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The significance of retrodisplacements of the uterus and the principles involved in a satisfactory correction
Society AMERICAN
Transactions
ASSOCIATION OGISTS
OF
AND
ABDO~IINAL
FORTIETH ASHEVILLE,
DR.
AXNUA C.,
GYNECOL-
SURGEONS I, MEE’l’TNG
SEPl’EiMBER
15,
16,
17,
19.27
entitled Ladin’s Sign of Early Pregnancy Compared With Hegar’s. (For original article see the current volume of the Transactions of the Association.)
W. TOVEY, New
DAVID
DR.
York
B. BACON, Macomb,
JOSEPH
Technic
and a New Instrument
(For original article the Association.) DR.
N.
OBSTETRICIANS,
City,
Ill.,
read
read
a paper
a paper
for Operating
see the current
volume
A New Stricture.
entitled
on Rectal
of the Transactions
of
DAVID HADDEN, Oakland, Cal., read a paper on The Significance of Retrodisplacements of the Uterus and the Principles Involved in a Satisfactory Correction. (For original article, see page 373.) DISCUSSION DR.
WALTER
T. DANNREUTHER,
NEW
YORK
CITY.-It
would
be futile
for
one to attempt a discussion here of the comparative merits of the many operations that have been devised an,d advocated for the correction of retrodisplacements, but I believe
that
it
is wise
to place
the
stamp
of
disapproval
again
upon
the
Kelly
suspension operation. Attending a clinic recently in another city, I was astonished to see the operator do two of these operations, despite the fact that I thought that most gynecologists had long ago been convinced that an intended suspension usually eventuates in either a fixation or a recurrence. It is always necessary to differentiate cases of retroversion that are congenital A congenital uterine displacement produces no from those that are acquired. symptoms and requires no treatment. The symptoms, if any, are due to the incidental hypoplasia and not to the displacement, and any form of therapy directed to the correction of the displacement will result in dis$ppointment. In cases of acquired retroversion, a distinction must be made between the so-called uneomAs a matter of fact, the retrodisplacements that plicated and the complicated ones. are regarded as uncomplicated often give rise to symptoms because of the assoThis explains the insidious ciated venous stasis in the perimetritic structures. and delayed onset of symptoms so frequently observed. pessaries from patients that A word regarding the pessary. I have removed have been inserted upside down, or back to the front, and in one instance both of these mistakes had been made. It is quite possible that the disrepute into which the pessary has fallen is due largely to the ignorance of some of those who apply it. A pessary cannot be expected to correct a retroversion. It is simply a device to bold the cervix back after the uterus has been replaced by the physician. 432
AM.
ASSN.
OBST.,
GYNEC.,
The various ‘curves are designed for specific which a pessary is moulded and constructed instrument will be misused less often.
AND
ABD.
purposes, and are thoroughly
433
SURQ. if the principles understood, this
upon useful
DR. D. L. JACKSON, BOS~N, MA&.--In the operation for the correction of retroversion, we always have to consider the fascial shortening on the anterior wall It is very simple to make a transof the vagina which holds the cervix forward. verse slit at the bladder jusction with the cervix, push the fascia upwards, and then sew longitudinally, thereby correcting that fault and allowing the cervix to drop back so that we do not get an anteffexion of the cervix when the retroversion is corrected. DR. HERMAN E. HAYD, BUFFALO, N. Y.-I agree with a great deal that all of the speakers have said, and perhaps disagree with some of them on some points. There is no question that we cannot do anything for a congenital retroversion. You may hitch it up, but the patient will suffer just the same. The classification those that have borue children that Dr. Dannreuther has made is very practical: and those that have not. Those who have no infection of tubes or ovaries will be cured by any kind of a round ligament operation. Those who have borne children have a disturbed pelvic outlet and that is the difficulty in connection with those cases. Dr. Hadden seems to prefer the Webster operatios. I have given up that operation altogether. I have given up all kinds of operations that involve the perforation of the broad ligament. In the first pIace, there will be adhesions, and the worst kind of adhesions follow that operation. Secondly, the incidence of a possible phlebitis is such as to contraindicate it. After all there is no operatioq that gives me as much satisfaction as the one done by the late Dr. Mann, where he simply lobps the round ligament., and if the case is complicated by a fallen tube and ovary, it is a very simple matter to hitch up the ovary with a few stitches, and There is no question in my mind that a in doing so you will hitch up the tube. retroversion, will sooner or later produce symptoms. DR. GORDON K. DICKINSON, JERSEY CITY.