. The diagnosis of diseases of women . Torsion of the uterus caused by twisting of the pedicle of an ovarian cyst. between the bony walls of the pelvis to resist intra-abdominalpressure and gravity. If the power of resistance is weakened, orthe intra-abdominal pressure and weight of the uterus are increased,or if both factors co-operate, prolapsus will occur. Webster takesexception to the view of Hart, who regards the perineum as a fixedsegment for the support of the uterus, and of Thomas, who holdsthat the perineum is a supporting wedge. By anatomical dissec- 222 SPECIAL DIAGNOSIS tions Webst
. The diagnosis of diseases of women . Torsion of the uterus caused by twisting of the pedicle of an ovarian cyst. between the bony walls of the pelvis to resist intra-abdominalpressure and gravity. If the power of resistance is weakened, orthe intra-abdominal pressure and weight of the uterus are increased,or if both factors co-operate, prolapsus will occur. Webster takesexception to the view of Hart, who regards the perineum as a fixedsegment for the support of the uterus, and of Thomas, who holdsthat the perineum is a supporting wedge. By anatomical dissec- 222 SPECIAL DIAGNOSIS tions Webster has demonstrated that the pelvic fascia and not theperineum and levator ani muscle is the real support. The various fascial tissues which meet in the perineum and givesupport to the pelvic viscera are: 1. The anterior and posteriortriangular ligaments. 2. The visceral layer of the rectovaginalfascia. 3. The anal fascia. 4. The deep superficial fascia. Web- FiG. 73. Complete laceration of the perineum with cystocele. C, divided ends of caruncular ring;Sph, divided ends of the sphincter. The loss of the pelvic floor and the sagging of theanterior waU of the vagina precede the descent of the uterus. ster holds that the perineal muscles are of little value as a supportcompared to the pelvic fascia. In the absence of actual rupture of the fascia it is possible forstretching alone to so weaken the support that prolapsus will occur. Prolapsus uteri is a term implying not only a descent of theuterus, but also involvement of the bladder, rectum, vagina, and DIAGNOSIS OF MALPOSITIONS OF THE UTERUS 223 adnexa. Descent of the uterus may be checked at any point betweenthe normal position and extreme prolapse. Nomenclature. With Webster, the author will speak of (1)descensus uteri, when the uterus and vaginal walls do not descendbeyond the vulvar outlet, and (2) prolapsus uteri, when the uterusand vagina descend beyond the vulvar outlet. Fig. 74
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