INTRA-PELVIC TECHNIC (Manipulative
Surgery of the Pelvic Organs)
PERCY H. WOODHALL, M.D., D.O.
The uterus is balanced, or in a manner floats, in its normal position
in the pelvic cavity in a state of equilibrium. Under natural conditions
when this state of equilibrium is disturbed it is quickly and readily regained
as soon as the disturbing agency has ceased to operate. The uterus is endowed
with a greater degree of mobility than any other internal organ in the
body. Its position is normally altered by every respiratory act, descending
with inspiration and rising with expiration. It is pushed backward as the
bladder fills and forward by a full rectum and upward when both these organs
are filled. Its position is changed by change of posture. It may be greatly
displaced in a bimanual examination only to immediately return to its normal
position which may vary considerably within certain limits. So to constitute
a displacement the condition must be continuous and more or less fixed.
Should the uterus become fixed or immobilized in what is called its "normal
position" such a condition would be pathological. Limitation of physiological
mobility is therefore one of the principal elements in a displacement.
The uterus is maintained in its normal position by a combination of
agencies, no one of which is wholly sufficient, yet the failure of any
one tends to upset the equilibrium and to produce a displacement. Of these
agencies the chief is the pelvic floor composed of the levator ani muscles
with their associated lesser muscles and fasciae. These form the pelvic
diaphragm, the "pelvic sling." They are the structures closing the pelvic
outlet and are the foundation support of the pelvic organs. When their
function is lost displacement is almost inevitable, sooner or later.
The adjacent organs not only afford a bed upon which the uterus lightly
rests when all is well, but when equilibrium is disturbed they afford some
actual assistance in the maintenance of position. The bladder and anterior
vaginal wall in front and below, the pressure of the intestines upon the
superior surface of the fundus, the posterior vaginal wall and the rectum
posteriorly are all factors in preserving position. These agencies must
be in normal condition. Should they become atrophic or otherwise lose their
tone they cease to provide support. Should they become congested or inflamed
their additional weight would serve to disturb rather than maintain position.
The abdominal walls have an important, though an indirect, influence
on uterine position. When they are an normal tone they assist in maintaining
the position of the abdominal organs and prevent their descent and pressure
upon the pelvic organs. That their “sustaining power” is more than this,
The uterine ligaments possess a certain degree of elasticity, or tone,
which operates in a slight degree to restore equilibrium after it is disturbed.
They give but little active support to the uterus until a considerable
degree of displacement has occurred.
Posture is an important factor in the maintenance of equilibrium. It
operates not only through its effect on the abdominal walls, as will be
mentioned later, but also by changing the plane of the pelvic brim and
allowing abdominal pressure and the abdominal organs more direct access
to the pelvis. When the normal lumbar curvature is maintained the plane
of the pelvic inlet approaches the perpendicular in the upright position
and the uterus is snugly ensconced beneath and behind the promontory of
the sacrum. Here it is fairly well protected from the influence of the
intra-abdominal pressure and the weight of the abdominal organs (Fig. 4).
With a slumping of the body a straightening of the lumbar curvature occurs,
the plane of the pelvic inlet is made more nearly horizontal, giving an
invitation, as it were, for abdominal pressure and the abdominal organs
to enter the pelvis.
Abnormal size or weight of the uterus would tend to upset equilibrium,
in time, even though the other elements of support were in every way normal.
Before diagnosing a displacement the condition of the bladder and rectum
should be known. It is possible for a retroversion to disappear after emptying
a distended bladder and for an anteposition to be removed by emptying an
impacted rectum. In fact, these organs should be emptied before an examination
Theoretically displacements may occur in any direction. Actually they
occur most frequently in a forward and backward and a downward direction.
Occasionally lateral displacements are seen. Combinations of these displacements
may occur as antero-lateral, postero-lateral, or some degree of torsion
with or without an accompanying displacement. Downward displacements are
commonly in a backward direction also.
Of the anterior, posterior and lateral displacements two forms are described,
flexions and versions. A flexion is a condition in which the uterus is
bent upon itself and the angle existing between the body and the cervix
is disturbed. The point of bending is usually at the junction of the body
and the cervix, though it may rarely occur at some other point. Either
causing or resulting from the flexion there is a diseased or weakened condition
of the tissues at the point where it occurs, giving rise to a two-fold
pathological condition in flexions. A version is a turning of the uterus
as a whole, the angle between the body and the cervix being unchanged.
Fig. 12. Left Latero-version
of the Uterus. The uterus is crowded to the left side of the pelvis, the
long axis of the uterus inclines to the left. The cause of the displacement
is a broad ligament cyst on the right side adherent to the wall of the
pelvis. (Findley, Diseases of Women.)
Fig. 13. Left latero-displacement
of the Uterus. The left broad ligament is thickened and contracted and
has drawn the uterus to the left. (Findley, Diseases of Women.)
Fig. 14. Contraction of the
left broad ligament drawing the uterus into a left lateral position. (Findley,
Diseases of Women.)
A slight degree of lateral displacement may be considered normal and
is probably due to a congenital shortening of the broad ligament of one
side. Some authorities claim that the uterus lies nearer the left than
the right side of the pelvis. Such conditions interfere with mobility very
slightly, if at all and have no pathological significance.
An abnormal lateral displacement usually occurs as a secondary and minor
accompaniment of one of the other forms of displacement. It may, however,
occur alone or as the predominant disorder. In such cases the uterus may
be forced toward one side of the pelvis by some form of pelvic tumor or
by the swelling from some pelvic inflammation originating on, the opposite
side. In the latter case the uterus may be later displaced toward
the side upon which the inflammation originated by the contraction of the
inflammatory exudate. Adhesions resulting from such inflammatory exudates
are the most common cause of lateral displacements. (Figs. 12, 13, 14)
DIAGNOSIS. While lateral displacements of the uterus are not frequent
their occasional occurrence must be borne in mind for they may be mistaken
for other conditions. The laterally displaced uterus may retain its
form, size and consistence though the conditions causing the displacement,
or the results thereof, may alter all of these. If the uterus is uniformly
drawn to one side the cervix is of course displaced. If latero-flexed
this is not necessarily so, but the fundus will be palpated somewhere between
the median line and the lateral wall of the pelvis. This condition will
be verified by its absence from its normal position. If a latero-version
be present the cervix points away from the side toward which the fundus
is directed. Mobility is decreased in either form of lateral displacement.
Various inflammatory conditions may be confusing. Inflammation in the
connective tissue lateral to the cervix and uterus will cause an indurated
mass of varying size in the pelvis. This induration as a rule is very dense
and often extends to the pelvic wall. It is associated with tenderness
and usually marked decrease in mobility. If the inflammation is acute,
local heat as well as general temperature will be present. There will be
a casual history of labor, abortion, cervical injury or an operation about
the cervix or uterus. The inflammation may have progressed to abscess formation
in which event fluctuation may be detected, depending upon the thickness
of the walls surrounding the abscess cavity.
The uterine tube may be inflamed, thickened, nodular, dilated and filled
with fluid and involved in peritoneal adhesions. Such a mass usually lies
opposite or level with the fundus and is distinct from the uterus. It may
be movable unless anchored by adhesions. When the tube is filled with fluid
its characteristic sausage shape and fluctuation can be detected. It can
often be traced back to the cornua of the uterus and the identity of the
The ovaries when prolapsed or when enlarged from inflammation or the
formation of any form of tumor may simulate a latero-flexion. An ovary
has a peculiar tenderness giving rise to a peculiar sickening pain on pressure.
