Charles B. Penrose

As has already been said, the uterus normally lies with its anterior surface in contact with the posterior surface of the bladder, and with its long axis approximately perpendicular to the long axis of the vagina. The forward inclination of the uterus varies with the degree of distention of the bladder; it is greatest when the bladder is collapsed.

In the normal woman the long axis of the body of the uterus is inclined forward at an obtuse angle with the long axis of the cervix. In other words, the uterus is normally anteflexed. This angle is subject to rather wide variations within the limits of health. It is greater in the multiparous than in the nulliparous woman. It varies with the distention of the bladder, the position of the woman, and the intensity of intra-abdominal pressure. The axis of the uterus when removed from the body is usually straight. The anteflexion found in the organ when in situ in the living woman rarely persists. The normal or physiological anteflexion is maintained during life by the utero-sacral ligaments, which hold the cervix back, and the intra-abdominal pressure, which, acting upon the posterior aspect of the fundus, pushes the body of the uterus forward.

In the fetus and in early infancy the cervix is relatively much more developed than the body of the uterus, and there is a very marked angle of flexion between them.

Anteflexion of the uterus becomes pathological when the bend in the cervical canal is sufficient to impede the escape of menstrual blood or other uterine discharges.

Obstruction of this kind depends upon two factors—the degree of the flexion, and the rigidity of the uterus, which diminishes the mobility that normally exists at the angle of flexion.

No matter how sharp the angle of flexion, it should not be considered a pathological condition unless obstruction in the cervical canal is present—unless the woman presents the symptoms of dysmenorrhea and sterility.

Three varieties of anteflexion have been described:

I. Corporeal anteflexion, in which the cervix has the normal backward direction, and the body of the uterus is bent forward upon it (Fig. 80).

Fig. 80.—Corporeal anteflexion.

II. Cervical anteflexion, in which the axis of the body of the uterus is inclined forward to the normal degree, and the cervix is bent forward upon it (Fig. 81).

III. Cervico-corporeal anteflexion, when the cervix and body of the uterus are both bent forward upon each other (Fig. 82).

Anteflexion of the uterus is a disease of single and sterile married women. It is very rarely found in women who have borne children. The disease is congenital or is caused by imperfect development during childhood.

The fetal condition of a large cervix and a small, sharply-flexed body may persist. The posterior wall of the uterus may develop while the development of the anterior wall is arrested, and thus the uterus would be flexed forward. A mark of such arrest of development is sometimes seen in the atrophied or undeveloped anterior lip of the cervix. Anteflexion is usually accompanied by a small, undeveloped condition of the whole of the uterus, and often by poorly developed vagina, tubes, and ovaries.

It is probable that improper dress and hygiene during the period of puberty have much to do with the development of anteflexion. The early menstrual history sometimes points to poor development of the sexual organs. The menses often make their appearance much later than usual—sometimes when a girl is nineteen or twenty years of age—and when established, the function is often irregular, the bleeding recurring at long intervals.

The most prominent symptom of anteflexion of the uterus is dysmenorrhea, or painful menstruation. The dysmenorrhea is characteristic: violent pains in the center of the lower abdomen, extending down the thighs, occur for several hours before the bleeding begins. In the later years of the disease the pain extends to the whole of the pelvis and the back. The pain is caused, in all probability, by the accumulation of blood behind the obstruction in the cervical canal. When the blood begins to escape freely, the pain is relieved, and may be absent during the remainder of the menstrual period. The blood is often clotted during the first part of the flow. Nausea and vomiting may be present during the height of the pain.

The menstrual period may be followed by several days of great physical weakness and debility.

Unless relieved by pregnancy or by proper treatment, the anteflexion will persist during the menstrual life of the woman. The suffering increases with time. Endometritis, salpingitis, and ovaritis follow old cases of anteflexion.

Sterility usually accompanies well-marked anteflexion. This may be due to the altered direction of the cervix in case of cervical anteflexion, to the obstruction in the cervical canal that interferes with the ingress of spermatozoa, to the generally undeveloped condition of the genital organs, or to the inflammation of the mucous membrane of the cervix and the body of the uterus.

The diagnosis of anteflexion is easily made. The character, position, and time of onset of the pain indicate some obstruction to the escape of menstrual blood. Vaginal examination reveals the sharp angle of flexion at the junction of the body and neck of the uterus.

