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Retrodisplacements of the Uterus and Pregnancy
292
THE
AMERICAN
JOURNAL
OF OBSTETRICS
AND
(:YNE:COLOc+T
strength by every drop of blood that is lost, and if we can shut that off by cornpression of the abdominal aorta, the blood supply to the uterus, it is amazing to see how quickly a tired uterus will come togcthcr and retract. In the third stage. the uterus goes through the physiologic acts of separation, expulsion and retraction? just as it has affected dilatation of the cervix, and conservation of the muscular tone during labor, assures retraction whrz1 the uterus is empty. DR. EDWA.RD SPElDEL, LOUISVILLE, KENTUCKY.--I :m glad to hrar the resuits of Polak’s investigations in regard to the amount of blood lost after the birth of the baby, because a few years ago, Williams, of Baltimore, published illrestigations made at the Johns Hopkins Hospital in which he found that it was Quite a common for a woman to lose 500 C.C. of blood after the birth of the child. number of women l,ost 1000 c.c., and somt ati much as 1600 c.c. without giving symptoms of postpartum hemorrhage. Polak’s figures arc one-half the figures given by Williams as the lowest, and they are important for the reason that they give us some clue as to what can be called normal blood loss in a woman. It would l)e unreasonable to suppose that a woman cwul11 lust from WC to three pints of Glootl in a normal labor without showing considerable distress. Another point in Nature’s method of checking hemorrhage was not mentioned by the essayist, that namely, the blood vessels of the placenta arc’ elastic, xud when in consequence of the contraction of the uterus the ainuscs are torn through they rctract into the muscle bundle, and the muscles being arranged in the form of a figure of eight, contract down upon them and ligate them in that way. I think a very important thin g in thr 1Jrcvcntion of postpartum hemorrhage is to stop instructing our trained nurses, ati *oun as it Imby is delivered to put their hands on the uterus and manipulate it. That is followed in OLK city to a great extent, and I b&eve the trained nurses hrrcafter sl~ould bc taught to let the uterus entirely alone after the birth of thp child and lea\-e it to them physician to watch for any s~idclt=n dilatation and hcmllrrliagr from rc~lnsation.
DR.
B.
R.
MCCLELLAN,
placements
SENIA,
of the Uterus
OHIO,
presented
and Pregnancy.
a paper (FOIL
original
on
Betrodisarticle
see
page 242.) DIS~CXJSSION DR. HERMAN E. HAYD, I%rrFPA.I,O, NEV YORK.---The subject which the doctor has presented this morning is as fecund as it was fifteen years ago when I wrote a number of papers ,011 rctroversion of the uterus and which led, as you may remember, to a very active and acrimonious discussion as to the methods which were to be employed in their treatment. The abstract of the do&or’s paper as given in the program reads, “are displacements of the uterus responsible for sterility? ” Yes, but there must be some other elements than the mere mechanical difficulties and they certainly come later from Therefore, we must realize that cavery displaced uterus obstruction to drainage. may sooner or later be associated with a eatarrhal endometritis or a catarrhal salpingitis which will, of course, increase the acidity of the vaginal secretions and I am satisfied that there does exist a class necessarily interfere with fecundation. of retrodisplaced uteri that do not proclucc symptoms, although I am equally satisfied that sooner or later many of these uteri will produce symptoms, and when they do so, they should be operated upon, as I think a pessary is only useful in recently retrorerted or retroflexed utrli. A utenls that has recently fallen after a miscarriage or after labor should be treated with a pessary, and if the woman wears the pessary for, a few months and it is found, when it is taken nut, that the uterus has fallen back, we should consider the cast a surgical one and operate.
AM.
ASSN.
OBST.,
GYNEC.,
AND
ABD.
SURG.