It is usually movable, but may sometimes be bound down by adhesions. Its
size, shape, position, peculiar sensitiveness and consistency are characteristic.
When cystic it is soft in consistence but when chronically inflamed it
is firm. On careful palpation, if not fixed by adhesions, its attachment
to the tubo-ovarian region can be determined.
A small uterine fibroid developing between the layers of the broad ligament
is attached to the side of and is usually movable with the uterus. Its
firm consistence, well defined borders and absence of tenderness will usually
make a diagnosis easy. Occasionally a solid tumor of the tube or ovary
is found which either because it is intra-ligamentary or is confined to
the lower part of the pelvis by adhesions, may resemble a latero-flexion.
It is less tender than an inflammatory mass and more definite in outline.
An ovarian or par-ovarian cyst may sometimes develop close to the cervix.
They are spherical as a rule and fluctuation can usually be detected.
In all cases of displacement the absence of the uterus from its normal
position must be determined as well as its location in an abnormal position.
TREATMENT. The same general plan of treatment is followed in these cases
as will be outlined in the treatment of the more common displacements.
Upward Displacement or the Elevation of the Uterus
This is least frequent of the pathological displacements. It normally
occurs with pregnancy as the uterus rises into the abdominal cavity.
The pathological cause are growths below which force the uterus upward
or tumors of the ovaries or the uterus, which rise out of the pelvis and
draw the uterus upward with them. Occasionally adhesions form during
pregnancy, between the abdominal wall and the uterus, so that after the
termination of pregnancy the uterus remains suspended by these adhesions
from the abdominal wall. Operations involving both the uterus and
the abdominal wall may be followed by adhesions which prevent the proper
descent of the uterus.
Torsion of the Uterus.
This condition is a twisting of the uterus on its long axis. It is usually
associated with the more common displacements and is caused by pressure
or traction action so as to rotate the uterus on its axis.
The treatment of these unusual displacements will readily suggest itself
after a study of the more common ones.
This is a condition in which the body of the uterus is bent forward
on the cervix which occupies its normal position, or in which the cervix
is bent forward on the body which remains in its proper location) or in
which both body and cervix are bent forward. (Figs. 15, 16, 17.) The first
of these is called Corporeal Anteflexion, the second Cervical Anteflexion
and the last Cervico-Corporeal Anteflexion. Anteflexion is also classed
by some into first, second and third degrees according to the angle produced.
Such classification is of but little practical value, Opinions differ widely
not only is to the relative frequency of anteflexion, but as to its pathological
importance when it does occur. By some writers it is given first place
in frequency while others scarcely mention it at all. Its symptoms pass
unnoticed by some and are recited at great length and accorded much importance
by others. This difference of opinion is due to the fact that the uterus
is normally slightly anteflexed, the degree off which is variable. The
point at which this anteflexion becomes pathological depends upon no fixed
standard but upon the opinion of individual physician. Where one sees an
extreme degree of normal anteflexion another finds a pathological condition.
The one seeing a normal condition naturally does not attribute symptoms
Fig. 15. Corporeal Anteflexion.
Fig. 16. Cervical Anteflexion.
Fig. 17. Cervico-corporeal Anteflexion.
The true state of affairs is found between these extremes. It does occur
with relative frequency and is often the cause of annoying and sometimes
very distressing symptoms.
Its occurrence is favored by the normal anteflexion in which position
the uterus is kept by intra-abdomina1 pressure and the attachment anteriorly
of the round ligament. This malposition is more frequent in virgins and
nullipara than in those who have borne children.
As heretofore mentioned, a flexion indicates a two-fold pathology, a
displacement plus a diseased or weakened tissue. The consistence of normal
uterine tissue is such that if the organ be flexed, it will spontaneously
return to its original position when the pressure is removed. So in every
case of an anteflexion there must occur a weakening of tissue at the point
of flexure or the normal tissue rigidity must have been overcome, to be
later replaced by a more resistant pathological rigidity. This final pathological
rigidity is most probably due to congestion and inflammation of the uterine
wall occurring on the compressed or concave side of the flexure, to be
followed as resolution of the inflammation occurs, by atrophy of the uterine
musculature and scar tissue development.
CAUSES. (1) Deranged Spinal Innervation. This produces a predisposition
to anteflexion. It would be impossible to foretell in a given case the
exact manner in which such a disturbance might operate. Much would depend
upon this length of time the disturbed innervation had existed; the particular
direction the aroused reflexes might take; the pre-existent or accompanying
predisposition, etc. However, we would expect this cause to manifest itself
in one of several ways.
(a). By causing loss of uterine tone. (b). By causing contraction of
sarco-uterine ligaments which are rich in involuntary muscular fibers.
(c) By interference with vaso-motor nerves resulting in congestion and
hyperplasia with consequent increase in weight.
(2). Endometritis and Metritis. These two conditions, usually associated
to some extent with one of the chief agencies weakening the tissues, the
normal tissues being replaced by hypertrophied glandular and hyperplastic
areolar tissue. At the same time a corporeal endometritis increases
the weight of the uterine body, adding to its normal, tendency to anteversion.
Acting in a similar manner are continued passive congestion and subinvolution.
Fig. 18. Anteflexion Caused
Fig. 19. Anteflexion of Uterus
from posterior perimetritic adhesions or contracting parametritic exudates
of Douglas' folds at the level of the internal os. The perirectal adhesions
produce pain and constipation. (Schaeffer, Atlas and Epitome of Gynecology.)
(3). Inflammatory Adhesions. (Figs. 18, 19.) These are the most frequent
causes of anteflexion. They are formed chiefly of connective tissue, and
are the result of a previous inflammation of the connective tissue, posterior
to the cervix and in the sacro-uterine ligaments. The organization and
contracture of the inflammatory exudate draws the uterus usually at, the
cervio-corporeal junction, backward and upward. At the same time intra-abdominal
pressure on the superior surface of the fundus and the natural tension
off the posterior vaginal wall upon the cervix in a downward and forward
direction, cause the uterus to bend forward at the servico-corpoeal junction,
rendering the normal angle at this point more acute. It sometimes happens
that the contracture in the ligaments is not equal on the two sides and
some degree of latero-flexion or latero-torsion will be produced.
Rarely, adhesions may be formed anteriorly which either pull the fundus
forward or immobilize the cervix so that it cannot recede when the fundus
is forced downward by intra-abdominal pressure.
(4) Increased Intra-abdominal Pressure. This may be from muscular efforts,
improper corseting, coughing, tumors or ascites. Abdominal ptosis, in cases
in which the pelvic floor is unimpaired, may increase the normal pressure
the superior surface of the fundus is called upon to bear and force it
downward. So, also, improper posture, such as the slumped position over
a sewing machine or elsewhere. This position obliterates the anterior lumbar
curve and allows the abdominal contents easier access to the pelvis, causing
a relatively increased pressure on the fundus. Should the vaginal walls
be slightly shorter than the average so that the cervix cannot move backward,
as the fundus is forced downward, some degree of anteflexion is inevitable.
