| FIG. 24. |
| Anteflexion with Post-uterine Fixation. |
A constriction of the uterine canal at the point of flexure may, by confining the secretions above, produce inflammation in the body of the uterus, Fallopian tubes, and ovaries analogous to the cystitis, ureteritis, pyelitis, and nephritis which follow stricture of the male urethra. The peri-uterine inflammations, having the relation either of cause or effect of the flexure, often bind the pelvic organs together in a mass of exudate, with resulting failure of nutrition, nerve-irritation, and constant pain, which sometimes render the patient's life miserable and useless.
SYMPTOMS AND COURSE.—The numerous symptoms due to the inflammatory and other complications should not be confounded with those of the displacement. The symptoms of anteflexion are polyuria and dysuria, dysmenorrhoea and sterility.
The vesical symptoms are produced either by the rigidity of the uterine tissue at the angle of flexure, which prevents the body from rising out of the way of the filling bladder, or by the inflammatory shortening of the utero-sacral ligaments, which, by drawing the uterus upward and backward, put the vesico-vaginal wall on the stretch, thereby causing traction upon the neck of the bladder.
The dysmenorrhoea may depend upon the presence of constriction of the uterine canal at the angle of flexure. This causes the blood to accumulate and to coagulate in the body of the uterus, from which it is expelled at intervals by uterine contractions simulating labor-pains. The pain when due to this cause is therefore always very severe just before the passage of a clot. Furthermore, the dysmenorrhoea may be caused by obstruction in the veins at the angle of flexure, which causes intense venous congestion of the entire body of the uterus; pain is then due to the pressure of the swollen vessels upon the nerve-filaments and to a consequent irritable condition of the muscular tissue of the uterus. Sometimes upon the establishment of the flow the uterine canal becomes temporarily straightened; this removes the cause of the vascular obstruction, and together with the flow gives relief.
Sterility is very commonly associated with anteflexion. The fact that dilatation and incision of the constricted canal have frequently been followed by conception has been accepted as proof that the sterility is due to the constrictive obstruction. This mechanical theory is questioned by many, who say that the dilatation cures sterility by straightening the uterus and thereby removing the venous obstruction and the consequent congestion.
DIAGNOSIS.—The educated touch which distinguishes the normal version, flexion, and movements of the uterus will appreciate the anatomical differences between pathological and normal anteflexion. The degree of flexure, the mobility or rigidity, and the size, shape, location, and consistency of the uterus may be ascertained by conjoined manipulation. The presence of post-uterine cellulitis is recognized by the pain caused in dragging the uterus slightly forward and by increased thickness and tenderness in the region of the utero-sacral ligaments, which may be felt by vaginal or rectal touch. Anteflexion is distinguished from a fibroid in the anterior wall of the uterus by the probe. When the diagnosis of anteflexion is obscured by the presence of cellulitis, it is usually better to wait for absorption of the exudate than to subject the patient to needless danger from the probe. Should it be necessary to pass the probe, the danger is decreased by gentle manipulation, which is facilitated by Sims's speculum and the latero-prone position. The common error of mistaking the normal version and flexion of a prolapsed uterus for pathological version and flexion has been exposed in a previous paragraph. (See Etiology and Clinical History of Descent.)
TREATMENT.—If complicating cellulitis or peritonitis exist, in the relation of either cause or effect to the flexure, its removal becomes the prime indication, because unless removed it is a positive contraindication to the more direct treatment of the malposition itself. Chronic metritis, hyperplasia, hypertrophy, and irremovable tumors sometimes render cure impossible. Improvement of the general health, treatment of complications, and palliation then become the only resources.
The direct treatment of pathological anteflexion has for its object the straightening of the uterine canal, which is usually accomplished either by division of the cervix or by dilatation. But before considering the treatment more specifically, it should be remembered that surgical treatment of anteflexion in cases of dysmenorrhoea and sterility is only justifiable when the anteflexion is pathological. To say that most women who suffer from dysmenorrhoea and sterility have anteflexion is only saying that in the majority of such cases the uterus is in its normal position.
The Marion-Sims operation of dividing the cervix is open to two objections: first, its results are apt to be only temporary, in consequence of rapid contraction upon healing of the wound; second, it has frequently been followed by death. Dilatation by means of tents is also transient in its results, and dangerous to life. Both Sims's operation and dilatation by tents have given frequent and serious warnings in the shape of pelvic inflammations, which, if not destructive to life, have been almost as disastrous in their influence upon health.