When all other methods fail, an oper ation will usually succeed. The posterior uterine wall may be incised longitudi nally in the median line, and the cervix stretched by means of dilators introduced into the peritoneal cup through the in cision. If the constriction ring dilates sufficiently, the incision is sutured and the fundus pushed up through the di lated parts (B. Bernard Brown).
In case the cervix does not yield to the dilators, the incision can be length encd until it extends from the fundus through the cervix into the posterior vaginal wall. At its extremity a trans vg se incision is made across the posterior vaginal fornix into the cul-de-sac of Douglas, and the uterus is easily turned right side out and sutured in the vagina. Then the fundus is pushed through the posterior vaginal opening and up into its proper position (Iiiistner).
On account of the liability to the oc currence of retroversion with adhesions after the posterior incision, it is prefer able to similarly incise the anterior uter ine and vaginal walls, separate the blad der, open the peritoneal cavity, restore the uterus to its normal shape, suture the uterine incision, and attach the fun dus over the bladder, and—if necessary —shorten the round ligaments intra peritoneally, before finally closing the vaginal incision.
T. G. Thomas recommended opening the abdomen and dilating the cervix from the peritoneal side. When this fails Everke incises the posterior cervical wall, and—if necessary—the anterior, reduces the displacement, and then sutures the uterine wound.
A simple operation for prolapsus con sists in making a transverse incision through the vaginal mucous membrane in front of the cervix, dissecting off flaps, and closing the wound vertically.
If necessary, the cervix may be drawn backward by making a vertical incision in the posterior fornix and uniting the flaps transversely. Schiicking (Brit.
Gynmc. Jour., No. 2. 1900).
Tuberculosis of the Uterus.—CoaPus. —Tuberculosis of the uterus may be caused, primarily, by tuberculous semen, instrumental inoculation, etc., but is nearly always secondary to tuberculosis in other parts. Although in the corpus it may exist in any stage, the miliary form is not recognizable clinically, and hence the ulcerative stage is the one usually encountered. The disease com mences as small miliary tubercles, usu ally near the fundus, and spreads dif fusely throughout the mucous membrane.
In a few instances it develops in the uter ine wall, constituting the interstitial form.
Symptoms and Diagnosis.—The early symptoms are those of endometritis, sometimes with menorrhagia. Later the uterine walls are thickened, and there is a grunions discharge containing cheesy particles. The menses are then apt to be scanty.
The diagnosis may be based upon a mi croscopical examination of uterine scrap ings or inoculation of a guinea-pig. The presence of tubercles in other organs, the absence of foul-smelling watery dis charges, and the slow progress distin guish it from cancer or sarcoma of the endometrium.
Treatment.—The uterus and append ages should be extirpated per vaginam unless the condition is secondary to ad vanced tuberculosis elsewhere. If the appendages are palpably affected, or if there be encysted tubercular peritonitis, the abdominal method is preferable.
In case an hysterectomy is contra-in dicated, a curettage and package of the uterine cavity with iodoform might re tard the progress of the disease.
CEuvix.—Tuberculosis of the cervix consists of a round-cell infiltration of the subepithelial structures, containing tu bercular nodules. The glands over the affected portions show epithelial prolif eration and sometimes form papillary masses. The vaginal portion is some what enlarged, nodular, and partly cov ered by a circular granular wound that gives off a sticky, grumous discharge.
The sympl(»»s are at first those of cer vical endometritis. Later the grunions discharge, containing glandular matter, the local pain, and the microscopical evidences obtained from a piece of cised tissue serve to establish a diagnosis.
The prognosis is usually bad because of the existence of the disease elsewhere in the system. If discovered early, the area of localization can be extirpated and the infection eradicated.
Treatment.—In the early stages a high amputation of the cervix may be de pended upon unless uterine scrapings show signs of tuberculosis or decided in flammatory changes in the endometrimn. If the vaginal fornices are affected, the vaginal wall should be excised well be yond the disease and the wound be strewn with iodoform powder and sutured.