(5.) Errors in Development. There may be persistence of the infantile
form of uterus, a small body with a relatively much larger cervix lying
practically in the same direction as the vagina. The cervico-corporeal
junction being flexible, as the fundus develops the cervix fails to extend
and a decided anteflexion results. In some of these cases the uterus remains
infantile in size. This condition is quite different from a small adult
uterus. More often the uterus will be of normal size but in an extreme
degree of anteflexion. If it is truly infantile there is usually a corresponding
lack of development in the ovaries and perhaps the vagina also.
(6.) Impacted Rectum. This may in rare instances and extremely pronounced
cases by pressure, cause the cervix to bend forward on the fundus.
SYMPTOMS. The most prominent symptoms of anteflexion are, dysmenorrhoea,
sterility, irritable bladder and reflex nervous disturbances.
The cause of the dysmenorrhoea in these cases has not been positively
determined. That it is due to an obstruction to the egress of the flow
by the bend in the cervico-uterine canal is denied by those who claim that
a sound can easily be passed under these conditions, showing an absence
of obstruction. There is a vast difference, however, between passing a
rigid sound from without the uterus inward and the passage of fluid from
within the uterus outward. In some of these cases the similarity of the
pains to labor pains almost convinces one that this miniature labor is
due to some obstruction. Yet the proponents of the no-obstruction theory
declare these characteristic pains occur when the uterus is perfectly empty
and even hours before the flow passes from the blood vessels into the uterine
cavity. Doubtless enough attention has not been given to the rigid and
unyielding tissue at the point of flexion, and the pressure upon nerve
terminals by the congestion preceding and accompanying the flow. When this
congestion is relieved by a copious discharge of menstrual blood, the pain
is relieved. Certainly sufficient importance has not bee accorded
the part of that irritation of the “pelvic brain,” the cervico-uterine
ganglion, plays in the dysmenorrhoea and other disturbances arising in
Sterility is common in cases of anteflexion. That it is due to
an obstruction to the passage of spermatozoa through a passage that allows
free egress of the menstrual flow does not seem reasonable. Some degree
of endometritis with an accompanying leucorrhoea is often present and doubtless
has something to do with the sterility. Ovaritis and salpingitis are not
infrequent especially in the cases due to inflammatory adhesions. These,
too, may play a part in causing the sterility. Yet more important in my
opinion, is some trophic disturbance from involvement of the cervico-uterine
ganglion, either affecting the mucous membrane of the uterus so that it
does not afford the normal favorable condition for the lodgement of the
fertilized ovum, or affecting the vitality of the ovum itself so that it
fails to become fertilized.
Irritability of the bladder is not quite so common as are the foregoing
symptoms. It is usually expressed by frequent urination and tenesmus. This
may be due occasionally to the pressure of the anteflexed fundus; though
more often to traction on the bladder walls through their intimate connection
to the cervix, as the latter is pulled backward and upward by the contracting
inflammatory adhesions. The relationship through blood and nerve supply
is very intimate and the disturbance of these accounts for some of the
Some degree of rectal disorder may be present if contractured adhesions
along the course of the sacro-uterine ligaments draw the uterus backward,
and constrict or irritate the rectum.
The nervous disturbances are varied. There are almost innumerable paths
they may take. They usually follow the path of least resistance, that is,
to some reflexly connected organ whose nerves have been previously affected
by some disturbed spinal innervation. So we may find headaches, disturbed
vision, dyspepsia, epigastric pain, backache, etc.
Anteflection predisposes to abortion and to excessive nausea and vomiting
should pregnancy occur.
DIAGNOSIS. In no case should a diagnosis be made from the direction
in which the cervix is pointing, which is usually in the direction of the
axis of the vagina, as either a cervical or a cervico-corporeal anteflexion
is most frequent. Without further examination it might be mistaken for
a retroversion. By careful bimanual palpation the fundus will be located
and the angle between it and the cervix will be found to be more acute.
In stout women this change in the cervico-corporeal angle can be more easily
and distinctly palpated with the patient in Sim's position.
In cases due to contracture along the sacro-uterine ligaments the cervix
is higher than normal, forward mobility especially is impaired and on careful
bimanual or recto-abdominal examination the cicatricial bands can be felt.
Fig. 20. Fibroid in Anterior
Uterine Wall Resembling an Anteflexion.
A small fibroid in the anterior uterine wall (Fig. 20) may closely resemble
an anteflexion and when bimanual examination does not make the diagnosis
clear, the passing of a sound into the uterus may do so.
Occasionally inflammation in the connective tissue between the cervix
and bladder may prove confusing. This lacks the distinct outline of the
fundus and has a causal history. Should abscess formation have occurred
fluctuation may be present. Very rarely a hematoma may collect between
the uterus and bladder. If recent the history and the fluctuation of the
mass will aid in diagnosis. The possibility of malignant infiltration in
this region or tumor or disease of the bladder must also be borne in mind.
In cases preceded by extensive inflammation of the pelvic peritoneum
or connective tissue a diagnosis may be extremely difficult.
Fig. 21. Replacement of an Anteflexion
Caused by Adhesions.
Fig. 22. Straightening an Anteflexion.
TREATMENT. The intra-pelvic technic to be employed is especially applicable
in those cases due to inflammatory adhesions or cicatricial bands. These
are usually attached to the posterior surface of the uterus at or about
the junction of the cervix and body and pass backward, outward and upward
to the front and sides of the sacrum on either one or both sides. If it
is possible such bands should be relaxed. This is best accomplished by
placing two fingers of the right hand in the posterior vaginal vault behind
the cervix, and then by pressure from above on the abdominal wall insinuate
the fingers of the left hand behind the fundus and approximate the fingers
of the two hands, (Fig. 21). The uterus is now pulled forward and downward
to the point of toleration of the patient, and while the adhesions are
thus stretched they are manipulated, transversely, from origin to insertion,
by either of the two hands. It often happens that they can easily be manipulated
between the fingers of the two hands. The angle of flexion should receive
attention. The uterine tissue itself as well as the connective tissue immediately
surrounding this point should be manipulated and relaxed as thoroughly
as possible. The uterus should he straightened by pressing the apex of
the angle forward with the internal fingers, while the fundus is pressed
backward by the external hand, (Fig. 22). It should be held in this position
for a few seconds, the idea being to make the cavities of the cervix and
body a straight line and by over correction, restore as nearly as possible
the normal cervico-corporeal angle.
It may require several minutes to execute this technic which applies
to any form of anteflexion. It may be repeated as soon as the effects of
the previous treatment have worn off.
Fig. 23. Arteversion.
This method of treatment goes far toward relieving any endometritis
or metritis present. It restores normal mobility when such is possible.
It relieves pressure upon the cervico-uterine ganglion and normalizes circulation
by opening blood and lymph channels. It tends to reduce whatever obstruction
may be caused by the angulation and in this way often cures the dysmenorrhoea
This is a condition in which the uterus is rigid and the cervico-corporeal
angle is either normal or extended, the fundus is turned forward and downward
and the cervix passes upward and backward. The normal flexion and flexibility
of the uterus is lost and the cervix and the body form one rigid whole
This is neither so frequent nor so troublesome a condition as anteflexion.
CAUSES. (1). The general causes are very similar to those of anteflexion,
the difference in the conditions being the unchanged or extended cervico-corporeal
angle and the rigidity of the tissue at this point in anteversion. Disturbed
spinal innervation operates as in anteflexion.
