| 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. |
| 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 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 rupture9 and the tissues involved to be incorrect, or at least inadequate.
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 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.