OF DISPLACEMENTS OF THE UTERUS.
In order to compress as much as possible what I say upon these topics, I
shall consider here displacements of the uterus, both of those which
occur in the pregnant and non-pregnant women.
By the inflection of the peritoneum the uterus is permitted to expand
freely during pregnancy, and to rise without inconvenience into the
cavity of the abdomen; this it could not do if it was confined to its
place by short ligaments, or by adhesions. But from the same cause,
women become liable to various diseases; to the retroversion of the
uterus, and other displacements; to dropsy of the peritoneum, and to
that species of hernia which is occasioned by the descent of the
intestines between the vagina and rectum.
By PROLAPSIS is meant that condition in which the uterus falls below its
natural level in the pelvic cavity. PROCIDENTIA is a term used to
signify the protrusion of the uterus beyond the vulva. Women are liable,
even when young, to a falling of the womb, but it occurs most commonly
after the age of thirty-five, in such as lead a laborious life. Amongst
other causes may be enumerated violent bearing down efforts, such as are
made in straining to pass hardened feces, or in urging an evacuation
through a stricture in the rectum, in coughing, lifting heavy weights,
etc.
The immediate causes of the displacements are the pressure on the uterus
by the viscera above it, and a diminution in tone of the uterine
supports.
Displacements of the womb are more common among women who have hollow
and capacious pelves; in sufferers from dropsy, and in delicate, flabby
subjects, where the broad and round ligaments are affected and
elongated.
There may be prolapsis during the early months of pregnancy, and in
cases where the pelvis is large and the ligaments are relaxed, the womb
may rest on the perineum; or the neck, and even the body may become
visible externally; but it subsequently rises out of the pelvic cavity,
assuming a normal position.
When a woman has prolapsis uteri she often complains of a sense of
weight about the pelvis, of dragging pains, of a wearisome backache, and
of a leucorrhocal discharge. Menstruation is seldom interfered with, and
as the uterus goes back of itself, or is easily pushed up when the
patient is in bed, conception may take place, and the general health may
not be directly affected.
In some few instances there is complete inability to pass water until
the patient lies down and replaces the uterus with her finger; in other
cases micturition may be annoyingly frequent. Constipation is often
complained of, and, if the woman be careless, a large accumulation of
feces may take place in the rectum.
By a vaginal examination the os uteri is found low down, and if the
cervix is of the natural length, we know that it is prolapsis.
If a round tumor is seen projecting beyond the vulva, and if at the
lowest part of it there is what seems to be the mouth of the uterine
cavity, it may be advisable to introduce a sound or catheter, to make
sure that the opening is not a mere cleft in a uterine polypus. (Of
course, you would not use a sound if you suspected pregnancy.) If there
are ulcers, cracks, etc., they may be detected, the ulcers looking as if
portions of the mucous lining had been punched out.
In pregnancy, displacements may occur either slowly or suddenly, though
the woman may have had nothing of the kind previously, or they may be
the continuation of a previous prolapse. The progressive development of
the uterus generally removes the prolapsis about the fourth or fifth
month, but if the pelvis is very large, it may possibly continue.
As in other cases of prolapsis, the pregnant woman may suffer very much
from it. She may suffer from a feeling of weight at the anus; painful
tractions in the groins, lumber regions and umbilicus; a fetid discharge
may come on; there may be complete retention of urine, very obstinate
constipation, etc.; and the pressure on the uterus may cause abortion.
For complete retention of the urine the catheter may be used, or the
womb may be pressed up by one or two fingers introduced into the vagina;
or the woman may be able to urinate if she lies down and elevates her
hips considerably.
THE OPERATION OF INTRODUCING THE CATHETER may be performed by the
educated nurse. The patient being placed upon her back and the labia
separated, the point of the forefinger of the left hand should be placed
just within the orifice of the vagina so as to press slightly the upper
edge; the catheter should then be passed along the inner surface of the
finger until it is arrested by the anterior part of the vagina; when
there, a very slight movement so as to elevate the point of the
instrument a little, enables the operator in the majority of cases to
enter the catheter into the canal. The operation is more difficult when
the parts are swollen or distended, as happens occasionally from
disease, during pregnancy or labor, or after delivery. If we cannot
detect the orifice by the touch, we may use a light, and the patient may
be placed on her side. We may adopt another way to proceed. The point of
the forefinger finds the clitoris, and passes from above downwards to
the middle of the vestibule; the first inequality met with is the
orifice of the urethra, into which the instrument can then be passed. It
will easily slide in if the instrument is not passed either to the right
or the left of the median line.
