Femina, A Work for Every Woman

by John A. Miller

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 leucorrhœa 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.