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paper he says he obtained from a London maker the statement that in a year he (the maker) supplies about 10,000 rubber rings and globular rings, and about 3,000 ‘Hodge's made of vulcanite; another London maker supplied in one month 250 dozen of all sorts, more or less; amounting in a year to about 36,000, and this number apart from vast quantities imported from Germany and other countries." Mr. Sutton, in conclusion, states “that nearly every gynæcologist has his own pet notions concerning the shape of pessaries or the material of which they are made, and he states that there is only one place for pessaries designed to cure retroversion of the uterus, and that is the fire." It has been indicated above that there are some cases which may at least be benefited and relieved of their symptoms by the wearing of a pessary, and if the patient does not find it disagreeable, or that it involves frequent vaginal injections, or that it interferes with marital relations, or that the periodical removal and replacement are not irksome, then she may choose this palliative method of treatment in preference to the alternative one of an operation designed for its cure, but it is the duty of her medical attendant to acquaint her of what the two lines of treatment mean and allow her to decide for herself. Pessaries are contra-indicated where the fundus is fixed, where the condition is rendered more painful by their insertion in cases of mobile retroversion, and where the ovaries, one or both of them, are prolapsed, especially when they are congested or inflamed. It is generally considered best not to use a pessary in young unmarried girls.

Vaginal Tampons.— The use of tampons or the packing of the vagina by plugs of cotton wool is adopted by some as a palliative measure in cases where the uterus is fixed and pelvic adhesions are present. This method is employed where pain is present and the pelvic inflammation is more or less recent, and a preliminary to the wearing of pessary. By the use of tampons when they have been carefully inserted into the vagina, the uterus is elevated, and by the repetition of the insertions extending over some weeks an alteration leading either to some mobility of the uterus or to

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some diminution in size of an inflamed tube or ovary may be noticed. The tampon may be soaked in boroglycerine, and should not remain in longer than twenty-four hours.

The method of insertion is to pack the posterior fornix as much as possible, so as to antevert the uterus just short of producing pain; in this way the adhesions may in time give somewhat. The process is tedious, and though there may be a great improvement in the general and local symptoms in the course of a few weeks, still the prospect of cure is uncertain as to the amount of relief that will be afforded, and, moreover, an operation may ultimately be necessary. Some patients at the outset may not be able or may not care to spend the time in what is after all only a palliative measure, and that of a very uncertain nature, but would rather undergo an operation in the first instance.

Operative Treatment.--The operations that may be performed for the relief or cure of retroversion divide themselves into two groups : I Those which may be done for some associated condi

tion of the displacement, but not involving abdominal

section; and 2. Those which have for their object the deliberate fixing

of the uterus forward, or which may be incidental to

the removal of diseased appendages and adhesions. In the first group there will be included the operations of curettage for metritis, endometritis, and subinvolution : trachelorrhaphy, colporrhaphy, and perineorrhaphy for injuries to the cervix, vagina, and perineum. One or more of these operations may be all that is required to be done or may be done as preliminary to the wearing of a pessary; frequently a puerperal case of retroversion with a large fundus, dilated cavity, and a leucorrhæal discharge may be cured by dilatation of cervix, curettage, and maintaining the organ in anteversion during the rest in bed : should the uterus remain in retroversion after this, cure of the displacement may be obtained by subsequently wearing a pessary for a short time. Sometimes a pessary will not keep in place until the

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perineum has been restored. Many cases of subinvolution with lacerated cervix can only be cured by repair to the cervix (Emmet's operation) in conjunction with curettage.

The second group include a great number, the chief amongst which are:-Fixing the round ligaments in the inguinal canals or Alexander-Adams' operation, ventrofixation, ventro-suspension, and vaginal fixation.