293
The doctor has spoken of and seems to endorse strongly the Gilliam operation. I am going to make a plea for the Alexander operation in uncomplicated cases of retroversion of the uterus; I mean cases where there is no recognizable tubal or I have ovarian trouble and the uterus is movable and yet producing symptoms. done a good many Alexander operations and I have succeeded in having women bear one, two and three children after this operation; they are grandmothers now I have seen in one and their daughters I have operated upon for retroversion. family three women upon whom I have done the Alexander operation, wherein the uterus stood the test of pregnancy, where it remained in position, and where the women were relieved of their symptoms and of all possible late intraperitoneal complications which were the result of operations, which open the adbominal cavity. However, when we have a different class of cases to deal with, where the tubes and the ovaries are involved, then we must employ an abdominal method as these Perhaps, once in a while, we are not uncomplicated cases of retrodisplaced uteri. may make a mistake in diagnosis in a case where some slight adhesion may exist, or probably a tube may be thickened and closed, but after all, these mistakes should be rare. Unfortunately it is claimed that all symptoms producing retrodisplaeements necessarily have tubal and ovarian pathology or there is present chronic appendicitis or some other intraabdominal trouble, so the abdominal operation is done, not alone for the retroposition, but to explore the abdomen. It is so much easier to do this, than it is to do an Alexander operation. I have done many Gilliam operations; I have done quite a number of Webster-Baldy operations, and I have made up my mind after twenty-five years of experience, and you will not change the result of that experience by your discussions today, and I shall continue to do the simple looping, reduplication of the round ligaments operation such as Mann described years ago, as it holds the uterus up and causes fewer adhesions and subsequent complications. I do not care particularly what operation you do on the round ligament as long as you reduplicate it sufficiently and sew it together with linen, being careful not to take too much of the ligaments or tie the sutures too tight, so that the ligament atrophies and shrivels up. If there is a heavy uterus, tuck it up to the abdominal wall with a fine catgut, to hold it in place for a few days, and sometimes, if the uterus be large and heavy and the broad ligaments sag, then you can shorten the uterosacral ligaments by putting a couple of stitches through them. I think with this simple technic you can place the uterus permanently where it belongs and you leave the ligaments in position to If the ovary has pull the uterus in the direction which nature originally intended. fallen into the euldesac, shorten its ligament with a couple of fine linen sutures and thus hold it in place. DR. RUFUS B. HALL, CINCINNATI, OHIO.-I should like to endorse the excellent paper that has been presented, as well as the remarks of the last speaker. When we come to consider the question of sterility in women, the essayist only considered one-half of the problem. When a woman comes to you and says that she is sterile, that she has been married five or six years, and wants to have a baby, a very important and interesting problem presents itself to you. You examine the woman and are not quite certain that there is pathology enough present to justify the sterility. Examination may simply show a retroverted uterus which may bc the cause of her sterility. I want to present the other side of the picture. A case came under my observation a few days ago. The husband was thirty-eight years of age, had been married seven years, but they had had no children. The wife was examined by six different men. She had had three curettements and was promised that she would be well. She had worn a pessary which seemingly corrected the retroversion, but still she did not become pregnant. After obtaining this history I said, “Very well, madam, go into the adjoining room,” and after she went into the room I turned to
the husband and said. “ When did you have gonorrheaf” He replied, “I hare not had that since I was married; I had it before.” I sent him to a specialist who found that he was al~solutely sterile. I did not do anything for his wife. DR. WILLISlE PFEIFFER, BROOKLYT, SEW YORK.-The last speaker concern one of the points I want t.o bring out. tion should be undertaken until two things have been done. on the female genitalia for sterility until the male partner the second point is, are the tubes patent?
