PART II.
ANATOMY AND PHYSIOLOGY OF THE FEMALE ORGANS AND FŒTAL DEVELOPMENT.
CHAPTER I.
OF THE PELVIS.
The formative organs of generation are situated within a large cavity, called the cavity of the pelvis, the walls of which are composed of bones and soft parts. This basin (in Latin, pelvis) is an irregular, long cavity, situated at the base of the spinal column, and above the inferior extremities. In the adult the bony pelvis may be divided into four parts or bones, viz: the os sacrum, two ossa innominata, and the os coccygis, but in early life they are more minutely divisible.
THE SACRUM.
The sacrum (Fig. 1) terminates the vertebral column, and is perhaps the most important bone in the pelvis, obstetrically considered, as it enters largely into the various deformities of the pelvis. In the adult it is of a triangular shape, the base of the triangle being above and inclining forwards, the apex below and somewhat backwards; its length is from four to four and a half inches; its breadth about four inches, and the greatest thickness, two and a half inches. The internal surface is concave to the amount of half an inch, crossed by four transverse lines, marking the former division by cartilage; here are four pair of holes, through which pass numerous nervous filaments, which afterwards form part of the great sciatic nerve.
| Fig. 1– | A | represents the internal or anterior surface of the sacrum. |
| B B | represents the articular processes. | |
| C C | represents the anterior sacral foramen. | |
| D | represents the articulating surface. |
It is placed at the posterior part of the pelvis, where it appears like a wedge forced in between the ossa innominata, immediately below the vertebral column and directly above the coccyx.
THE OSSA INNOMINATA.
The os innominata (nameless bone, Fig. 2) is of a very irregular figure, and the pair occupy the lateral and anterior parts of the pelvis. The external or femoral surface is turned backwards and downwards, as well as outward; at its superior part, inferiorly it looks downwards. Towards the front, the external face presents the cotyloid cavity, or the acetabulum; a little more in advance and below is the subpubic or obturator foramen, which is nearly closed by the obturator ligament.
Fig. 2. Right os innominatum, external surface.
Fig. 2—Represents the external surface of the right os innominatum. A. The external iliac fossa; B, crest of the ilium; C, anterior superior spine of the ilium; D, anterior inferior spine of the ilium; E, horizontal branch of the pubis; F, posterior superior spine of the ilium; G, posterior inferior spine of the ilium; H, acetabulum; I, ischium; K, obturator foramen. At birth the haunch bone, or os innominata, is composed of three bones connected by cartilage. Fig. 3.
The superior portion of the bone is characterized on its abdominal or internal face by a large excavation called the internal iliac fossa (Fig. 4.) This portion is terminated below by a large rounded and concave line. The inferior (lower) portion presents behind a nearly triangular plane surface; near the middle of this is the obturator foramen, and in front is the internal face of the os pubis.
Fig. 3. Left os innominatum, external surface, etc.
Fig. 3—Left os innominatum, partly ossified. The haunch bone as it exists in the child. A, pubis; B, ilium; C, ischium.
Fig. 4. Right os innominatum, internal surface.
Fig. 4—Right os innominatum, internal surface. A, internal iliac fossa; B, anterior superior spinous process of the ilium; C, crest of the ilium; D, posterior superior spinous process of the ilium; E, posterior inferior spinous process of the ilium; F, articular surface; G, spine of the ischium; H, tuberosity of the ischium; I, obturator foramen; K, ischia pubic ramus; L, crest of the pubis; M, the pectineal eminence.
THE OS COCCYGIS.
Fig. 5.
The os coccygis.
The OS COCCYGIS (Fig. 5) is three or four little bones united together on the median line of the body, and attached to the os sacrum. Each little bone is tipped with cartilage, and they are so united as to be movable. The entire bones form a pyramid, the apex of which is below. The internal surface is smooth, like that of the sacrum, terminating the plane of the sacrum and bounding it anteriorly.
Fig. 6. Vertical section of the pelvis.
Fig. 6—Inlet, outlet, and axis of the pelvis. a, b, plan of inlet—superior strait; c, d, plan of outlet, or inferior strait; e, f, axis of cavity; g, the coccyx extended as it is in labor.
