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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.