The cases of retrodisplacement of the uterus suitable for treatment by the pessary are those in which there are no adhesions and in which there is no disease of the Fallopian tubes or the ovaries. If a prolapsed ovary returns to its normal position when the displacement of the uterus is corrected, it will of course not be pressed upon by the bar of the pessary. But in some cases the ovarian prolapse continues even though the uterus is in its normal position, and under such circumstances a pessary usually cannot be tolerated.
The cases that offer the best prospect of cure by the pessary are those cases of retroversion, occurring as the result of labor, in which the perineum is intact, and which are seen within one or two years after the occurrence of the lesion. The prognosis becomes more unfavorable the longer the condition has existed before treatment.
Cases of congenital retroversion, or those occurring in young unmarried women, are very difficult to cure with the pessary. This instrument should always be tried for a few months, however, before operative measures are advised. In such cases the uterus has been so long in an abnormal position that its natural supports have become permanently altered, and some continuous additional aid is necessary to maintain the normal position.
Every woman who uses a pessary should be under the supervision of a physician, and for this reason it is often most advisable to recommend immediate operation to poor women as the quickest and surest method of cure.
Immediate operation should always be advised in all cases of retroversion with adhesion or with disease of the tubes and ovaries.
It should not be forgotten that we occasionally see women with retroversion of the uterus who present no symptoms whatever referable to this lesion. In such cases no treatment is required.
Note (in fourth edition).—The operation of ventro-suspension as described above has been done by the writer and his assistants 310 times during the past seven years, 1893-1901. Two hundred and eleven of these women have recently made written reports of their condition, which are tabulated as follows:
Legend: A Number of cases relieved of the symptoms for which treatment was sought. B Number of cases improved C Number of cases not improved D Number of cases who became pregnant and went to full term E Number of cases who miscarried.
A B C D E Ventro-suspension with unilateral salpingo-oöphorectomy. 20 7 7 1 0 Ventro-suspension with perineorrhaphy and trachelorrhaphy. 34 15 5 6 3 Ventro-suspension with perineorrhaphy. 22 12 8 4 1 Ventro-suspension with trachelorrhaphy. 20 6 5 4 4 Ventro-suspension alone. 35 9 6 5 0 131 49 31 20 8 Of the 20 women who became pregnant and went to full term, the course of pregnancy was normal, and the children were all born alive. One woman had a prolonged and difficult labor, though forceps were not used. In 1 case forceps were used to deliver a ten-pound child, who presented in occipito-posterior position; in the remaining 18 cases labor was normal.
The operation of ventro-suspension seems to have had nothing whatever to do with producing the miscarriages. In fact, the number of miscarriages is small for any series of 211 women, most of whom were of the dispensary class.
Note.—Since collecting the statistics in the preceding note, we have continued to perform this operation in all cases of retroversion suitable for operation, with equally satisfactory results.
| Legend: | |
|---|---|
| A | Number of casesrelieved of thesymptoms forwhich treatmentwas sought. |
| B | Number of casesimproved |
| C | Number of casesnot improved |
| D | Number of caseswho becamepregnant andwent to full term |
| E | Number of caseswho miscarried. |
| A | B | C | D | E | |
|---|---|---|---|---|---|
| Ventro-suspension with unilateral salpingo-oöphorectomy. | 20 | 7 | 7 | 1 | 0 |
| Ventro-suspension with perineorrhaphy and trachelorrhaphy. | 34 | 15 | 5 | 6 | 3 |
| Ventro-suspension with perineorrhaphy. | 22 | 12 | 8 | 4 | 1 |
| Ventro-suspension with trachelorrhaphy. | 20 | 6 | 5 | 4 | 4 |
| Ventro-suspension alone. | 35 | 9 | 6 | 5 | 0 |
| 131 | 49 | 31 | 20 | 8 |