Uterine prolapse

“ Fig. 70, A.—Elongation of supra-vaginal cervix (St. Bartholomew’s Hospital Museum) .
Many cases of prolapse would be avoided, even though there might be serious perineal injury, if women remained in bed a sufficient time after delivery. By rising too early prolapse is favored, for a variety of reasons. The uterus is large and heavy; the uterine ligaments are elongated, and the abdominal walls are weak; consequently the retentive power of the abdomen is poor; the vagina is flabby and much larger than normal ”

“ The injured muscles retract, and, being functionally useless, undergo atrophy, and when finally repaired never possess their former strength. Involution in the vagina and the uterus may be arrested, and all the disasters incident to subinvolution may appear. Vaginal and uterine prolapse occur; the natural supports of the 63 vagina and uterus become stretched, and, though afterward the perineum may be restored, yet it may be found impossible to retain the uterus in its proper position. It is always good surgery to repair an injury as soon as possible. ”

“ If the ovary has become adherent in Douglas’s pouch, the condition can be relieved only by operation—celiotomy, and usually oöphorectomy.
A variety of pessaries have been invented for the relief of ovarian prolapse. They are of but little, if any, use. In many cases the pressure of the pessary upon the ovary renders its employment impossible. No pessary will cure a simple prolapse of the ovary. The cases in which the pessary does good are those in which there is a primary uterine displacement. ”

“ A pinkish or red discharge or backache should be taken as warnings against standing or walking or working. The possible consequences of ignoring these warnings and being up and about too soon, may be displacement, even prolapse of the uterus; hemorrhage, from dislodgment of clots in the uterine vessels; metritis or endometritis.
It is not a good plan, as a rule, for the patient to go up and down stairs until the baby is about four weeks old, nor wholly to resume her normal activities within six or eight weeks after delivery. ”

“ The cervix now is seldom amputated except for malignant disease.
Congestion of the uterus consequent upon obstruction in the stretched and displaced veins is often so extreme as to induce a state analogous to erection. Measurements by the probe just before and a few minutes after replacement generally show an appreciable decrease in the length of the uterine canal. If the prolapse has been of the third degree, the difference may amount to one or even two inches. It is important not to confound the enlargement of congestion with increase in the solid constituents of the organ. ”

“ The constrictor is more manageable if held in the hand of the assistant instead of the clamp, since it can be loosened and tightened as required. To prevent prolapse of intestines he sutures the upper end of the abdominal incision before turning out the uterus, tying the sutures before that organ is opened. Extraction of the fœtus by the head is much easier than by the feet. When a long uterine incision is required, it is better to go an inch into the fundus than to extend the wound into the lower segment, which may cause troublesome hæmorrhage. ”

“ The albuminoids of the muscular protoplasm are not so readily converted into fat capable of easy resorption. A comparatively large quantity of decidua vera—even in the absence of portions of the foetal envelopes—is retained within the uterine cavity, and the secretory activity of the endometrium is seriously disturbed. Then, women are less careful after miscarriages than labor at term.
Laceration of the cervix uteri—an accident liable to occur in abortion as well as during confinement at term—if at all extensive, usually interferes with the retrograde metamorphosis of the uterus. ”

“ In dysmenorrhoea the pain is ovarian, more violent, and aggravated with the cessation of the discharge, whilst in abortion it is uterine, more particularly referable to the cervix in the period of dilatation and to the fundus in that of expulsion, and lessens or ceases with the cessation of the discharge. The hemorrhage due to fibroids and polypi may greatly resemble that of abortion, especially if mole formations occur, but the pregnant and aborting uterus is greater in size than the congested menstrual organ. ”

“ Diseases of the uterus itself are not so important etiologically as those of its lining membrane: uterine tumors, unless of enormous size, usually admit of the completion of gestation; flexions and versions rarely interfere with the development of the ovum; a prolapsed uterus may bear the foetus to term unless the adhesions are unyielding and impregnation is impossible, because the uterus as it develops with the growth of the ovum rises beyond the confines of the pelvic cavity, and the displacement is thus remedied. ”

“ After the puerperium the extreme engorgement of the pelvic organs often produces uterine hemorrhage, which should not be confounded with the returning menstruation. Especially after abortion the hemorrhage often persists for a long time unless cured by treatment. Gradual or sudden replacement may occur spontaneously, or the causes may continue active, and even be enforced by cystocele and rectocele. The displacement may also be complicated by disease and displacement of the ovaries. Organic disease of the uterine walls may induce a superadded retroflexion. ”

“ If the cervix, the portion of the uterus most frequently wounded, is found punctured or lacerated, while the ovum is still retained, there is reason for suspicion; if the membranes are torn and extensively detached, while the cervix is but little dilated, such is increased; and it is made almost a certainty, if with the latter condition, nothing remain of the ovum in the uterine cavity but lacerated fragments. Here the abortion would probably not merely have been intentionally induced, but by the direct introduction and agency of instruments. ”

“ Pregnancy seldom happens when the catamenial discharge is attended with great and spasmodic pain, particularly if the discharge is small in amount, and of deteriorated quality. If, under such circumstances, conception does take place, the next periodical flow is very apt to cause the uterus to discharge the germ, thus bringing on an early miscarriage.
The state of weakness and debility of the uterine system occasioned by too frequent sexual intercourse, is a common cause of sterility. Those unfortunate creatures who follow a life of prostitution seldom bear children. ”

