enlargement of the entire organ. At any rate, those cases in which the
reduplication of the vaginal walls does not almost entirely explain the
great elongation so called, or in which great disproportionate circular
enlargement has not been caused by laceration of the cervix, are the
rare exceptions. The great merit of having secured general assent to
the foregoing proposition, and of having given to the subject a new and
right direction, must be accorded to Emmet. 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.
SYMPTOMS AND COURSE.--A dragging sensation and pelvic and abdominal
pain are generally present. Rectocele and cystocele and rectal and
vesical catarrh often cause painful and severe functional disturbances
of the rectum and bladder. In descent of the third degree excoriations
of the exposed vagina and cervix sometimes cause extreme suffering. The
course is ordinarily chronic, but attacks of acute vaginitis and pelvic
peritonitis are not uncommon. The peritonitis sometimes effects a
spontaneous cure by peritoneal adhesions which fasten the uterus in an
elevated position and hold it permanently. The symptoms of descent may
be so severe as to necessitate absolute rest in bed. In other cases
they are often attended with very little discomfort.
{159} DIAGNOSIS is by inspection, palpation, and exploration. The
prolapsed uterus may be distinguished from cystocele, rectocele,
inverted uterus, and fibroid tumor by the presence of the os externum.
The sound may be passed through the urethra into the cystocele, and the
finger through the anus into the rectocele. The length of the uterus
may be determined by the sound, the size, shape, position, extent of
descent, and difficulty of replacement by conjoined manipulation.
PROPHYLAXIS.--This requires such measures during labor as may be
necessary to prevent long and powerful pressure upon the pelvic floor.
After labor any injury to the perineum should be promptly repaired. The
vagina should be kept clean by irrigations. The urine, if necessary,
should be regularly drawn and the bowels moved daily without straining.
If conditions be present likely to induce subinvolution--such, for
example, as pelvic inflammation or laceration of the cervix--they
should receive treatment at the proper time. Undue relaxation of the
pelvic floor necessitates a more prolonged rest in bed, the use of
astringent douches, and the application of a pessary when the patient
resumes the upright position.
TREATMENT.--The first indication is replacement, which in the first and
second degree of descent is not difficult unless the uterus be held
down by cicatrices or by a tumor. Complicating pelvic cellulitis and
peritonitis may render replacement dangerous or impossible, and may for
a time contraindicate all direct treatment. Replacement of the organs
from the third degree of prolapse is accomplished in the inverse order
of their descent: first, the posterior vaginal wall, then the uterus,
and last the anterior vaginal wall. Not infrequently the completely
prolapsed uterus and pelvic floor, hernia-like, become strangulated.
Then taxis will usually suffice if supplemented by hot applications,
elastic pressure, anodynes, and the knee-chest position. Should these
fail anæsthesia may be required.
Undue pressure from above should if possible be removed. The clothing
should be loose, and the weight of the skirts supported from the
shoulders either by straps or preferably by buttoning them upon a waist
made for the purpose. This waist is a good substitute for the corset,
which under all circumstances and in all its forms is injurious.
Increased uterine weight from subinvolution or congestion is to be
overcome by appropriate means. Enlargement of the uterus when due to
hypertrophy or hyperplasia is generally incurable. Amputation of the
cervix for what was formerly considered circular hypertrophy and
hypertrophic elongation is now seldom or never required for the purpose
of decreasing uterine weight. Amputation except for malignant disease
has given place to the operation of trachelorraphy. Tumors exerting
pressure above or traction below should if possible be removed.
Regulation of the bowels and general tonics are usually necessary. The
knee-chest position assumed several times a day causes the uterus to
gravitate toward the diaphragm, and thereby gives temporary rest to the
overburdened supports. While in this position the patient should
separate the labia, so that the air may rush in and the vagina become
expanded. The measures enumerated above, together with rigid care of
the diet and of such other hygienic requirements as the individual case
may demand, are essential as adjuvants to the more special treatment
which almost every case requires.
{160} In exceptional cases of sudden descent, even to the third degree,
replacement alone is sometimes followed by permanent relief; but if the
descent has been gradual it always recurs immediately after
replacement. Measures are therefore required for the maintenance of the
uterus in its normal location and position. This indication is
fulfilled by pessaries and by operations.
Pessaries.--The function of the pessary is not only to maintain the
uterus on the health level in its normal location, but also, if
possible, in its normal position, which requires the cervix to be about
one inch from the sacrum. The cervix being thus placed, the organ
cannot turn back into retroversion, because in so doing the fundus
would encounter the sacrum. The direction of least resistance would
then be forward into the normal anterior position. The application of
the pessary is then based upon the general proposition that if the
cervix be normally placed the body of the uterus will in the absence of
complications take care of itself. Since the vagina at its upper
extremity is attached to the cervix, displacement of the latter is
clearly impossible if the upper extremity of the vagina be sustained in
its normal location. The pessary restores and maintains the relations
of the relaxed vaginal walls by crowding the posterior vaginal
cul-de-sac backward into the hollow of the sacrum. It thereby also
holds the attached cervix within a proper distance of the sacrum. The
Hodge pessary or some modifications thereof fulfils this purpose in
ordinary cases more satisfactorily than any other.
