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Un daa symboias suivants apparattra sur la darnlAra imaga da chaqua microficha. salon la cas: la symbols — »> signlfia "A SUIVRE". la symbols y signlfia "FIN". IVIaps, plates, charts, ate, may ba filmad at different reduction ratios. Thosa too large to be entirely included in one exposure are filmed beginning in the upper left hand corner, left to right and top to bottom, as many frames aa required. The following diagrama illustrate the method: Lea cartes, planchaa, tableaux, etc., peuvent Atre filmia A daa taux da rMuction diffArents. Lorsque le document est trop grand pour itra reproduit en un seul cliche, ii est filmA A partir da I'angia supArieur gauche, de gauche A droite, et de haut en boa, an prenant la nombra d'images n^cessaira. Las diagrammea suivants lllustrant la mithoda. 1 2 1 3 1 2 3 4 5 6 Q-r \j^ .silrj^ ^ ^ ^ G GfS--/^ A CRITICISM OF RECENT VIEWS REGARDING LATERAL DEVIATION AND ROTATION OF THE UTERUS. By J. C. WEBSTER, M.D., F.R.C.P.Ed., RR.S.E. Reprinted from the P^dinburgh Medical Journal. Edinburgh and London, Young J. Pentland, September, 1897. ^y^^i^gfeiOilL^ .\ A CRITICISM OF RECENT VIEWS REGARDING LATERAL DEVIATION AND ROTATION OF THE UTERUS. AClilTICISM OF JiE('KNT VIKVVS liKOAliDlNC LATEUAL DEVIATION AND JtOTATlON OF 'I'HE U'I'EiiUS. Wy J. C. Wkijstkk, M.D., F.li.C.l'.Ed., F.H.S.E., Be mo list m tor of Gi/nccolo(/i/, M'OlU University; Assistant Gyncculoijist, Royal Victoria Ilosjyital, ^Montreal. In a recent paper, })ul)lislied in this Juuriiiil, entitled "On Dellee- tion and Kotation of the Pregnant and l'uer[)eral UteruK," the anthor, Dr. Mihie Mnrray, did me the hunonr of referring to a pai)er ^ of nunc, written several years ago, entitled " On tlie Occur- rence and Significance oi llotation of the Uterus." I very greatly regret the saddening ellect which, Dr. Murray says, resulted from its jierusal, and especially lament that it v,as not accom- panied by any intellectual enlightenment. My study of Dr. Murray's paper has al'tected me in ([uite a dilferent manner. I arose from its perusal in no state of depression, but enormously stimulated in my mental ])rocesses. I said with the poet, " that my tongue could utter the thoughts that arise in me!" but, alas for me! the Edinljurgh Obstetrical Society, that famous tilting-ground, was far away, and my voice failed me for want of listening ears. My poor pen alone is left to me, but I trust that, in spite of its shortcomings, I may bo enabled therewith to furnish an analysis of his paper, which will demonstrate the specious fallacies of his arguments. In the first part of his paper, Dr. Murray discusses the (piestion of lateral tLviation or deHection of the uterus, and states that in pregnancy the organ inclines to the right side ii 70 to 80 per cent, of all cases, and in 120 to 30 per cent, of cases inclines to the left or lies mesially. This tendency, he states, is also found in the puerpf!rium. He tlien considers the various explanations of this preponderant tendency to right deviation, e.y. the infiuence of pressure of the rectum on the left side of the pelvis, of the place of insertion of the placenta, of the liver, etc., and concludes that none of them are satisfactory. It is sur})rising to me that Dr. Murray has made no reference t(j the position of the uterus in the non-pregnant condition in healthy states, where no in- ilammatory remnants are present. If a pregnant or puerperal uterus be found deflected to one or otlier side, how are we to know that this position is in any way associated with pregnancy, and that the same deviation did not exist in the same case before pregnancy occurred ? Of what value, then, I ask, are Pajot and Dubois', Murray's or anybody else's one-sided statistics of this nature ? So it would be advisable that those who find the uterus devi- ated to one side or the other in pregnancy or in the puerperium ^ Trans. Edin, Old. Soc, vol. xviii. r.ATKRAL DKVIATION AND ROTATION OF THK UTKRUS. 