Download - Some observations on the operative treatment of fixed backward displacement of the uterus
SOME OBSERVATIONS ON THE OPERA1'IVETREATMENT OF FIXED BACKWAI{D DIS~
PLACEMENT OF THE UTERUS.
By A<\LFRED Sl\IITH, F.R.C.S.I.;
Professor of Midwifery , N. U .1. ;
GYllfficologist, St. Vincent's Hospital, ])uLlin.
lRead in the Section of 0 bstctrics, l\Iarch 2, 1917. J
f).'HE operative treatment for fixed backward displacement
of the uterus is one of the most gratifying advances in
gynetic surgery. If you, about a decade ago, asked any
gynsecologist what was their treatment for a fixed back
ward displacement uterus, he would advise you to use
either ichthyol and glycerine plugs, hot douches, mud
baths, or pelvic massage, &c. Now a laparotomy is per
formed, adhesions are broken down, and the uterus is
suspended or fixed at the choice of the operator.
Has finality been reached or has the last word been said
when you have suspended or fixed the uterus? The class
of fixed backward displacements that I had to deal with
was that caused by pelvic peritonitis, the uterus being
held down by fibrous adhesions, complicated in many cases
with prolapsed and fixed appendages. My routine treat
ment was to separate the uterus Irom the adhesions,
straighten out the tubes, free the ovaries, resect when
necessary, and draw" loops of the round ligaments through
the recti muscles, stitch them there after the manner
By DR..ALFRED S~IITH. 181
recommended by Dr. Gilliam. The" end results " were
not satisfactory. Many patients afterwards complainedof dragging pains; referred to the suspension points in the
recti muscles. I thought that perhaps my technique was
faulty.I soon found that all cases could not be treated alike,
but that each should be treated on its merits. The be
haviour of the uterus was different after the separation of
the adhesions. In some cases the uterus came easily up
to the abdominal wall, showing a certain amount of relaxation of its supports. In others it did not come up so easily,but some considerable degree of force was necessary to
draw it up into position. Thus, I was able to divide my
cases into two groups: (a) The uterus with relaxed sup
ports. (b) The uterus with unrelaxed supports.
Group (b) should he treated quite differently from
group (a). The uterus with relaxed supports-group (a)
must be suspended or fixed. Suspended preferably during
the child-bearing age; fixed when the climacteric waspassed.
On freeing uteri with unrelaxed supports three typeswere met with: (1) Where the uterus righted itself auto
matically; (2) where manual replacement was necessary;
and (3) where, owing to a thickened and shortened utero
sacral ligament, the uterus could not be brought into the
normal position of anteflexion. Types (1) and (2) have
little tendency to fall back; suspension or fixation is there
fore unnecessary.
As there is always a certain amount of interference with
the blood circulation in fixed displacements of the uterus,
I find it advisable to place a gauze tampon in the vagina,
so as to tilt the cervix backwards. This enables the blood,
circulation of the uterus to become normal, Tampons
182 Fixed Backuxird Displacement of the Uterus.
-should be removed at the end of twenty-four hours, the
vagina irrigated, and a fresh tampon introduced.The treatment of type (3), fixed displacements, with
.thickened and shortened utero-sacral ligaments baffles me.I merely free the uterus from its entanglements, straightenout tubes, release the ovaries where necessary, and leavethe rest to nature. It would be hopeless to attemptsuspension or fixation.
The unsatisfactory " end results" previously mentioned
of the dragging pains referred to the suspension points in
the recti muscles was now explained. I had been suspend
ing uteri with unrelaxed supports when I should have leftthem alone.
I bring these observations before you in the hope oi
interesting you in determining the limitations of suspension
or fixation, and of putting the operation treatment of fixeddisplacement on a scientific footing. Few of the modern
works deal with the question. Dr. J ellett, in his 1916"Practice of Gynrecology,' ~ recommends the breaking
down of adhesions with a view of correcting the malpositions which they cause, and in the ventral suspensionor fixation of the uterus.
My classifications and groupings are purely provisional.Judging from the literature at my disposal, this subject hasnot been fully dealt with. Possibly, members may give
me references. At any rate, we have ample material inour clinics at the Rotunda, Coombe, and HolIes Street
Hospitals to once and for all determine and give a lead asto the correct principle that should govern gynrecologistsin 'their treatment of fixed backward displacements.
DR. HASTINGS 'fWEEDY said that he too had found greatdifficulty in dealing with the class of cases described by Professor Smith. They usually showed a shallow pOUGh of
By DR. ALFHED S~lITH 183
Douglas and' very hard and unyielding sacro-uterine ligaments. The condition arose from a previous. peri-metritis,and affected the structures included between the sacrauterine folds.
He was in the habit of cutting these folds down to theirbasement connective tissue. By this he frees the uteruswithout injuring the uterine support, for the uterus owes itsentire stability to the utero-peritoneal connective tissue,which lies at the bases of the so-called ligaments. Thefibrous bands are intimately connected with the uterinemuscles, and form tendons to them.
THE PRESIDENT OF THE ACADEMY said.-The subject treatedin Dr. Smith's paper owes its importance to the frequencyof its occurrence amongst the serious sequelte of parturition,the impairment of general health which often attends it,and the partial success which is all that -sometimes attendsour treatment of it. I think Dr. Smith's classification ofsuch cases is a useful and practical one, calculated to aid usin selecting the treatment best suited to each case.
DR. BETHEL SOLOMONS thought that in all cases of fixedbackward displacement which were treated by operation theuterus should be suspended in the manner suitable to thecase. He considered that the mere loosing of adhesions, assuggested by Dr. Smith, was not enough to bring about. apermanent cure. Where there was a tendency for uterosacral ligaments to exert tension on the uterus. which wassuspended, tumponnade , by means of medicated vaginalplugs, would cure this inflammatory condition. He deemedit advisable to curette the uterus in addition t-o correcting themalposition. .
THE PRESIDENT said the classification which had been madewas very necessary in the treatment of cases. He hadadopted the method of suspension of the uterus to the abdominal wall for some time, but came to the conclusion thatit was unsatisfactory to bring the fundus forward to a fixeddegree in all cases, and now performed a modified Gilliamoperation, as thus the fundus could be brought forwardsufficiently to prevent retrogression without putting unduetension on those uteri which would not come into complete
184 Fixed Backward Displacement of the Uterus.
anteversion. He also considered it most ess-ential when theuterus was brought forward to see that the appendages didnot fall back again, as they often have loose ligaments. TheGilliam operation has the advantage that it takes up someof this slack of the broad ligaments, but if not sufficient theovary should be fixed to the top of the broad ligament.