--There are two kinds of wisdom: one is the wisdom of the operating surgeon who has found a cure in a certain specific method; the other is the wisdom of the older man who has tried every method and failed in all of them. My experience is that we are developing slowly along this line. Ten or fifteen years ago there were only one hundred methods of operating for ratrodisplacemeqts; now the doctor tells us there are one hundred and twenty. We are not centralizing on this because in our work we are not thinking, but are trying to follow a beaten path instead of working out each individual case and trying to treat it accordingly. We are all prone to forget that we have the patient as well &s the condition. Some women have retrodisplacements and suffer, while others do not suffer, showing that there is a large neurotic element to be considered. Dr. Dannreuther speaks of the venous congestion. It may be venous or capillary. I find that it is necessary to add to the operative procedure medical treatment. I have found apparently a speci& effect in relieving the congestion by stimulation of the circulation in the pelvis by strophanthus. We must also add proper hygiene, vigorous exercise, and out of door life. The scrub woman, and women in active life never complain of this condition. It is the sedentary, the fashionable woman, who has not enough exercise to throw the blood through the capillaries, who has trouble. We, as surgeons, should be hygienists and physicians as well, but there is no one type of operation in my experience which is going to give us 100 per ceqt results. this
DR. JAMES condition,
E. DAVIS, ANN ARBOR, grossIy one finds the uterus
MlcH.-In is enlarged,
considering the the endometrium
pathology of congested,
434
THE
AMERICAN
JOURNAL
OF
OUSTETRICS
AND
GYNECOLOGY
the stroma hypertrophied or passed on to a condition of hyperplasia. The blood In other words, there is an early state of passive congestion. vessels have thickened. Later there is a condition of atrophy in the face of the condition of an enlarged and heavier uterus than normal. A cross-section of the wall will show that the tissue has changed and it is easy to observe with the naked eye that the walls are thickened and that the organ is not receiving a normal blood supply. Microscopically on,e will see that the nerve trunks have enlarged. Many uteri are removed by the operator because he has suspected myomas or fibromas, and when sectioned it is often a surprise to find only atrophy and fibrosis. Reasoning from this picture of ultimate change, it is quite apparent that something should be done, a suspension, or some form of exercises following delivery, as J. 0. Polak has advocated, or some other procedure to prevent this very obvious pathology. This can be a decision of importance in each individual case. DR. HADDEN (closing).-1 read the last two pages of I severely that I fear Dr. Hayd did not get my meaning. Baldy operation, but what I do under favorable conditions tion. The Webster-Baldy operation can be improperly done see more failures from that than perhaps from the Gilliam, done, very effective.
DR. FRANCIS Vaginismus.
REDER,
(For
St. Louis,
&lo.,
original
article,
read
a paper
see page
paper so hurriedly criticized the Websteris not the same operain many ways and you but it is when properly my
on The TreNatment of 420.)
DISCUSSION DR. LOUIS E. PHANEUF, BOSTON, MASS.-I want to emphasize the satisfactory method of operating by means of local anesthesia. I have operated upop two women recently, using morphine and scopolamine, and half of one per cent novocaine, injecting the mucocutaneous border and depositing about 5 C.C. of the solution in each levator. These women have consented to operation readily on finding that they would not be submitted to general anesthesia. I used a median incision, splitting in the middle line, and sewing laterally with perfectly satisfactory results. I have also delivered some of the women whom I had operated upon b) this method. DR. JAMES W. KENNEDY, PHILAIXL,PHIA, Ph.-During the past three years I have seen more cases of vaginismus than I have had during my entire previous experience. It is a real pathologic entity, aqd we have learned to be more considerate toward the patient than in former years, when we looked upon vaginismus as more or less of a neurotic condition, having little true surgical pathology. T recognize the condition as either a true vaginismus or a pseudovaginismus. If we recognize the pseudovaginismus as a symptom secondary to some local irritating inflammation about the meatus, painful conditions, such as urethral caruncle, fissures in the region of the vaginal orifice or the anus, rigid hymen, or that painful neuroma which may be a remnant of the hymen, then of course we have a I have seen a number of patients have happy solution, of the annoying condition. a paroxysm of the muscles of the vaginal introitus if the examiner merely touched a skin tag which marked the remnants of the hymen, and I have also seen the same symptom emanate from simply palpating with the finger a tense nabothian cyst of the cervix. Some of these patients are in need of sympathy and investigatioq from a nervous standpoint, others need surgery but they are all worthy of careful investigation. DR. ADAM P. LEIGHTON, PORTI~~ND, ME.-This seems to be a malady from It has been my peculiar experience which the women in Maine suffer tremendously. to meet a number of them, and to follow them through to the divorce courts. It seems that many of these cases can be cured, and the penal@ that follows married life may be avoided if we only intelligently try to treat these individuals.
