AN INQUIRY INTO THE NATURE OF THE UTERINE SUPPORTS AND OF THE CAUSES OF DISPLACEMENTS. By SAMUEL C. BUSEY, M. D., Washington, D. C., Physician to the Louise Home; one of the Physicians to the Children’s Hospital, etc. [Reprinted from “Tite American Journal of Obstetrics and Diseases of Women and Children,” Vol. IV, No. IV, February, 1872.] AN INQUIRY INTO THE NATURE OF THE UTERINE SUPPORTS AND OF THE CAUSES OF DISPLACEMENTS. By SAMUEL C. BUSEY, M.D., Washington, D. C. Physician to the Louise Home; one of the Physicians to the Children’s Hospital, and Physician in Charge of Diseases of Children at the Columbia Dispensary. There exists great diversity of opinion among Anato- mists and Gynaecologists as to what properly constitutes a uterine support, and, especially, as to the particular function, utility and extent of action of the special or- gans and tissues to which this supporting power is as- cribed. Some hold that all the pelvic viscera, together with its facias, its membranes and its muscles, must be comprehended within this designation—that the pelvis must be viewed as a whole, and that each and every organ and tissue is an essential part of the supporting framework, while others limit the power or function of support to the uterine ligamentous appendages. I cannot accept the limitations which ignore the agency of any part of this whole, though each part may and does possess and exercise distinct and peculiar func- tions, or which deny to any part all other power than the mere execution and preservation of its normal 4 Busey on the Nature of Uterine Supports, healthy inherent function. In the study of human anatomy, and of the purposes of the various parts there- of, it must not be forgotten that all organs and tissues are animated by a living principle, and that contiguous and adjacent organs and tissues bear to each other cor- relative and reciprocal agencies, acting together in the harmonious fulfillment of a natural purpose, and, at the same time, each for itself performing the special func- tions of its organization. The position and relationship of the bladder, rectum and uterus, with their attachments, membranous cov- erings and folds, together with their connections with the vagina and peritonaeum, must be viewed as a whole, this whole must be considered in its relations and at- tachments to the bony frame, and the pelvis, with its visceral contents, must be viewed as a part of the body, both with reference to its position as a pait, and its re- lations in all the movements of the entire body, to enable us to reach a plilosopliical conclusion in regard to the supports proper of the uterus, the particular power of each, and as to the nature of the cause of mal- position. In regard to uterine displacements authors do not correctly and distinctly trace the relationship of cause and effect. Every conceivable influence, recognized co- existing lesion, or associated mal-relation has been de- nominated a cause of displacement, when, in fact, such morbid condition was simply an effect of the operation of a primary cause, which primary cause might have produced any one of the existing conditions antecedent- ly to the others, or all simultaneously, or each might and the Causes of Displacements. 5 have followed consecutively in the chain of alterations, consequent upon the continuous operation of such cause. To illustrate: It is insisted by some that cystocele is the initial mal-relation in the causation of procidentia, and that relaxation of the utero-sacral ligaments is the morbid condition primary to retroversion, whereas clin- ical observation, as well as sound reasoning, demon- strate that cystocele does not necessarily precede, as a cause, procidentia, nor ligamentous relaxation a retro- version. The uterine displacement and associated mal- relation may occur pari passu, or either may follow the other, or both may be consecutive results of the persist- ent action of a primary cause. Prof. T. Galliard Thomas has very comprehensively summarized the usually assigned causes of uterine dis- placements as follows: “ 1. Influences increasing the weight of uterus. 2. Influences weakening the uterine supports. 3. Influences pressing the uterus out of place. 4. Influences exerting traction on the uterus.” These influences operate mechanically. It is alledged that tight clothing is an influence pressing the uterus out of position, pregnancy an influence increasing weight of uterus, rupture of the perinseum an influence weaken- ing uterine supports, and shortening of uterine liga- ments an influence exerting traction upon the uterus; and, in fact, these are frequently the circumstances and structural alterations co-existent with uterine displace- ment, but if they constituted the primary causes it is amazing that any woman should escape. If pregnancy operates through the mechanical agency of weight, and 6 Busey on the Nature of Uterine Supports, tight and heavy clothing, and muscular effort through that of pressure, it seems marvellous that so many women should escape injury. The comparative infre- quency of uterine mal-position does not justify the con- clusion so universally received, that these influences are the chief and essential agencies. I do not mean to under estimate the agency of the mechanical forces—weight, pressure, traction, and loss or diminution of supporting power in the causation. I concede that displacement cannot occur independently of the operation of one or more of these forces, but I deny the acknowledged sources of the power. Statistics show that much the larger portion of dis- placements occur subsequently to parturition, and that the liability to occur increases in proportion to the fre- quency of and to the quickness of recurring pregnancies. Hence it would seem to follow, as a logical sequence, that uterine displacements, either primarily or second- arily, were due to the alterations in the texture and po- sition of the pelvic organs and tissues, consequent upon the physiological changes which occur during gestation and to parturition. So likewise may like results follow any pathological lesion of the uterine tissues, which augments its volume and increases its weight. But displacements occur in virgins, and in married but nul- liparous women, and when there is neither augmenta- tion of volume nor increase of weight; and, notwith- standing the greater proportion of displacements occur in child-bearing women, yet, comparatively, a small portion of the child-bearing suffer from any such injury. Hence the conclusion is irresistible, that, though preg- and the Causes of Displacements. 