Of the JOINTS OF THE PELVIS it is only necessary here to say that there is no motion in them to facilitate labor, except that the sacro-coccygeal joint is of the kind called ginglymoid, admitting of extensive motion, especially backward, so as to permit the enlargement of the lower outlet an inch or more. (Fig. 6.)
OF THE PELVIS IN GENERAL.
We will now consider the pelvis collectively or as a whole; its relation to the rest of the body; its magnitude, axis, etc. It is connected with the trunk by the articulation of the sacrum with the last lumber vertebra, effected in the same manner as the junction of the vertebra with each other; with the lower extremities it is connected by means of the hip joints. When the pelvis is in situ, the brim is neither horizontal nor perpendicular. It represents a cone, slightly flattened from before backwards, the base of which being above, while the apex is directed downwards.
When the body is erect the upper part of the sacrum and the acetabula are nearly on the same descending line, the point of the os coccygis being a little above the arch of the pubis, and the sacro-vertebral angle three inches and nine lines higher than the pubis. Were it not for the obliquity owing to the upright position of the human female, the womb would gravitate low in the pelvis, and produce most injurious pressure on the contained viscera. The lower or true pelvis is the part involved in parturition, and its size and shape demands our attention.
THE BRIM OF THE PELVIS.
This is defined by the LINEO ILIO PECTINEA, which marks the boundary of the true and false pelvis, and this superior strait is the entrance of the lesser pelvis. Its form has been variously described as being oval, heart-shaped, and triangular. If we call it “triangular with angles rounded off,” the base of the triangle is behind and the apex in front. It would be nearly oval were not the oval form broken by the promontory of the sacrum. This brim is the first solid resistance the head of the fœtus meets in its descent through the pelvis.
DIAMETER OF THE PELVIS.
Different estimates are made by different anatomists of the measurements of the brim of the pelvis. The following is nearly the correct size of the ordinary female pelvis:
Fig. 7. The bony pelvis.
Fig. 7—The pelvis seen from above. a a, The antero-posterior or sacro-pubic diameter; b b, the transverse diameter; c c, the two oblique diameters.
The circumference varies from thirteen to fifteen inches; the antero-posterior diameter, i. e., from the prominence of the sacrum to the upper edge of the symphasis pubis, (Fig. 6), is about four and a quarter inches; the transverse across the widest part of the brim, at right angles to the antero-posterior, is five and a quarter inches, and the oblique from the sacro-iliac synchondrosis of one side to the opposite of the brim, just above the acetabulum, is five inches. (Fig. 7).
The cavity of the pelvis, of which the fixed boundaries are the sacrum and the pubis, is of unequal depth. The height in front is one and a half inches; upon the sides, three and three-quarter inches, and it is four and a quarter inches if a straight line be drawn from the sacro-vertebral angle to the point of the coccyx, five and a quarter inches following the curve of the sacrum, and six inches if the coccyx be extended. (Fig. 6).
The antero-posterior diameter of the outlet from the arch of the pubis to the point of the coccyx is usually four and a quarter inches, but may increase to five inches during labor by the retrocession of the coccyx (Fig. 8); the transverse from one tuber ischii to another is four and a quarter inches, and the oblique about four and three-quarter inches.
Fig. 8—Position of the pelvis and the axis at the termination of labor.
Fig. 8—a b, Total axis of the excavation; c, the axis of the superior strait; d e, perineum as distended at the moment of the passage of the head.
It is important to notice that the diameters are entirely changed between the rim and the outlet, and that the change is effected gradually. The axes of the inlet and outlet form an obtuse angle with each other (this is illustrated in Figs. 6 and 8.) The three diameters taken at the center of the pelvis are very nearly equal—about four and three-quarter inches.
DIFFERENCES OF THE PELVES.