[Illustration: FIG. 7. The Emmet Curves.]
[Illustration: FIG. 8. The Albert Smith Curves.]
The curves of the pessary demand careful attention in its application.
When the uterus is below the normal level, the broad ligaments are
necessarily rendered more tense than natural, and the blood-vessels,
more especially the veins, which are looped one upon the other, and
which traverse these ligaments to and from the uterus, are made to
collapse. This causes venous congestion and consequent increase in
weight of the uterus--a condition favorable to malposition, uterine
catarrh, and pathological changes in structure. A pessary which will
raise the uterus to the health level clearly fulfils an indication. A
pessary which raises it above the health level renders the broad
ligaments tense and reproduces a condition which it was designed to
relieve. Maintenance of the uterus upon the health level depends
largely upon the curves of the pessary. The accompanying cuts
illustrate the shape and curve of the Hodge pessary as modified by
Emmet and Albert Smith. Fig. 7 represents the curve of Emmet, and Fig.
8 that of Albert Smith. For convenience let us characterize that curve
which rests in the posterior vaginal cul-de-sac as the uterine curve,
and that which occupies that part of the vagina {161} adjacent to the
pubis the pubic curve. The acuteness and length of the uterine curve
determine the height to which the pessary will lift the uterus. The
longer and more acute the curve, the higher the uterus will be lifted,
and vice versâ. The smaller curve of the Emmet modification will answer
the average indication more nearly than the sharper curve of the Albert
Smith modification, which may lift the uterus too high. The pubic
should generally be proportioned to the uterine curve; that is, the
greater the uterine, the greater the pubic curve. A pessary properly
adjusted in all other respects may, by pressure upon the urethra and
neck of the bladder, create vesical tenesmus and urethral irritation.
This calls for increase in the pubic curve. The pubic curve may,
however, be so great that the lower part of the pessary occupies the
centre of the vulva, where it may create irritation. For this condition
lessening of the pubic curve is the remedy. The pessary should not be
so wide as to distend the vagina. Its length should be measured by the
distance from the lower extremity of the symphysis pubis to the
posterior vaginal cul-de-sac, less the thickness of the finger. If
properly adjusted it should sustain the pelvic floor in its normal
relations and the uterus in stable equilibrium.
The uterus in the first and second degrees of descent is usually either
retroverted or retroflexed. The reader is therefore referred to the
remarks on the application of pessaries in the treatment of these
displacements.
In advance prolapse dependent upon extensive injuries to the perineum
and other parts of the pelvic floor, and usually associated with
extreme subinvolution of all the pelvic organs, the axis of the vagina
is often changed from its forward oblique to the vertical direction.
(See Fig. 3.) The downward traction of the prolapsing cystocele and
rectocele upon the fornix of the vagina may then be so great that the
pessary is inadequate to maintain in place the upper extremity of the
vagina. The cervix then moves forward, the corpus turns back, and the
whole uterus easily descends in a vertical direction along the
prolapsing walls of the vagina to the second or third degree of
prolapse. In this condition pessaries which disappear within the vagina
are liable to be forced out with the prolapsing pelvic floor, or if
retained seldom maintain the uterus in position. In such cases the
various cup pessaries which are supplied with external attachments and
abdominal belts are often used, but they are inadequate, because they
either so fix the uterus as to prevent its normal movements, or they
hold it in such unstable equilibrium that it may assume any one of the
various malpositions, anterior, posterior, or lateral; and they are
open to the further serious objection of constantly reminding the
patient of their presence. As an expedient the uterus may sometimes be
held within the pelvis by means of a large Albert Smith pessary with
extreme uterine and pubic curves. The rational treatment, however,
requires first an operation on the anterior vaginal wall to restore the
fornix of the vagina to its normal place in the hollow of the sacrum,
and with it the attached cervix; and second, an operation at the
vaginal outlet to bring the posterior wall in contact with the
anterior, and thereby to restore the lower extremity of the vagina to
its normal place under the pubis.
