Page images
PDF
EPUB

also the tension of the pelvic fascia throughout the pelvis, that proper support may be given to the levatores and the connective tissue and its vessels and the rectum and bladder. When this is thoroughly done, we shall be able to discard various auxiliary operative procedures such as the Alexander ventro-fixation and others, and stand squarely by the results of our plastic work on the pelvic floor.

Previous to any surgical procedures, Emmet advocates preparatory treatment. After replacing the uterus and pushing it up as far as may be in the pelvis, the patient is placed in bed, the foot of which is raised from twelve to eighteen inches from the floor. The object of this treatment is to cause contraction of all the pelvic veins with a resulting involution of the uterus and vagina. This treatment must, however, be carried out for some time, which will be urged as a serious objection, as many poor patients cannot afford the loss of time. Munde's custom was to amputate the cervix high up and leave a granulating wound at the fornix, which, by its contraction, was to hold the cervical stump backward, when the fundus must fall forward.

If the cervix is repaired two objects must be attained: first, the complete removal not only of all scarred tissue, but equally important, of all diseased tissue; second, the excision must be carried down to the plane level with the bottom of the tear where it touches the canal. You may choose between Emmet's and Reynolds's anterior colporrhaphy. In doing the posterior operation the writer would advise carrying the denudation the whole length of the vaginal wall. I have succeeded in obtaining splendid results in five cases operated upon according to the above described methods.

To maintain a prolapsed uterus in a normal position by means of a series of plastic operations is by no means an easy task; still, there is less danger to the patient than in doing either a ventro-fixation or a suspension. The writer

has abandoned the operation for ventro-fixation for the following reasons: It is unscientific, as it places the uterus in an arbitrary position--the uterus is made to support rather than to be supported. It is a barrier to normal gestation. The circulation is more or less disturbed, as the vessels are put on the stretch and vesical irritation is sometimes caused by dragging the uterus beyond a certain level, which is certainly done in this operation. Again, no operator can predict in advance how large or how small the resulting adhesions may become. Just here is the element of uncertainty and danger. If small, they will probably stretch into a suspensory ligament; if dense and large, you may expect trouble.

The writer is opposed to creating artificial supports. Nature has furnished enough if proper use is made of them. After the menopause there may be no such objections as to making a fixed uterus support relaxed tissues, for then it is at functionless organ.

Soon after Dr. Gilliam published his operation known as Round Ligament Ventro-Suspension for Retro-Deviations, the writer performed it in a number of cases. From a physiological standpoint, it would seem that a suspended rather than a fixed uterus would better meet the demands of gestation. Unfortunately the writer has not had an opportunity to study the effect of gestation upon ligaments so treated. Like fixation, there are serious objections to it,-the great possibility of intestinal strangulation and obstruction. Again, the uterus is in an arbitrary position, one set of supports doing the work of all. How long ligaments treated thus will act as a sustaining power, is a question the writer is not prepared to answer.

In failures, after a series of plastic operations, the intrapelvic method advocated by Mr. Henry T. Byford, for prolapse and procidentia, is worthy of consideration as it makes use of every available support.

When a hysterectomy is decided upon the vaginal route is preferable, uniting the anterior and posterior peritoneal margins, and then an end to end approximation of the stumps of the broad ligaments ought to form such a perfect support that there will be no danger of any future hernia.

In conclusion permit me to say that whichever method you may choose, it will depend upon the degree of skill with which the work is executed, whether the outcome will be success or failure.

DISCUSSION.

Dr. J. C. IRISH, of Lowell: I beg to differ somewhat radically from the reader in regard to the treatment of retrodisplacement and prolapse of the uterus by ventral-suspension. I am very much at a loss to understand why it has become so much the fashion to criticise or condemn this operation, or why, when we have at our hands so simple and so effective a means of correcting retroversion and prolapse, so many other more difficult and uncertain procedures should be resorted to.

The four principal criticisms of the after results of the operation are: First, that there is danger of obstruction of the bowels by being caught in the resulting ligament; second, dystocia of labor; third, that the uterus is still left in an abnormal position; fourth, that it is an unsurgical procedure.

I have had a long experience with this operation, going over a good many years, and including more than one hundred and fifty cases. In no instance in my own practice

has obstruction of the bowels occurred from ventralsuspension, nor indeed have I ever heard of a case. This danger, I am certain, is very much more imaginary than real. In regard to the dystocia of pregnancy, a few years ago Dr. Noble, of Philadelphia, investigated over eight hundred cases of ventral-suspension in reference to this point. The only dystocia of pregnancy or labor that he established was the following:

In some cases as the pregnant uterus enlarged, there was a thickening of the anterior muscular structure of the uterine

body and neck, which encroached upon the entrance to the pelvis and interfered with the engagement of the head. The os uteri was also carried backward towards the sacrum.

This single dystocia in labor, due to suspension of the uterus (and this is the only one that is shown), I believe to be entirely avoidable. I am very certain that this faulty development of the pregnant uterus has resulted from the introduction of the sutures on the posterior uterine surface. It is very evident that such forced right-angled attachment to the abdominal wall might interfere with uterine development. By placing the ligatures on the upper anterior surface of the uterus this whole difficulty would be prevented. If my conclusions are correct, the operation should be absolved from the charge of producing this dystocia of labor. It may be true that the uterus after suspension is not left in an exactly normal position, but it is near enough normal so that it ceases to give any trouble to its possessor, and the patient with the suspended uterus is exactly as well satisfied with it as though the position were perfect. At any rate, the patients consider themselves perfectly cured.

This is characterized as an unsurgical operation, but it seems to me that an operation which is so entirely simple, so easy to do, free from danger, and which perfectly corrects the disability for which it is done, is really a very surgical one. Finally, from the result of my own experience and that of my confreres who do ventral-suspension, I believe that no other surgical procedure should be considered in the treatment of uterine retro-displacement or prolapse.

Dr. J. G. BLAKE, of Boston, said that he had not seen any unsatisfactory results follow the operation of suspension of the uterus. If danger of strangulation of intestine arose from the adhesions between the fundus and the abdominal wall, this danger is just as great before as after the menopause; yet many writers say that the operation is indicated after the child bearing period, but not earlier. There are definite indications for suspension, in retro-displacements and moderate degrees of prolapse. In all the cases he has seen, either in hospital or private practice, no trouble has arisen following the operation, and in almost every case partial or complete cure has resulted. The actual cases of strangulation reported as a sequel are extremely few.

ARTICLE XLVI.

TREATMENT

OF LATERAL CURVATURE.

BY EDWARD H. BRADFORD, M.D.

OF BOSTON.

READ JUNE 7, 1904.

« PreviousContinue »