(2.) Chronic congestion, endometritis, subinvolution, tumors, pregnancy,
etc. All of these conditions increase the weight of the uterus and cause
it to tip forward when the indivdual is sitting or standing.
(3). Inflammatory Adhesions. These may rarely be in the anterior portion
of the pelvis and draw the fundus forward and downward. More frequently
they are along the course of the sacro-uterine ligaments, and draw the
cervix upward. The cervico-corporeal angle being rigid, the fundus of necessity
(4). Increased abdominal pressure. Tight clothing, improper corseting,
muscular efforts, ascites, tumors, etc, all tend to force the fundus downward.
(5.) Posture as in anteflexion.
(6). Violence, as falls upon the feet especially when the bladder is
PATHOLOGY. The uterus is congested, enlarged, and a low grade of endometritis,
metritis, or both, is usually present. Adhesions anteriorly are rarely
seen, but are common posteriorly. A tube or ovary adherent to the anterior
pelvic wall is occasionally found.
When not involved in adhesions the sacro-uterine ligaments are retracted
from non-use. Some degree of cystitis may be present.
SYMPTOMS. These are not as pronounced and constant as in anteflexion.
Anteversion of pronounced degree may exist for years with but few if any
symptoms. They are to a large extent due to the associated endometritis
Vesical irritability is perhaps more common than in anteflexion. It
is caused by the pressure of the fundus upon the bladder as well as by
the associated cystitis.
Dysmenorrhoea and sterility are less common than in anteflexion. They
may be caused by the close apposition of the external os to the posterior
vaginal wall, though more probably by the chronic endometritis so commonly
present. In those cases in which the fundus points downward and is
on a lower level than the cervix, pain may be caused by the increased contractions
necessary to expel the flow against the influence of gravity.
Menorrhagia, metrorrhagia and leucorrhoea are occasional symptoms,
doubtless due to the accompanying congestion and endometitis.
Rectal symptoms are sometimes seen. An irritation, sometimes amounting
to tenesmus may result from the pressure of the cervix against the rectum.
An obstructive constipation may result from the same cause.
Fig. 24. Replacement of an Anteversion.
Fig. 25. Replacement of an Anteversion.
DIAGNOSIS. On digital examination the cervix is higher than normal.
It is reached with difficulty and is directed backward toward the hollow
of the sacrum. In extreme cases it may be directed somewhat upward. On
passing the finger forward to the anterior vaginal vault the inferior surface
of the body can be felt passing forward toward the symphysis. A careful
bimanual examination should be made to confirm this position. The diagnosis
is made from the extended position of the uterus, the cervix high, the
fundus low, and the rigidity of the organ as a whole.
TREATMENT. This should begin with a removal of causes. These are most
frequently inflammatory adhesions along the course of the sacro-uterine
ligaments. The treatment of these differs in no way from the treatment
of such adhesions described under anteflexion. The congestion, endometritis
and metritis are treated by securing normal mobility for the uterus and
by direct manipulation of the organ itself and to the tissues immediately
surrounding it. The uterus can be bimanually replaced by passing two fingers
of the right hand into the anterior formix of the vagina and lifting the
fundus upward as far as possible at the same time an attempt is made by
placing the fingers of the abdominal hand just above the symphysis, to
approximate the fingers of the two hands in front of the fundus (Fig. 24).
By this means the fundus is not only prevented from returning to its abnormal
position, but can be pushed further backward and upward. The intravaginal
fingers should now be placed in the posterior vaginal fornix and the cervix
drawn downward and forward, the fundus being simultaneously pressed upward
and backward with the abdominal hand (Fig. 25).
This attempt at replacement should be made at every treatment, but it
will not be permanently successful until the adhesions have been relaxed
and the accompanying congestion or inflammation relieved.
The other causes are to he relieved by the usual methods.
Fig. 26. Retroversion.
These are said not only to be the most frequent of displacements, but
the most frequent of pelvic disorders.
Of the backward displacements there are two: retroversion and retroflexion.
In retroversion the uterus is fixed in a position in which the fundus
points upward, or backward, the cervix more or less downward or even forward
or upward, the cervico-corporeal angle being unchanged or slightly extended.
The normal flexibility of the uterus is lost and the organ is rigid.
The general condition of the uterus is very similar, but its position is
the reverse of that seen in anteversion.
Fig. 27. Retroflexion.
Fig. 28. Retroposition and retroversion
of the uterus, with fixation. Peritoneal adhesions bind the posterior surface
of the uterus to the sacrum and rectum, holding the uterus firmly in retroversion
and retroposition. (Findley, Diseases of Women.)
Fig. 29. Retroversion of a Fixed
Uterus. The uterus is vertical and is fixed by sacro-uterine and recto-uterine
adhesions - the contracted and shortened uterine ligaments. Vagina put
on the stretch by the elevation of the uterus.
In retroversions the chief causes for the deviation are changes in the
ligaments; in retroflexion, changes in the uterine parenchyma. together
with changes in the ligaments. Retroversion easily passes into retroflexion.
If the adnexa are not bound down in Douglas' pouch, they usually lie above
the uterus and laterally. (Schaeffer, Atlas and Epitome of Gynecology.)
Fig. 30. Retroflexion of a Fixed
Uterus - uterus bound down throughout its entire length to serosa of Douglas'
pouch by perimetritic adhesions. Cervix forced anteriorly, anterior lip
thinned, the anterior cervical wall likewise; posterior lip thickened.
Vagina thrown into folds by the descensus. Pressure of the intestines upon
the uterus. (Schaeffer, Atlas and Epitome of Gynecology.)
Fig. 31. Retroposition of the
Uterus. The uterus is drawn backward into retroposition by peritoneal bands
of adhesions, extending from the supravaginal portion of the cervix to
the sacrum. (Findley, Diseases of Women.)
In retroflexion the uterus is fixed in a position of flexion over its
posterior surface. The fundus is directed backward or downward and the
cervix downward and sometimes somewhat forward. The apex of the cervico-corporeal
angle is reversed and points anteriorly. The general condition of the uterus
is very similar, but its position is the reverse of that seen in anteflexion
(Fig. 27). In most cases of backward displacement there is some degree
of both retroflexion and retroversion, the cervix pointing downward
arid sometimes forward.
In practically all cases of backward displacement there is associated
some downward displacement as well.
CAUSES. (1). Deranged Spinal Innervation. This causes relaxation of
uterine tissue and ligaments and by vaso-motor disturbances causes congestion
which naturally increases the weight of the organ, and if continued will
lead to chronic endometritis. In every case of pronounced retro-displacement
the round as well as the sacro-uterine ligaments are relaxed. Relaxation
of the sacro-uterine ligaments is a necessary part of the retro-displacement
of the uterus of normal size. This is especially so in cases of retroversion.
Without this the cervix could not move downward and forward, allowing the
fundus to move backward and upward.
(2). Inflammatory Adhesions (Figs. 28, 29, 30, 31). These may
occur high up, posteriorly and by their contraction draw the fundus backward.
They originate from the usual causes of inflammation of the pelvic connective
tissue and differ from the adhesions causing anteflexion only in that they
involve an area higher on the uterus, above the cervico corporeal angle,
and by their contraction draw the body of the uterus backward. In some
cases the adhesions are seemingly peritoneal in origin and secondary to
the displacement. These seem to be due to the irritation caused by the
opposed posterior surface of the uterus against the posterior wall of the
pelvis. Often the uterus feels to bimanual palpation, as though it were
glued to the posterior wall of the pelvis. No doubt the colon bacillus
is an important factor in the low grade, localized peritonitis responsible
for these adhesions.
