There is often considerable venous hemorrhage when we ablate pro lapsed vaginal folds, and a few emall twigs of the art. vag. may spurt. When the whole base of the fold can be grasped by the toothed forceps, that instrument will be very useful; nevertheless we prefer to pass a number of silver-wire sutures instead of the silk ligatures above the forceps at once, so as to check the hemorrhage. C.V. Braun (1. c. p. 320) has recently recommended. this procedure.
G. Simon' and A. Hegar` have done more than any others in Germany to introduce and systematize operative procedure for prolapse of vagina and uterus. After them many modifications and variations have been propos ed, especially by Bischoff' and L. Neugebauer.' As to the details of the prolapsus operation, they are fully considered by Fritsch in the part of this work dealing with uterine displacements, to which we refer the reader.
For the palliative treatment by retention of vaginal inversion, any of the ordinary pessaries and bandages used for uterine prolapse may be employed. We will not attempt to describe their innumerable varieties, since their choice depends largely upon the physician's prejudice or habit. Every one of them has some disadvantage. If the structure of the introi tus vag. and the muscular floor of the pelvis allows the retention of pes saries within the vagina, they are always to be preferred to instruments which are in part worn externally; the latter being less convenient and being liable to cause great irritation of the vaginal entrance. And also they retain the vagina in place by maintaining it in a state of tension above the diaphragma pelvis. If the introitus is so dilated by relaxa tion, diastasis or loss of substance of the muscular and aponeurotic base of the pelvis, that a pessary can find no vaginal support, they may still be retained if certain conditions are present. Thus peculiarities in the shape and width of the pelvis (funnel-shaped pelvis), or of the form of the pessary (large lateral wings), may enable the instrument to rest against the bony walls of the pelvic canal. It is very well known that under these conditions of continuous localized compression of the soft parts between a hard instrument and the bone, evil consequences will soon ensue; and it does not seem proper to me that we should continue to gather renewed experience upon the subject.
But in any case the maintenance of the replaced vagina above the diaphragma pelvis necessitates an amount of tension of the vaginal walls which cannot be attained with most pessaries without a deleterious amount of local pressure. The more irregular these instruments are in their
shape, the more certainly will they cause uneven pressure at certain places. Often we find that pessaries which have been introduced whilst the pelvic organs were in a stata of rest, have assumed a different position shortly after being placed. Elongated and winged instruments readily get into crooked positions, and cause contusion and friction; and these lead in time, if carelessly left to themselves, to ulcerations and deeper pressure-necroses, and even to perforations Yet, though these accidents have occurred time and time again, they have not been sufficiently noticed in medical circles; and even yet the intro duction of a "womb-ring" is oftentimes looked upon as a trivial matter, to be relegated to the midwife. I have seen so much evil result from neglect of this kind that I do not deem it superfluous to say a word of warning in regard to the introduction of pessaries. In addition to the ordinary treatment of the complicating erosions and ulcers, the following precautions should be observed: 1. The pessary should be chosen in accordance with the width of the vagina. It should be introduced in the knee-elbow position, and after the prolapse has been thoroughly reduced, and the vag,ina filled with air. It slips easily into the dilated Sae, when it finds plenty of room. Now, with its opening encircling the portio vag., it is kept pressed against the posterior vaginal wall, and against the fornix, whilst the patient gradually raises herself into a kneeling position. The stretching of the posterior vaginal wall at the moment of rising prevents the sinking forwards of the collum, and the descent of the movable adnexa and the intestines into Douglas's Very often we thus effect an anteversion of the uterus; a position most favorable for retention; and we will frequently prevent painful pressure upon an ovary which may be lying in Douglas's 2. We should never rest satisfied only with an immediate examination as to whether the pessary remains in place well when walking, standing, and bearing-down; we should always examine the patient again next day, after she has been moving around for some time, and has had a passage.