There is considerable difference between the male and female pelvis, in shape and size. The pelvis in the male is smaller but deeper; the bones are thicker and the brim is more circular, the depth of the symphasis pubis is greater, the sacrum is more perpendicular, the arch of the pubis is narrower, the tuber ischii are nearer each other, and the coccyx less movable. In the female the iliac fossæ are larger, the interval separating the angle of the pubis from the acetabulum is greater, causing the prominence of the hips and wider separation of the thighs, the superior straight is larger and more elliptical, the curve of the sacrum deeper and more regular, the tuberosities of the ischii are further apart, and the arch of the pubis broader. From the greater width of the female pelvis, and from the upper end of the thigh bones being farther apart than in the male, the thigh bones approach each other in their descent, giving a peculiarity to the movements of the female in walking.
The soft parts lining the pelvis and covering it externally modify the diameters of the pelvis, but the effect of these additions in diminishing the internal diameter is not very great. The diameter of the cavity is lessened thereby from one-fourth to one-half an inch.
USES OF THE PELVIS.
One function of the pelvis is to inclose and protect the bladder, rectum and seminal vesicles of the male, the uterus, Fallopian tubes and ovaries, as well as the bladder and rectum in the female. During labor it affords a passage for the child.
TERMINAL OUTLET OF THE PELVIC CANAL.
This is not at the coccyx, but rather at the anterior commissure of the perineum. This is so greatly distended at the last moment of labor as to much prolong the posterior wall of the pelvic excavation and the canal to be traversed by the fœtus. (Fig. 8).
Fig. 9—Section of sacrum and pubis.
Measuring superior strait.
Fig. 10.
Measuring inferior strait.
CHAPTER II.
PARTS CONTAINED IN THE PELVIS.
The internal organs of generation are the vagina and uterus with its appendages; but I will first describe the urethra and the perineum.
The URETHRA is a membranous dilatable canal about an inch and a half in length, and directed obliquely from before backwards, and from below upwards, running under and behind the symphasis pubis, from which it is separated by loose celular tissue. Its inferior portion is intimately united to the vaginal walls. Its meatus, the outlet for the urine, is situated about an inch from the clitoris, and immediately above the prominent enlargement of the anterior part of the vagina.
Internally the urethra opens into the bladder. Its direction is subject to variation during pregnancy, the bladder being carried upwards with the uterus, the urethra curves under the pubic arch, and then ascends perpendicularly. The same change occurs when the uterus is enlarged from other causes. In prolapse of the pelvic viscera the course is reversed.
The PERINEUM is the portion between the rectum and the vagina.
THE UTERUS.
The uterus is the organ provided for the reception, growth, and ultimately for the expulsion of the fœtus. In the virgin normal state it is pear-shaped, flattened from before backwards; is situated in the cavity of the pelvis, between the bladder and the rectum, and projects into the upper end of the vagina below. Its upper end or base is directed upwards and forwards, so that its axis corresponds very nearly with that of the superior strait, and forms an angle with the vagina.
The uterus measures about three inches in length, at its upper part two in breadth, an inch in thickness, and it weighs from one ounce to an ounce and a half. The fundus is the upper broad extremity of the organ; it is convex, covered by peritoneum, and placed in a line below the level of the brim of the pelvis. The body gradually narrows from the fundus to the neck. Its anterior surface is flattened, covered by peritoneum in the upper three-fourths of its extent, and separated from the bladder by some convolutions of the small intestines; the lower fourth is connected with the bladder. Its posterior surface is convex, covered by peritoneum throughout, and separated from the rectum by some convolutions of the intestines. The lateral margins are concave, and give attachment to the Fallopian tubes above or superiorly, and the round ligaments below; and behind these, and also below the ligament of the ovary. The cervix is the lower and constricted portion of the uterus; around its circumference is attached the upper end of the vagina, and this extends upwards a greater distance behind than in front. At the vaginal extremity of the uterus is a transverse aperture, the OS UTERI, bounded by two lips, an anterior one which is thick, and a posterior one, narrow and long. The os uteri, or os tincæ, is generally about the size of a small goose-quill. The canal of the cervix is from half to three-quarters of an inch long; leading from the os uteri it first widens and then contracts again where it enters the body of the uterus. The surface of the canal exhibits a variable number of follicles or vesicles called the glandula nabothi, which secrete a thick mucus; this blocks the canal after impregnation. The cavity of the body and neck has a longitudinal extent of about two and a half inches; in virgins it is much less. (Fig. 12).