7 nancy and parturition may produce such changes in the relative position of the pelvic viscera—such mal-relation of the pai*ts as may facilitate the operation of these forces and even favor their development—it is essential that some additional force or agency should be devel- oped or brought into action. If these premises be correct, it is evident that an in- vestigation into the effects of pregnancy and parturition ujtm the anatomical arrangement and relation of the pelvic viscera and adjacent organs and tissues, will furnish the solution of the modus operandi of this es- sential force. Whether the displacement occurs in a virgin or subsequent to parturition, the same mal-rela- tion of parts must co-exist and the same consecutive alterations must occur. The same mechanical force, be it weight, traction or pressure, acting to the same ex- tent, in the same direction, developed under like condi- tions, Avill produce like results in the virgin and in the child-bearing. Then what are the effects of pregnancy and parturition ? In discussing these results reference is only had to the physiological and anatomical changes which the pelvic and contiguous organs and tissues un- dergo as a necessary consequence of pregnancy. The gravid womb increasing in volume in consequence of the proliferation of its tissues and development of the foetus, gradually fills the pelvic cavity, presses upon the adjacent viscera, distorts their forms, alters their position, and occasionally their structure. During the earlier months the pregnant womb descends, but subse- quently ascends the plane of its inclination, and at the ex- piration of the sixteenth week, it has risen above, though 8 Busey on the Nature of Uterine Supports, not resting upon the linea ilio-pectinea. This elevation may, in some measure, be due to the relative position and peculiar adaptation of the growing womb and pel- vis, or else how account for the primary movement of descent and subsequent ascent of the organ, with ac- cumulated weight and bulk. The gravid womb, co- lloidal in form, presents its greatest admeasurements to the pelvic brim, with apex below. Development is greatest and most rapid in the body and fundus. \#et, in the absence of actual co-aptation of the uterine walls with the margin of the brim, its ascension of the plane of its inclination cannot be explained upon the bare supposition that its elevation is due to a power in na- ture to adapt its position to its growth. To do so, the conoid, with apex in the pelvic cavity, must impinge against the margins of the pelvic brim, or else the body, which adapts position to size, is without a fulcrum. Hence there must be some inherent power of elevation, some force sufficient to overcome the force of gravita- tion, to maintain the growing organ upon an inclined plane and to carry it up the plane, and, furthermore, to overcome the resistance offered by its attachments. To accept this elevation as the illustration of a mere me- chanical force, growing out of the peculiar anatomical relation of the impregnated uterus to the pel vie cavity, by which the apex of a cone constantly and gradually increasing in dimensions, is the lower part in its ascen- sion from a cavity of fixed and unalterable dimensions and shape, is altogether unphilosophical, and involves the doctrine of co-aptation and impingement of the uterine and pelvic surfaces, a relation known not to and the Causes of Displacements. 9 exist, except as a casualty. This elevation, which I assume to he a physiological process, stretches and elongates the vaginal columns, round and broad liga- ments, and cervical attachments. Whether the increase of the superficial area of these parts he due to attenu- ation or development, it is a physiological process and not one of violence. The abdominal walls are distend- ed—the evident effects of this distention being most manifest between the umbilicus and pubis; the bladder is pressed forward and downward, thus narrowing or constricting its opportunity for distension, thereby cre- ating, when in a state of repletion, an aditional force or power directly expended upon the anterior vaginal col- umn, which being superadded to the traction of the ele- vated cervix produces still greater elongation of the va- gina, vesico-uterine and pubo-vesico-uterine ligaments. But the most remarkable increase in superficial area of any of the tissues, is that which the peritonaeum under- goes. Being the peripheral covering of the greater por- tion of the uterus, and forming, by its duplications, the anterior and posterior uterine excavations, and by a transverse fold the broad ligament, “ into which the uter- us is implanted,” adhering to all the organs, tissues and muscles, it is involved in all the changes of position, shape and size which they undergo; and especially is the attenuation marked in the portions constituting the vesico-uterine ligament and Douglas’s space. So great sometimes may be the attenuation and diminished contractility of these folds that Scanzoni has known a rupture to follow from the pressure of a loop of in- testine. It is during parturition that the vagina and 10 Busey on the Nature of Uterine Supports, perinaeum suffer tlie greatest distention, not unfrequent- ly even to laceration and rupture. The resulting effect of these alterations in these ad- jacent organs and tissues admits greater mobility of the non-gravid womb, and increased pressure from the in- testines into the uterine excavations, in consequence of their enlargement, and, anteriorly, admits the pressure of the intestines directly upon the anterior vaginal col- umn, in consequence of the elongation and relaxation of the vesico-uterine ligament, which is but a perito- neal fold. Nature has wisely provided the tissues concerned in these physiological processes with the inherent power of adaptation to the necessity incurred. Whether it be, as is the case with the uterus, by a proliferation of tissue, or, as seems more probable as regards the facias, membranes and muscles, an attenuation of fibre, it is an indisputable fact that the power of restoration to a normal anti-pregnant condition is not an equally devel- oped inherent power in all the tissues involved. The uterus, having reached its greatest development at the close of gestation, expels its contents and returns, by a process of involution, to its normal position and size, though pregnancy and parturition impress decided mod- ifications on its size and form. The weight of a nullip- arous womb varies from one to one and one-half ounces, of a child-bearing from one and one-half to two ounces. The anterior and posterior walls become more convex, and the superior margin rises above the insertion (Ben- net) of the fallopian tubes, with which they are nearly rectilinear in the virgin. So to a less extent do the round and tlie Carnes of Displacements. 11 ligaments—they being a continuation of the uterine muscular tissue. “ The vagina,” says West, “ undergoes hypertrophy during pregnancy.” “It grows longitudi- nally to allow the womb to ascend high up above the pelvic brim; transversely to afford space for passage of the child in labor, room for which could not be obtain- ed by any mere stretching of a membranous canal;” and that it fails to follow the womb in its involutions, remaining longer, wider, and with thicker walls than previous to conception. Scanzoni says, “ the excess of volume and temporary elevation of the inferior part of the womb which pregnancy occasions, produce a dilata- tion and a notable lengthening of the vaginal canal, which are always accompanied by a distension of its walls. It is during parturition that this distention at- tains its greatest degree, and the puerperal retraction is not always sufficiently complete to allow the walls of the vagina to resume all the tonicity which naturally belongs to them. When pregnancies are frequent the walls become still more lax and supple, and easily yield to pressure.” The peritonaeum and perinaeum never re- sume, though contracting to some extent, their virgin condition, but remain relaxed, attenuated and flaccid. The peritonaeum is found lying in folds at the bottom of the uterine excavations, “wrinkled and loose in the elongated Douglas space,” and the abdominal walls ex- hibit ample evidence of continued relaxation. These conditions are aggravated by every recurring pregnan- cy, and the peritonaeum and vagina may, by the repeat- ed operation of the cause, attain that degree of relaxa- tion and tenuity as to loose all power of contractility. 