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 location of the uterus, the degree of the flexure, and the difficulty of replacement. An inflammatory exudate or hæmatocele, posterior to the uterus, or a fibroid in the posterior uterine wall, may be mistaken for the retroflexed 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 inflammation. Great and lasting injury is often done in the attempt to complete 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 overloaded with fecal matter, the diagnosis should be deferred. The displacement 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 cotton 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 which was published in the Chicago Medical Gazette, Jan. 1, 1880:
| "Ordinary Method of Application. | "Proper 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. | "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. The patient is seldom impressed with the importance of regularity in its administration. | "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 is ordinarily not specified or heeded. | "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. |
| "IV. Ordinarily, the patient abandons its use after a short time." | "IV. 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 circulation 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 covered 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 replacement 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 adjusting the pessary, otherwise the instrument will press upon the sensitive uterus, when one of three unfortunate results must occur: (1) The pessary 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 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 anæsthesia.
| FIG. 16. |
| Commencing Reposition of the Retroverted or Retroflexed Uterus by Conjoined Manipulation (modified from Schultze). |