255 3 Hhould bo ('(^rtiiin uh to the (Mmditioii in l\w ii()n-])r('<^Miiint Htate, bufuru Lhey think of attiibutiii^' tlx' ])ositioii to the iiilhiuiicu of jdu^iiiiiR'y, or Hpcculate aw to liow it ini<^ht be iii(hice»l. Is Dr. Murniy not aware that in the healthy miHiiiara, the uterus, in a lai'^'e numl)er of cases, does not lie exactly iiiesially, but is deviated to one or other side? Let me refer to the most recent im])ortant anatomical work by an acknowledged master, W. Nagel.' This author has carefully studied the works of Aran, His, von Kiilliker, Symington, Waldcycr, and others, who have worked at the subject of the normal position of the uterus, and his conclusion is, " Dabei liej^t seine Liingsachse selten geuau in der Mittellinie des Kiirpers, luiufig ist ehie seitliche Abweichunj;' besonders nach rechts (aber audi nach links) zu bemerken." The obstetrical world, therefore, while (grateful to I'ajot, Dubois, Murray, and others for the information that the pregnant uterus is very often deilected to the right, and less often mesially ]»laced or deilected to the left, say to them, "We might have told you so. What else would you expect if the same conditions are found in the non-pregnant state ? " The causes of these variations are not known. As regards the tlieories put forward, I incline to that one which regards the ijithience of the rectum as of chief importance. Dr. Murray, in considering this inlluence as it has been put forward to explain tiie deviation of the pregnant uterus, states that, while it seems [)lausible enough as ex])laining the 80 per cent, of deviations to the right, " breaks down entirely when we come to consider the 20 ])er cent, of cases in which the uterus is inclined to the left." " If," says he, " the uterus is to be regarded as the cause in one set of cases, it would re([uire to be shifted over to the right side in order to account for the otliers." Dr. Murray is, I understand, a critic of the sectional method of studying anatomy. Is he also disdainful of the results of dissection? He nmst be, for he does not seem to have noticed that the rectum does not always normally lie nuiinly in the left, l)ut often in the right half of the pelvis. Indeed, in the ojnnion of many anatomists, in the majority of cases tlie first part of the rectum is directed from the sigmoid tiexure across to the right side of the pelvis, whence it gradually passes towards the anus. Nagel refers to the widespread ignorance of this fact among gynecologists. Keferring to the direction of the gut, he uses the words : " Steigt von linkes gegen das J^iecken, begiebt sich sodann, manchmal bereits in Hohe des Promontoriums, in die rechte Seite mid niihert sich nun von reclits her der Mittellinie, um durch den JJeckenboden zu treten. Diese Lage ist die hiiufigste, selten er verli'ingert sich der letze ]>ogen ueber die Mittellinie hinaus nach links ; nur in diesem Falle kann man von einer Linkslagerung des Darmes sprechen." It is possible that with this evidence ^ "Die AVeibliclie Geschlcctsorgane," Jena, 1896. 25G .). C. VVKHSTKll. Dr. Murray iiiay liiid cumfurt in liis uiioasiiiosR ('oiU'('riiin p(!r colli, of casua in wliicli lio sLiitcs tlio iiLuriia ia ilc^viuLcHl to nil; Itil't aido. In the ne.xt part of liia paper Dr. Murray criticises certain views rej^ardiii^' rotation of the uterus, lie has heeii haunted hy the restless ^host of an old heHef, which he refers to as having heeii ruthlessly dc^stroyed hy work of mine some years ago in Kdinhurf^h. My peace, I am glad to say, has in no way hecn disturhed hy this spirit-visitor, whereas 1 might well have ex- pected to he tho first to siill'er from its reproaches. In order to give my esteemed friend peace, 1 will endeavour to slay this hogio which has disturbed him, in the hope that, hereafter, l)erpetual peace of mind may remain witii him. In my pa[)er on rotation I discussed the varicms views current regariling tiiis phenomenon in the nullipara, in ])regiiancy, in labour, and in the puerperium. As regards the nulliparous state, my conclusions were as follows: "I do not mean to say that true rotation never exists ; it has been undoubtedly observed, l)ut, as far as trustworthy records go, we caii'.iot speak accurately with reference to tho frequency of its oocurronce, though the ])re- sumption is in favour of its being found in only a small percentage of cases." No observations of my own or of other workers, nuule in recent yeara, have led me to alter this view in any way. \\y whomsoever investigations are made in regard to this subject, I would again insist upon attention being p. .d to the following points, namely : — 1. It is in all cases difficult, and in many impossible, by the bimanual examination to distinguish a slight degree of rotation, or to be sure that the rotation felt is not caused by the artificial disturbance of parts. 