12 Busey on the Nature of Uterine Supports, or escape the necessity of any future development or attenuation to accommodate the dimensions of a recur- ring pregnant womb. Scanzoni mentions having ob- served a relaxation of the uterine appendages and adjacent tissues, which would allow elevation of the uterus two inches above its normal position into the abdominal cavity, by pressure against the os tinea). Such are results of pregnancy and parturition, but they are insufficient to account for displacements. If so, such would be the inevitable sequence of frequent, and, per- haps, of every pregnancy, and the after life of child- bearing women would be burdened with the ailments and suffering incident thereto. They are conditions precedent to postpartum displacements that develop and facilitate the operation of the necessary force. The re- sulting mal-relation of the uterine excavations and of the vaginal columns favor the descent of the intestines, and consequently augments the weight and pressure of the abdominal viscera, but so long as the equilibrium of pressure is maintained, the uterus being of normal size, harm cannot result. In the normal virgin condi- tion there is no pressure of the abdominal viscera upon the anterior vaginal column, except through the medium of the bladder, for the peritonseal fold, consti- tuting the vesico-uterine ligament does not lie upon the anterior vaginal column, consequently, it is only subse- quent to pregnancy or to some agency which may pro- duce a like attenuated condition of this membranous attachment, that any intestinal pressure or force can be brought to bear directly upon the anterior column, or even, but to a very limited extent, upon the anterior and the Causes of Displacements. 13 uterine wall, through the anterior uterine excavation. In the posterior excavation, even in the normal virgin condition, there is always a portion of intestine lying loosely upon the posterior vaginal column. Nature seems to have so shaped and constructed the uterus, and to have adjusted the pressure from the surrounding and superincumbent viscera as to protect and preserve it in situ naturali. It occupies nearly a central posi- tion in the pelvis, not in contact with any solid or hard substance, is “ suspended in the midst of tissues, which, from their construction, and their pultaceous, watery and gaseous contents afford a secure nidus.”* Weigh- ing about an ounce,f it is “delicately and unstably poised in its position,” supported “ on every side by the soft and elastic structures which everywhere surround it as closely as if it were enveloped in a fluid.”% “Its long axis (Sims) should stand at about right angles to that of the vagina,” or, according to Hodge, at an acute angle. The bladder occupies the anterior angle, so that the degree of the angle increases with the distention of that viscus and lessens with its subsidence. It is a “ flattened cone,” “ a hollow conoid,” presenting its broadest surfaces in its anterior and posterior axial de- viations to the pressure of the superincumbent and surrounding viscera. The increased mobility obtained by the relaxation of connected parts admits greater * Ilodge. f Duncan, Researches in Obstetrics, p. 4. | Weight of nulliparous womb is from 1 to 14 oz., child-bearing from 14 to 2 oz. Bennet on The Uterus, p. 2G. Duncan, Researches in Obstetrics, p. 2, says the unimpregnated uterus weighs about 1 oz. 14 Busey on the Nature of Uterine Supports, axial deviations, and consequently increased liability to variations of pressure from the surrounding organs, in- vites, as it were, the destruction of that equilibrium of pressure which is essential to the maintenance of its delicately poised position. Its longitudinal axis is co- incident with or parallel to the axis of the plane of the pelvic brim, forming with the vagina, at the point of junction anteriorly (Klob) an angle of 155°, and* upon itself at the point of union of cervix and body an angle of 165°, so that the line of gravitation, which, in its relations to its attachments and to the adjacent organs, is through the line of the longitudinal axis, would, according to the natural tendency of all bodies, be through a line drawn vertical to the horizon through its centre of gravity. Its centre of gravity being sup- posed (Duncan) to be the centre of its mass must be a point above, and the vertical line of gravity must be anterior to the point of cervical attachments. The plane of the brim inclines at an angle of G0°, and the longitudinal axis, vertical to this plane, inclines at an angle of 30° to the horizon, the angles being in oppo- site directions, the two incident lines form with them- selves a right angle, but with the horizon angles bear- ing always the proportion to each other as 2 to 1—that is, if the angle of inclination of the uterus be 30Q the angle of inclination of the plane of the brim will be * Meadows (Manual of Midwifery, p. 42) denies that there is ordinarily any “ curvature whatever in the general direction of the uterine canal,” and maintains that the “ normal axis of the uterine cavity is identical with that of the pelvic brim or inlet,” being represented by a line forming with the horizon an angle of 30°. Bennet, who first pointed out the existence of these angles, asserts that they are obliterated by child bearing. and the Causes of Displacements. 15 00°. This relation, though not mathematically accu- rate as thus expressed, is accepted as the established rule of normal anatomical construction, and is constant and unvarying, except so far as it may be disturbed by exigent oscillations, within a limited arc, of a body so delicately poised amidst contiguous organs subject to such fluctuating conditions as the female pelvic viscera. Then, so long as the coincidence or parallelism of the normal uterine axis and of the axis of the plane of the brim is maintained, so will the uterine axis approach the horizontal line in direct proportion with the ap- proach of the plane of the brim to the vertical line, consequently, as the inclination of the plane of the brim, and, in fact, of the pelvis, increases or dimin- ishes, so, reversely, will the uterus approach or recede from a vertical line. Now, what is the practical ap- plication of this relation? The axis of the body is represented by a line touching the 3d lumbar vertebral articulation and passing through the symphysis pubis. The body, in the erect position, is balanced upon the ilio-femoral articulations, and “the centre of gravity of the parts above is nearly vertically over the ilio-fe- moral articulations.”"' These articulations, the points of support, are the points about which the forward and backward movements of the trunk take place, and, it must follow, that as the trunk movement is forward or backward the centre of gravity of the parts above varies from the vertical line passing through these ar- ticulations, and the uterus approaches or recedes from a vertical line, the obliquity of the pelvis and of the * Duncan, Researches in Obstetrics, p. 40. 