Fig. 11 Uterus, bladder, etc., showing relative position.
Fig. 11—Section of pelvis. a, section of pubis; b, bladder distended; c, the uterus in normal position; e, sacrum; f, urethra; g, vagina; h, hymen; i, the os uteri; j, meatus of urethra; k, vagina.
STRUCTURE OF THE UTERUS.
The proper tissue of the womb is composed of fibres, and is proved to be muscular. In the unimpregnated state it is dense, firm, and of a grayish color. The neck appears less firm than the body.
The internal or mucous membrane is thin, smooth, and closely adherent to the subjacent tissue. It is a quarter of an inch thick at the middle of the body of the uterus; in the neck it does not exceed one-twenty-fourth part of an inch in thickness. It is continuous through the fimbriated extremity of the Fallopian tubes with the peritoneum, and through the os uteri with the mucous membrane of the vagina.
THE FALLOPIAN TUBES.
The uterine or Fallopian tubes are two canals, about four inches long, placed in the superior border of the broad ligaments of the uterus. They extend for about three inches and a half, when they expand and terminate with a fringed process called the fimbria, which is applied to the ovary after impregnation. The Fallopian tubes serve the double purpose of a canal for transmitting the fecundating principle of the male and for carrying the germ furnished by the female to the uterus—in fact they are excretory ducts of the ovary.
Injections into the uterus may pass into the peritoneal cavity, through the Fallopian tubes, and cause peritonitis.
At each menstrual period an ovula passes along with the serum current in the Fallopian tubes to the uterus.
THE OVARIES.
The ovaries in the female are said to be the analogues of the testicles in the male; they both secrete a fluid that is essential to impregnation. They are situated on either side of the uterus, and are attached to either side of it by the posterior duplicature of the broad ligament called the ligament of the ovary. (Fig. 12).
They are oval flattened bodies about an inch and a half long, three-quarters of an inch wide at their greatest breadth, and a quarter of a inch thick. They are situated on the sides of the uterus in that portion of the broad ligament called the posterior wing, just behind the Fallopian tubes. The ovary consists of a peculiar structure enclosed by two envelopes, one of which is serous and the other fibrous. Within the fibrous coat is a special tissue called the stroma; imbedded in this are numerous small round transparent vesicles in various stages of development, varying in size from that of a millet seed to that of a hemp seed. They are the ovisacs, containing the ova, and are called the Graafian vesicles. These have thin transparent walls and contain a clear fluid, and within that the ovula. Fifteen or twenty may readily be distinguished in the adult female without the aid of magnifying glasses.
THE VAGINA.
The vagina is a membranous canal, extending from the vulva to the uterus obliquely through the pelvic cavity, between the bladder and rectum, having about the same direction as the axis of the pelvis. It is described as being five or six inches in length and about two inches in diameter, but it would be more correct to say that it is capable of being distended to these or greater dimensions, for in its common state the os uteri is seldom found to be more than three inches from the external orifice, and the vagina is contracted as well as shortened. In great part the walls of the vagina are composed of spongy erectile tissue, and their vascularity is a cause of considerable hemorrhage consequent on their rupture. Three layers combine to form the walls; one external or cellulo-fibrous, a middle or muscular one, and the internal or mucous one. The latter is of a pale red hue, which becomes violet during menstruation and especially during pregnancy. The mucous coat is disposed in the form of rugæ or folds anteriorly and posteriorly, which are better developed in young virgins and aged females; during advanced pregnancy, and for a short time after delivery, they are entirely effaced.
Fig. 12—Section of the Uterus, &c.
Fig. 12—Uterus, ovaries and Fallopian tubes. Section of the uterus, etc. a, Fundus of the uterus; b, cavity of the womb; c, cavity of the neck of the uterus; d, d, the cavity of the Fallopian tubes; e, fimbriated extremity; f, f, the ovaries; g, the vagina; h, h, the round ligaments; i, i, the ligaments of the ovaries.
