Displacements And Their Correction
( Originally Published 1918 )
BECAUSE of the elasticity of the supporting structures, the female pelvic organs are quite mobile, and therefore very subject to displacement. This is true not only of the uterus, but of the ovaries as well, and very often there is an accompanying displacement of the abdominal viscera also. A very large percentage of the cases examined in gynecological clinics show some degree of uterine malposition.
The uterus may be displaced forward or backward, upward or downward, or to either side, but only two of these are of any great consequence, viz. backward displacement, or retroversion and downward displacement, or prolapsus. You probably know of retroversion as "tipping of the womb," and of prolapsus as "falling of the womb."
The normal position of the uterus varies ac-cording to the center of gravity of the body, and the physiological state of the neighboring organs. While lying on the back the tendency is for the fundus or upper part of the uterus to fall back-ward towards the sacrum ; if you are lying face downward, it tends to fall forwards; if on either side, towards the side upon which you are lying; in the standing position it sinks slightly in the pelvis. It also has an upward movement. The full bladder raises the body of the uterus and tends to throw it backward, while the alternate filling and emptying of the rectum also produces some change in position. It may be said, however, that the general position of the uterus is with its fundus tipped forward and the cervix directed backward, the cervical canal being at right angles to the long axis of the vagina.
Although the uterus may ,be abnormally anteverted, this is of no very great importance unless it is flexed, or bent on itself, at the same time, thus causing menstrual disturbances. Lateral displacements are of no consequence.
CAUSES OF UTERINE DISPLACEMENT.—Acquired malpositions of the uterus of whatever character are all practically due to the same causes. Tell me that you have "falling' of the womb" and I can describe your general condition of health quite accurately, and also your habits of living. You have been since girlhood disinclined to activity, and as a consequence your muscles are weak and flabby, especially those of your abdomen, which may be in a stretched and sagging condition. You have also been a fairly heavy eater and suffer from constipation. You are either very lean, or inclined to be very stout. To keep your figure "trim" you wear corsets which you put on while standing up, thus forcing the abdominal contents downwards.
Among other causes are heavy lifting, active exercise, such as jumping, dancing, and running when in an untrained condition (these are beneficial when the woman is in condition for such exercise) ; relaxation of the pelvic floor following lacerations in childbirth; habitual constipation, or constant distension of the bladder; the presence of pelvic or abdominal tumors.
One potent cause is getting up too soon after childbirth. At this time the uterus is heavy and its supports stretched and relaxed, and if the woman gets on her feet and does too much moving about before complete involution, or return of the uterus to normal, has taken place, a retrodisplacement, or prolapsus, may subsequently occur. Although some consider it a sign of superior strength and vitality that savage women, and certain women of the laboring class, go about their work immediately after giving birth to a child, in reality this must sometimes be considered their misfortune, as it is well known that displacements of the uterus are very common among these women, many of whom are chronically overworked and have a very poor posture in any case.
Symptoms of Retroversion.—A certain degree of displacement is possible without symptoms, but when there is a decided retroversion the patient may suffer considerably.
You may have been feeling in the best of health, but now you notice that you are not as vigorous as formerly. You tire easily—in fact feel tired all the time. Your sleep and rest do not refresh you. There is a dragging feeling in the pelvic region and at times an intense pain, or an ache, in the sacral region. Your menses are unduly protracted and you have pain at this time. You are constipated and have frequent urination. If there is pregnancy, a miscarriage may follow.
Symptoms of Prolapsus.— Prolapse, or "falling of the womb," may be a slight or pronounced descent into the vagina, or the entire uterus may even appear outside of the vulva, carrying the vaginal walls down with it. In other cases it is simply an elongation of the cervix. Prolapsus is practically a more advanced stage of retroversion. The uterus sinks gradually into the vagina until the cervix appears at the orifice. If the tissues here are relaxed, the entire uterus is soon outside the vagina. Up to this time you will suffer greatly from the continual dragging sensation incident to the stretching of the ligaments. This discomfort ceases when full descent has occurred, and the only distress is the sense of a foreign body between the thighs. The vaginal wall covering the uterus gradually becomes dry and hardened, resembling skin, or it may become eroded and ulcerated.