16 Busey on the Nature of Uterine Supports, plane of the brim to the vertebral column being main- tained, or but very partially disturbed, in consequence of the slight mobility of the lumbar vertebral articu- lations. Thus the longitudinal uterine axis is made either to approach parallelism to the axis of the body, thereby receiving directly the pressure of the superin- cumbent viscera through its long axis, or to approach a horizontal position at right angles with the axis of the body, thereby receiving the weight and pressure upon its posterior surface. Whatever mal-position or mal-formation of the body, or mal-relation of parts, whether congenital or acquired, that approximates the uterine longitudinal axis to the axis of the body or to the horizontal line, evolves a force that disturbs the equilibrium of pressure, which nature has so accurately adjusted for the maintenance of the uterus in situ nat- urali. Any permanent disturbance, or destruction of the normal axial relations of the pelvis with the body or with its viscera, or interruption of the natural cor- relation of the pelvic contents become factors in the causation of uterine displacements. These preliminary suggestions bring me directly to the consideration of the mode and manner of evolution of the essential force or forces concerned in producing uterine deviations, for I maintain that these displace- ments find their causes in the action of new forces gen- erated by anatomical mal-relation, or in the irregular or disturbed operation of normal forces consequent upon anatomical mal-relation; and, per contra, that the ute- rus finds its support in situ naturali in forces due to normal anatomical construction and arrangement. aml the Causes of Displacements. 17 But I must for the moment depart from the consider- ation of these axial relations, to study the natural cor- relation of the various pelvic viscera, and the utility of the various parts thereof as factors in maintaining the uterus in its natural position, that I may the more clearly elucidate the propositions just stated. There exists another relation of parts which has heretofore escaped the attention which it demands. The locality of cervical attachments is the only stable (not positively fixed) point of the uterus—here is the axis of rotation. Anterior to these attachments the greater length, weight and bulk of the uterus. If preponderance de- termined its rotary movements, the fundus and body would surely rotate anteriorly around this axis, but such is only exceptionally the rule, for antiversion, though claimed by some to be the normal position of the virgin womb, is, comparatively, a much less frequent casualty than retroversion. Certainly the position of the bladder, with its constantly recurring conditions of collapse and repletion, acts as a barrier to anti-version, and forces a descending fundus back to its natural site; but that is seeking an explanation too remote from and independent of the organ itself, implies that the uterus is maintained in situ naturali by the least scientific of all mechanical contrivances, a mere prop, and presup- poses that the varying condition of the anterior exca- vation is entirely regulated by the extent of vesical re- pletion, the varying amount of pressure of the intes- tines upon the anterior uterine wall being, consequent- ly, estimated at nothing. I concede that vesical reple-1 tion, which is, frequently, by the force of habit or per- 18 Busey on the Nature of Uterine Supports, sonal neglect carried to an extraordinary extent, may become an auxiliary to the force or forces developed 1 >y some pre-existing mal-relation. It is a law in physics that weight operates through the line of gravitation, and traction through the direction of the force, and, furthermore, that a body suspended by an attachment to its centre of gravity will hang in exact equipoise, so also will it maintain equipoise if supported by its cen- tre of gravity. So, if the cervical attachments of the uterus were affixed at points respectively opposite its centre of gravity, its normal position of exact equipoise could be easily understood, but the anatomical arrange- ment does not fulfill this condition. Weight preponder- ates anteriorly to these attachments, consequently, as in physics, the tendency should be for the greater weight, the body and fundus, to rotate anteriorly, and for the lesser weight, the cervix, to rotate posteriorly. Yet, the uterus being in situ naturally the equipoise is exact. The anatomical arrangement of these attachments fur- nishes a beautiful illustration of another law of physics, and readily solves the problem of uterine equipoise. To facilitate the elucidation of this law the posterior ligaments and vaginal column may be regarded as the ujiper or suspensory attachment, and the anterior vagi- nal column as the lower or supporting attachment. In physics, if the body gravitates unequally equipoise may be restored either by correcting the irregularity of weight or by diminishing the leverage of the prepon- derating portion, which may be accomplished by mov- ing the suspensory attachment to such point toward its distal end as may secure, by the counter traction of and the Causes of Displacements. 19 the upper and lower attachments, perfect counterpoise. This is the precise arrangement of the vaginal attach- ments to the uterine cervix—the posterior column, to- gether with the utero-sacral ligaments, being attach- ed nearer the fundal extremity. The respective points of attachment constitute the points around which the body and fundus rotate in anterior and posterior axial deviations, according as either may becomewthe centre of rotation, the force being always greater in posterior rotation, because the posterior or suspensory attachment approaches nearer the distal end of the preponderating part. The rotary movement thus se- cured is peculiar. It is doubly rotary, perhaps more properly a reciprocating vibratory motion (not a pendu- lum-like motion, for that is a to and fro vibration upon a single fixed point), more like a double see-saw motion, each attachment alternately constituting the fulcrum of movement and the counterpoising power. The curvi- linear arrangement of these attachments affords greater amplification of the oscillatory movements of the uterus, and without compromising in any degree their counter- poising power, yet antagonize each other in their oppo- site tendencies to produce anterior and posterior axial deviations, while, as traction acts through the direction of the force, the probable power of the posterior at- tachments in promoting descent, (the direction of the force approaches the direction of the longitudinal axis,) is antagonized by the counter power of the anterior at- tachments, which, though not acting in an opposite di- rection, must by virtue of their anatomical arrangement impede descent so long as the long uterine axis is main- 20 Busey y the relaxed condition of its pejtomeal attachments to the abdominal parietes, thus admitting the intestines to wedge in between the latter and this viscus; and as the distention and conse- quent elevation progress, so must the tension of the ve- sico-uterine ligament increase, and its traction force thus enhanced, must antagonize the pressure force derived from repletion. The action of vesical repletion is two- fold. Situated in the angle formed by the uterus with its anterior cervical attachments, roughly estimated at 155°, which angular obtuseness favors the suggestion of its auxiliary agency in promoting retroversion, it oper- ates upon both arms of the lever constituted by the ute- rus and anterior vaginal column, the posterior cervical attachments being the fulcrum, and converts, by virtue of this anatomical arrangement, the lesser into the greater arm of the lever. Whatever effective force or power is evolved by vesical repletion must operate at the bas-foml as at the fundus of the bladder, and the leverage being greater at the bas-fond the effect is ob- viously equal, if not greater, than upon the body and fundus of the uterus, the shorter arm of the lever; and more especially is this true in view of the attachment of the peritoneal coat to the abdominal parietes, which limits the elevation of that viscus. Consequently, we find here a force to oscillate the uterus about the point of posterior cervical attachment to accommodate the re- plete viscus, while, pari passu, with the accumulating force of increasing distension