PROLAPSUS OR FALLING OF THE WOMB.

If one desires to familiarize himself with a thorough understanding of this subject, it is absolutely necessary to bear in mind what was said of the natural support of the uterus, for unless one has a full knowledge of the foundation of a structure, how can he comprehend its defects and remedy them when the structure falls? The workman who potters on a building that has shifted from its foundation without first devising means for a new and solid basis for it to rest upon, would be considered a fool. The term “falling of the womb” has no longer the significance that it once had, for it is only a symptom that something is wrong, and in the present state of our knowledge it is misleading and a misnomer, inasmuch as it conveys the impression that it is due to an affection of the uterus, when as a matter of fact it is not due to any disease of the womb at all. If the prolapsed uterus has become involved in a morbid process, it is the result of the abnormal conditions that have brought the prolapsus about, and in which the uterus was in no way concerned.

Professor Schroeder, of Berlin, takes a similar view of these cases, and he groups into one chapter three distinct varieties, yet, because one is depending on the other, he considers them all as one disease. These affections are: prolapse or falling of the womb; prolapse or falling of the vagina, and an inflammatory elongation or hypertrophy of the cervix or neck of the womb. He says “that the displacement of the womb is very seldom a primary affection, but that it is oftener the consequence of a prolapse or falling of the vagina, and a giving way of other structures, or of the pelvic floor, and, as such, ‘falling of the womb’ cannot be properly separated into an individual affection of the womb.”

Falling of the vagina is principally due to a widening of the vaginal canal, a relaxation of its walls, and injuries or lacerations of the pelvic floor. Lacerations of the perineum generally occur during confinement, in which the vagina tears through the vaginal orifice backwards towards, or into, the rectum. This so weakens the pelvic floor that it becomes inadequate to support the pelvic organs and tissues, and this predisposes to all the varieties of prolapsus that have been enumerated above. It is during the period of gestation that the vagina grows considerably longer and wider. In the latter months of pregnancy the womb ascends and its body inclines greatly forwards, which naturally tilts the cervix high up in the pelvis, and also draws that portion of the vagina to which the cervix is attached with it, but notwithstanding this upward dragging of the vagina, the lower portion of the vaginal canal has so augmented its proportions that it often protrudes between the lips of the vulva during the last period of gestation. The normal relation of the vagina to the neighboring organs is more or less disturbed, that is, its attachment to the bladder and rectum is stretched and loosened, so that under the most favorable circumstances the mucous membrane of the lower portion of the vagina falls out of the vulva or prolapses, of course in the majority of cases only in such a degree that it neither inconveniences nor is it noticeable by the pregnant woman.

Immediately after confinement, in a healthy state of affairs, nature should rectify these abnormal proportions, that were only designed by her to serve a temporary purpose, namely, to accommodate the child and provide for its safe passage into the world. Medical writers have invented a special term to designate this process of regeneration, namely, involution. This means to infold or grow less so as to assume the former natural proportions of organs. Unfortunately, nature is often contravened in her wholesome regenerative purpose, by adventitious circumstances that completely frustrate her intentions, and the reparative process being thus balked, the organs and tissues remain in their abnormal proportions, which constitutes now a disease, and this uncompleted effort to repair is termed subinvolution.

It takes at least from six weeks to three months after delivery for the reparative process or involution of the organs and tissues to be completed. And women cannot exercise too much care after confinement to avoid any possible check to the regenerative process. If the involution has been arrested, the vagina retains its large, flabby proportions, so that its relaxed walls naturally protrude or prolapse, and that entails all the other consequences.

Intra-abdominal pressure should be explained in connection with this subject, for it constantly encourages prolapsus of the organs under consideration. By that is meant the pressure which the contents of the abdominal cavity exert on its walls, and this is greatest at its most dependent part, which is the pelvic floor. This pressure is continuous on the organs of the pelvic floor while the woman is standing, and greatest at the point of least resistance, which is the relaxed and enlarged vagina, so that it bulges out at the vaginal orifice. When the patient resumes a recumbent position, this point is greatly relieved from pressure, and the vagina may regain its normal relations, but whenever the woman is in the upright position, the intra-abdominal pressure will again force the weakened pelvic floor and vaginal walls downwards. After a time the prolapse no longer subsides after the pressure is reduced, for the tissues have lost their recuperative power, and the prolapse becomes permanent. When the intra-abdominal pressure is supplemented by the action of the diaphragm and the contraction of the abdominal muscles, as occurs in a long paroxysm of coughing, repeated vomiting, and inordinate and prolonged bearing down at stool, a prolapse may take place quite suddenly, precisely as in a rupture or hernia, and for these reasons some authorities (Drs. Hart and Barbour, of Edinburgh) have described prolapsus of the womb as a sacro-pubic hernia.