The upper part of the vagina is connected to the circumference of the os uteri but not in a straight line, for the former stretches beyond the latter, and being joined to the cervix, its mucous membrane is reflected over the os uteri, which by this mode of union is suspended with protuberant lips in the vagina, and permitted to change its position in various ways and directions.
THE EXTERNAL ORGANS.
The situation of the external organs of generation are indicated in the accompanying diagram (Fig. 11.) It is not deemed necessary here to describe these, but in regard to the hymen (the membrane that in infancy nearly closes the orifice of the vagina), we may remark that it is not a perfect test of virginity. There are, however, examples recorded in works on midwifery where a slight surgical operation was necessary after marriage, because this membrane was uncommonly strong.
CHAPTER III.
PHYSIOLOGY OF THE UTERUS AND OVARIES.
Menstruation is a periodical flow of blood having its source in the walls of the uterus. But menstruation is excited by and dependent upon ovulation, and the effective cooperation of both the uterus and ovaries is necessary to both menstruation and conception. We shall consider these functions separately.
MENSTRUATION.
In healthy women at the period of puberty, a certain amount of sanguineous fluid is secreted by the lining membrane of the uterus, and is excreted through the vagina every month; this is termed the catamenia, or menses, and the function itself menstruation. A female in whom the discharge recurs at the usual periods, in the usual quantity, and of the usual quality, is said to be regular, The occurrence of menstruation defines the period of puberty at which a girl becomes a woman capable of conception, and its cessation terminates the prolific period of female life.
Dr. Robinson, of Manchester, England, in a paper on the natural history of menstruation, has stated the age at which it occurred in 450 cases.
According to his table, 10 menstruated for the first time at 11 years of age, 19 at 12, 53 at 13, 85 at 14, 97 at 15, 76 at 16, 57 at 17, 26 at 18, 23 at 19, and 4 at 20.
The time at which the first menstruation occurs varies exceedingly from the influence of climate, habits of life and constitution. There have been occasional instances of very precocious menstruation, in which the first appearance of the discharge was attended with all the attributes of puberty. I myself knew one case where a girl of nine years, not only menstruated, but presented the external signs of puberty, such as prominent breasts, wide pelvis, rounded contour of body, &c.
The first appearance of the menses very rarely occurs without being preceded by premonitory symptoms. There is usually a degree of languor and lassitude, fatigue after exertion, inequality of spirits, dark shade under the eyes, headache, sometimes pain in the thyroid gland, pain in the back, a sensation of tension and swelling in the lower part of the abdomen, and occasionally considerably fever. Not unfrequently strange nervous disturbances occur; but all of these symptoms may pass off, the first and second time, without the appearance of the menses, or with a white discharge only. Usually the phenomena may last from one to eight days, then there is an abundant flow of mucus, which after one or two days is mixed with blood, and soon gives place to almost pure blood. When this discharge takes place most of the unpleasant symptoms disappear, and the female only complains of weakness and is somewhat pale. The hemorrhage continues for several days, then the amount of blood mingled with the vaginal mucosities diminishes, soon there is mucus alone, then the discharge ceases.
I should remark now that the propriety of applying the terms, blood or hemorrhage, to the menstrual secretion is properly questioned.
Sometimes the first menstruation takes place without being preceded by any discomfort, but pretty generally there is a change in the girl at the time, both in her body and mind, a change that fits her for the important duties that devolve upon her.
Most young girls have a return of the discharge after a month, the menses afterwards recurring regularly; some do not become regular until after several months. Sometimes the function is imperfectly performed; such cases are accompanied with considerable distress.
In some young girls the precursory symptoms of the first appearance of the menses may not be followed by a flow of blood, and there is an apparent effort of nature recurring monthly for several months before the courses become established.
There are occasional examples of retarded menstruation. I am acquainted with one woman who at the age of twenty-five years has not menstruated. The absence of the menses does not render conception impossible, in every case.
After the menses are established, until the time of their cessation, they generally return every month, unless interrupted by pregnancy or nursing. The average of the catamenial period is about twenty-eight days; in a large number it is thirty days; in some instances they recur every fifteen days.
