A system of practical medicine. By American authors. Vol. 4

by Unknown

FIG. 7.

The Emmet Curves.

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 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 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.

FIG. 9.

The First Suture before Twisting in Emmet's Operation for Procidentia (Emmet).