2. Care nnist be taken to distinguish between true or inherent rotation, and that due to accidental conditions, c.(/. temporary changes in intra-abdominal pressure, altered degrees of fulness in bladder or rectum, and peritonitic or cellulitic cicatrisation. 3. Ordinary post-mortem dissection cannot be trusted for the determination of the true position. Frozen sections are necessary for the exact estimation of topographical relationships. As regards the uterus in pregnancy, I pointed out the un- reliable nature of the evidence on which the statement had been based, that the organ underwent a rotation as it grew upwards, and I gave it as my opinion that there was no proof that the rotation characterised the growth of the gravid uterus. At the present time I am iware of no well-ascertained facts which have been published, su ficient to alter my scepticism regarding these old-time beliefs. I do not deny that the uterus may occasionally be found rotated in pregnancy. This condition may certainly be found just as in the nulliparous state. But that it is the rule no proof is as yet forthcoming. I believe that the statements as to LATKRAL DRVFATION AND ROTATION OF TITK rTKIUTS. 257 its froquenoy am duo to a nninbor of fallacios, not ronsidnrod by tlios(; Nvlio have inado tlio .stati.sticH. Tlioy aic as followH: — Ciu'taiii ohsorvorH havo basod tluiir views upon conditions fitnnd in the alidonien durin<^ tlio IVtrro or ('ji'sarcan operation. Dr. Murray has triumphantly l)rout^ht forward a ease of this kind, ojxu'ated on hy Dr. HaUiday (Jrooin and liiniself, in wliieh the ])r(!<,'iiant uterus was rotated so that th(( h;ft ovary lay near the abdominal ineision. I fail to understand why a man of lo<^ical mind, and an obstetrician, should brin^' forward such evidence. Surely it is not nec(!ssary to remind Dr. Murray that these cases are (Mitirely abnormal, and that, owin^^ to the impossibility of tire uterus sinkin;^' into the ])elvis, an abnormal condition of intra- abdominal pressure is ])roduced, so that the uterus may be turned to the front or to one or other side, varying accordiuf^ to the condition and resistance of the abdominal walls, of the abdominal viscera, and to the nature and degree of the pelvic deformity. Krrors have also arisen in the clinical examination of normal cases, in the endeavour to make out rotation of the ])regnant uterus. I have stated and again reiterate the belief, that it is only r.mdy possilde to estimate rotation by the examining hands. Dr. Murray, however, disputes this view. I hold that it is impossible to deline the outlines of the soft uterine bag, or to make out the landmarks necessary to the exact determination of rotation. No doubt, in some cases, conditions described as rotation have been really only the moulding of the uterus on the f(ctus by the examining hand, or against surrounding structures. Again, rotation lias been described in conditions due entirely to accidental caus(»s, c.//. pressure of loaded bowel or distended bladder, or (lisj)lacement resulting from old inflammatory troubles. An important fallacy consists in deciding upon rotation of the uterus, according to the i)alpation of the ovaries through the alxlominal wall. I certainly believe that in a marked degree of rotation of the uterus, in a woman with thin and lax abdominal walls, it is possible to palpate the ovary which lies in front. But I hold that, in all cases whore the walls are tense or of moderate thickness, it is impossible to be certain in regard to feeling the organ, which is so easily moulded against the soft uterus. I believe, moreover, very strongly that, in the great majority of cases of advanced pregnancy, one cannot at all satisfy one's self as to the position of the ovaries. An important error may, however, bo made in determining rotation, even if the ovaries be felt. I have in my former work ponited out that anatomical evidence goes to show that, in pregnancy, the ovary is capable of being moved about through a considerable range by variations in intra-abdominal pressure, especially by variations^in the distension and movements of the bowel. Their position, in the great majority of cases, is no true 18 KI). MKD. 507— NBW SER.