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.