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Related post: force restraining it in an opposite direction has been removed
A large hospital experience led Dr. Sims, some years ago, to
abandon all methods as unsafe and negative in result, for the
relief of this condition, except the incision of the neck, as pro-
posed by Prof. Simpson. My experience since has fully cor-
roborated his teaching; Ave agree perfectly in principle, and
only differ in the method by which it should be done. His in-
genuity suggested an incision of the posterior lip backward,
directly in the median line. But after a few operations he
abandoned this method as unsatisfactorv. Cases which have
208 Buy Lidocaine Powder Online TEEATMEXT OF DTSMENOREHffiA, ETC. [June,
since come under my observation haye proved that they could
not have been permanently relieved by either. He has since,
I believe, practised Simpson's method entirely, although, judg-
ing from some of his late contributions to the London Lancet,
he has not been uniformly successful, but still regards that
operation as promising tlie best results.
I am satisfied that neither operation will permanently relieve
any case, unless the flexure is confined to the neck and is below
the vaginal junction; while the backward operation as pro-
posed would relieve a moderate flexure, the lateral one, how-
ever, even if extended on each side to the vaginal junction,
could not accomplish so much, unless the posterior one, in
the process of healing retracted sufficiently to clear the seat of
stricture, which it could not do. The dysmenorrhoea would
return after a few months, although the sound might be readily
passed.
The explanation to be offered is, that the posterior lip, lying
on the floor of the pelvis, with the weight of the viscera above
pressing downward, would keep the two surfaces so closely
in contact that the menstrual fluid would be retarded in its
escape.
The representation repeated by all works on anatomy, in
locating the uterus on a line of the superior strait, is not
strictly correct. Some approximation is reached, it is true,
yet, in a woman who has borne children or who has suffered
from uterine disease, (unless the organ is retroverted.) the cer-
vix is found resting either on the rectal septum or on the floor
of the pelvis. The objection, therefore, to the lateral operation
by pressure on the posterior lip, is tenable.
The position of the uterus is not appreciated by the use
of the ordinary speculum, as its length in conformity with the
accepted position must push the organ before it.
If a female is placed on the back, with the extremities flexed,
and the perinteum firmly pressed back as far as possible by the
thumb, the cervix will be brought into view in almost all who
have borne children; the length of the p(Tina?um is the only ob-
stacle in cases where it cannot be readily demonstrated.
Li cases seeking relief, a change has been going on for years
with every deviation of flexure from a simple version, until
1865.] TREATMENT OF DYSMEXORRHCEA, ETC. 209
a condition has at length been reached approximating to tliat
represented in the diagram. In this case complete atrophy of
the body has not yet taken place, except on the anterior wall at
the seat of flexure. The canal is also shown above the flexure
as dilated in consequence of the menstrual accumulation. This
dilatation at times takes place to such an extent as to give
an idea of hypertrophy of the uterus, while in fact the walls are
thinner than natural. As soon as menstruation ceases the
organ collapses, and we recognize a state of atrophy. On
carefully introducing a uterine probe which has been bent
to the curve of the organ, the passing of the point of constric-
tion will immediately be recognized, for the resistance to the
instrument will cease so suddenly as to convey the impression
of perforation. When this dilatation exists there is always a
greater or less degree of retention of the secretions, which are
retained long enough to act as an irritant on the lining mem-
brane along its course of escape, causing pruritus on coming in
contact with the atmospheric air at the outlet of the vagina.
By referring to the diagram, it will be seen at a glance that
a simple division of the posterior lip, extended backward even
to the vaginal junction, could not relieve the difficulty, as the
seat of constriction is still above the point reached by the
incision.
In such cases, for the purpose of straightening the canal, I have
found it necessary, in addition, for their relief, to freely divide
the angle formed by the doubling of the anterior wall of the
uterus upon itself; without this step no permanent relief can
be obtained. It must be done boldly, with the view of opening
the canal perfectly; but at the same time it should be borne in
mind that, without a due realization of the danger, with the parts
in a state of fatty degeneration and the uterine walls so thin at
this point, a perforation is possible. The danger, as in any
other operation, however simple, has only to be appreciated by
the careful operator for its occurrence to be avoided; and
to take place, I can only comprehend it as the result of the
greatest carelessness. I can fully corroborate Dr. Sims' testi-
mony as to the degree of risk in a simple division of the cervix.
During the past six or seven years we have performed the
operation several hundred times for various purposes, in hos-
210

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