(3). Developmental Errors. The relatively long cervix of the infantile
uterus directed in the axis of the vagina, a correspondingly small uterine
body, with a short anterior vaginal wall will sometimes cause retroversion.
I have seen some of these cases in which an infantile and retroverted uterus
seemed to have developed in and to have been a part of the anterior rectal
wall. Senile atrophy may act in a very similar manner and cause retroversion
in the aged.
(4). Posture. Following delivery it is common to have the patient remain
in the dorsal position for some time. In addition to this an abdominal
binder is often applied. The increased weight of the uterus of itself tends
to cause a retro-displacement. The application of an abdominal binder increases
this, and it needs only a distended bladder (and this is not always necessary)
to cause a retro-displacement. This danger of retro-displacement continues
until involution is complete. Not only must the uterus have returned to
its normal size and tone, but its supporting structures as well, pelvic
floor, vagina, abdominal walls, ligaments, etc. Especially must this be
so of the sacro-uterine ligaments whose normal tonicity prevents the forward
and downward displacement of the cervix. It requires from six to eight
weeks after confinement for this normal involution to be completed.
(5). Increased Intra-abdominal Pressure. This may result from muscular
efforts, violent vomiting, tumors, ascites or improper corseting. Associated
with it is usually increased weight of the uterus, especially of the fundus,
as may result from pregnancy (in the early months) or subinvolution. Chronic
constipation, with the presence of a fecal mass in the rectum pressing
the cervix forward and thus tilting the fundus backward and allowing the
intra-abdominal pressure to act upon its anterior surface, is also a definite
factor. Habitual over-distension of the bladder by forcing the fundus upward
and backward is also a predisposing cause. The sudden increase of pressure
resulting from a fall, especially upon the sacral region or buttocks, may
cause the retro-displacement of a previously normal uterus. Rarely the
fundus is prevented from occupying its usual anterior condition by the
failure of the descent of an ovary.
PATHOLOGY. Remembering the course of the blood and lymph vessels and
nerves that supply the uterus, as they pass between the layers of the broad
ligaments, and the distortion and pressure that must ensue when the fundus
of the uterus as a whole is turned backward, one would expect some degrees
of congestion or inflammation of the uterus itself. So it is. The uterus
is enlarged, slightly prolapsed, and the endometrium is in a state of chronic
inflammation. This is present in addition to whatever causative pathology
that may have preceded the displacement. The chronic congestion or inflammation
has extended to the tubes and ovaries also. These may be dragged backward,
and downward with the fundus. Adhesions being prominent among the causative
factors are often seen. When not an etiological factor they may later develop
from pressure, irritation, congestion and inflammation of the opposed peritoneal
surfaces. Pressure of a deeply retroflexed fundus has been known to cause
gangrene of the posterior vaginal wall.
SYMPTOMS. Menstrual disturbances are common. Menorrhagia and metrorrhagia
whether due to the secondary congestion and chronic endometritis or directly
to the displacement, usually promptly disappear when replacement is effected,
if no complications are present. The excessive bleeding sometimes leads
to severe anemia with its associated symptoms. The presence of a retro-displacement
may delay the occurrence of the menopause. The early reappearance of menstruation
during lactation is sometimes due to a retro-displacement. Leucorrhoea
is often present as a result of the congestion and chronic endometritis.
Dysmenorrhoea is not a prominent symptom.
An obstructive constipation may ensue from pressure of the fundus upon
the rectum. This may also give rise to a feeling of fullness in the rectum
and occasionally may be an element in the production of hemorrhoids. Irritability
of the bladder evidenced by frequent and painful urination is an occasional
symptom. Retro-displacements may so distort the ureters as to cause kinks,
leading to their partial occlusion. They are so frequently associated with
inflammatory affections of the upper part of the urinary tract that the
connection can hardly be always accidental.
A peculiar and rather distinctive sacral backache is often present in
retro-displacement, and besides this there may be an ordinary lumbar ache.
Pains and weakness in the legs are not uncommon. A sense of weight and
heaviness, a bearing down sensation in the pelvis is frequently present.
This is easily aggravated by exertion, or standing, and is most common
in the cases with complications. Pains and soreness about the ovaries result
from the distortion of the blood vessels supplying them and the consequent
congestion or inflammation.
Sterility is not so frequent as in anteflexion. It is in some cases
apparently due to the displacement, though in most cases doubtless due
to the complicating congestion and inflammation. Abortions frequently occur
in retro-displacements. When pregnancy does occur and goes to term a spontaneous
cure of the displacement sometimes occurs, if proper attention is given
The general nutrition suffers from the anemia and reflex gastro-intestinal
or other disorders.
DIAGNOSIS. The diagnosis must be made from the physical findings upon
bimanual palpation. On passing the two fingers of the right hand into the
vagina, the cervix may rarely be found in its normal position and pointing
in its normal direction in a case of retroflexion. Usually it is anterior
to its normal position, is low and points downward, occasionally forward
and in extreme cases of retroversion may be directed upward and be difficult
to reach. If the finger is now passed to the posterior surface of the cervix
and directed upward a mass will be felt of the general size, shape and
consistency of the body, and apparently continuous with the cervix. In
some cases this tumor will be found below the level of the cervix in the
retro-uterine fossa. As a mass in this position may be caused by other
conditions it is necessary to determine the absence of the fundus from
its normal position. This is done by bimanual palpation, the fingers of
the abdominal hand and those within the vagina being approximated anterior
to the cervix and the absence of the body of the uterus noted. The diagnosis
may often be verified by a rectal examination, especially in fleshy individuals,
by feeling the fundus through the anterior rectal wall.
Ordinarily the diagnosis of a retro-displacement is not difficult.
Thorough acquaintance with the normal feel of the organ, familiarity with
its size, shape, position, consistence, tenderness, and mobility, is indispensable.
Certain conditions may, however, prove confusing.
A fibroid tumor occurring in the posterior wall of the uterus, or if
pedunculated and behind the uterus or even when in the anterior wall of
the uterus and displacing the organ backward, may require careful examination
to make the diagnosis.
An enlarged and prolapsed ovary may be mistaken for the retro-displaced
fundus. The characteristic tenderness and the presence of the fundus in
its normal position will make the diagnosis, clear. An enlarged, and prolapsed
uterine tube usually has a sausage shaped outline, and if filled with fluid,
fluctuation car usually be detected.
An inflammatory mass back of the cervix is usually tender and lacks
the distinct outline of the displaced fundus and presents a history of
an acute inflammation. A hematoma or other product of an ectopic gestation,
has its distinctive history and lacks the outline and consistence of the
fundus. A fecal mass in the rectum is of putty-like consistence, can be
indented upon pressure, is practically insensitive, is in the course of
the rectum and can be removed by a properly administered enema.
Sometimes the use of a sound to determine the direction of the uterine
canal may be necessary.
TREATMENT. Replacement of a retro-displaced uterus depends upon free
mobility. Unless the uterus is freely moveable, replacement if effected
is but temporary. A most careful bimanual examination must be made in every
case to determine the cause of immobility, and the first indication in
treatment is to remove such cause. Unfortunately this is not always possible.