is being generated a coun- ter force by the pressure of the enlarging viscus down- ward and forward upon the greater arm of the lever, 22 Busey on the Nature of Uterine Supports, sufficient to counteract the pressure backward, and to restore the natural equipoise. The anatomical con- struction generating these forces seems to warrant the conclusion that the see-saw uterine motion takes place simultaneous with vesical repletion and collapse; thus perfect consonance of action is secured between the movements of the bladder and the uterine counterpois- ing mobility, and thus also the utility of the loose and indirect vesico-uterine attachment is clearly defined. The dipping of the anterior excavation limits this at- tachment and affords, by the necessary peritoneal re- duplication, and the filling of the vesico-utero vaginal interspace with areolar tissue, the amplest arrangement for vesical distention and elevation, without direct in- jury to either of these adjacent organs. If the bladder was directly adherent to any part of the uterus, and the vesico-uterine ligament direct in its course, disten- tion of that viscus below the ligament would be limit- ed by the tensibility of such structure, or else the uterus would follow the bladder in its elevation. The normal movements of both organs, though correlative, are inde- pendent, and the power finding its origin in the exigent movements of the bladder is expended harmlessly in the direction of and auxiliary to the counterpoising movements of the uterus. The latter organ rotates on its transverse axis following the changing conditions of vesical repletion and collapse. The tendency to retro- version is further obviated by the structure and direc- tion of the round ligaments. Rising'"' laterally from * Klob, Pathological Anatomy of Female Sexual Organs. and the Causes of Displacements. 23 the margin of the fundus, their course is in a convex bend anteriorly and externally to the point , of attach- ment in the loose tissue of the pudenda. Their origin at the fundus and convex course affords another beau- tiful illustration of nature’s adaptation of means to the conservation of purpose and to frugal utility. Constitut- ing, as they obviously do, the main guide stays to the gravid womb in its gradual ascension of the parietal inclined plane, yet they subserve other purposes in limiting the lateral distention of the bladder and guid- ing its upright elevation, for it rises within their curves, and add/its auxiliary restraint to the backward press- ure of a distended bladder, and, by the very nature of the anatomical arrangement and construction, this re- straining force augments in direct proportion to the force of distention, for as distention may increase later- ally the convexity of their curves is increased, thereby increasing the power of traction upon the fundus, thus antagonizing the backward pressure. Again, we find a force threatening injury creating its own counter- force, and yet fulfilling all the purposes of nature. But there is a point beyond which their utility may cease, and their power become perverted to an agent of serious danger. The moment the fundus uteri in posterior os- cillation passes, in the arc of rotation, beyond the point of their greatest tension, though the nature of their pudendal attachments and the relaxation consequent upon continued tension favor further rotation, that mo- ment their power, acting in the same direction, carries the fundus down the arc of rotation towards the pos- terior cul de sac, and vesical distention, acting as be- 24 Jjusey on the Nature of Uterine Supports, fore by increasing the convexity of their course, be- comes auxiliary to this perverted force, which is further aided by the accumulated weight of the abdominal viscera which is gradually, as the posterior descent of the fundus progresses, transferred from the posterior to the anterior uterine surface; and still another factor, passive in its mode of operation, is found in the relaxa- tion of the peritoneal coat of the bladder, the result of pathological changes or of attenuation from inordi- nate and habitual vesical distension or utero-gestation, which, while its attachments to the pubis, bladder and uterus are never disturbed* by womb displacements, ceases to offer its conservative resistance to the forces now perverted; and, even if its normal structure and superficies be maintained, the tension to which it may be brought by the traction of the retro-verted body may generate a force which, acting through the medium of vesical repletion, may so alter the direction of the forces that rotation may be converted into descent, pre- ceded by vaginal inversion. The agency of the broad ligaments in maintaining the uterus in the median line is so obvious that I need not pause to consider it, and that they constitute im- portant accessory aids in resisting versions and flexions is equally obvious. Savagef has demonstrated upon the cadaver that these ligaments constitute the last ob- struction to complete prolapsus. Hence, as they are formed by transverse folds of peritonaeum, into which * Savage on the Female Pelvic Organs, p. f Anatomy of the Pelvic Viscera, Plate XI. and the Causes of Displacements. 25 tlie “ uterus is implanted,” which folds undergo very considerable attenuation or development during utero- gestation, and possess, if at all, to a very limited extent the power of involution, it becomes manifest that in this anatomical mal-relation a new force, passive but potent, finds its origin in the lessened resistance to de- scent and increased bilateral mobility afforded to the womb. The relations of the uterus and rectum are also im portant. Situated behind and below, and, when view ed in regard to their anatomical position, above the uterus, and, when considered in its relation to line of descent, under the uterus, a casual observer would con- clude that impaction would necessarily offer obstruc- tion to both retroversion and prolapsus, yet clinical ex- perience teaches absolutely the contrary. Hence the force thus called into operation is not one of pressure. Rectal impaction must begin below, at the anal end, and accumulate upwards in the line of the gut; thus, it is obvious, that any pressure upon the womb must first be expended upon the os and cervix in the direc- tion of the longitudinal axis, and, subsequently, as it may increase, upon the broad posterior surface. Hence elevation and antiversion would, necessarily, be the pri- mary deviation, reposition following removal of rectal distention; but this is not the resultant mal-position, which comes clinically to our notice. The utero-sacral ligaments, “crescentic prolongations of sero-nnisculary>fa- tysrna, containing besides muscular fibres from the va- gina and uterine cortex,”* arising from the posterior * Savage. f Kolrausch. 