When a woman who has previously suffered from prolapsis becomes
pregnant, it is sometimes necessary for her to keep the horizontal
position during the first three or four months of pregnancy, and after
her confinement she should keep her bed a considerable time—perhaps for
two months.
For the treatment of prolapsis in non-pregnant women, the general
principles are to be applied: To afford artificial support to the
superincumbent abdominal viscera; give tone to the broad and round
ligaments of the uterus, to the vaginal walls and the perineum; and to
remove any complications that induce the falling, such as uterine
congestion, hypertrophy, cough, constipation, etc.
The uterus may usually be easily pushed back to its place when the
patient is lying down, or, what is better, her head much lower than her
pelvis. (Fig. 13). The knee-chest position is the best one.
Without going into the details of treatment in the use of bandages,
tents, etc., I may say that a nurse may, in the absence of a physician,
use astringent vaginal injections, astringent pessaries (F. 154, 163),
and cold soft water; hip baths may also be used. The nurse should know
how to tamponade the vagina, because, when this is deemed advisable by
the physician, he desires that the process be repeated every day, and in
many instances it is not convenient or possible for him to make daily
visits. The vaginal tampon is used as a means of retaining the uterus in
its normal position, and also to hold medicinal agents applied to the
cervix and vagina; besides, in some cases, direct pressure on the pelvic
vessels stimulates and thus benefits them when in a state of chronic,
passive dilatation, or venous hyperemia. Tampons are also used in cases
of hemorrhage from the uterus, and as an absorbent of vaginal or uterine
discharges, and for various other purposes.
The nurse may receive instruction from the physician in each case in
regard to the material, etc., to be used as tampon. When it is desired
to simply support the uterus in its place, fine cotton batting may be
used, and this perhaps is, in ordinary cases, as good as any material.
But in some cases absorbent cotton, oakum, marine lint, or wool may be
preferred. The size of the tampon will, of course, vary; ordinarily one
as large as a hen’s egg may be introduced without difficulty; sometimes
one nearly as large as a goose egg may be necessary, because a small one
would not be retained. Cotton may be rolled tightly into the form of a
cylinder, or a small bag may be made of muslin or linen, and cotton or
other substance can be enclosed in this and applied.
The knee-pectoral position (Fig. 13) is the one in which a prolapsed
uterus can best be replaced, and the nurse can best tamponade the vagina
while the patient is in that position. The _proper_ knee-pectoral or
knee-chest position is shown in Fig. 13.
The physician would, with or without the aid of the nurse, use a Sims’
speculum, and first pack four small pledgets of cotton around the neck
of the uterus. One string can be tied in the kite-tail manner around
each of these pledgets, and there should be an end about ten inches long
to be left out from the vagina, so that the whole may be easily removed.
The nurse, if alone, however, will usually press in but one tampon, and
she may do this while the patient is in the knee-chest position, or,
what is nearly as well, on her side or back, having first, by a digital
examination, ascertained that the uterus is in its proper position.
[Illustration:
Fig. 13. Genu-pectoral position.
Fig. 13—Knee-chest or genu-pectoral position.
]
a, Retroversion of the uterus.
b, Natural position of the uterus.
Either the nurse or the patient herself may easily press a tampon into
its proper position, if she possesses an ordinary amount of boldness and
dexterity. She will find it more difficult to properly place it,
however, if there is tannin or other astringent substance on the outside
of it. This has an astringent effect immediately when it comes in
contact with the vagina, and an unusual amount of vaseline is necessary
to cover it.
If a solution of tannin, alum, acetate of lead, sulphate of zinc, or
carbolic acid be used, it is best to prepare several tampons at the same
time; soak all the tampons in the solution, squeeze them out and dry
them, then when one is used put it inside a bag and apply it dry.
The patient herself, if she is intelligent, and is not too timid, can
introduce the tampon. She should first smear its surface with vaseline,
lard, or olive oil. Then lying on her back with thighs separated and
flexed, draw the labia apart with the fingers of one hand and steadily
crowd the tampon into the vagina with the other, always taking care to
have a good, strong cord, one end attached to the tampon and the other
hanging down to facilitate removal.
