INTRA-PELVIC TECHNIC (Manipulative Surgery of the Pelvic Organs)

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, I doubt.

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 is made.

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.)

Lateral Displacements.

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 uterus determined.

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 to it.

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 by Adhesions.

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 this condition.

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 bladder symptoms.

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 and sterility.


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 (Fig. 23).

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 tips forward.

(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 empty.

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 and metritis.

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. First Step.

Fig. 25. Replacement of an Anteversion. Second Step.

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.

Backward Displacements.

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. (Fig. 26).

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 patient.

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. (Fig. 32.)

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. First Step.

Fig. 34. Replacement of a Retroversion. Second Step.

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 Postion.

Fig. 36. Replacement of a Retroversion. Second Method.

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 Prolapse.

Fig. 38. Complete Prolapse.

Downward Displacement.

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 mucous membrane.

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. Sectional View.

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 tumor.

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 death.

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 displacement.

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 uterus.

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 cases.

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 replacement easier.

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 broad ligaments.

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 result.

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.)

Fig. 41.

Fig. 42.

Fig. 43.

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.