A permanent distension of the bladder or an accumulation of feces in the rectum facilitates the development of a prolapse of the vagina, because the former pushes the anterior wall of the vagina downwards, while the latter depresses the vaginal wall.

A large or subinvoluted uterus is by some considered as a fruitful cause of prolapse; this Professor Schroeder denies, and I am convinced from experience that he is right. A uterus that is simply enlarged is not inclined to prolapse, because the enlarged pregnant uterus never prolapses if the pelvic floor is in a normal condition. But a chronic endometritis or uterine catarrh may in time involve the vagina in a vaginal catarrh and this may induce a prolapse. A chronic vaginal catarrh or leucorrhoea can so relax the vaginal walls that its lower folds protrude from the vaginal orifice.

Women who are beyond the change of life and in whom the lost elasticity of the tissues and a general absorption of fatty and connective tissue has destroyed the natural support which retains the vaginal walls, may be annoyed with partial prolapses of the vagina.

The most aggravated types of prolapses are found among the working classes, who cannot avail themselves of the comforts and hygiene of the lying-in chamber that are so essential for a complete and permanent recovery.

Elongation or hypertrophy of the cervix of the uterus is the third variety of prolapses that Professor Schroeder includes in the group. This form is consequent upon a falling or prolapse of the vagina, and it occurs in the following manner. The body of the uterus being retained by its natural supports or by adhesion of a former inflammatory process in the pelvic cavity, remains stationary where it naturally belongs, while the upper end of the vaginal canal being attached to and surrounding the cervix or neck of the womb, gradually draws or stretches the cervix out, so that it grows one or two inches longer than it is natural for it to be. The cervix of the womb projects under these circumstances down into the vagina, and in some cases it may be seen between the lips of the vulva. This condition is mistaken for falling of the womb, when in reality it is a falling of the vagina with an incidental lengthening of the cervix of the womb. To recognize and make these distinctions is of the greatest practical importance, for thus alone can the measures adopted for the relief of these distressing complaints be successful.

The symptoms of prolapsus grow principally out of the changed relations of the uterus to the surrounding organs and tissues. The mechanical interference and pressure of the womb on neighboring parts, and the changes that are induced in the organ itself by the altered circulation in its tissues, cause the inflammatory enlargement or hypertrophy that is characteristic of one variety of the affection.

In some persons the development of the disease is so gradual that it has progressed for years without any serious inconvenience and the symptoms that did exist were generally attributed to other causes. In the course of time there is such a combination of morbid processes, like painful menstruation, inflammatory enlargement of the womb and erosions of the cervix with profuse leucorrhoea, as to render the parts painful and sensitive to pressure and friction. These symptoms excite in the end suspicion, so that the sufferer may seek advice that will reveal to her the real condition of her case.

Other signs of these affections are a dragging down or a feeling as though a weight pulled the pelvic organs downwards; there is also traction on the bladder, making this viscus exceedingly irritable, so that there is a frequent desire to micturate; the rectum suffers also from similar traction. There is another sign that is very often present, and particularly in the early stages, and this is a feeling as if the vagina was open; this is due to the relaxation of the vaginal walls. Walking for any distance becomes burdensome and causes great fatigue; pain in the back and loins is hardly ever absent. There is an inability to lift weights, because the pelvic floor cannot endure the extra strain that is superimposed on the intra-abdominal pressure; ascending or descending stairs aggravates the symptoms much more than walking on the level floor.

TREATMENT.

This must be directed to the accomplishment of two ends, without which no relief, much less a cure, is possible, and these are, first, to return the displaced organ to its normal position, and, secondly, to retain it there. The course first indicated is, as a rule, not difficult to follow out; in fact, if the patient is placed in a favorable position, the uterus replaces itself through the natural forces of traction and gravitation, unless it has become so enlarged that it is a physical impossibility.

The “knee-chest” or “knee-elbow posture” is the term that has been given to this position, and it is assumed in the following manner.