— VOL. II.— UI J r 258 J. C. WKHSTKK. iiiiliciitioii of tlici rniutioii of the iitcniH oii its lon^ iixis, bccanso tluiy do not takci up dcliiiilc! jHwitioiiH, concHpoiKliii^' to every en-minded readers to dcK^de if such a bold fancy need be; indulged in, even if W(f credit the uterus as being th(! most wonderful organ in the body. One might indulge; in any nundier of speculations on this score, r.//. one might expect this powerfid organ to empty itself in an hour or two, instead of working away for seven or eight hours. Dr. Murray's next statement is as follows : " If tho uterus expands absolutely synmietrically, it is the only hollow viscus in the world which does — the bladder, the stomach, the intestines, the heart, all rotate during distension, and derotato when rtdaxed, and I think we may safely assume that tho uterus will do likewise." Hero is reasoning by analogy with a vengeance. I cannot understand how any but a fantastically ingenio s mind could stray into such far-fetched comparisons ; as if one could in any way compare the slowly developing uterus, increasing owing to intrinsic changes in its wall, to tho sudden mechanical dis- tension of the various viscera mentioned ! En jiassant, I challenge Dr. Murray for proof that rotation occurs in the bladder owing to its distension. I know that it may be moulded by neighbouring structures, and that it may often expand more in one half of the pelvis than in the other, because it is often normally somewhat asymmetrically placed, and I know that when greatly distended it has an ovoid shape ; but it is news to mo that it actually under- goes a rotation. I would have thought this scarcely possible, owing to the strength of the attachments of the visceral pelvic fascia to it. As regards the rotaticjn of the ventricular portion of the heart during diastole, I have always understood it to be the mere undoing of the slight rotation which occurs during the active contraction of the ventricles during systole. The so-called rotation of the stomach and intestines is mainly due to the restr.aining influence of their one-sided ligamentous or mesenteric attachments. 1 FiATKRAI- DKVIATION AND ROTATION OF THR UTERUS. 259 (lis- I Dr. Murray 'h next h\,v\) i.s an ('iidcavdur to ostaMisli a rclation- Hliip lt('tw«'(^ij rotuLion jiimI latrial (U^viatioii of the iitcruH. IIo Itelii'VOH that the latter is the (liri-ct result of the former. He saya that " the (lintortioii of the nuiHH of the early |»rej,'naiit uterus, which is the iimiie(Mate result of the rotation, results in throwing the uterus to one or other side of the uuisial jilaue of tlu^ hody, and so determining,' the deHection to the ri^'ht or to the h'ft." In the li<.,dit of our ]>resent knowledge, I consider that this statement exhihits (»nly a grave logical fault, nanudy, a (loid)U! jwlitio pri/irl/iil. I JiaAc already in my ])aiier refei-red to the (juestion of lateral deviation, pointing out that this concUtion exists normally in the non-i)regnant state in a large nund)er of eases, and thfit, therefore, it is not surprising to find it in the pregnant uterus. Dr. Afurray, taking for granted that rotation and lateral deviation are regularly and normally jiroduced in tlie uterus during pregnancy, at liMigth ]»roceeds to unfold the mystery of tluur pi'oduetion. ft is to the construction of the muscular wall (»f th(! organ, he says, that we must look for their exjdanation. An analysis of his line of ai'gument shows that that is a conipfjsition of assumption and conjecture. He assumes, in the first })lace, Helie's descrijition of tiie musculature of tlu; uterus as consisting of an outer coat largely longitudinal, an inner layer which forms sphincters aroinid t)»e Fallopian tubes and os internum, and a middle coat of ve?'y complex arrangenu^nt of interlacing fibres. Speaking of these in relation to the gradual expansion of the uterus and increase in intra-uterine pressure, he states: " Tiuit it is inconceivable that the fibres (of the middle coat) are so symmetrically arranged as that the strain of the internal ])ressure