Indications for Operation.— The number of cases requiring an operation, compared with the total number of cases of retroversion which either want no treatment or else can be relieved by some support, do not amount to many. Herman states that of 10 per cent. of all the cases that come for treatment, only about two of these need an operation. Dührssen admits to operating on one half of his cases, and Theilhaber of Munich states that retroversion causes symptoms and needs no orthopædic treatment, and that all the co-existing troubles are due to uterine catarrh, hysteria, neurasthenia or intestinal atrophy. Most gynæcologists, however, agree that many cases cause no symptoms or discomfort, while in some serious trouble is produced, but no one is agreed as to the symptoms which retroversion may cause; reflex symptoms connected with the stomach, etc., as gastric oppression, dyspepsia, and general lassitude, headaches, and the like have been attributed to a retroversion, and by the writings of some this displacement has been adopted as a universal cause for all subjective ailments. In the matter of indications for treatment, great care must be exercised : in the first place, not necessarily to hinge irregular pains in the head and stomach and other ailments on to an accompanying displacement of the uterus because it happened to occur in the same patient and was the only physical sign of anything abnormal, just as though it were the exciting cause and that the predisposing cause of neurasthenia or hysteria played no part; and, in the second place, to suppose that a correction of the retroversion will also rectify all the other troubles, but rather it should be generally stated that no case should be submitted to operation, unless the symptoms

present are clearly accounted for by the pathological condition, and failure of relief has attended the palliative treatment in the hands of an intelligent and experienced practitioner. It is frequently most difficult to decide how far the symptoms, be they local or reflex, are due to the pathological state of the uterus, and how far to a weakened nervous system, and if the latter is dependent on the former how far such is the case, and also how far correction of this displacement will relieve the general condition. Backache is a very variable symptom in these cases, and, being subjective in nature, is most fallible for estimation; again, with congestive dysmenorrhæa it is also difficult to correctly gauge its severity. As before remarked, the effect of an operation may to some extent be deterinined beforehand by first supporting the uterus by means of a pessary, and if this produces relief then much the same amount of benefit will result. Cases, however, of fixed retroversion with adhesions or inflamed appendages, most will agree, require an operation for their

cure.

Alexander-Adams' Operation, or the inguinal shortening of the round ligaments, has now been fully established as one of the classical operations of surgery. The operation was first successfully performed by William Alexander, of Liverpool, in 1881, and soon after followed by James Adams, of Glasgow, in 1882, and in consequence is often called after both surgeons. Briefly, the technique consists in making an incision over the external abdominal ring external to the spine of the pubes and parallel to Poupart's ligament; the external oblique fascia covering the inguinal canal is incised, and the ligament, a pinkish-white fibro-muscular cord, is isolated, pulled upon, and anchored to the fascia. This is done on both sides in turn. Many slight modifications are adopted by different surgeons, but the same object is aimed at. As an operation, it has been attended with a considerable measure of success, for Kellogg, quoted by Edebohls in 1896, writes that he has done the operation more than five hundred times, and his failures amount to less than 5 per cent. Quite as good a record as this attends other surgeons who make this

operation a routine method of practice. The arguments in favour of this operation may be stated :-(1) That, for the correction of retroversion, shortening of the round ligaments is the simplest and safest method of treatment: this is important, seeing that it is undertaken for the relief of health and not for the saving of life; the mortality may be put down at nil. (2) That the shortened ligaments will stretch and retract with pregnancy and after labour. Lapthorn Smith (Amer. Journ. Obs., July, 1898) states that in an enquiry which he had made in order to discover the experiences of American surgeons as to the influences of pregnancy and labour on this and other operations, that in no case were they unfavourably interfered with in the former, whereas, when firm adhesion had been secured by ventro-fixation and pregnancy followed, trouble of some kind, as pain, miscarriage, or difficult labour, occurred in about 30 per cent. of the cases. (3) That no band is artificially produced in the abdomen capable of producing ileus. (4) That the ligaments are strengthened at their weakest parts, whereas with intra-abdominal shortening the weak inguinal parts remain. Prof. J. W. Taylor, speaking of this operation in 1901, said " he believed it was the best for uncomplicated backward displacement. The troubles which he formerly experienced had entirely disappeared with stricter asepsis and the use of fine ophthalmic silk as a buried suture to entirely close the wound in the external oblique, and to sew the upper end of the ligament to the under surface of the aponeurosis. He had watched pregnancy come and go afterwards without any difficulty or recurrence of this displacement. Performed as he described in well-selected cases, the results were perfect, and few operations gave patient and operator more unalloyed and permanent satisfaction." Of the objections that have been raised against this operation, some may be mentioned, as the following: That two wounds are made, leaving two scars instead of one; that hernia is more likely to occur in consequence, and especially as the wounds are situated in the inguinal regions; that the operation is attended with some difficulty, either because the ligaments are not easy to find, or else when found they may be so weak as to break

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