remarks
ma&
1,~ the
We feel that nu opera%‘e should not operate is first exanincd. And
DR. HUGO 0. I’ANTZER, IXDIANAPCXAC IKDIANA.--A patient confined in the last week came to me after having been married six pears. I found she had a rctroand right lateral retroflexion of tho uterus. I fomicl associated with that ileoceeal torsion au11 a rol2- much shortened ileotendinous band coming down from the ileoceeal jnnctiou to the ovary. I cut the ileotendinous lland, lengthenetl it and she sul)sequently had a baby. DR. JOHN OSBORX PO11.4K, BROOKIsX, NEW Yox---Thcrr is one lruint I most of which we all f~dorse, and want to bring out ia regard to the doctor’s paper, that is, there is a very great difference in the action of spermdtozua that you examine under thcl microscope and thosca examined ia situ. For t,he last five years we have ht?n examining these (‘as(ls after intercourse to determine the condition of tlic sp(~rmatozoa. Many of tllcse rctroversions that were formerly operated on have surprised us. Many of these anteflexions on which we have done operations on the cervix have surprised us 11~ our finding living straight tail spermatozoa well withill tilt* I.clrvie:tl canal; cons~qucntly, it scemb to me, that in any discussion of this sort, not only the anatomical factors on the part of the woman but the potency of the man as the doctor brought out should be investigated, particularly the potency of that man with that particular woman. Another interesting thing is that there is something more important in the mnu than even the production of spermatozoa, because women in whom we have demonstrated patent tubf3 and the presence of spermatozoa inside the cervical canal, and who at operation 11nd apparently healthy ovaries, have not conceived, and yet those same men have married other women and pregnancy has followed. Consequently there must be something in the claim made by genitourinary surgeons, that the stimulation of the sexual act and the consistency of the semen have something to do with the question of sterility. I do not believe we should go on record-and we have all seen certain cases of retroversion of the uterus after correct,ion become pregnant-that that operation or any operation of itself has produced this or that particular pregnancy. There may be something in the stimulation at the time of copulation that does not occur at another time. DR. EDWaRD SPEIDEL, l&JISVlLLE, KENTUCKy.-There is another feature to consider in connection with these cases, and that is, with a uterus in the normal position we have healthy arterial circulation, whereas in retroversion we have a passive venous congestion which interferes with normal function.
DR. JAMES A. HARRAR, NEW YORK, N. Y., presented a paper entitled Functional Dystocia in Nwm!al P&es: Recognition and Banagemen& (For original article see pnge 246.) DISCUSSION DR. examine
JAMES the
Ii. fetal
QUIGLEY, heart
every
ROCHESTER, thirty
minutes,
NEW and
Yom.---Our oftener
interns than
that
in
and
nurses
the
second
THE
AMERICAN
JOURNAL
OF OBSTETRICS
AND
(:YNE:COLOc+T
strength by every drop of blood that is lost, and if we can shut that off by cornpression of the abdominal aorta, the blood supply to the uterus, it is amazing to see how quickly a tired uterus will come togcthcr and retract. In the third stage. the uterus goes through the physiologic acts of separation, expulsion and retraction? just as it has affected dilatation of the cervix, and conservation of the muscular tone during labor, assures retraction whrz1 the uterus is empty. DR. EDWA.RD SPElDEL, LOUISVILLE, KENTUCKY.--I :m glad to hrar the resuits of Polak’s investigations in regard to the amount of blood lost after the birth of the baby, because a few years ago, Williams, of Baltimore, published illrestigations made at the Johns Hopkins Hospital in which he found that it was Quite a common for a woman to lose 500 C.C. of blood after the birth of the child. number of women l,ost 1000 c.c., and somt ati much as 1600 c.c. without giving symptoms of postpartum hemorrhage. Polak’s figures arc one-half the figures given by Williams as the lowest, and they are important for the reason that they give us some clue as to what can be called normal blood loss in a woman. It would l)e unreasonable to suppose that a woman cwul11 lust from WC to three pints of Glootl in a normal labor without showing considerable distress. Another point in Nature’s method of checking hemorrhage was not mentioned by the essayist, that namely, the blood vessels of the placenta arc’ elastic, xud when in consequence of the contraction of the uterus the ainuscs are torn through they rctract into the muscle bundle, and the muscles being arranged in the form of a figure of eight, contract down upon them and ligate them in that way. I think a very important thin g in thr 1Jrcvcntion of postpartum hemorrhage is to stop instructing our trained nurses, ati *oun as it Imby is delivered to put their hands on the uterus and manipulate it. That is followed in OLK city to a great extent, and I b&eve the trained nurses hrrcafter sl~ould bc taught to let the uterus entirely alone after the birth of thp child and lea\-e it to them physician to watch for any s~idclt=n dilatation and hcmllrrliagr from rc~lnsation.
