Judging from my own observation, I should say that rectocele is hardly curable in any other way than by operation. The perineum is almost, if not always, deficient, which requires an operation for its restoration. When this is the case, the two may be cured by the same operation. (Chapter VII.)

Dr. Gillette, of New York, performs an operation for condensing the mucous membrane without removing it, by passing silk ligatures between the membrane and the fibrous sheath and drawing it up over the most protuberant portion.

The after-treatment is of great importance. The patient should be kept quiet in bed and have opium enough to relieve pain, and in cystocele the urine should be evacuated by the catheter often enough to prevent distension. In rectocele the rectal tube must be used to prevent the accumulation of gas, and the bowels moved by saline laxatives every other day. Salines should be used because they liquefy the stools.

CHAPTER XXIX.

DISPLACEMENTS OF THE UTERUS.

THE uterus is normally located at or near the centre of the pelvis, extending from the pelvic brim or slightly below it, to within an inch of the coccyx. Its long axis changes its direction or inclination with the filling or emptying of the bladder and rectum, with the different positions of the body, and with the variations in abdominal pressure. In the standing posture the relatively increased direct abdominal. pressure, and its own weight, carries the fundus downward over the bladder; in the dorsal decubitus the relatively increased backward or reflected pressure, and its weight, carries it slightly backward. In recumbent postures, however, the abdominal pressure has but a feeble effect upon the position of the uterus and allows it to move freely among the viscera. The action of its supports is then paramount, and is sufficient to restore and keep its axis in close relationship with the axis of the superior strait.

An abnormal location of the entire organ, independent of any alteration of its shape or the direction of its axis, constitutes a dislocation or simple displacement; an abnormal position or direction of its axis, is called a version; an abnormal curve of its axis, or the relation of its parts, is called a flexion.

Simple displacements may take place in any direction, and may be called forward displacements, or ante-location; backward displacements, or retro-location; right or left lateral displacements, dextroand sinistro-locations; upward, or elevation; and downward, in the direction of the axis of the superior strait, constituting descent, or lapsus. Descent of the uterine axis on the curve of the pelvic axis is called prolapse, and if beyond the pelvic outlet, protrusion or procidentia. (See Fig. 221). The inverted vagina, the rectum, the bladder, the small intestines, one or all, may also come outside of the pelvis with the protruded uterus.

In cases occurring in childbearing women, the bladder, or rectum, or both, may precede the uterus, and often act partly as a cause of the prolapse, by pulling the uterus down to or through the injured or lacerated pelvic outlet. In nullipars the uterus and inverted vagina protrude first and may or may not drag the rectum and bladder after them.

Versions are forward, anteversions; backward, retroversions; right

or left, dextro- and sinistro-version, according as the fundus turns in any of the directions mentioned. The altered position of the fundus. is accompanied by a turning of the lower end of the cervix in the opposite direction, upon the cervical attachments as an axis.

Flexions have the same nomenclature as the versions, and are forward, backward, or lateral, according as the concavity is formed by an anterior, posterior or lateral uterine wall.

Two or all of these three varieties of deviations may occur in the same case, for instance, anteflexion, retroversion and retrolocation (Fig. 225).

FIG. 221.

Pathological Changes in Location of the Uterus. Dislocations. The dotted lines show the

normal position.

In some cases it is better for the sake of accuracy to mention the parts dislocated. For example, in case of anteflexion we may have merely a forward displacement of the fundus, or of both fundus and lower end of cervix, or we may have a backward displacement of the upper end of cervix, or of the corpus with a normal location or forward inclination of the fundus alone, or lower end of cervix alone or of both. We may have a displacement of the cervix to the left with fundus in a normal location; or a displacement of the fundus to the right with the cervix in the normal position, yet either would be called a right lateral version (dextro-version).

What Constitutes a Displacement of the Uterus.

The normal variations in location and position of the whole or a part of the organ have been termed, by some, physiological displacements. Thus when the bladder is empty the fundus is pressed over the bladder causing the uterus to bend at or near the internal os; when the bladder is full the fundus is pressed up so as to straighten the organ; the flexion thus produced is called a physiological flexion. The same may be said of a flexion of the cervix forward during fulness of the rectum. Such displacements, or, more properly speaking, changes of accommodation in the parts, or the whole, of the uterus do not interfere with its normal motions or functions.