It is well also, sometimes, to place another pledget of cotton between
the labia, that can be removed when the woman urinates. When all is well
crowded into place, the tampon should be retained by a broad T bandage,
covered by oiled silk when it rests against the vulva.
Generally the whole should be removed within from eighteen to
twenty-four hours, and hot water or some cleansing injection used, and
the tampon be soon reapplied.
If opium or morphine is used with the tampon, as it is sometimes when
there is considerable pain, first dip the cotton in glycerine, and then
sprinkle the narcotic on the outside.
If borax, tannin, alum, acetate of lead, sulphate of zinc, chlorate of
potash, or carbolic acid is used, I think it well to envelop the
undissolved drug in cotton, put it in the middle of the tampon, and let
it dissolve slowly in the vagina. It is best when thus applied to let
the whole suppository remain as much as forty-eight hours; it should,
however, be removed when it seems to cause smarting or excoriations.
The accompanying cut (Fig. 13) is inserted to show what is the
knee-chest or genu-pectoral position, as well as to exhibit the
retroversion of the uterus. Note that in this position the hips are
elevated, and remember that it does not suffice to get on the hands and
knees if the haunches are low down on the legs and ankles.
RETROFLEXION AND ANTIFLEXION.
[Illustration:
Fig. 14. Retroflexion of the uterus.
]
The condition known as _retroflexion_ consists of a bending back of the
uterus at a point where the neck joins the body, so that the fundus is
found between the cervix and rectum, the os uteri being in the natural
position.
In _antiflexion_ we find the fundus pressing upon the bladder. These
displacements are rare in virgins. The false membrane formed in
peritonitis is now and then the cause of these deviations, when there is
superadded such causes as are mentioned for prolapsis. The symptoms of
RETROFLEXION are usually a dull, weary and constant backache, which is
more marked about the sacral region, pains that shoot down the thighs or
the groins, and a frequent desire to go to stool, although nothing comes
away. The passage of a motion that is not at all constipated aggravates
the pain and aching; sexual intercourse is attended with suffering, and
is not followed by pregnancy; and just before and after the monthly
periods there is so much tenderness that sexual connection cannot be
tolerated.
[Illustration:
Fig. 15. Antiflexion of the uterus.
]
The catamenia come on with pain and difficulty, but about the second day
the flow of blood seems to give some relief. The general health is bad,
there are frequent attacks of nausea, the appetite is small, the spirits
are depressed, and there are many what are called hysterical symptoms.
On examination the congested fundus may be found encroaching upon the
rectum; on touching this part the patient will exclaim that it is the
seat of her sufferings, and it is not uncommon to find tenderness of one
or both ovaries.
Not many of these symptoms are present in ANTIFLEXION, but this commonly
produces great irritability of the bladder, so that when the patient is
in the erect position, the desire to micturate is almost as great as in
disease of the bladder.
[Illustration:
Fig. 16. Anteversion of the uterus.
]
The treatment includes replacing the uterus with the sound. Should there
be adhesions, however, this might cause intolerable pain. In such cases
relief is given by the use of belladonna plasters and belladonna, opium,
hyoscyamus, or conium tampons. One-half to one dram of the tincture of
one of the narcotics may be added to the glycerine in which the tampon
is soaked, or the cervical end of the tampon may be dipped in the
tincture. Suppositories and ointments may also be used. (F. 163, 214).
RETROVERSION AND ANTEVERSION.
In RETROVERSION (Fig. 13) the fundus is turned toward the hollow of the
sacrum, while the os is drawn under the arch of the pubis.
ANTEVERSION is characterized by the fundus being towards or against the
bladder, the os being directed to the cavity of the sacrum. (Fig. 16.)
Retroversion is liable to occur at the third month of pregnancy, from
the neglected distention of the bladder, and from a morbid weight and
enlargement, though after the fourth month the uterus is too much
enlarged to fall down in any way. The chief symptoms are backache and
bearing down pains. It may happen that micturation will be impeded; and
if the bladder may be felt at the lower part of the abdomen, or if the
patient complain of a constant desire to pass water, or especially if
the urine should dribble away, the catheter ought to be passed without
loss of time, and the bladder should be kept evacuated. It may be
necessary, in order to restore the organ to its proper position, to
introduce the first and second fingers of one hand into the vagina, and
a finger of the other into the rectum.