DR.
B.
R.
MCCLELLAN,
placements
SENIA,
of the Uterus
OHIO,
presented
and Pregnancy.
a paper (FOIL
original
on
Betrodisarticle
see
page 242.) DIS~CXJSSION DR. HERMAN E. HAYD, I%rrFPA.I,O, NEV YORK.---The subject which the doctor has presented this morning is as fecund as it was fifteen years ago when I wrote a number of papers ,011 rctroversion of the uterus and which led, as you may remember, to a very active and acrimonious discussion as to the methods which were to be employed in their treatment. The abstract of the do&or’s paper as given in the program reads, “are displacements of the uterus responsible for sterility? ” Yes, but there must be some other elements than the mere mechanical difficulties and they certainly come later from Therefore, we must realize that cavery displaced uterus obstruction to drainage. may sooner or later be associated with a eatarrhal endometritis or a catarrhal salpingitis which will, of course, increase the acidity of the vaginal secretions and I am satisfied that there does exist a class necessarily interfere with fecundation. of retrodisplaced uteri that do not proclucc symptoms, although I am equally satisfied that sooner or later many of these uteri will produce symptoms, and when they do so, they should be operated upon, as I think a pessary is only useful in recently retrorerted or retroflexed utrli. A utenls that has recently fallen after a miscarriage or after labor should be treated with a pessary, and if the woman wears the pessary for, a few months and it is found, when it is taken nut, that the uterus has fallen back, we should consider the cast a surgical one and operate.
AM.
ASSN.
OBST.,
GYNEC.,
AND
ABD.
SURG.
293
The doctor has spoken of and seems to endorse strongly the Gilliam operation. I am going to make a plea for the Alexander operation in uncomplicated cases of retroversion of the uterus; I mean cases where there is no recognizable tubal or I have ovarian trouble and the uterus is movable and yet producing symptoms. done a good many Alexander operations and I have succeeded in having women bear one, two and three children after this operation; they are grandmothers now I have seen in one and their daughters I have operated upon for retroversion. family three women upon whom I have done the Alexander operation, wherein the uterus stood the test of pregnancy, where it remained in position, and where the women were relieved of their symptoms and of all possible late intraperitoneal complications which were the result of operations, which open the adbominal cavity. However, when we have a different class of cases to deal with, where the tubes and the ovaries are involved, then we must employ an abdominal method as these Perhaps, once in a while, we are not uncomplicated cases of retrodisplaced uteri. may make a mistake in diagnosis in a case where some slight adhesion may exist, or probably a tube may be thickened and closed, but after all, these mistakes should be rare. Unfortunately it is claimed that all symptoms producing retrodisplaeements necessarily have tubal and ovarian pathology or there is present chronic appendicitis or some other intraabdominal trouble, so the abdominal operation is done, not alone for the retroposition, but to explore the abdomen. It is so much easier to do this, than it is to do an Alexander operation. I have done many Gilliam operations; I have done quite a number of Webster-Baldy operations, and I have made up my mind after twenty-five years of experience, and you will not change the result of that experience by your discussions today, and I shall continue to do the simple looping, reduplication of the round ligaments operation such as Mann described years ago, as it holds the uterus up and causes fewer adhesions and subsequent complications. I do not care particularly what operation you do on the round ligament as long as you reduplicate it sufficiently and sew it together with linen, being careful not to take too much of the ligaments or tie the sutures too tight, so that the ligament atrophies and shrivels up. If there is a heavy uterus, tuck it up to the abdominal wall with a fine catgut, to hold it in place for a few days, and sometimes, if the uterus be large and heavy and the broad ligaments sag, then you can shorten the uterosacral ligaments by putting a couple of stitches through them. I think with this simple technic you can place the uterus permanently where it belongs and you leave the ligaments in position to If the ovary has pull the uterus in the direction which nature originally intended. fallen into the euldesac, shorten its ligament with a couple of fine linen sutures and thus hold it in place. DR. RUFUS B. HALL, CINCINNATI, OHIO.