This is a condition in which the body of the uterus is bent forward on the cervix which occupies its normal position, or in which the cervix is bent forward on the body which remains in its proper location, or in which both body and cervix are bent forward. (Figs. 15, 16, 17.) The first of these is called Corporeal Anteflexion, the second Cervical Anteflexion and the last Cervico-Corporeal Anteflexion. Anteflexion is also classed by some into first, second and third degrees according to the angle produced. Such classification is of but little practical value. Opinions differ widely not only as to the relative frequency of anteflexion, but as to its pathological importance when it does occur. By some writers it is given first place in frequency while others scarcely mention it at all. Its symptoms pass unnoticed by some and are recited at great length and accorded much importance by others. This difference of opinion is due to the fact that the uterus is normally slightly anteflexed, the degree of which is variable. The point at which this anteflexion becomes pathological depends upon no fixed standard but upon the opinion of individual physician. Where one sees an extreme degree of normal anteflexion another finds a pathological condition. The one seeing a normal condition naturally does not attribute symptoms to it.

Fig. 15. Corporeal Anteflexion.

Fig. 15. Corporeal Anteflexion.

Fig. 16. Cervical Anteflexion.

Fig. 16. Cervical Anteflexion.

Fig. 17. Cervico corporeal Anteflexion.

Fig. 17. Cervico-corporeal Anteflexion.

The true state of affairs is found between these extremes. It does occur with relative frequency and is often the cause of annoying and sometimes very distressing symptoms.

Its occurrence is favored by the normal anteflexion in which position the uterus is kept by intra-abdominal pressure and the attachment anteriorly of the round ligament. This malposition is more frequent in virgins and nullipara than in those who have borne children.

As heretofore mentioned, a flexion indicates a two-fold pathology, a displacement plus a diseased or weakened tissue. The consistence of normal uterine tissue is such that if the organ be flexed, it will spontaneously return to its original position when the pressure is removed. So in every case of anteflexion there must occur weakening of tissue at the point of flexure or the normal tissue rigidity must have been overcome, to be later replaced by a more resistant pathological rigidity. This final pathological rigidity is most probably due to congestion and inflammation of the uterine wall occurring on the compressed or concave side of the flexure, to be followed as resolution of the inflammation occurs, by atrophy of the uterine musculature and scar tissue development.

Causes

(1) Deranged Spinal Innervation. This produces a predisposition to anteflexion. It would be impossible to foretell in a given case the exact manner in which such a disturbance might operate. Much would depend upon this length of time the disturbed innervation had existed; the particular direction the aroused reflexes might take; the pre-existent or accompanying predisposition, etc. However, we would expect this cause to manifest itself in one of several ways.

(a.). By causing loss of uterine tone. (b). By causing contraction of sarco-uterine ligaments which are rich in involuntary muscular fibers, (c) By interference with vaso-motor nerves resulting in congestion and hyperplasia with consequent increase in weight.

(2). Endometritis and Metritis. These two conditions, usually associated to some extent, are one of the chief agencies weakening the tissues, the normal tissues being replaced by hypertrophied glandular and hyperplastic areolar tissue. At the same time a corporeal endometritis increases the weight of the uterine body, adding to its normal tendency to an-teversion. Acting in a similar manner are continued passive congestion and subinvolution.

(3). Inflammatory Adhesions. (Figs. 18, 19.) These are the most frequent causes of anteflexion. They are formed chiefly of connective tissue, and are the result of a previous inflammation of the connective tissue, posterior to the cervix and in the sacro-uterine ligaments. The organization and contracture of the inflammatory exudate draws the uterus usually at the cervico-corporeal junction, backward and upward. At the same time intra-abdominal pressure on the superior surface of the fundus and the natural tension off the posterior vaginal wall upon the cervix in a downward and forward direction, cause the uterus to bend forward at the servico-cor-poral junction, rendering the normal angle at this point more acute. It sometimes happens that the contracture in the ligaments is not equal on the two sides and some degree of latero-flexion or latero-torsion will be produced.

Fig. 18. Anteflexion Caused by Adhesions.

Fig. 18. Anteflexion Caused by Adhesions.

Fig. 19. Anteflexion of Uterus from posterior perimetritic adhesions or contracting parametritic exudates of Douglas' folds at the level of the internal os. The perirectal adhesions produce pain and constipation. (Schaeffer, Atlas and Epitome of Gynecology.)

Fig. 19. Anteflexion of Uterus from posterior perimetritic adhesions or contracting parametritic exudates of Douglas' folds at the level of the internal os. The perirectal adhesions produce pain and constipation. (Schaeffer, Atlas and Epitome of Gynecology.)

Rarely, adhesions may be formed anteriorly which either pull the fundus forward or immobilize the cervix so that it cannot recede when the fundus is forced downward by intra-abdominal pressure.

(4) Increased Intra-abdominal Pressure. This may be from muscular efforts, improper corseting, coughing, tumors or ascites. Abdominal ptosis, in cases in which the pelvic floor is unimpaired, may in crease the normal pressure the superior surface of the fundus is called upon to bear and force it downward. So, also, improper posture, such as the slumped position over a sewing machine or elsewhere. This position obliterates the anterior lumbar curve and allows the abdominal contents easier access to the pelvis, causing a relatively increased pressure on the fundus. Should the vaginal walls be slightly shorter than the average so that the cervix can not move backward, as the fundus is forced downward, some degree of anteflexion is inevitable.

(5.) Errors in Development. There may be persistence of the infantile form of uterus, a small body with a relatively much larger cervix lying practically in the same direction as the vagina. The cervico-corporeal junction being flexible, as the fundus develops the cervix fails to extend and a decided anteflexion results. In some of these cases the uterus remains infantile in size. This condition is quite different from a small adult uterus. More often the uterus will be of normal size but in an extreme degree of anteflexion. If it is truly infantile there is usually a corresponding lack of development in the ovaries and perhaps the vagina also.

(6.) Impacted Rectum. This may in rare instances and extremely pronounced cases, by pressure, cause the cervix to bend forward upon the fundus.