The restoration of the misplaced uterus may be effected by vaginal fixation, in which the fundus is brought forwards to lie between the bladder and anterior vaginal wall, or by abdominal fixation, in which it is brought through the peritoneum of the anterior abdominal wall and sutured to the recti muscles, or, still better, to the back of the anterior wall of the rectal sheath. These measures effectually fix the uterus and prevent not only retroversion, but also prolapse. They should never be carried out on any patient who has not passed the child-bearing age, as pregnancy in a uterus so fixed would be disastrous. When pregnancy is still a possibility, the uterus should be suspended from the anterior abdominal wall. This may be done in many ways. TI,c4se most favoured at present are Gilliam's operation, in which the round ligaments are picked up in the middle of their length and drawn out taut through the recti muscles on either side; and lastly the Alexander Adams operation, in which the round ligaments are exposed in the ingninal canals, drawn upon so as to elevate the uterus, and then fixed to the aponeurosis.
Prolapse.—The subjects of prolapse and retroversion are closely connected. for a prolapsed uterus is invariably retroverted. The pro lapse may he of less or greater extent, and it is noticeable that more pain and dragging are complained of when the prolapsed organ still lies within the orifice of the vulva than when its supports have yielded completely, and it has made its way outside the hody (procidentia). In the majority of cases advanced prolapse is associated with hypertrophy and elongation of the cervix, which in procidentia may attain two Or three times its normal dimensions, and in these circumstances ulceration often arises from the exposure of the mucous membrane to mechanical injury.
The uterine displacement is often associated with eversion of the vagina through a relayed vaginal outlet caused by stretching or rupture of the anterior fibres of the levator ani, with cystoccle, a hernia] protrusion of the anterior vagina] wall and bladder, or reduce*, a similar protrusion of the posterior vaginal wall and rectum. These conditions may be present without marked prolapse of the uterus itself and may require treatment.
In undertaking the care of a case of prolapse, including evstocele and rectocele, two lines of treatment are open—radical or palliative—and in deciding on which is to be adopted the following considerations should he kept in view: When the patient is young and likely to become pregnant at no long interval, there is little benefit to be gained by an operation for repairing lacerations which will probably he renewed at the next con finement, or for narrowing a canal which is soon to be distended by a full-term foetal head. On the other hand, when the approach of the menopause finds a woman with a gaping vulva and uterine prolapse, it is scarcely good practice to advise her to endure the discomforts and restraint of a pessary for the term of a long post-sexual life, even if the stretching of fascia and weakening of muscle which accompany the loss of youthful vigour are not likely to render the wearing of such a support ineffectual. When the patient suffers from cervical endometritis, an
attempt should he made to cure it. before a pessary is inserted, and if the cure demands curetting or the repair of a cervical laceration, a complete operation for the relief of the prolapse will add little to the risk and will be more satisfactory. Operation may be only partially successful, and the patient may have to resort to the wearing of a pessary through yielding of the united structures. On the other hand, many patients cannot retain a pessary on account of relaxation of the vaginal outlet, and operation is necessary if they are to have any comfort at all. There is no inherent objection to a pessary if a patient prefers it to operation, if she will submit to proper hygiene while wearing it, and if a suitable one can be fitted.
If a pessary is decided on, the methods of using the instrument already described under retroversion should he followed. Broadly speaking, the most satisfactory results will be got from a ring, but in cases of rectocele a Smith-1 lodgewith the broad end forwards is sometimes more successful, and in cases of cystocele a Galabin's cradle or a Gehrung pessary may be more serviceable. A bad case of prolapse can often be kept up by a stem pessary, when a ring cannot be retained ; the ring portion is first introduced and the stem is then screwed into place. A still better form is the " shelf " pessary, which is, however, very difficult to introduce. In the worst cases a cup-and-stem pessary supported by a belt with perinea' straps may be the only apparatus that will keep up the uterus.
Operative treatment usually entails a number of procedures, and it may be taken for granted that a simple perineorrhaphy will seldom cure a prolapse, though it usually enables a pessary to be retained when that could not be done before. It is wise to commence by curetting the uterus to remove any traces of chronic endometritis, and to promote involution of the organ, which is usually in a state of congestive hyper zemia. The cervix often requires to be attended to ; lacerations should he sutured, and hypertrophy should be met by a wedge-shaped excision of the exuberant tissue. The vagina frequently requires to be narrowed, and this may be effected by anterior colporrhaphv if cystocele be present. or by posterior or lateral colporrhaphy. The vulva] opening should be narrowed by a perineorrhapliy, either Lawson Tait's or a modified Emmett. Lastly, in cases of advanced prolapse, where the uterine supports are so lax as to have lost all value, means must be taken to anchor the uterus in its place, and this may be done by abdominal suspension or fixation, or by vaginal suspension as suggested under Retroversion (q.v.). The temptation to remove a uterus for procidentia should never he yielded to, as, no matter how neat the result at the time, the vagina itself is practically certain to yield and a hernial protrusion of it to form.