Transactions
ASSOCIATION OGISTS
OF
AND
ABDO~IINAL
FORTIETH ASHEVILLE,
DR.
AXNUA C.,
GYNECOL-
SURGEONS I, MEE’l’TNG
SEPl’EiMBER
15,
16,
17,
19.27
entitled Ladin’s Sign of Early Pregnancy Compared With Hegar’s. (For original article see the current volume of the Transactions of the Association.)
W. TOVEY, New
DAVID
DR.
York
B. BACON, Macomb,
JOSEPH
Technic
and a New Instrument
(For original article the Association.) DR.
N.
OBSTETRICIANS,
City,
Ill.,
read
read
a paper
a paper
for Operating
see the current
volume
A New Stricture.
entitled
on Rectal
of the Transactions
of
DAVID HADDEN, Oakland, Cal., read a paper on The Significance of Retrodisplacements of the Uterus and the Principles Involved in a Satisfactory Correction. (For original article, see page 373.) DISCUSSION DR.
WALTER
T. DANNREUTHER,
NEW
YORK
CITY.-It
would
be futile
for
one to attempt a discussion here of the comparative merits of the many operations that have been devised an,d advocated for the correction of retrodisplacements, but I believe
that
it
is wise
to place
the
stamp
of
disapproval
again
upon
the
Kelly
suspension operation. Attending a clinic recently in another city, I was astonished to see the operator do two of these operations, despite the fact that I thought that most gynecologists had long ago been convinced that an intended suspension usually eventuates in either a fixation or a recurrence. It is always necessary to differentiate cases of retroversion that are congenital A congenital uterine displacement produces no from those that are acquired. symptoms and requires no treatment. The symptoms, if any, are due to the incidental hypoplasia and not to the displacement, and any form of therapy directed to the correction of the displacement will result in dis$ppointment. In cases of acquired retroversion, a distinction must be made between the so-called uneomAs a matter of fact, the retrodisplacements that plicated and the complicated ones. are regarded as uncomplicated often give rise to symptoms because of the assoThis explains the insidious ciated venous stasis in the perimetritic structures. and delayed onset of symptoms so frequently observed. pessaries from patients that A word regarding the pessary. I have removed have been inserted upside down, or back to the front, and in one instance both of these mistakes had been made. It is quite possible that the disrepute into which the pessary has fallen is due largely to the ignorance of some of those who apply it. A pessary cannot be expected to correct a retroversion. It is simply a device to bold the cervix back after the uterus has been replaced by the physician. 432
AM.
ASSN.
OBST.,
GYNEC.,
The various ‘curves are designed for specific which a pessary is moulded and constructed instrument will be misused less often.
AND
ABD.
purposes, and are thoroughly
433
SURQ. if the principles understood, this
upon useful
DR. D. L. JACKSON, BOS~N, MA&.--In the operation for the correction of retroversion, we always have to consider the fascial shortening on the anterior wall It is very simple to make a transof the vagina which holds the cervix forward. verse slit at the bladder jusction with the cervix, push the fascia upwards, and then sew longitudinally, thereby correcting that fault and allowing the cervix to drop back so that we do not get an anteffexion of the cervix when the retroversion is corrected. DR. HERMAN E. HAYD, BUFFALO, N. Y.-I agree with a great deal that all of the speakers have said, and perhaps disagree with some of them on some points. There is no question that we cannot do anything for a congenital retroversion. You may hitch it up, but the patient will suffer just the same. The classification those that have borue children that Dr. Dannreuther has made is very practical: and those that have not. Those who have no infection of tubes or ovaries will be cured by any kind of a round ligament operation. Those who have borne children have a disturbed pelvic outlet and that is the difficulty in connection with those cases. Dr. Hadden seems to prefer the Webster operatios. I have given up that operation altogether. I have given up all kinds of operations that involve the perforation of the broad ligament. In the first pIace, there will be adhesions, and the worst kind of adhesions follow that operation. Secondly, the incidence of a possible phlebitis is such as to contraindicate it. After all there is no operatioq that gives me as much satisfaction as the one done by the late Dr. Mann, where he simply lobps the round ligament., and if the case is complicated by a fallen tube and ovary, it is a very simple matter to hitch up the ovary with a few stitches, and There is no question in my mind that a in doing so you will hitch up the tube. retroversion, will sooner or later produce symptoms. DR. GORDON K. DICKINSON, JERSEY CITY.