Fig. 32. Loosening the Uterus
from the Posterior Pelvic Wall.
Spinal innervation must be normalized. Inflammatory adhesions whether
of connective tissue or peritoneal origin must be located and relaxed,
as has been heretofore described. In some cases the uterus seemingly has
to be "pried loose" from the anterior rectal or posterior pelvic wall,
working downward with the abdominal hand and upward through the posterior
vaginal vault or sometimes through the rectum with the intra-pelvic hand.
Developmental errors offer an almost insurmountable difficulty, yet
in some of these, apparently hopeless, after treatment, I have seen pregnancy
occur and go to term, to be followed by full development of the uterus
and remarkable improvement in the displacement. Senile cases do not as
a rule cause much distress. If treatment is indicated stretching the tissues
with replacement is usually beneficial.
Other contributing causes inust be corrected or removed.
Replacement may be accomplished in several ways, no one of which will
prove successful in every case. Personally I have been most uniformly successful
by using a bimanual abdomino-vaginal method, with the patient in the dorsal
position, head and shoulders somewhat raised to relax the abdominal muscles.
The bladder, rectum and pelvic colon should be empty. In these cases it
in often best to have the patient, brought to the end of the table so that,
if necessary, you can not only stand between her knees and have the benefit
of the weight of your body to press your fingers deeper into the pelvis,
but can depress the wrist of the examining hand to assist in raising the
fundus out of the recto-uterine excavation. The index and middle fingers
of the right hand are passed into the posterior vaginal fornix against
the posterior surface of the uterus, as near the fundus as possible. Steady
pressure is now made upon the body of the uterus upward and forward along
the sacrum and to that side of the sacral promotory toward which the fundus
seems inclined. When it is medially placed either side may be selected,
preferably the one toward which it most easily moved. It may be necessary
to use considerable pressure and the manipulation may be rather painful,
even when no adhesions exist. If the attempt causes too great pain or an
undue amount of force seems necessary, it should be abandoned for the time
being, and a careful search be made for the hindrance to replacement As
soon as the fundus is forced to the promontory of the sacrum by the fingers
of the internal hand, an attempt is made to get the heretofore idle fingers
of the external hand behind the fundus from above by gentle, firm pressure
upon the abdomen. In doing this place the hand upon the abdomen, press
the superficial tissues upward so that they may be carried with the hand
and it will not be necessary to move the hand over the skin. Now by downward
and backward vibratory pressure penetrate the pelvis from above and behind
the fundus. The desire is to lift the fundus upward with the internal fingers
and at the same time insinuate the external fingers behind it from above,
and so approximate, as nearly as possible the fingers of the two hands
and turn the fundus forward into its normal position. (Figs. 33, 34.) This
is the most difficult part of the technic. The fingers of the operator
may be too short, or the depth of the vagina may be insufficient to allow
the fundus to be raised high enough, or the abdominal walls may be too
thick or too contracted, to allow the external fingers to get sufficiently
behind the fundus to turn it forward.
Fig. 33. Replacement of a Retroversion.
Fig. 34. Replacement of a Retroversion.
In cases of retroversion external pressure deep into the pelvis immediately
above the symphysis pubis, may so depress the cervix as to assist in tipping
the fundus upward and forward. After the fundus is partially raised the
index finger may be passed to the anterior surface of the cervix to press
it backward and downward while the middle finger maintains the upward pressure
upon, the fundus so as to bring it in control of the external fingers.
As soon as this is done the internal fingers are placed against the anterior
part of the cervix and it is pushed backward and upward into the pelvis
while the fundus is pressed downward and forward with the external hand.
If the replacement is effected it is well to bring the uterus into a position
of anteversion, and thus, as it were, over correct the displacement.
Occasionally better results may be obtained by lifting the fundus out
of the recto-uterine excavation with the index or index and middle fingers
introduced into the rectum.
An abdomino-recto-vaginal method is sometimes successful, the fundus
being pushed upward by the index and middle fingers in the rectum while
the cervix is forced backward by the thumb of the same hand in the vagina
making pressure upon the anterior surface of the cervix. The abdominal
hand lends the same assistance as before.
Fig. 35. Sim's or Left Lateral
Fig. 36. Replacement of a Retroversion.
Again the Sims position (Fig. 35), or the knee-chest position may be
used to advantage in dislodging the fundus from the depths of the pelvis.
In either of these positions the index and middle fingers of the right
hand are introduced into the posterior vaginal vault, the fundus is pushed
upward and forward and while it is held in this position by the middle
finger, the index finger is passed to the anterior surface of the cervix
pushing it upward and backward.
Another method especially useful in retroflexion is to pass two fingers
into the anterior vaginal vault and make backward pressure at the cervico-corporeal
junction, or wherever the angle occurs, and straighten out the flexion
angle by pressure against the sacrum. The uterus is now pressed upward
in the direction of the sacro-iliac articulation, to the side of the promontory
of the sacrum, and the fundus reached and pulled forward by the external
hand as already described. (Fig. 36.)
Dr. C. W. Young secures splendid results in retro-displacements and
in other intra-pelvic disorders by the use of the index finger in the vagina
and middle finger in the rectum. The other hand is placed upon the abdomen
giving an abdomino-vagina rectal manipulation. (Journal of the American
Osteopathic Association, May, 1918)
Whenever possible the patient should assume the knee-chest posture for
several minutes after replacement, and then lie down in the Sim's position
so that gravity will tend to prevent the uterus from resuming its mal-position.
Instruct her to assume the knee-chest posture for several minutes before
retiring at night, and while in this posture have her separate the walls
of the vagina so as to allow the entrance of air and thus balloon out its
walls, securing the aid of atmospheric pressure as well as gravity in maintaining
the proper position of the uterus. Other methods for maintaining proper
position after it is once secured will be discussed in Chapter VIII.
Fig. 37. Degrees of Incomplete
Fig. 38. Complete Prolapse.
Prolapse of the uterus ordinarily called "falling of the womb" is a
condition in which the uterus permanently occupies a lowe level in the
pelvis than is normal (Figs. 37, 48). This condition varies in degree
from the slightest appreciable descent to that state in which the uterus
is entirely without the pelvis and hangs between the thighs of the patient.
In this case the vagina is turned inside out. In the majority of cases
the cervix is above or just within the vaginal orifice. Often, however,
it protrudes beyond the vulva. Different degrees are recognized, as first,
when the cervix remains within the vagina; second when the cervix protrudes
beyond the vaginal orifice, and third when the uterus is outside of the
pelvis. When the uterus remains within the vagina it is called "incomplete"
prolapse and when it is outside the vagina it is called "complete" prolapse
or "procidendia uteri."
Of the several agencies retaining the uterus in normal position, the
tissues forming the pelvic floor, the levator ani muscle, in particular,
is of chief importance. It, more than any other single factor, opposes
the action of gravity and intra-abdominal pressure and prevents the descent
of the uterus. This is due largely to the position of the uterus relative
to the opening in the muscle through which the vagina passes. The cervix
overlaps this opening in the direction of the sacrum and the fundus in
the direction of the symphysis pubis so that the uterus extends beyond
the opening in both directions, (Fig. 1) posteriorly and anteriorly. To
allow prolapse of any considerable degree the cervix must either be brought
forward or the opening must be enlarged so as to allow the cervix to slip
into it. In all cases of prolapse of any considerable degree the cervix
will be found anterior to its normal position. Complete prolapse is restrained,
but not prevented, by the round and broad ligaments.