Treatment.—If in a case of anteflexion pregnancy does occur and runs a normal course the disease will be cured. After labor the uterus does not return to the infantile shape and size. The stimulus of pregnancy brings about full permanent development of that organ. Miscarriage, however, is very apt to occur during the early months of pregnancy, especially in cases of long standing.

Various methods of treatment have been introduced for the cure of anteflexion. The object of all these methods is the straightening and enlargement of the cervical canal. Slow dilatation by graduated bougies has been successfully employed. Gradual straightening of the canal by the introduction of the uterine sound with increasing angle of flexion will also cure some cases, if seen early.

The use of the stem pessary (Fig. 83), which is worn continuously in the cervical canal, is dangerous and should not be practised.

The best method of treatment consists in rapid forcible dilatation with the uterine dilator. Various instruments have been made for this purpose. The principle of all is the same. Two blades are introduced, in contact, in the cervical canal, and are then separated. Two of these instruments should be on hand—a small and a large dilator. The Goodell dilator (Figs. 84, 85) is so made that the blades open parallel with one another, so that the whole of the cervical canal is uniformly stretched.

The best time to perform forcible dilatation is about one week after a menstrual period. The woman should be etherized and placed in the dorso-sacral position. The vagina should be sterilized. All aseptic precautions which one would follow in any gynecological operation should be observed here. There is always danger of producing septic inflammation of the endometrium. The cervix should be exposed through the Sims speculum, and the anterior lip should be seized with the double tenaculum. Downward traction on the cervix straightens the cervical canal and renders easier the introduction of the dilator. The smaller dilator should first be introduced. No force should be used in passing it through the cervical canal. If an obstruction which cannot be gently overcome is met, the dilator should be introduced as far as the obstruction and the blades should then be separated. Slight dilatation of this kind below the angle of flexion will usually enable the operator to pass the instrument through the cervical canal at a subsequent attempt. After the smaller instrument has been introduced to the full extent the blades should be gradually separated, for a half inch or more, until the canal becomes large and straight enough to admit the large instrument. It should always be remembered that no force should be used in the introduction of either instrument. After introduction the blades of the large dilator should be slowly separated. On the handles of the Goodell instrument is a graduated scale showing the extent of the dilatation. In no case should the dilatation be carried beyond one and a half inches. In women in whom the cervix and uterus are small an inch of dilatation is sufficient. The maximum dilatation should be reached slowly and gradually. Laceration of the cervix or of the margin of the external os should be avoided. Sometimes ten or fifteen minutes are required before full dilatation is attained. When this point is reached the handles should be held in place by the screw, and the instrument should be kept in the uterus for ten or fifteen minutes longer. The longer the dilatation, the more permanent will be the result.

After the instrument is withdrawn the cervical canal and the vagina should be washed out with a 1:2000 solution of bichloride of mercury, and a light gauze pack should be introduced into the vagina. The pack should be removed at the end of forty-eight hours, and a daily douche of 1:4000 bichloride solution should be administered for the following week. The patient should remain in bed for two weeks, or longer if there is any pelvic pain. Pain, however, does not follow this operation if we avoid operating upon those cases in which there is inflammatory disease of the tubes and ovaries. The too early resumption of the erect position may cause the failure of the operation. The abdominal pressure exerted upon the fundus uteri, before the organ has become fixed in its altered shape, may bring about a recurrence of the anteflexion. In case the external os be very small—too small to admit the dilators—it may be incised by small crucial incisions or reamed out with the closed blades of the scissors.

Dilatation of this kind usually produces a permanent broadening and shortening of the cervix. The cervical canal is rendered straighter and larger.

The good effects of the operation are not always apparent at the menstrual period immediately following the operation, because the results of the traumatism to the mucous membrane and the structures of the cervix are still present. At the periods after this, however, the dysmenorrhea is absent or is very much relieved. The benefit usually derived from this operation is a strong proof of the truth of the obstructive theory of the dysmenorrhea. If, after dilatation, conception takes place, the woman may look forward to perfect cure. In some cases the dilatation does not seem to be sufficient to produce a permanent open condition of the cervical canal, and the signs of obstruction (dysmenorrhea) return. In such a case the dilatation should be repeated. The more thoroughly the dilatation is performed the first time the less often will the second operation be necessary.