Fixed Backward Displacemeut o/ the Uterus. '257

persisted, and the median nerve was obviously involved in the cicatrix, on Major Purser's advice, and with his kind assistance, I exposed the nerve and dissected off it a con- siderable amount of scar-tissue, with the result that the pain had now almost entirely disappeared.

These cases give some small idea of the variety of the symptoms which may occur, and of the difficulty of form- ing a correct diagnosis. As to the methods of treatment employed, I do not lay any claim to infallibility, and shall be extremely glad if these remarks call forth useful sug- gestions as to future alterations and improvements.

The importance of studying the question of shell-shock will probably be recognised only after the war, when in civil life every trivial or serious injury may be followed by "' shock," compared with which " railway spine " will seem the merest child's play. What a time the lawyers, medical experts, and insurance companies will have ! Tile fate of those ingenuous enough to enlist in tho threatened State Medical Service when engaged in curing such cases on a strictly limited salary will make that of an Irish dispensary doctor seem almost Elysian.

ART. XX.--Son~v Observatio~s on the Operative Treat- ment o/Fixed Backward Displacement o/ the Uterus.a By ALFaED S~ITH, F.R.C.S.I . ; Professor of Midwifery, N .U. I ; Gyn~ecologist, St. Vincent's Hospital.

THE 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 gyn~ecologist what wa~ 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.

Read before the Section of Obstetrics in the Royal &cademy of Mediaine in Ireland on Friday, March 2, 1917.

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258 Fixed Baekwa,rd Displaccme~tt o] the Uterus.

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 from 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 recommended by Dr. Gilliam. The " end results " were not satisfactory. Many patients afterwards complained of dragging pains ; referred to the suspension points in the recti muscles. I thought that perhaps my technique was faulty.

I soon fround 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 relaxa- tion 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 be 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 was passed.

On freeing uteri with unrelaxed supports three types were 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

By Dm ALFm~D SmTm "259

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 ~'agina, so as to tilt the cervix backwards. This enables the blood circulation of the uterus to become normal. Tampons 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-saeral ligaments baffles me. I merely free the uterus from its entanglements, straighten out tubes, release the ovaries where necessary, and leave the rest to nature. It would be hopeless to attempt suspension 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 left them alone.

I bring these observations before you in the hope o[ interesting you in determining the limitations of suspension or fixation, and of putting the operation treatment of fixed displacement on a scientific footing. Few of the modern works deal with the question. Dr. Jellett, in his 1916

Practice of G3nwcology, recommends the breaking down of adhesions with a view of correcting the real- positions which they cause, and in the ventral suspension or fixation of ~he uterus.

1VIy classifications and groupings are purely provisional. Judging from the literature at my disposal, ~his subject has not been fully dealt with. Possibly, members may give me references. At any rate, we have ample material in our clinics at the Rotunda, Coombe, and Holies Street ttospitals to once and for all determine and give a lead as to the correct principal that should govern gyn~eeologists in their treatment of fixed backward displacements.