A pathological displacement of the uterus is more or less permanent and interferes with its normal motion and healthy functions. For instance, Fig. 1 represents a normal position of the uterus when the bladder is empty, or nearly so. If, however, the uterus remain in this position during filling of the bladder and the fundus cannot, except by force and discomfort to the patient, be raised or pushed backward, the organ is anteverted. Or there may be a greater bend in the uterus than shown in Fig. 1, without constituting a pathological anteflexion, but when the axis cannot be straightened by the filling bladder or variations in abdominal pressure, or when it interferes with functions, it is pathological. Sometimes, however, the fundus may be found turned into the hollow of the sacrum at one examination; at another it may be found lying low on the bladder. In such cases the normal motions are interfered with on account of the inability of the supports to promptly return it and hold it in the centre of the pelvis, and we observe anteversion and retroversion alternately.

Causes of Uterine Displacements.

Elevation is caused by tumors intimately or remotely connected with the uterus growing up out of the pelvis and dragging the uterus up with them, by inflammatory or other contraction of tissues at the pelvic brim, by the pressure of pelvic tumor or abscess below or beside the uterus, or by a loss of substance, or imperfect development. In the latter case the lightness of the organ, and the comparatively small surface presented to abdominal pressure above, give the uterine supports greater elevating power.

Of Descent or Lapse.

Descent or lapse is brought about by symmetrical enlargement of the uterus-as pregnancy or other forms of congestion, hypertrophy, hyperplasia, subinvolution, small uterine tumors, etc., or by a general relaxation of the pelvic supports resulting from parturition, extreme emaciation or debility, overwork, prolonged lactation, tuberculosis,

etc. Haste in getting up after abortion and labor at term affords one of the most common causes, and acts in both of the ways mentioned.

Of Prolapse and Procidentia.

Prolapse and procidentia are produced by the same causes as the last, but acting in a greater degree upon the sacro-uterine ligaments. Relaxation of these posterior supports and the contiguous connective tissue from tumors, fecal impaction of the upper rectum, or from rectal or peri-rectal disease, and the like (with but little change anteriorly), may cause simple prolapse, or descent of the uterus along the pelvic axis toward the perineal body. In procidentia the supporting structures of the uterus are all relaxed, but the sacro-uterine to the greatest degree. Perineal lacerations and the accompanying drag of congested or hyperplastic vaginal and vulval tissues may also have much to do in the etiology of both of these displacements, but especially the latter. Labor is the most frequent originator of this condi tion.

Of Displacements Forward, Backward, Sideways.

Forward, backward and lateral dislocations are seldom the result of a heavy uterus or of a weakened system of supports, but rather of traction or shrinkage of tissue in the pelvis, or of pressure from pathological growths. Hematocele and contraction in the pubo-uterine peritoneum or connective tissue are the common causes of forward displacement, or ante-location. Posterior displacements are ordinarily due to contraction of peritoneal inflammatory deposits over or beside the sacro-uterine folds or rectum, to relaxation of the vesico-uterine ligaments from an over-distended bladder or habitual physical exercise in stooping or leaning postures. Tumors or inflammatory deposits often press the uterus back. The lateral displacements result from the pressure of tumors, abscesses, or inflammatory masses, or from relaxations or contractions in the broad ligaments.

Of Versions.

Versions are caused chiefly by asymmetrical enlargements of the uterus, by tumors or deposits pressing or drawing the fundus or cervix out of place, or by misdirected or excessive abdominal pressure due to deformities, tight lacing, sedentary occupations, etc. In the majority of cases the cervix is drawn by a contraction in the tissues about it so that the abdominal pressure is brought to bear more directly against one of the walls of the uterus. Thus a contraction in the sacro-uterine ligaments draws up the lower end of the uterus so that the posterior wall is presented to the abdominal pressure, and the fundus or movable end is borne down over the bladder, while the external os is turned backward toward the sacrum (Fig. 53). Contrac