necessary to maintain the normal position.

Every woman who uses a pessary should be under the supervision of a physician, and for this reason it is often most advisable to recommend immediate operation to poor women as the quickest and surest method of cure.

Immediate operation should always be advised in all cases of retroversion with adhesion or with disease of the tubes and ovaries.

It should not be forgotten that we occasionally see women with retroversion of the uterus who present no symptoms whatever referable to this lesion. In such cases no treatment is required.

Note(in fourth edition).—The operation of ventro-suspension as described above has been done by the writer and his assistants 310 times during the past seven years, 1893-1901. Two hundred and eleven of these women have recently made written reports of their condition, which are tabulated as follows:Legend:ANumber of cases relieved of the symptoms for which treatment was sought.BNumber of cases improvedCNumber of cases not improvedDNumber of cases who became pregnant and went to full termENumber of cases who miscarried.ABCDEVentro-suspension with unilateral salpingo-oöphorectomy.207710Ventro-suspension with perineorrhaphy and trachelorrhaphy.3415563Ventro-suspension with perineorrhaphy.2212841Ventro-suspension with trachelorrhaphy.206544Ventro-suspension alone.3596501314931208Of the 20 women who became pregnant and went to full term, the course of pregnancy was normal, and the children were all born alive. One woman had a prolonged and difficult labor, though forceps were not used. In 1 case forceps were used to deliver a ten-pound child, who presented in occipito-posterior position; in the remaining 18 cases labor was normal.The operation of ventro-suspension seems to have had nothing whatever to do with producing the miscarriages. In fact, the number of miscarriages is small for any series of 211 women, most of whom were of the dispensary class.Note.—Since collecting the statistics in the preceding note, we have continued to perform this operation in all cases of retroversion suitable for operation, with equally satisfactory results.

Of the 20 women who became pregnant and went to full term, the course of pregnancy was normal, and the children were all born alive. One woman had a prolonged and difficult labor, though forceps were not used. In 1 case forceps were used to deliver a ten-pound child, who presented in occipito-posterior position; in the remaining 18 cases labor was normal.

The operation of ventro-suspension seems to have had nothing whatever to do with producing the miscarriages. In fact, the number of miscarriages is small for any series of 211 women, most of whom were of the dispensary class.

Note.—Since collecting the statistics in the preceding note, we have continued to perform this operation in all cases of retroversion suitable for operation, with equally satisfactory results.

Laceration of the neck of the uterus is of very frequent occurrence. It is said that nearly every woman suffers with a laceration of greater or less extent at her first labor. The majority of such lacerations, however, undoubtedly heal during the puerperium and give no subsequent trouble. The lacerations that concern the gynecologist are those that persist, remaining ununited after the woman leaves her bed. The description of the injured parts and the treatment therefor will be applicable to such old cases of laceration. It is true that some gynecologists have advised immediate examination and the primary operation for repair in case of laceration of the cervix, as in case of injury to the perineum; but such a course has at present but little endorsement. It is difficult to obtain a satisfactory examination under such circumstances. A digital examination alone, unless the sense of touch be very acute, would often fail to detect the lesion in the soft cervical tissue. The woman is exposed to the danger of infection of the upper genital tract from the manipulations of the examination and the operation, and such exposure may be unnecessary, because there is no doubt that many lacerations of the cervix unite of themselves.

It has been found necessary to perform the operation immediately after labor on account of severe hemorrhage from the lacerated wound.

Laceration of the cervix may take place in any direction, and the injury is described according to the direction and number of the tears. A lateral laceration takesplace on either side of the cervix. A bilateral laceration involves both sides (Fig. 104,A). The left is the more usual lateral laceration (Fig. 98), and in case of a bilateral tear the injury on the left side is usually the more extensive. The stellate laceration (Fig. 99) occurs when three or more lacerations radiate from the cervical canal. The less common varieties of laceration seen by the gynecologist are through the anterior and through the posterior lip. It may be that such lacerations occur as often as the lateral lacerations, and that spontaneous repair more often occurs, so that they produce no subsequent trouble. The relations of the neck of the uterus are such that accurate apposition of the injured parts is more likely to occur in case of antero-posterior laceration than in the lateral form of the injury. In some cases there seems to be no doubt that the laceration has extended through the posterior lip of the cervix into the cellular tissue above the posterior vaginal fornix, and that spontaneous repair has taken place, leaving a dense band of scar-tissue to mark the site of the lesion.

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