There is a very common form of descent of the uterus which according
to the classification of our text books can hardly be called "prolapse."
A term of my own choosing is "settling" of the uterus. The uterus is lying
heavily in its bed. The cervix and fundus are directed normally, the cervico-corporeal
angle is unchanged. The relation of the uterus to the opening in the levator
ani is undisturbed, its mobility under bimanual examination is either unaffected
or slightly increased, but its normal respiratory excursion is, limited
and sluggish. It is congested, heavy and enlarged and lies lower in the
pelvis than is normal. This is usually a part of a general visceroptosis.
CAUSES: (l.) Childbirth. The liability to prolapse is proportionate
to the number of children a woman bears. Each parturition adds its own
liabilities. Only about one percent of cases of prolapse occur in women
who have never borne children. This with its sequelae is one of the most
important causes of prolapse. It is often followed by perineal lacerations
and when these involve the levator ani, prolapse is almost inevitable,
sooner or later. Even when the laceration is not so extensive it may allow
the formation of a cystocele which in turn draws the cervix forward and
downward. Should the woman escape a perineal laceration, subinvolution
with its consequences may ensue. The uterus may not only be left larger
and heavier than normal but its ligaments, the pelvic floor, the abdominal
walls, may at the same time be left relaxed, and weakened, and less capable
of sustaining the heavier uterus. Subinvolution or relaxation of the pelvic
floor is next in importance to laceration. If the levator ani does not
regain its tone after each parturition the vaginal opening through this
muscle having been stretched enormously in labor remains large, relaxed
and patulous. The cervix easily slips forward into it under the influence
of increased intra-abdominal pressure and a prolapse occurs. Under these
conditions the subinvolution has involved the uterus also and its increased
weight facilitates the prolapse. Lacerations of the cervix with consequent
inflammation, enlargement and increase of weight are other sequelae of
childbirth that tend to cause prolapse.
(2.) Deranged Spinal Innervation. This interferes with the nerve supply
of the ligaments and pelvic floor and causes their relaxation. By vasomotor
disturbance congestion and increased weight of the uterus is caused. It
thus has a two-fold influence in causing prolapse, and especially "settling"
of the uterus. It operates also as a predisposing cause of subinvolution
of the pelvic organs and structures.
(3.) Increased Weight of the Uterus. This may occur from tumors, chronic
metritis or endometritis, chronic congestion or subinvolution.
(4). Anterior Traction on the Cervix. Adhesions may draw the cervix
forward into the vaginal opening in the levator ani and abdominal pressure
then forces the uterus downward. A cystocele or a rectocele may form after
slight lacerations of the perineum and act in the same way.
(5). Increased Intra-abdominal Pressure. This is a factor which operates
in conjunction with nearly all the other causes. Of itself it may occasionally
cause an acute prolapse. It may be from violent and continued muscular
efforts, straining at stools, coughing, sneezing, falls, abdominal tumors,
or ascites. A sudden and violent increase of intra-abdominal pressure may
cause acute prolapse in virgins.
(6). General Debility or Senile Changes. In cases of constitutional
weakness, whether due to senility or other causes, the pelvic tissues participate.
After the menopause there is atrophy of the supporting structures of the
uterus, an absorption of fat usually, both of which tend to prolapse.
(7.) Posture. This is particularly a cause of "settling" of the uterus
which so often occurs as a part of a general abdominal and pelvic ptosis.
"Slumping," as has before been suggested eliminates the anterior lumbar
curve and changes the plane of the pelvic inlet so that the intra-abdominal
pressure and organs have more direct access to the pelvis.
PATHOLOGY. The uterine ligaments are stretched and the vaginal walls
are congested, thickened and inverted, in proportion to the descent. As
a consequence of their congestion, thickening and increase in weight, they
make additional traction upon the uterus and draw it further downward.
In cases of complete prolapse the inversion may be so great that the vaginal
walls are turned inside out, the uterus being inside the inverted vagina.
Ulceration of the mucous membrane sometimes occurs. All of it that is exposed
becomes dry, lustreless, thickened and resembles epidermis rather than
The cervix, especially if it extends beyond the vulva, is eroded and
ulcerated, if not from a primary laceration, then from friction against
the clothing. The external os may appear normal or it may be gaping with
its mucous membrane exposed.
Fig. 39. Cystocele and Rectocele.
Cystocele is a constant accompaniment, but rectocele is less so, as
the anterior wall of the rectum follows the uterus down much less frequently
than does the bladder. (Fig. 39.) The course of the urethra is distorted,
passing backward and downward instead of upwards. Its orifice in complete
prolapse may be found in the transverse folds on the upper part of the
In long standing cases the accumulation of urine in the bladder may
lead to a chronic crystitis with hypertrophy of the vesical mucous membrane.
This inflammation may extend to the ureters and even to the pelves of the
kidneys. Prolapsus may cause an obstruction to the ureters, and acting
in this way is the only uterine displacement which has been known to cause
The recto-uterine excavation usually extends down behind the prolapsed
uterus to the lowest part of the tumor. It only occasionally contains some
of the small intestines. The vesico-uterine excavation does not as a rule
extend so far down.
Congestion of all the pelvic viscera results from the distortion of
and obstruction to the blood vessels.
SYMPTOMS. Marked cases of prolapse may exist without producing symptoms.
In most cases there are pronounced bearing-down sensations, a feeling of
weight and heaviness in the pelvis as if all the organs were going to drop
out. These symptoms often occur when the prolapse is very slight, the so-called
cases of "settling." There is difficulty in walking, discomfort on standing,
pain in the back and loins, all which are increased by any muscular exertion
sufficient to cause fatigue. The bladder empties incompletely or with difficulty,
it sometimes being necessary for the patient to replace the cystocele through
the vagina before it can be emptied at all. The retained urine decomposes
and irritates the bladder and causes frequent and painful urination. Symptoms
of a severe cystitis sometimes result.
The descent of the anterior rectal wall, or a rectocele, is not so common
as the formation of a cystocele. When it does occur the feces may collect
in the pouch thus formed and cause difficulty or pain on defecation, constipation
and sometimes a slight proctitis.
Leucorrhoea is usually present but menstrual disorders are not marked,
though menorrhagia sometimes results from the congestion incident to the
Conception may occasionally occur and take its normal course, the uterus
prolapsing until its size retains it in position. Return of the prolapse
usually occurs after confinement, but with care and attention during the
period of involution a cure may be effected.
In cases of acute prolapse there is a sensation of something having
given away, violent pain, shock, nausea, or vomiting, retention of urine,
collapse, feeble pulse and clammy perspiration.
DIAGNOSIS, In the cases of "settling" of the uterus a diagnosis may
have to be made chiefly from the symptoms. Often very little derangement
in position will be found when the patient is examined in the dorsal posture.
As a rule the uterus is found enlarged, boggy and unusually sensitive to
pressure. If the patient is examined in the erect posture the descent of
the organ can be determined. In the ordinary cases on vaginal examination
the cervix will he found low down and pointing downward and sometimes forward
as well. It may be within the vagina or protruding through the vulva. Bimanual
examination will disclose the uterus as a whole lower than normal in the
pelvis and retroverted as well. If completely prolapsed the uterus may
be inspected and palpated as it protrudes from the vagina. It presents
a smooth, dry-surface with the vaginal rugae showing at the base of the
tumor and the external os at its apex. On palpation a soft, elastic doughy
mass of the characteristic shape of the uterus is felt within the inverted
vaginal walls. In some cases of incomplete prolapse it is often necessary
to examine the patient in the upright position, as in this position the
maximum of prolapse will be evident. In the dorsal or Sim's position some
degree of replacement may naturally occur.