ANTERIOR ELYTRORRHAPHY.--Numerous operations on the vaginal {162} walls
have been devised for the purpose of narrowing the vagina, and thus
preventing descent along the vaginal canal, but they are temporary in
their results, because, as long as the direction of the vagina remains
vertical, its walls again become dilated by the prolapsing uterus and
the former condition is re-established. The operation to be effective
is performed as follows: A Sims's speculum of long blade, perforated at
its extreme end, to which the cervix has been attached by a piece of
silver wire, passing through the perforation and the posterior lip, is
introduced, the patient being in Sims's position. The cervix is thereby
drawn by the point of the speculum far back into the hollow of the
sacrum. The author finds this preferable to the method described by
Emmet, who has the cervix held back by a sponge probang in the hand of
an assistant. The space in the anterior part of the pelvis is now so
increased that the uterus readily falls forward into decided
anteversion. While the uterus is thus held in position by its
attachment to the blade of the speculum, the operator with two uterine
tenacula finds in the loose vaginal tissue on either side of the cervix
two points which can be brought together in front of the cervix. Then
at each of the two lateral points a surface is denuded with the curved
scissors about one-half inch square, and in front of the cervix a
surface an inch long by half an inch wide across the anterior vaginal
wall close to the uterine attachment. A No. 26 silver-wire suture is
then passed, as shown in Fig. 9, and twisted as shown in Fig. 10, so as
to secure the lateral denuded surfaces in contact with the larger
surface in front of the cervix.
[Illustration: FIG. 9. The First Suture before Twisting in Emmet's
Operation for Procidentia (Emmet).]
[Illustration: FIG. 10. Folds on the Anterior Vaginal Wall formed after
Twisting the First Suture (Emmet).]
Inasmuch as the operation often fails at the point of the first suture,
the author has usually introduced two or three of this kind instead of
one. Two longitudinal folds are now formed on the anterior vaginal
wall, which serve as guides for denuding and turning in the remaining
redundant tissue by a line of sutures, which should extend forward
along the centre of the vesico-vaginal wall until the folds are lost in
the vaginal surface near the neck of the bladder. Sometimes the
redundant tissue about the urethra cannot be disposed of by turning it
in from side to side. Then it is desirable to make a crescentic
denudation across the lower portion of the vagina, its concavity being
on the uterine side, and {163} to unite the margins below to those
above by means of a curved line of sutures. The completed operation is
shown in Fig. 11.
[Illustration: FIG. 11. Emmet's Operation for Procidentia and
Urethrocele completed. Sims's Speculum, Left Latero-prone Position
(Emmet).]
The after-treatment requires the self-retaining Sims's sigmoid catheter
in the urethra for a week or frequent catheterization, absolute rest in
bed, hot-water vaginal douches, regulation of the bowels, and the
removal of the sutures on the twelfth day. After the completion of the
operation the cervix is maintained near the hollow of the sacrum, and
the organ remains normally anteverted and anteflexed, making an acute
angle with the vesico-vaginal wall, which has now been restored to its
normal direction and length. Unfortunately, it is not unusual to
abandon the patient after this operation, in the vain hope that the
uterus and anterior vaginal wall will maintain their normal relations
without the support of the perineum and posterior vaginal wall. This is
a great mistake, because the cystocele and procidentia almost always
completely reappear within a few months. Anterior elytrorrhaphy,
therefore, is simply one of the steps in the treatment.
PERINEORRHAPHY.--This is the name usually applied to the repair of the
ruptured perineum, but the scope of the operation has been extended to
include also the surgical treatment of rectocele and relaxation of the
posterior vaginal wall. The most scientific operation yet devised is
the one proposed by Emmet,[8] which is performed as follows: The
patient being etherized and in the lithotomy position, the operator
seizes with a tenaculum the crest of the rectocele or posterior vaginal
wall at a point which can be drawn forward without undue
traction--point _a_. With another tenaculum the lowest caruncle or
vestige of the hymen (point _b_), {164} and with another the posterior
commissure of the vulva (point _c_), are hooked up. The triangle
included between these points defines one-half of the surface to be
denuded. The three tenacula are now placed in the hands of assistants,
the sides of the triangle are made tense by traction, and the included
surface denuded. The tenaculum at _c_ is then removed, and the middle
point of the line _a b_ is caught and drawn toward the interior of the
vagina in the direction of the vaginal sulcus on that side, and the
sutures are introduced, as in Fig. 13. The same thing is then repeated
on the other side, and the sutures are all tightened, forming a line of
union running back into each sulcus, as shown in Fig. 14.
[Footnote 8: _Trans. Am. Gynæcological Society_, 1883; _Principles and
Practice of Gynecology_, 3d ed.]
[Illustration: FIG. 12. _a_ is at the crest of the rectocele; _b_ at
the caruncle just within the labium; and _c_ at the posterior
commissure. The cut represents that half of the surface to be denuded
which is on the operator's right. The dotted lines represent the other
half, on the left.]
[Illustration: FIG. 13. The Sutures in Place. When secured they will
unite _a d_ with _b d_, and lift the perineum up in contact with the
anterior vaginal wall.]
[Illustration: FIG. 14. All the Vaginal Sutures Twisted. One suture,
including the crest of the rectocele and the labium majus on either
side, and three superficial external sutures, are yet to be secured.