Treatment of Uterine Displacements. — If there are no symptoms and the condition is discovered in examination, you should not worry about it, as no treatment is necessary, unless you are married and you think the displacement is preventing you from becoming pregnant. If you have decided symptoms, however, and the trouble is undermining your health, it must be at-tended to before a more advanced stage is reached.
In many cases the uterus must be put back into position by manual means. This, however, is not of much use unless it can be kept there. For this purpose the vagina is sometimes packed with gauze or pledgets of cotton, but these must be removed in twenty-four hours and are there-fore not very effective. The pessary is often used and this is more practical, and is useful temporarily when the woman is obliged to be on her feet continually, and some relief is necessary. The pessary is often the cause of inflammation and leucorrhea, and ulceration may occur from pressure. Therefore it should not be worn continually, and other treatment should be undertaken with the idea of discarding the pessary as soon as possible. Frequent douches are necessary during the time the pessary is used, and these, too, are objectionable. The pessary, therefore, should only be used when absolutely necessary
Before any permanent cure can be expected the tone of the entire muscular system must be improved. Some system of exercise which uses every muscle should be adopted. The effect of exercises is not alone on the voluntary muscles ; the involuntary muscles and the ligaments also are nourished and toned up by the increased circulation. We know of various cases where nothing of a local nature was done, and with general exercise alone the condition was corrected. Of course if the uterus is bound down by adhesions, it can not be restored to position until these are broken up or stretched by manual means.
In some cases, and especially if there is complete prolapse, the services of a physician are necessary in replacing the uterus. However, there are certain positions which may be assumed by the patient herself that will cause the uterus to return to its proper place. For instance the knee-chest position may be taken. Kneel down on the bed, or other comfortable soft surface. With head forward and chin on chest bend far forward until the chest and abdomen bear heavily on the legs. It will readily be seen that in this position the tendency is for the uterus to fall for-ward to its normal position. You should take this position several times daily for from five to ten minutes at a time. While in this position place the fingers of both hands on the "small of the back," and then attempt to harden or flex these muscles. You may secure a result not unlike the sensation of "straining at stool," which will indicate that the exercise is taken correctly. Repeat until the muscles tire.
The knee-chest position is hard for some women to assume and for such the slanting table is useful. This is a table one end of which is at least a foot lower than the other. A carpenter will make it for you, or any one in the home who is handy with tools can easily do it. Or you can elevate one end of a couch for the purpose. The ironing board, or any other board two feet wide and five or six feet long, may be used, by placing one end on a chair or the window sill. The patient lies on this, either on the back, or face down, with the head at the lower end. For retroversion face down. You may lie quiet on this table for ten minutes to an hour at a time, several times daily, or certain exercises may also be taken on it. For instance the legs may be raised alternately upward. The body may be raised by straightening the arms, and then lowered. The legs may be alternately moved outward. After a time exercises may be taken while lying on either side and also upon the back, such as moving, the legs to the side and up-ward, alternately and together. All of these exercises will develop the muscles of the abdominal and pelvic region, which is very important.
Another very valuable exercise is to contract the muscles of the anus and the constrictor muscles of the urinal canal—in plainer terms the muscles that are used in urinating and in defecating. Make it a point to contract these muscles a number of times while on the slanting table. They can also be exercised advantageously while lying in bed.
After taking the exercises it is well to lie quiet, face downward, for a few minutes before getting off the table. This is the most important part of the whole treatment, and we know of many cases which have been benefitted. Sleeping chest downward is also of value.
The use of the cold sitz bath will tend to bring the blood to the pelvic region and thus tone up the muscles and ligaments. This should be taken daily, for from one to four minutes, according to the temperature of the water, being discontinued of course, during the menses. If there is inflammation use the hot sitz.
In case of complete prolapse, or "falling," after replacement of the uterus, the woman should go to bed for several days, remaining most of the time in the prone position. Large pledgets of cotton attached to a string may be introduced into the vagina to prevent the uterus from descending again. These must be changed daily. If the woman is not obliged to work, or be on her feet for a considerable part of her time, we would advise the avoidance of pessaries, or supports of any kind, the exercises mentioned being relied upon for the relief of the trouble. If one continues in bed for any length of time, it is especially important to take the reclining exercises mentioned, including all possible leg movements for strengthening the abdominal region.