A condition giving some of the physical signs of prolapse is caused
by hypertrophy and elongation of the cervix. To differentiate them it is
necessary to locate the body of the uterus by bimanual palpation. If the
body is found high in the pelvis in its normal position the case is one
of hypertrophy of the cervix. Cervical hypertrophy and prolapse may occur
together, but in cervical hypertrophy the unusual length of the cervix
will be discovered. The introduction of a sound disclosing the increased
depth of the uterus will aid in this. It is impossible to replace the apparently
displaced organ in a cervical hypertrophy as can usually he done in prolapse.
A polypus or an inverted uterus may occasion some difficulty in diagnosis
but in neither of these conditions is there an opening in the lower end
of the tumor, while their small ends are upward, the reverse of a prolapsed
PROGNOSIS. In those cases not due to severe lacerations of the perineum,
tumors, ascites or absolute loss of tone, early relief and a possible ultimate
cure are to be expected. A great deal has been done for some very unpromising
Fig. 40. Knee-chest Posture.
TREATMENT. Prophylaxis is an important part of the treatment of prolapsus.
Childbirth and its incidents cause most cases. Care at this time to prevent
lacerations, or to see that they are promptly repaired when they do occur,
is imperative. The period of involution should be closely observed to see
that the uterus and all the tissues involved in pregnancy and parturition
return to their normal condition. Severe physical exertion of any nature
should be avoided for some time after delivery. All other contributing
causes should be located and removed.
The immediate indication is for replacement. All the complicating conditions,
ulceration, congestion or inflammation, yield more quickly and readily
after replacement is effected. Replacement is ordinarily easiest performed
in the knee-chest posture. (Fig. 40.) The bladder and intestines should
be emptied. The patient may occupy the knee-chest position fifteen or twenty
minutes before replacement is attempted. This allows the intestines to
gravitate away from the pelvis and in some degree relieves congestion also.
At times it may be advisable to put the patient to bed with her hips elevated
for several hours, or longer, to free the pelvis of intestines and make
If the prolapse is not complete; pressure may be applied to the cervix
and the uterus firmly but gently lifted in the direction of the inferior
strait of the pelvis. The pressure should be steady, but slow and deliberate,
taking fifteen or twenty minutes, if necessary, in reducing the displacement.
Less time may be necessary in minor degrees of displacement, but the procedure
is the same. After replacement a sweeping movement should be made with
two fingers in the vagina, beginning at the median line or the anterior
wall of the vagina and passing out on each side. This reduces the congestion
in the vaginal walls as well as in the tissues between the layers of the
In cases of complete prolapse, if the tumor is large and the vaginal
walls thickened it must be replaced by beginning near its base and replacing
that part of the inverted vagina that is nearest the vulva. As the vaginal
walls are replaced, gentle and increasing pressure is made upon the uterus
to compress it, and at the same time force it upward and backward in the
direction of the sacral curve.
The uterus passes back into the pelvis in a position of retro-displacement.
Replacement is not completed until by bimanual technic is it brought into
its normal anteposition.
Occasionally in cases of long standing the formation of adhesions between
the fundus and some adjacent organ or tissue, or great hypertrophy of the
vaginal walls, may prevent replacement. Means for retaining the uterus
in position are discussed in Chapter VIII.
In the cases of "settling" relief of the congestion and reduction in
the size of the uterus are necessary. Direct treatment to the organ itself
as is described under the treatment of Endometritis will accomplish this
The treatment recommended by Dr. Still in "The Philosophy and Mechanical
Principles of Osteopathy" is particularly applicable to these cases. He
says, "We recommend placing the patient in the knee-and-chest position,
with the chest for ease and comfort resting on a pillow, allowing the chin
to hang over the head end to the table. Pass the right hand across the
body in the lumber region and under the abdomen to the right iliac fossa.
Then place the right hand flat upon the bowels from the pelvis, with the
left hand pressing gently on that part of the abdomen. Be slow and gentle
in all movements, for fear of bruising the caecurn, ileo-caecal valve and
the mesentery of that region. Make a gentle, strong pressure upward toward
the ribs with the ascending colon. Follow across the abdomen from right
to left, in order to straighten up the transverse colon to its normal position.
Then lay the hand back toward the symphysis and gently press the sigmoid
division toward the stomach, with a view to pulling that division of the
colon and small intestines out of the pelvis. Then, with both hands gently
and firmly pressed upon the anterior region of the abdomen come up toward
the stomach with this gliding motion, with a view of straightening the
bowels, from the caecum to the transverse, the descending and sigmoid division
to the rectum. Also adjust the mesentery in all its attachments both to
the large and small intestines, and give freedom to the ileo-caecal valve,
that the softening fluids may pass without delay into and through the colon.
By so doing, we set at liberty and give freedom to the blood and nerve
supply of the uterus, ovaries and Fallopian tubes. We also take all pressure
off the nerves which govern the uterus and venous motion of blood from
the pelvis and through the whole uterine system of blood, nerves and lymphatics."
Exercises to regain the tone of the abdominal, thoracic and pelvic muscles
are necessary. The knee-chest posture for from three to five minutes should
precede the exercises and should be assumed particularly on retiring at
night and before a mid-day rest of an hour or more in bed.
For a full discussion of the necessary exercises the reader is referred
to "The Therapeutics of Activity" by Dr. Andrew A. Gour. I often prescribe
four simple exercises which I call the "fundamental four." These can be
quickly demonstrated to the patient, are easily remembered, are effective
if persistently followed, and are more likely to be carried out than a
more elaborate system.
1. Assume the knee-chest position for three to five minutes. Then lie
on the back with knees flexed, hands back of head. Inhale deeply as knees
are pressed forcibly to the right as far as possible, rotating pelvis in
that direction, but keeping shoulders flat. Exhale as the knees are brought
back to the median line. Inhale as they are carried to the left as far
as possible and exhale again as they are returned to the median line. Repeat
ten or twelve times to begin with. (Fig. 41.)
2. Lie on back, hands by sides. Inhale and reach as far upward and to
the right with the right hand as possible and at the same time reach as
far downward and to the left with the right foot as possible. Exhale as
return to beginning position. Inhale and repeat with left hand and foot.
Repeat ten to twelve times. (Fig. 42.)
3. Lie on back, hands back of head. Keep knees straight. Inhale as both
feet are raised to a right angle with body or higher if possible. Exhale
as they are lowered to beginning of this position. If this exercise is
found too heavy begin by raising only one foot. Repeat five or six times
to begin with. (Fig. 43.)
4. Lie face downward, hands on small of back. Inhale and raise head
and shoulders as high as possible. Exhale as return to beginning of this
position. Repeat six or eight times to begin with. (Fig. 44.)
These are essentially "mat" exercises, and restore tone and activity
to the muscles of the thorax and abdomen, so fundamental to the maintenance
of position and circulation of the pelvic and abdominal viscera.
Particular attention must be given to spinal innervation.