26 Buseij on the Nature of Uterine Supports, uterine surface, at a point opposite the internal os, en- compass tlie rectum on both sides, proeeed in a semi- lunar course to their attachment to the sacrum, about one and a half f inches from its apex, a point obliquely above the pelvic attachment of the anterior vaginal col- umn, so that while they are, to a certain extent, in an- other and obvious relation suspensory, they also possess a force acting through the direction of their attach- ments, and this force is augmented by inversion of their normal crescentic arrangement, whereby the weight of superincumbent viscera is increased. The effect of rec- tal distention, the normal contractility of these liga- ments being destroyed by the continuous tension of their muscular filaments, is relaxation, attenuation, stretching, consequent inversion of their anatomical arrangement and augmentation of weight from the downward press- ure of the intestines in the Douglas space. Now, sup- posing a force to be acting simultaneously through the longitudinal axis,, which is favored by the consequent movement forward of the cervix due to the loss of power and elongation of these ligaments,)the direction of the uterine deviation would necessarily be through a line median to the two forces, except so far as it might be interrupted by the normal action of the other at- tachments, or effected by the perversion of their normal operation. Hence retro-version or descent would oc- cur according as one or the other of the two forces was the more powerful, the direction of a body being always through the diagonal median to two equal forces, and approaching the direction of the greater of two un- equal forces crossing each other acutely. This law in and the Causes of Displacements. 27 physics is verified by the fact that prolapsus cannot oc- cur beyond the impingement of the os against the pos- terior vaginal wall without retro-version, whereby the median line of motion is deflected anteriorly and down- wards. This demonstration furnishes a direct and pos- itive contradiction to the accepted theories in regard to the causation of descent and retro-version, inasmuch as it becomes apparent that cystocele is not necessarily a pre-existing, co-existing, or consecutive mal-relation with descent, and that retro-version is not the neces- sary resultant displacement from relaxation of the utero-sacral ligaments, except so far as such deviation of the fundus may occur as descent proceeds through the axis of the vagina. In all cases of descent the con- dition of the perimeum presents important considera- tions, either facilitating or impeding the operation of these perverted forces. “The motion of a body is in the direction of the foi ’ce that produces it, and is proportional to that force,” (Arnott.) The uterus, in its physiological ascent and descent, moves through the line of its longitudinal axis, ordinarily, a line perpendicular to the plane of the brim—up and down a line acutely inclined to the line of gravitation. Whatever force or forces are engaged in this regular and symmetrical movement, and what- ever their origin, they act through the direction of the longitudinal axis. The cervical and other attachments possess an inhibitory agency, limiting the extent of the descending and ascending motion, and it seems evident that this restraining power—the result of the conjoint operation of all the attachments in harmonious action, 28 Busey on the Nature of Uterine Supports, cannot also constitute tlie forces employed in the rising and falling of tlie womb, having their origin in the al- ternate contraction and relaxation of the uterine ap- pendages, for this physiological movement is always, invariably, through the same axis, even though its nor- mal axial relation is subject to constant variations inci- dent to the fluctuating conditions of the adjacent vis- cera. While descent might be explained upon the hy- pothesis of contraction of the cervical attachments, as- cent cannot be accounted for upon the suppositon of the immediate subsequent relaxation, for clinical observation teaches the contrary result from relaxation, and during the menstrual period when physiological prolapsus occurs as the result of the increased weight of the uterus, the physiolgical ascent and descent is not disturbed in the regularity of the alternating move- ment. Admitting, for the sake of the argument, that descent is the result of pressure having its origin in the descent of the diapragm in inspiration, there must be some force other than its withdrawal in expiration, to produce ascent. The force that carries a body down an inclined plane will not elevate it, nor will a body car- ried down such a plane reascend upon the withdrawal of the force, nor will a body ascend in a vacuum. The uterus neither rests at the point where the impelling force is expended, nor descends, according to the law of gravitation, but ascends the inclined plane. Surely there is some force active and direct, other than any which can be attributed to its appendages, or to i>ress‘ ure from below, which occasions this ascending mo- tion. and the Causes of Displacements. 29 The important factor in the maintenance or perver- sion of these normal forces is the “retentive power of the abdomen,” to which attention was first called by the distinguished Edinburg obstetrician, J. Matthews Duncan. That some such power does exist seems ob- vious, or how explain the synchronous ascent and de- scent, through its longitudinal axis, of the uterus dur- ing respiration. The anatomical arrangement and con- struction of its ligaments and attachments, which ad- mits this regular and constant movement along a plane inclined at 30° to the horizon—a movement which ab- solutely opposes the law of gravitation, precludes the supposition of their exclusive‘agency, inasmuch as the point of tension of no one of them can be reached either in this physiological descent or ascent. Without stop- ping to investigate the sources and nature of this “re- tentive power,” it is sufficient for the present purpose to recognize the important part which the abdominal walls play in the maintenance of its integrity. And, now that 1 have/presented the correlative re- lation of the female pelvic organs and endeavored to demonstrate the existence and modus opera mil of cer- tain forces essential to the maintenance of the uterus in situ naturali, and their perverted action and the origin of other abnormal forces in the causation of mal- positionsil must recur to the consideration of the rela- tion of the pelvis with the trunk. At j >age 1(> 1 submitted the following proposition, to wit: Whatever mal-position or mal-formation of the body, or mal-relation of parts, whether congenital or acquired, that approximates the uterine longitudinal 30 Busey on the Nature of Uterine Supports, axis to tlie axis of the body or to the horizontal line, evolves a force that disturbs the equilibrium of press- ure, which nature has so accurately adjusted for the maintenance of the uterus in situ naturali, and, conse- quently, favors displacement. Descent, in the relation in which it is now being con- sidered, is synchronous (or nearly so) with inspiration, consequently as the bulging of the abdominal walls, as pointed out by Hutchinson, follows, in the female, thoracic expansion, so uterine descent corresponds with this phy- siological bulging of the abdominal walls, and thus must the “ retentive power ” be diminished by the bulging. If this be the normal coincidence of the component movements of a purely physiological process, it surely is logical to conclude that relaxation of the abdominal parietes,; which is but another expression for abdominal bulging, / favors, facilitates, and may produce uterine descent. But, apart from any relation which the relax- ation of the abdominal walls, (a necessary consequence of, and increased by, every recurring pregnancy, may bear to “ the retentive power of the abdomen,” tlie di- minished action of the abdominal muscles, ](vhich is in proportion to the extent of distention and relaxation,) favors the gravitation of the abdominal viscera, espe- cially of the intestines. Hence, a new force may be brought into action, which, according to the direction of its action) may alone or in synchro- nous co-operation with other new or perverted forces, uterine displacements. If the relaxed and protuberant walls permit descent of its visceral contents through the axis of the body, surely there must be augmented and the Causes of Displacements. 