Flexions disappear during abortions, so that the diagnosis of these cases is only possible before the beginning of abortion or some time after its termination.
It is not uterine flexion itself which produces abortions, but the ante- or retro-versions which accompany them.
Treatment must, therefore, be directed against anteversions and retro versions.
Philips adopts, without reserve, the opinion of fluter as regards the frequent recurrence of abortions.
3. Anteversion.
Uterine anteversion is merely an exaggeration of a normal state, and becomes really pathological only when it exceeds a certain limit or when it occurs in the true pelvis, i.e., in the first months of pregnancy. Dur ing the last months, it constitutes what is called pendulous abdomen, and it is well known under what circumstances this is produced. The mul tiparous state, relaxation of the abdominal walls, eventration and rachitis are causes. It is not rare, in these cases, to find women whose abdomens rest, as it were, upon the thighs, the fundus uteri forming the lowest part of the abdomen, the cervix being carried upward and backward. The patients, of course, suffer from renal pains and dysuria. The fcetus is not within reach and delivery is difficult.
Bnt anteversion may occur during the first months of pregnancy (Fig. 14,) before the uterus has risen from the true pelvis, and it is in these cases that it really becomes pathological.
Hiiter has examined it, particularly from this point of view.
Recalling the observations of Baudelocque, Chopart, Ashwell, Boivin, Hachmann, Welcke, Godefroy and adding two cases of his own, he distin guishes three degrees of anteversion.
First Degree.—This is about the normal state. The longitudinal uter ine axis forms a very acute angle with the pelvic axis.
Second Degree.—The fundus approaches the sympbysis but does not reach it,. The angle formed by the two axes is less acute.
Third Degree.—The fundus reaches the symphysis. The angle is al most a right angle. The portio vaginalis of the cervix is carried niore or less backward toward the posterior pelvic wall. It is very rare to see the cervix remaining in front, except in the case where there is, simultane ously, anteversion and anteflexion. It is, usually, during labor that this result is brought about by the influence of the pains. At the same time that it inclines forward, the uterus undergoes a torsion upon its transverse axis. As a result, the anterior vaginal wall is distended by tbe uterus
and pushed forward. The posterior wall does not look directly toward the rectum but becomes oblique and almost horizontal. The uterus com presses both the rectum and the bladder, causing difficulty in micturition, in defecation and in the introduction of the sound.
Causes. —Lohmeier, Kiwisch and Scanzoni do not believe in primary anteversion. Miter shows that, the uterus being already normally ante verted, if the pelvis is wide and larger than usual, and if the pelvic axis is more inclined, the posterior surface of the uterus has a greater and greater tendency to become superior. It follows that the pressure exerted by the intestines becomes more considerable and thus tends to produce and to increase the anteversion. Ovarian or other tumors, ascites and peritoneal adhesions act in the same way. If there be superadded to this a relaxa tion of the vaginal wall and of the uterine ligaments, particularly of the round ligaments, and, filially, vaginal cystocele, it is plain how the accu mulation of urine in the bladder will produce ante-version. It may be de veloped slowly or suddenly and be particularly favored by a sudden and exaggerated pressure of the bowels, by sudden contmctions of the abdom inal muscles and by sudden depression of the diaphragm. When the an teversion has reached a certain degree it may thus pass to a more advanced stage from the slightest cause.
long as it is moderate, anteversion passes unnoticed, but, when it is exaggemted, there soon follow dysuria, frequent micturition, constipation, tenesmus, and pains in the loins and sacrum, which attain their maximum in the third deg-ree of anteversion. The lumbar and sacral pains are constant, and are due to traction upon, or, according to IIiiter, even to laceration of the retro-nterine folds. Constipation be comes complete, and there is a constant desire to urinate, although the bladder contains very little urine. The patients feel a sense of weight in the pelvis, as if there were something to be expelled by the anus. The abdominal walls and the diaphragm accordingly contract, and, tending to further depress the fundus uteri, increase the trouble. Then follow fever, nausea, emesis and spasms.