The woman gets down on her knees, the thighs being kept in an upright or vertical line; the object of this is to keep the pelvis as high as possible, while the chest is bent or inclined forwards until the head rests on the floor; the shoulders must be as low to the floor as it is possible for the patient to endure.

This position at once reduces the intra-abdominal pressure on the pelvic floor to the least degree, and besides this, the abdominal viscera gravitating towards the diaphragm, the prolapsed uterus and surrounding tissues are drawn upwards and forwards with it. If the prolapse was complete or nearly so, so that the organ almost protruded through the vulva, then the patient should retain this posture for ten or fifteen minutes before an attempt is made to replace the organ; for the intense congestion should be first allowed to subside.

No sudden or violent force should be employed, but a gentle, steady pressure. In cases where the organ has simply descended into the vagina, the knee-chest posture alone will replace the uterus. Those displacements that are due to a chronic catarrh of the vagina are particularly suitable for home treatment, because the patient can surely cure her vaginal catarrh, and combining with this the knee-chest posture, which should be practiced night and morning, for at least ten minutes, and until the catarrhal inflammation has entirely subsided, she has at her command the most useful and beneficial resource to accomplish a cure.

If the reader will refer to page 179 and note carefully what was said in this connection, she will learn that the phrase falling of the womb is sometimes nothing more or less than a relaxation of the vaginal walls that is due to a chronic catarrh of the vagina. It is quite natural that it should be so, for if the structures that make up the pelvic floor lose their tonicity and strength, the womb must naturally descend. If we now succeed in temporarily replacing the organ by assuming the knee-chest position, and in the meantime cure the catarrh and inflammation the patient must get well. The reader is again referred to the chapter on vaginal catarrh.

The fatigue or lassitude which makes every physical effort of some patients a great hardship, can be greatly relieved, if not cured, by this formula.

NO. X.

Directions: A tablespoonful three times a day, between meals.

When the prolapse is due to some of the structural defects that were enumerated in the causation of displacements, and that were traced to the accidents of childbirth, then no permanent relief can be hoped for, until these defects are remedied.

Pessaries or rings that are introduced into the vagina for the purpose of stretching or spreading out the relaxed folds of the vagina, that they cannot prolapse or fall down, and thus indirectly support the uterus, were suggested by the ancient fathers of medicine. In view of the fact that they were wholly ignorant of the causes that were responsible for prolapses, the remedy was quite practical and ingenious, but to-day, when we are acquainted with the causes that operate in bringing the prolapse about, they are, to my mind, a very unsatisfactory makeshift, and afford only a temporary amelioration.

A woman who is compelled to wear a ring or pessary is certainly not well, and if she has any hard work to do or must be on her feet a great deal, the pessary will sooner or later so irritate the vagina that it must be removed. Besides this, I always contended that, in the long run, this extra strain on the vaginal walls would only relax them more, and, instead of ever being able to dispense with the use of a pessary, she must increase the size after a while.

There are a great many devices in the form of pessaries; some of them are absurdly ridiculous, and more in the nature of instruments of torture than of remedial expedients. Since I learned to know better, I no longer recommend them, and those who desire a radical cure for a prolapse of any kind, will surely be disappointed if they pin their faith to them.

I am convinced that they are a great source of evil, and a sure index of ignorance on the part of those who habitually recommend them. The German school of gynecologists have of late years greatly perfected the plastic operations of the vagina, in fact, it is almost a sub-specialty in itself, to which they have given the term prolapse operations. A specialist, who is competent in the details of these prolapse operations, can hold out the very best possible chance for a radical and permanent cure, and while the operation requires a certain degree of skill and special training, which should be obtained by practicing these operations on the cadaver, in order to save time, and not bungle the operation on the living subject, as too often, unfortunately, happens. In skillful hands, the operation is entirely without danger, and under proper antiseptic precautions, the results are very satisfactory.

The question is simply this: If the knee-chest treatment, and the remedies that have been suggested, do not give permanent relief, then there must be some such defect in the pelvic floor as I have heretofore described.

If the vagina is too wide, it should and can be narrowed to its normal dimensions, by removing the excessive tissue; if the vagina is torn into the perineum, this too must be united. Should the cervix of the uterus be abnormally elongated, so that it makes it physically impossible to return it to its natural position, it should be shortened or amputated, and if all these three complications coexist, then an operation combining and remedying all these defects, should be performed at one sitting. This method alone will restore the patient to health and usefulness.