31 pressure upon the womb through its longitudinal axis, if into the vesico-uterine space> upon its anterior surface and anterior cervical appendages. These considerations present a ready explanation of the infrequency of uter- ine displacements in young and virgin females, though that is the period of life in which the organ is subject- ed to the most violent and irregular jostling, incident to the habits and bodily movements of young life. Holding, as 1 do, fa at the pelvic facias possess no peculiar or distinctive functions separate and apart from the organs and parts with which they are connect- ed and to which they are attached, but that their uses and agencies in uterine support and displacement are co-operative with, and accessory to, the agencies of the various parts constituting the complex supporting frame work, adding strength and stability to each part separately, to all the organs as a whole, and subserving the important purpose of uniting the pelvic organs with the pelvic frame, thus fastening and establishing their relation with the trunk, I deem it unnecessary, here, to consider their anatomical arrangement in de- tail. And space forbids, nor is it essential to this in- quiry, that 1 should enter upon the discussion of the agencies which the structure, conformation, position, size and density of the uterus contribute to its mainte- nance in situ natural}. In viewing the wonderful me- chanism of the human body, of every organ and tissue, I cannot resist the conclusion that the physical quali- ties of each part has been wisely adapted to the main- tenance of position as well as to the due performance of function. 32 Jhtsey on the Nature of Uterine Supports, To enable the reader the more readily to comprehend the law of force or forces producing motion, to which reference has been so frequently made, referring, for a more comprehensive demonstration, to Arnott’s Ele- ments of Physics (pp. 55tli sec.), I submit the follow- ing diagrams from the same author: The forces are repesented by the arrow-heads; the body by the circle at the crossing of the direction of the forces; the direction of the body by the dotted lines. In the square and twro irregular parallelograms the forces are equal, though crossing each other at a right, acute and obtuse angles; in the regular parallelogram the forces are unequal, but cross at right angles. Accepting the conclusion of Weber that the body, in the erect position, is balanced upon the ilio-femoral ar- ticulations, and the theory of Duncan that the line of gravitation of the parts above is through a vertical line passing through these articulations, or the more com- monly accepted view that the line of gravitation is through the axis of the body, as previously described; and the Cannes of Displacements. 33 it is perfectly evident that the vertical line of pressure of the super-incumhent viscera cannot be through the longitudinal uterine axis, but maybe deflected from the anterior abdominal walls, against which it must im- pinge, through the line of the longitudinal axis, upon and against the fundus, and also, in a direct line, upon its attachments. Hence, it is that, usually, in virgins, and not unfrequently in multiparse, when the uterus is healthy, that posterior axial deviations are the imme- diate result of some violent and sudden shock to the trunk, whereby this deflected force is momentarily in- creased beyond the natural resistance of the antago- nistic influences, or is expended upon the anterior uter- ine surface, because the intestines are forced below the normal relation of the long axis. The same deflection of force would follow, as surely, though not with such momentum, relaxation of the abdominal parietes, which permitted such descent of the intestines below the um- bilicus, as would change the line of vertical pressure to the direction of the longitudinal axis. Retro-version and descent may result from such deflection of the nat- ural force of gravitation of the abdominal viscera, to which may be added the auxiliary force derived from muscular contraction or increased pressure of the super- incumbent viscera; and thus it is that abdominal tu- mors, enlargement of the abdominal viscera, accumula- tion of fluid in the peritoneal cavity, tight and heavy clothing, diminished thoracic expansion, unusual and violent effort may occasion uterine mal-position—their agency being always enhanced by the inevitable mal- relation of parts consequent upon pregnancy. Thus it 34 Busey on the Nature of Uterine Supports, also is that sudden prolapsus is chiefly the result of abdominal pressure, concussion, straining, carrying heavy weights, lifting, stooping, Ac. A roomy and an insufficiently oblique pelvis are con- sidered predisposing causes of prolapsus uteri—the for- mer admits increased pressure; the latter favors the operation, and increases the power, by increasing uter- ine inclination, of the gravitating force, whether acting through its vertical or deflected line. Any departure from the normal dorso-lumbar curve, either by increas- ing or diminishing the anterior arch is also a predis- posing cause. Increased curvature augments the force of impingement against the anterior surface of the ab- dominal walls, and, consequently, the deflected force against the pelvic organs; lessened curvature, by di- minishing pelvic inclination, thus approximating the uterine long axis to the vertical line of pressure of su- per-incumbent viscera. I have condensed from Rokit- ansky the following observations, bearing upon the relation of the pelvis to the spinal column. Every pri- mary curvature is compensated by a second curve in •the opposite direction, which generally occupies the part of the column immediately adjoining the first. The compensation generally equals the primary curve. Lordosis, arising from too great pelvic inclination is compensated for by increased backward inclination of the pelvis. Distortions of the spine diminish both tho- racic and abdominal cavities. The chest is lengthened and flattened from before backwards by excessive pel- vic inclination. The pelvis is always oblique in lateral curvature and loses its natural bi-lateral symmetry— and the Causes of Displacements. 35 the transverse diameter being always increased. Pel- vic capacity is generally increased in angular curvature, its height elevated, inclination decided, due to dimin- ished capacity of the abdominal cavity, caused by de- pression of the thorax. Extraordinary anterior curvature in the loins involves a corresponding excessive inclination of the pelvis, and when compensating and consequent upon too great inclination, causes still greater pelvic inclination. These observations show how the normal relation of the uterine and corporeal axes may be dis- turbed by certain alterations in the natural conforma- tion of the spinal column. As these relations may be disturbed the centre of gravity and line of gravitation are altered, and as the pelvis and pelvic organs consti- tute the objective against which the force of gravitation of the super-incumbent viscera is always expended, their normal relation must suffer in proportion as the uterine supports are weakened or overcome. Pelvic inclination and dorso-lumbar incurvation bear a direct and positive relation to each other, either, in excess, being compensated by an excess of the other. If the pelvic inclination be the primary mal-conformation its dorso-lumbar compensation seeks its compensation in further pelvic inclination, so the cause and effect re-act upon each other, producing alternately further inclina- tion and greater spinal