ARTIFICIAL DISLOCATION OF THE UTERUS, AND THE DIAGNOSTIC EXCISION.
To effect this prolapse, a double or multiple tenactilum is fastened into the vaginal portion of the cervix, and strong downward traction is exerted in the axis of the pelvis. Strong sutures passed through the cervix were substituted for the tenacula in order to gain space. Only the uterus with relaxed ligaments allows such forcible dislocation without danger. Usually the utero-sacral ligaments, to a less degree the broad and the round ligaments, resist energetically this traction, and also, as Savage has .shown, the cellular tissue below the peritoneum and around the uterine vessels. Very exaggerated traction may lead to rupture of the peritoneum and to severe traumatic affections, particularly in those cases where, as the result of antecedent inflammatory processes, the structures adjacent to the uterus have lost their elasticity. Schroder has called attention to the risk run, and Mermann has recorded an instance of perforation of the tube in case of salpingitis with fatal result. Artificial prolapse must therefore be regarded as a dangerous procedure, and the process controlled by frequent rectal examination to determine the degree of tension. In case the uterus is readily brought down to the introitus vaginas and the ligaments are not deprived of their normal elasticity, then no harm is done, and the organ returns to its natural position after relaxation in the traction. Such extreme dislocation as to bring the uterus outside the vagina is rarely requisite. Lesser degrees of prolapse are, however, use ful during operations, although we should aim at operating in Wu as much as possible. Such lesser degrees are also valuable for purposes of diagnosis. Where the uterus is not fixed by disease such ohange in its position is allowable, although the organ has not such a normal range of movability.
As we stated when speaking of inspection, Sims almost always used a simple tenaculum to bring the cervix into the desired axis, but Hegar and Kaltenbach prefer the tenaculum forceps, and are of the opinion that the procedure has advantages from a diagnostic standpoint, and that it is not dangerous. We may use a simple tenaculum or one or another of
the double tenaculums. In order to avoid injury to the cervix the blades of the instrument should be slender and slightly apart. The extremities must be bent at right angles, otherwise it is difficult to remove them.
Before resorting to the procedure the vagina and the cervix should be carefully cleansed and disinfected; then either through the speculum or under the guidance of the finger alone, the entire cervix or one or another lip is seized so strongly by the instrument that it will not tear out under gentle traction, and we have the organ perfectly under control. When the uterus is drawn downwards we may examine its surroundings better with the finger in the vagina, we may test the movability of the organ, and we may the better differentiate the nature and attachment of tumors in connection or adjacent to it. Indeed the information obtainable can not be had in other ways.
It goes without saying that this method of examination may be com bined with any of the others of which we have spoken. Thus we may at the same time examine by the bladder, vagina or rectum; we may palpate the abdomen, or cause an assistant to impart motion through it to a sup posed tumor. For the examination of the internal surface of the uterus we frequently cannot dispense with the tenaculum forceps, although in case of ductile uterus the organ is drawn out so as to make it difficult for the finger to reach deeply. Excellent results are obtainable from rectal examination during dislocation of the uterus, for the posterior uterine ligaments, the ovaries, and adhesions become more accessible.
Even as with the uterus so may the vaginal walls or tumors of the genital tract be dislocated and examined. We may thus sometimes be. able to determine the insertion site of a myoma or polyp and feel the pedicle.