-I should like to endorse the excellent paper that has been presented, as well as the remarks of the last speaker. When we come to consider the question of sterility in women, the essayist only considered one-half of the problem. When a woman comes to you and says that she is sterile, that she has been married five or six years, and wants to have a baby, a very important and interesting problem presents itself to you. You examine the woman and are not quite certain that there is pathology enough present to justify the sterility. Examination may simply show a retroverted uterus which may bc the cause of her sterility. I want to present the other side of the picture. A case came under my observation a few days ago. The husband was thirty-eight years of age, had been married seven years, but they had had no children. The wife was examined by six different men. She had had three curettements and was promised that she would be well. She had worn a pessary which seemingly corrected the retroversion, but still she did not become pregnant. After obtaining this history I said, “Very well, madam, go into the adjoining room,” and after she went into the room I turned to
the husband and said. “ When did you have gonorrheaf” He replied, “I hare not had that since I was married; I had it before.” I sent him to a specialist who found that he was al~solutely sterile. I did not do anything for his wife. DR. WILLISlE PFEIFFER, BROOKLYT, SEW YORK.-The last speaker concern one of the points I want t.o bring out. tion should be undertaken until two things have been done. on the female genitalia for sterility until the male partner the second point is, are the tubes patent?
remarks
ma&
1,~ the
We feel that nu opera%‘e should not operate is first exanincd. And
DR. HUGO 0. I’ANTZER, IXDIANAPCXAC IKDIANA.--A patient confined in the last week came to me after having been married six pears. I found she had a rctroand right lateral retroflexion of tho uterus. I fomicl associated with that ileoceeal torsion au11 a rol2- much shortened ileotendinous band coming down from the ileoceeal jnnctiou to the ovary. I cut the ileotendinous lland, lengthenetl it and she sul)sequently had a baby. DR. JOHN OSBORX PO11.4K, BROOKIsX, NEW Yox---Thcrr is one lruint I most of which we all f~dorse, and want to bring out ia regard to the doctor’s paper, that is, there is a very great difference in the action of spermdtozua that you examine under thcl microscope and thosca examined ia situ. For t,he last five years we have ht?n examining these (‘as(ls after intercourse to determine the condition of tlic sp(~rmatozoa. Many of tllcse rctroversions that were formerly operated on have surprised us. Many of these anteflexions on which we have done operations on the cervix have surprised us 11~ our finding living straight tail spermatozoa well withill tilt* I.clrvie:tl canal; cons~qucntly, it scemb to me, that in any discussion of this sort, not only the anatomical factors on the part of the woman but the potency of the man as the doctor brought out should be investigated, particularly the potency of that man with that particular woman. Another interesting thing is that there is something more important in the mnu than even the production of spermatozoa, because women in whom we have demonstrated patent tubf3 and the presence of spermatozoa inside the cervical canal, and who at operation 11nd apparently healthy ovaries, have not conceived, and yet those same men have married other women and pregnancy has followed. Consequently there must be something in the claim made by genitourinary surgeons, that the stimulation of the sexual act and the consistency of the semen have something to do with the question of sterility. I do not believe we should go on record-and we have all seen certain cases of retroversion of the uterus after correct,ion become pregnant-that that operation or any operation of itself has produced this or that particular pregnancy. There may be something in the stimulation at the time of copulation that does not occur at another time. DR. EDWaRD SPEIDEL, l&JISVlLLE, KENTUCKy.-There is another feature to consider in connection with these cases, and that is, with a uterus in the normal position we have healthy arterial circulation, whereas in retroversion we have a passive venous congestion which interferes with normal function.
DR. JAMES A. HARRAR, NEW YORK, N. Y., presented a paper entitled Functional Dystocia in Nwm!al P&es: Recognition and Banagemen& (For original article see pnge 246.) DISCUSSION DR. examine
JAMES the
Ii. fetal
QUIGLEY, heart
every
ROCHESTER, thirty
minutes,
NEW and
Yom.---Our oftener
interns than
that
in
and
nurses
the
second