will be symmetrically distril)uted. . . . Unless we assume that this symmetrical distribution of strain is possible, it must follow that as increase of internal i)ressure arises it will pr(Kluce an alteraticm of contour, and a change in the distribution of the mass of the organ alxnit a vertical axis." Now I claim that the first part of tliis statement is a pure assumption, and the second a voii xfiquUnr. Eveiy (me who has examined the uterine wall is struck with the fairly symmetrical thickness of the musculature, in the great majority of cas(^s. One-half of the organ is as like the other half as one-lialf of tlie brain is like the other. Ihit even if there should be differences in the thickness or complexity of the middle layer of the musculature, why, in the name of physics or physi- olcjgy, should it necessarily rotate the uterus about its vertical axis ? I should imagine, if I desired to speculate on the distensicm of sacs of une(iual strength or thickness under increasing internal fluid pressure, that at the weak spots there would l)e a thinning, an extra-protrusion, or a rupture. Has Dr. Murray ever noticed little boys distending rubber bags ? If he will trouble himself 200 J. C. WEBSTER. I to do tliis he may cliancc to notice ono or other of these phenomena. But ])i'. Murray need not speculate as to asymmetry. Let liim give heed to the anatomical conditions, and he will discover that a very marked asymmetry is developed ^>ari ^)«,ss?^. with ])regnancy, hut not qua the lateral halves of the pelvis. The difference exists between the upper and lower portions of the uterine body. Might I point out to iJr. Murray the unquestion- able differentiation of the corpus uteri, as it increases in size during pregnancy, into an upper uterine segment and a lower, the latter being considerably thinner than the former ? Will l)r. Murray eidighten us as to how this distinction can in any way bring about a rotation of the organ ? The following, then, is Dr. Murray's masterly syllogism : — 1. It is inconceivable {rcmcmhcr, only inconceivable) that the uterine wall can be so symmetrically developed as to receive the strain of the internal pressure equally. 2. Consequently, increasing internal pressure produces an alteration of contour — distortion, and a rotation of the uterus around its vertical axis. But the most amusing part of Dr. Murray's paper is that in which he employs the vicious deductive method to explain his assumptions : " If so and so were so and so, then such and such might be the case." He is evidently timorous, however, for he recognises the perilous nature of the ground on which he treads. He admits that " it is practically impossible to analyse the influence of the various groups of fibres " in the middle muscular wall. He then supposes that they must be arranged in such a manner as to act as he thiidcs they would act. In the last part of his paper, Dr. Murray attempts to establish a relationship between occipito-jiosterior positions and left devia- tion of the puerperal uterus. He states that out of twenty-six cases observed by him, the uterus ufter delivery was nearer the left than the right side of the pelvis, and concludes that there must be some well-defined causal association. If I were to follow Dr. Murray's lead, and give an expression to what I co^ ider the inconceivable, I should say that I fail to comprehend how the position of the frctus in utcro can in any way influe.ice the rotation or deviation of the post-partum uterus. Had Dr. Murray known the relationships of the uterus before jwcgnancy in his cases, the comparison with the puei-peral conditions might have furnished some useful information. As it is, his statistics are onl;y instructive, in so far as they point tlie moral that it is dangerous to form conciusiims from insuflicient data. In view of the facts presented ])y me in the beginning of my paper, as to the frequency of lateral deviation of the uterus in the normal nulliparous state, I fail to see that it is at all remark- able that either the pregnant or puerperal uterus should, in a I 4 I I LATERAL DEVIATION AND ROTATION OF THE UTERUS. 261 large number of cases, also lie nearer one side of the pelvis than the other. I trust that Dr. Murray will acknowledge the justice of my criticisms.