“ That abortions, even when criminally induced, may sometimes be safely borne by the system, is of little avail to disprove the evidence of numberless cases to the contrary. We have instanced death. Pelvic cellulitis, on the other hand, fistulæ, vesical, uterine, or between the organs alluded to; adhesions of the os or vagina, rendering liable subsequent rupture of the womb, during labor or from retained menses, or, in the latter case, discharge of the secretion through a Fallopian tube, and consequent peritonitis; diseases and degenerations, inflammatory or malignant, of both uterus and ovary ”

“ If the cause of the abortion affects the mother instead of the ovum, she generally experiences, at the time of the accident, a sharp pain about the loins or abdomen, which may continue slightly for several days, and then be renewed, with violent uterine contractions, and some serous and then bloody discharges from the vagina.
The progress of a miscarriage is not as regular as a labor at full term. In many cases there are shiverings succeeded by fever for a day or more preceding the hemorrhage. ”

“ The operator should always remember the danger of perforating the uterus by the curette. This accident, which has happened in the hands of the best surgeons, occurs usually as the instrument is introduced, not as it is withdrawn. It is much more liable to occur after labor or recent abortion, when the uterine tissues are soft, than in the conditions now under consideration. ”

“ When the uterus lies in the vagina it is spoken of as prolapse, when it protrudes through the vulva it is procidentia. The causes are directly due to increased intra-abdominal pressure, increased weight of the uterus by fibroids, violent straining, chronic cough and weakening of the supporting structures of the pelvic floor, such as laceration of the vagina and perinaeum. Traction on the uterus from below (as a cervical tumour) may be a cause; advanced age, laborious occupations and frequent pregnancies are indirect causes. ”

“ Physical shocks, such as falls, blows upon the abdomen, jumping, tripping over carpets, jars, jolting or overexertion, may be the exciting cause of an abortion where there is a marked irritability of the uterine muscles. This factor is largely influenced by individual stability, however, as a slight jar will cause an abortion in one woman, and violent experiences will have no effect upon another, at the same stage of pregnancy. ”

“ The couple, all of whose children had died soon after birth, longed once more for children. The woman had aborted several times, and both were intelligent enough to see that everything could not be right with the sexual organs, and even begged for a gynæcological examination. The result was in a few words: inflammation of both lips of the uterus, a thickening of the cervical canal with a swelling of the posterior uterine wall as hard as cartilage, and retroversio uteri. Menstruation too early, dysmenorrhœa, blood dark, tarry, passing in clots. Yellowish, fetid leucorrhœa. ”

“ Anteflexions and anteversions are always rectified; retroversions in rare cases only lead to abortion; adherent retroflexions are most to be dreaded; when the uterine body, bound down to the pelvic floor, expands within the cavity to such a size as to make escape through the brim impossible, abortion must necessarily follow. ”

“ If the abortion is passed easily, the patient rarely keeps her bed, pays little or no attention to the occurrence, certainly none to her getting up, and subinvolution, by far the most frequent sequence to abortion, follows. Abortion is altogether the most prolific cause of uterine disease, in consequence of the indifference with which it is treated, not only by the patient, but by her physician. With the expulsion of the ovum and the cessation of hemorrhage the case is considered finished ”

“ In all probability, the embryo is still in the morula stage and is about the size of the head of a pin when it reaches the uterus, where it finds that the endometrium has been prepared for its reception by the premenstrual swelling. The mucosa has grown thicker, more velvety and vascular, and its glands have increased in number and activity. The columnar epithelium of the endometrium is replaced by a thick layer of large, vacuolated cells, called decidual cells, and the uterine lining from now on is termed the decidua gravidatis. ”

“ It is of the first importance however to be certain, before using any forcing means whatever, that there is no physical impediment. If the pelvis should be deformed or small, if the child's head should be unusually large, or dropsical, or if the soft parts of the mother should be undilated and rigid, the most serious consequences must ensue from violent uterine contractions. In like manner if the presentation be unfavorable, particularly if it be one of the trunk, the danger is equally great. ”

“ An incomplete abortion is one in which the fetus is expelled but the placenta and membranes remain in the uterine cavity. The treatment is removal of the retained tissues, followed by the same care that is given during the normal puerperium. Prompt action in completing the delivery is important because of the hemorrhage that usually persists until the uterus is entirely emptied of its contents. ”

“ But it is not necessary to pass the hand into the uterus for the removal of coagula, because if the binder has been properly applied, and strong pressure made over the fundus uteri, clots cannot accumulate within the uterus, and if they have been permitted to collect in consequence of neglect, then expulsion will immediately follow the use of proper compression of the hypogastrium, without the introduction of the hand. Nor do I consider it necessary, to excite uterine contractions, that the hand should ever be introduced into the cavity of the uterus after the removal of the placenta. ”

“ There was no sign of a double uterus, and the patient menstruated regularly during pregnancy, being unwell three weeks before the abortion. Harley and Tanner speak of a woman of thirty-eight who never had borne twins, and who aborted a fetus of four months' gestation; serious hemorrhage accompanied the removal of the placenta, and on placing the hand in the uterine cavity an embryo of five or six weeks was found inclosed in a sac and floating in clear liquor amnii. ”

“ Uterine hemorrhage, contractions, and expulsion of the ovum in consequence of neurotic influences are more likely by far to occur during the existence of predisposing causes. Fright, a nervous shock of any kind which in no way affects healthy gestation in a healthy woman, will result in abortion in a person afflicted with uterine disease or in a system otherwise weakened. ”

“ 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.
77The 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. ”