--There are two kinds of wisdom: one is the wisdom of the operating surgeon who has found a cure in a certain specific method; the other is the wisdom of the older man who has tried every method and failed in all of them. My experience is that we are developing slowly along this line. Ten or fifteen years ago there were only one hundred methods of operating for ratrodisplacemeqts; now the doctor tells us there are one hundred and twenty. We are not centralizing on this because in our work we are not thinking, but are trying to follow a beaten path instead of working out each individual case and trying to treat it accordingly. We are all prone to forget that we have the patient as well &s the condition. Some women have retrodisplacements and suffer, while others do not suffer, showing that there is a large neurotic element to be considered. Dr. Dannreuther speaks of the venous congestion. It may be venous or capillary. I find that it is necessary to add to the operative procedure medical treatment. I have found apparently a speci& effect in relieving the congestion by stimulation of the circulation in the pelvis by strophanthus. We must also add proper hygiene, vigorous exercise, and out of door life. The scrub woman, and women in active life never complain of this condition. It is the sedentary, the fashionable woman, who has not enough exercise to throw the blood through the capillaries, who has trouble. We, as surgeons, should be hygienists and physicians as well, but there is no one type of operation in my experience which is going to give us 100 per ceqt results. this
DR. JAMES condition,
E. DAVIS, ANN ARBOR, grossIy one finds the uterus
MlcH.-In is enlarged,
considering the the endometrium
pathology of congested,
434
THE
AMERICAN
JOURNAL
OF
OUSTETRICS
AND
GYNECOLOGY
the stroma hypertrophied or passed on to a condition of hyperplasia. The blood In other words, there is an early state of passive congestion. vessels have thickened. Later there is a condition of atrophy in the face of the condition of an enlarged and heavier uterus than normal. A cross-section of the wall will show that the tissue has changed and it is easy to observe with the naked eye that the walls are thickened and that the organ is not receiving a normal blood supply. Microscopically on,e will see that the nerve trunks have enlarged. Many uteri are removed by the operator because he has suspected myomas or fibromas, and when sectioned it is often a surprise to find only atrophy and fibrosis. Reasoning from this picture of ultimate change, it is quite apparent that something should be done, a suspension, or some form of exercises following delivery, as J. 0. Polak has advocated, or some other procedure to prevent this very obvious pathology. This can be a decision of importance in each individual case. DR. HADDEN (closing).-1 read the last two pages of I severely that I fear Dr. Hayd did not get my meaning. Baldy operation, but what I do under favorable conditions tion. The Webster-Baldy operation can be improperly done see more failures from that than perhaps from the Gilliam, done, very effective.
DR. FRANCIS Vaginismus.
REDER,
(For
St. Louis,
&lo.,
original
article,
read
a paper
see page
paper so hurriedly criticized the Websteris not the same operain many ways and you but it is when properly my
on The TreNatment of 420.)
DISCUSSION DR. LOUIS E. PHANEUF, BOSTON, MASS.-I want to emphasize the satisfactory method of operating by means of local anesthesia. I have operated upop two women recently, using morphine and scopolamine, and half of one per cent novocaine, injecting the mucocutaneous border and depositing about 5 C.C. of the solution in each levator. These women have consented to operation readily on finding that they would not be submitted to general anesthesia. I used a median incision, splitting in the middle line, and sewing laterally with perfectly satisfactory results. I have also delivered some of the women whom I had operated upon b) this method. DR. JAMES W. KENNEDY, PHILAIXL,PHIA, Ph.-During the past three years I have seen more cases of vaginismus than I have had during my entire previous experience. It is a real pathologic entity, aqd we have learned to be more considerate toward the patient than in former years, when we looked upon vaginismus as more or less of a neurotic condition, having little true surgical pathology. T recognize the condition as either a true vaginismus or a pseudovaginismus. If we recognize the pseudovaginismus as a symptom secondary to some local irritating inflammation about the meatus, painful conditions, such as urethral caruncle, fissures in the region of the vaginal orifice or the anus, rigid hymen, or that painful neuroma which may be a remnant of the hymen, then of course we have a I have seen a number of patients have happy solution, of the annoying condition. a paroxysm of the muscles of the vaginal introitus if the examiner merely touched a skin tag which marked the remnants of the hymen, and I have also seen the same symptom emanate from simply palpating with the finger a tense nabothian cyst of the cervix. Some of these patients are in need of sympathy and investigatioq from a nervous standpoint, others need surgery but they are all worthy of careful investigation. DR. ADAM P. LEIGHTON, PORTI~~ND, ME.-This seems to be a malady from It has been my peculiar experience which the women in Maine suffer tremendously. to meet a number of them, and to follow them through to the divorce courts. It seems that many of these cases can be cured, and the penal@ that follows married life may be avoided if we only intelligently try to treat these individuals.