The lines _a d_ and _d b_, Fig. 13, have been brought into coincidence
by means of the sutures, and now form the line of union _d b_. The
tissues between the lines _a c_ and _c b_, Fig. 13, have been so lifted
up and are so held under the line of union _d b_ that the line _c b_,
Fig. 13, has been reduced to _c b_, Fig. 14, which makes the external
portion of the wound insignificant in extent.]
The essential part of the operation inside the vagina almost always
succeeds, but the external part of the rupture at the posterior
commissure often fails to unite; furthermore, the operation as
described by Emmet does not overcome the patulous condition of the
introitus vaginæ in case of great relaxation of the vagina. The author
has sought to obviate the first of these difficulties by the use of
deep silver sutures instead of the superficial ones described by Emmet.
They should be introduced before tightening the vaginal sutures, and
should be passed far around in the posterior vaginal wall, their points
of entrance and exit being the same as for the three lower unsecured
superficial external sutures in Fig. 14. The second difficulty may be
overcome by further denuding a triangular surface in the vaginal sulcus
on each side, the base of the triangle corresponding {165} to the line
_a b_, Fig. 12, and its apex being in the vaginal sulcus at a distance
corresponding to the degree of relaxation. This increases the length of
the lines of union running into the sulci represented by _d b_ and
_e f_, Fig. 14. In the vaginal portion of the wound silk or catgut is
preferable to silver, the latter being difficult to remove.
Emmet is entitled to great credit for having given to the profession an
operation which brings the posterior vaginal walls up against the
anterior more perfectly than any other, and which, being mostly inside
of the vagina, is therefore followed by very little of the pain during
convalescence which formerly rendered perineorrhaphy one of the most
trying operations in gynecology. The operation furthermore has
demonstrated the former teachings relative to the direction of perineal
rupture[9] and the tissues involved to be incorrect, or at least
inadequate.
[Footnote 9: At the meeting of the American Medical Association in
June, 1883, the author presented a paper describing the transverse
laceration of the perineum and its operative treatment, which was
published with illustrations in the transactions by the journal of the
Association, Dec. 22, 1883. This communication referred only to the
recent rupture and the immediate operation.]
Retroversion.
Retroversion is that position of the uterus in which the fundus is
posterior to the axis of the pelvic inlet. If the cervix be in its
normal place near the sacrum, retroversion is scarcely possible,
because it is prevented by the proximity of the over-arching sacrum.
(See Fig. 2.) The first degree of prolapse must therefore precede any
considerable backward turning of the uterus. When the cervix has been
displaced downward {166} and forward so far that its distance from the
sacrum is equal to or greater than the length of the uterus,
retroversion to any extent becomes possible. (See Figs. 3 and 16.)
ETIOLOGY AND HISTORY.--From the above it follows that the causes of
commencing retroversion must be identical with the causes of the first
degree of prolapse. After the puerperium the relaxation of the supports
and the weight of the organ may persist, and spontaneous replacement
may be prevented by the pressure and weight of the intestines upon the
anterior surface. Every act of defecation forces the cervix forward and
downward, and the uterus, being in the axis of the vagina, and having
therefore little support below, must depend upon the subinvoluted
peritoneal suspensory ligaments and pelvic fascia, which are
inadequate. This condition is very often induced by abortions, with
resulting increased weight and relaxation of the vaginal walls. Local
peritonitis and cellulitis may permanently fix the corpus in its
retroverted position by cicatricial bands and adhesions.
SYMPTOMS AND COURSE.--The displacement and its complications usually
cause bearing-down sensations, a feeling of heaviness in the pelvis,
exhaustion upon walking and standing, especially the latter, and
constipation. 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. The heavy organ may descend along the
relaxed subinvoluted vaginal walls even to complete procidentia.
DIAGNOSIS AND PROGNOSIS.--The symptoms outlined in the preceding
paragraph indicate the probability of displacement, but the diagnosis
depends upon direct examination of the uterus. Conjoined manipulation
and the probe will usually show the retroverted organ with the cervix
displaced toward the pubes and with the corpus in the hollow of the
sacrum. The introduction of the probe is contraindicated by cellulitis
and peritonitis. In certain cases of anteflexion, as represented in
Fig. 23, the cervix is bent forward in the vaginal axis as in
retroversion. The condition is in reality one of retroversion of the
cervix with high anteflexion of the corpus, which may usually be
detected by careful conjoined examination. The prognosis with treatment
is generally favorable both for speedy relief and ultimate recovery.
TREATMENT.--As in descent, the treatment consists in removing
cellulitis, peritonitis, and other complications, in the use of
pessaries, and in operations on the anterior and posterior vaginal
walls if needed. Inasmuch as the treatment corresponds to that of
retroflexion, it will be presented under that subject.
Retroflexion.