5 Ibid.
Permeating the pelvic floor in all directions, entering into the composition 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 The old idea that the uterus is supported by the vaginal walls or by the perineum or by the uterine ligaments is obsolete; they are important parts of the pubic and sacral segments, and as such contribute their share, but the pelvic floor as a whole supports the uterus.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 supports 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 foregoing 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 its normal limits are as follows: ascent, retro-location, ante-location, lateral 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, retroflexion, lateral version, lateral flexion, anteversion, anteflexion.
SYMPTOMS AND DIAGNOSIS IN GENERAL.—Each variety of displacement 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 displacement, but which belong to all alike, will be mentioned at once. They may arise either from the displacement itself or from its possible complications, 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 complications, 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; dysmenorrhoea, menorrhagia, sterility, frequent abortion, constipation, 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, anæmia, 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 phenomena 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 presence, therefore, of the second division of the group or any part thereof, even though the first be absent, will justify, may even necessitate, a careful 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 anteflexion 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 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 useless. 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 position; one day with the cylindrical or bivalve speculum, another day with Sims's or Simon's.