curvature. If the suggestion, that the force of impingement of the abdominal viscera against the anterior walls is increased by increased in- curvation of the dorso-lumbar curve, be in conformity with the laws of force and motion, which force of im- pingement derives additional power from the dimin- 36 JBusey on the Nature of Uterine Supports, islied capacity of the abdominal cavity, always co-ex- isting with spinal distortion, and as the uterine incli- nation (to the horizontal line) is diminished in direct proportion with the increase of pelvic inclination (to the same line), it must follow that increased force is expended in the direction of diminished resistance, that is, that the same mal-conformation which generates the additional force ultimately expended upon the uterus and appendages, so presents these parts to that force, that the resistance which its natural position and at- tachments offer, is diminished in direct proportion to the degree of force thus evolved. Such being the re- sultant issue of this mal-conformation, it would seem, per contra, that the opposite deviation of the normal dorso-lumbar curvature, would be unattended with uterine displacement. The difference is only in the form of deviation. Lessened pelvic inclination with increased uterine inclination is the natural relation with diminished dorso-lumbar curvature. The action of the pressure force of the super-incumbent viscera upon the objective, the pelvic viscera, becomes, consequently, more direct for the obliquity of the axis of the pelvic brim to the axis of the body or vertical line of pressure is diminished, and the longitudinal uterine axis approxi- mates the vertical course of the gravitating force. Hence, it is universally conceded that abnormal ante- rior pelvic deviation is a predisposing cause of displace- ment. In setting forth the principles herein stated, I am not unmindful of the fact that so long as they are not cor- roborated by actual linical observations, which accu- and the Causes of Displacements. 37 rately trace tlie histories of cases of uterine displace- ments, showing their connection with the anatomical anomalies, which through the perversion of the nor- mal forces, predispose to the results deduced! that I may incur the criticism of those who adhere to the dogmas and follow the lead of men whose learning and experience entitle them to pre-eminence of opinion. I might, if space permitted, quote, from many distin- guished authorities, isolated paragraphs, which go to show, that the inquiries to which I have endeavored to direct special attention, are not original with me; vari- ous authors, in discussing the subject of uterine dis- placements, have so nearly approached, in their multi- tudinous array of causes, the views here thrown out, that I am compelled to forego all claims of originality, and to he content with the simple claim of endeavoring to trace and illustrate the relationship of cause and ef- fect. And while I foil to furnish positive demonstration, by giving clinical histories, there are many facts and circumstances, which must have come to the knowledge of every observant practitioner, which go far towards establishing the verity of these conclusions. It must be apparent, to even a casual observer, that the curva- tures of the spine change with the advance of life, and that the alterations are more marked in the cliildJbear- ingjvvomen. Th§ woman during gestation adjusts the centre of gravity to the increasing dimensions and weight of the pregnant womb by throwing back the head and thorax, and that the frequent repetition of this process of adjustment, through frequently recurring 38 Busey on the Nature of Uterine Supports, pregnancies should work some fixed mal-conformation of tlie normal is not only a fair inference from a study of the natural laws of the human economy, but is verified by actual observation, and as the primary departure from the normal curvature always finds its compensation, and usually in the part immediately ad- joining, and, more especially, as any increase of the ordinary anterior curvature in the loins involves a corresponding excess of pelvic inclination, the thinking reader will readily discover that I am not entirely des- titute of clinical facts. The equipoise of the body upon the ileo-femoral articulations must be preserved, and Duncan has called attention to the fact that while “ the small and especially short bodied women” seek the adaptation of the centre of gravity by moving back- wards the head and shoulders, another class, the “ tall and long bodied,” seek it by “ moving forward the supports,” which is accomplished “ by diminishing the angle which the pelvis forms with the horizon.” “ In this dimunition of the inclination of the pelvis, forward movement of the ileo-femoral articulation takes place, and the equipoise is restored without any backward motion of the upper part of the trunk. This change in the pelvis is analagous to that taking place in old age, when the forward stoop is counterbalanced by it.”* While there may be many typical illustrations of these two classes of women, the probability is, that in a ma- jority the two arrangements exist, one “in complement to the other.” Another important fact in this connec- tion, perhaps also first pointed out by Duncan, though * Researches in Obstetrics, Duncan, pp. 40, 41. and tlie Causes of Displacements. 39 it must have generally arrested the attention of gynae- cologists, is that where the adjustment is effected hy backward inclination of the head and shoulders, the hips become very prominent, indicating, as suggested by the same author, “a probable considerable obliquity of the pelvis.” In the other class the “ hips are generally flat, indicating, of course, lessened obliquity and pelvic elevation. These observations illustrate and demon- strate the existence of the mal-conformations consequent upon pregnancy, and verify the suggestions made above relative to the perverted relation of the pelvic and corporeal axes. The same mal-relations will follow ac- quired habits of carriage, which may produce like changes in the natural configuration of the body, and so, likewise, must alterations ensue from persistently excessive indulgencies of certain positions. Sitting upon the sacrum, instead upon the upper part of the fennr. ra, must inevitably affect a change in the normal rela- tion of the pelvis and spinal column, and excessive dorsal recumbency must surely work alterations in the normal spinal curvatures, especially in lessening the dorso-liunbar arch. Time and space forbid the further pursuit, at present, of this interesting and suggestive inquiry. Hereafter, I may resume the work, now so abruptly terminated, and seek to show the practical utility of the study of the laws of force and motion, in their application to the investigation into the causes of uterine displacements, and how they may be utilized in the treatment. For the present, I must be content, if I can induce others to the study of the philosophy of the question. THE AMERICAN JOURNAL § OBSTETRICS AND DISEASES OP WOMEN & CHILDREN IS THE Only Journal of its kind in the English Language, It is read by the Leading Practitioners of Medical Science in all parts of the world. “ All the best medical journals quote from it.” R6ad the Press Notices on another page, and the fol lowing from the MedicalWorld for November, 1871 :— “The American Journal of Obstetrics and Diseases of Women and Children.—The last number of this valuable quarterly is now before us, and will compare favorably with any of its predecessors. Its able editor, Dr. Benjamin F. 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