The statistics show that, out of every five women who are suffering from female diseases, one has a posterior displacement, either a retroflexion or retroversion. The greatest number of these are traceable to their last confinement. All these displacements, as well as those that are accidental or induced by a fall, jumps or the like, should be replaced as soon as possible, otherwise inflammatory adhesions may complicate and greatly obstruct the replacement.
The reposition or replacement of the womb may be accomplished through natural agencies, that can be employed by the patient herself. These are, in a great measure, the same forces to which the womb’s posterior displacements are to be attributed, namely, intra-abdominal pressure and gravitation. To employ these for the purpose of remedying the evil, the so-called knee-chest position must be assumed by the patient. The first step towards assuming this position is to get down on the bended knee, the thighs in a vertical position, then the body is gradually inclined forwards until one or the other shoulder touches the floor or level of the knee. If this position is retained for ten minutes it will alone replace the organ forwards, sometimes suddenly, at other times gradually, provided the organ is moveable and not squeezed into the pelvis or adhered by inflammatory exudation.
Dr. Henry F. Campbell, of Georgia, introduced this natural therapeutic agent into the profession, but it appears to be very little known or understood by the profession, perhaps because it is so very simple. Dr. Mundé, in an article on “Uterine Displacement and Its Curability,” in the American Journal of Obstetrics, indorses the knee-chest or knee-shoulder position in the following language: “A moment’s thought will demonstrate the utility of this combined vis a fronte (gravitation of the abdominal viscera towards the diaphragm) and vis a tergo (air suction into the vagina and pressure against the vaginal roof). This position is to be assumed several times daily, and maintained each time as long as the patient can bear it, continued for months, if necessary; the best time is at night at retiring, when the lateral position is to be taken for the night.”
In a certain proportion of cases the knee-chest position alone will not dislodge the retroflected uterus, so that manual aid is required to effect that purpose. There is a number of methods that have been suggested from time to time, but none are so good as that in which the knee-chest position is combined with the manipulation of the operator. Reposition may occur spontaneously, and it undoubtedly does in a large proportion of cases, in which the retroflected organ becomes pregnant. When the retroflected organ occasions symptoms of retention of urine, the bladder should first be emptied with a soft No. 8 catheter, then the patient is directed to kneel on both of her knees, her thighs remaining perpendicular, while her body inclines forward until one or the other shoulder touches the floor or level of her knees. The operator may then gradually lift the womb and elevate the body sufficiently so that it will fall forward into its natural place. When there is no bladder trouble from compression, and the womb resists even mild force to replace it, I have accomplished gradual reposition by keeping the woman in bed for three or four weeks, with the instructions that she resume the knee-shoulder position two or three times a day, and from five to ten minutes, also that she shall lie on her side and chest and never on her back. In this manner I have accomplished in time and without force what could not have been accomplished with forcible attempts without inducing an abortion.
It curiously happens that there are cases of retroflection which are never suspected nor recognized until the patient has become pregnant. After the woman is about three months gone, the growth of the pregnant uterus can no longer be accommodated in the pelvis, because the direction of its growth is in the direction of the retroflected organ, namely, backwards and downwards (see Plate IV) which makes it a physical impossibility to escape from or grow out of the bony pelvis. The symptoms are retention of urine or a constant dribbling of urine and a straining at stool or pain in the rectum or pelvis, and, of course, the absence of the menses since the commencement of pregnancy. Retroflection may be also acquired during the first three or four months of normal pregnancy, from a jump or fall on the back, in which all the symptoms that indicate this condition are suddenly manifested.
In pregnancy, the course that is to be pursued, in order to rectify the displacement, must be obviously different from that pursued when the woman is not pregnant. The pregnant uterus is a “touch me not;” it permits of no tampering without running the fearful risk of inducing an abortion, and no one but a tyro or an ignoramus will ever meddle with the pregnant womb.
The replacement of the retroflected uterus, that is positively not pregnant, and there must be no question about it either, will admit of introducing a sound into its cavity. This sound is used as a lever upon which the organ may be lifted out of its abnormal position and inclined over the bladder in an anteflected position, which is its natural one. The sound which I employ, and which is my own invention, for replacing the uterus is screwed into a thimble, and from two and one-half to three inches long. The object of this is to artificially elongate the finger so that it can be introduced into the womb. The force which one employs by using this instrument is keenly appreciated by the operator, hence there can be no undue strain, that otherwise might be exerted on adhesions which are too strong to be safely lacerated or even stretched, while slight and recent adhesions might be torn without any bad results. Truax, of Chicago, manufactures my repositor.
Before introducing any sound into the uterine cavity, it is absolutely necessary that the vagina should be thoroughly cleansed with borax water.
The inflammatory enlargements of the womb, subinvolutions, uterine catarrhs, and any of the complications that may exist at the time that the organ is replaced, should be treated on the same principles that have been laid down in the respective chapters on these diseases; in fact, these complications constitute part of the after treatment for retroversion or flexion. The other treatment is to be directed toward retaining the womb where it naturally belongs. The daily exercise in the knee-chest position should never be neglected, and in cases in which this is insufficient, it is very probable that the pelvic floor or natural support of the uterus has been injured or lacerated during confinement, and this may require a plastic operation as a preliminary to a cure. In obstinate cases there is no cure so effectual as pregnancy and a full-time delivery, provided precautions are taken so that the mother will not acquire a new retroflexion during her lying-in period, from the cause that has been already detailed. The patient must accustom herself to sleep either on the chest with face turned to one or the other side, or in a semi-prone position on either the right or left side. Perseverance in sleeping in this manner for a few weeks cultivates the habit that gives more refreshing sleep than lying on the back, which most persons are inclined to do.