The duration of the flow varies from one to eight days; three or four days is the most usual duration. The quantity of blood lost is variable; from three to five ounces is said to be the average.
When the ovaries are congenitally absent, or have been removed, or have become disorganized, menstruation is absent, or ceases. The cause of the menses is the successive evolution of the Graafian vesicles; but the regular process may go on in the ovary without the regular sanguineous discharge.
The menses continue in the majority of cases until about the age of 46 years, or perhaps in this country 48 years.
According to Dr. Robertson, of England, the periods at which it closed in 77 individuals was, in 1 at the age of 35 years, 4 at 40, 1 at 42, 1 at 43, 3 at 44, 4 at 45, 3 at 47, 10 at 48, 7 at 49, 26 at 50, 2 at 51, 2 at 52, 2 at 53, 2 at 54, 1 at 57, 2 at 60, and 1 at 70.
The average duration of the menstrual function is about 30 years. The cessation of the ovarian function is generally announced several years in advance by irregularities of the menses. Besides the intermissions and irregularities, there are other symptoms; a general and indefinite feeling of uneasiness, pelvic pains, itching at the genital parts, flashes of heat in the face, alterations of chilliness and perspiration, leucorrhœa, etc. These troubles are usually slight, and disappear promptly. The time of life has been called the CRITICAL PERIOD, because there has been an opinion prevalent that peculiar dangers attend it. However, the mortality is not greater between the ages of 45 and 50 years than at any other period of life. Yet it is true that in some instances diseases that had been latent previously, declare themselves at this period.
THE FUNCTION OF THE OVARIES.
We will now consider the physiological action of the ovaries and its intimate connection with the action of the uterus in menstruation, etc.
Preceding the first menstruation an ovary is considerably enlarged, becomes of a red color, and its vascular apparatus is considerably congested; the Fallopian tube also becomes congested; its fimbriated extremity is of a violet red color, and has a velvety appearance. The Graafian vesicles increase in size; fifteen or twenty of them, more advanced than the others, project from the surface of the ovary; one of these grows so that after a few days it forms a tumor of the size of a cherry; the walls of the vesicle, being distended by an increased secretion of fluid, becomes quite thin, and at last are ruptured. When the thinned walls give way, the ovule is expelled, with a part of the granular contents of the vesicle; these are grasped by the fimbriated extremity of the Fallopian tube which is prepared to receive it and convey it through its canal into the cavity of the uterus.
This evolution of an ovule excites numerous sympathies throughout the organism of the female, and especially the generative organs. The vascular apparatus of the womb becomes developed in an unusual manner; a network of fine blood vessels surround the orifices of the numerous glandular tubes, of which the membrane is almost entirely composed; this gives a violet hue to the internal surface of the womb; the utricular glands increase in size, the muscular structure of the uterus acquires greater extension, becomes redder and more spongy and supple, the volume of the organ is increased, the neck is tumefied and its orifice narrower, the lips of the os tincæ are warmer and their color deeper.
The vascular congestion which the uterus undergoes is accompanied with the exudation of sanguineous fluid, which is at first but a few drops; this communicates to the increased vaginal mucus a reddish hue. After a day or two there is a bloody flow from the vascular network of the mucous membrane. This flow, which constitutes the menses, is diminished after three or four days, and the discharge again contains a large proportion of mucus and serum. It is probable that the rupture of a Graafian vesicle occurs during the last days of the flow, ordinarily, and it is also believed that venereal excitement is capable of exerting so much influence upon it that it may determine the rupture of an enlarged vesicle, which, without sexual intercourse, would have remained whole several days longer.
After the discharge of the ovule consequent on the rupture of the Graafian vesicle, the walls of the vesicle contract on the matter that is effused within it, and form a compact mass, which after a time has an orange yellow color—this is called the corpus luteum.
Ordinarily, in the human female in the normal condition, a new Graafian vesicle increases in size every month, becomes excessively developed, and finally bursts and discharges its ovule, to become, through successive transformations, the corpus luteum. What is called the “monthly sickness,” “monthlies,” “courses,” etc., never occurs without having been preceded and accompanied by the development of a Graafian vesicle.
CHAPTER IV.
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.
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.