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NORTHWEST MEDICINE

January, 1905.

ORIGINAL CONTRIBUTIONS.

THE TECHNIC OF PELVIC OPERATIONS BY VAGINAL

SECTION.

By J. RIDDLE GOFFE, PH. M., M. D.,

NEW YORK.

Professor of Gynecology in the New York Polyclinic, Visiting Gynecologist to the City Hospital, etc., etc.

(Concluded.)

UTERO-SACRAL LIGAMENTS.-In this connection I might refer to the comparatively new procedure of shortening the utero-sacral ligaments for the relief of retroversion. Your honored president, Dr. Bovee, has resorted to this in a greater number of cases, perhaps, than any other operator, sometimes reaching the ligaments through an abdominal incision and sometimes through a posterior vaginal section. I have used it in connection with shortening of the round ligaments in a number of cases and found it a feasible procedure in cases of procidentia and those in which the vagina is relaxed and the cervix low in the pelvis. I reach the ligaments through the posterior vaginal incision and shorten them by doubling them on themselves as I do the round ligaments. My conviction is that the utero-sacral ligaments are a most important factor in retaining the uterus in its normal position. They are, indeed, the all-important factor. Whether they are shortened and made to perform their normal functional support by direct operation upon them or whether the indirect result of some other operation enables them to involute and recover their tone and sustaining power, certain it is that unless they come to the aid of the other ligaments and hold the cervix high in the hollow of the sacrum, sooner or later the condition of displacement will be reproduced. I regard the utero-sacral ligaments as the most rational structures to utilize for the cure of retrodisplaced uteri, but find it difficult to apply except in selected cases.

Speaking from my own experience, although, like most of us, I have had more or less experience with all the operations that have been suggested for the relief of displacements, I have not found one that has given me such universal satisfaction as shortening of the round ligaments through the vaginal incision. So far as my knowledge goes, I know of but three failures in a series of over 200 cases, and these were due to some departure from the regular procedure in which a modification was attempted. Among the 200 cases, 8 private and 4 charity patients are known to have become pregnant and 10 have gone to full term, pregnancy proceeding most comfortably and satisfactorily, and the uterus retaining its proper position thereafter. Doubtless many others have borne children since the operations but of them I have no knowledge. Of the miscarriages one was in a syphilitic negress, and in the other the cause could not be learned.

In my experience the most frequent cause of retrodisplacement of the uterus is suppurative disease of the appendages, involving from 75 to 80 per cent. of all cases coming under my observation requiring surgical interference for this affection. Because of these complications the Alexander operation, pure and simple, is applicable to an extremely limited number of cases; it becomes necessary, therefore, in order to treat the remaining cases satisfactorily and effectively to open into the peritoneal cavity, and the question is, shall it be done through the abdomen or shall it be done per vaginam? The advantages of the vaginal operation are that the healing process goes on unconsciously to the patient, without any more constitutional or local disturbance than that which attends a simple trachelorrhaphy. The patient is not mindful of having had an inciscion made, nor does she bear upon her person any trace of a surgical operation. There are no adhesive plasters to be applied, no stitches to be removed, no bandage or supporter to be worn; there is no ugly scar, and there is no danger of a future hernia.

This procedure has its most appropriate application in cases of congenital or acquired retrodisplacement in unmarried women. Among my cases I have 9 of congenital retroversion or flexion in unmarried women, whose ages range from nineteen to twentyseven years. In these cases, although the vagina was small and the hymen intact in all of them. I was able to perform this operation, and effect a cure. In most of these cases I found it necessary to incise the vagina on one or both sides at the seat of the hymen, extending the incision one or two inches into the canal.

The condition in cases of congenital displacement is rather peculiar. In them the utero-vesical ligament is shortened, the uterosacral ligaments are lengthened, and the cervix is drawn forward into the axis of the vagina. The anterior vaginal wall, too, is attached low down on the anterior lip of the cervix, thus drawing down the short arm of the lever (the cervix) and throwing the long arm or fundus back into the hollow of the sacram. The operation through the anterior fornix necessarily severs the utero-vesical ligament at its attachment to the cervix and sets the latter free so that it swings back into the hollow of the sacrum and allows the fundus to come to the front. In these cases, in closing the vaginal incision, after the round ligaments have been shortened, the attachment of the anterior vaginal wall is carried up on the anterior face of the uterus. This brings the pull of the utero-vesical ligaments on the long arm of the lever or the fundus.

Congenital cases of retrodisplacement are notoriously difficult to cure, but with these combined procedures my results have been uniformly successful, all the cases now being under observation for periods ranging from five to two years. These women bear no mark upon their persons of having been submitted to an operation except that the hymen has been destroyed.

MYOMECTOMY.-The trend of gynecologic work in all its departments for the past ten years has been strongly toward conservatism, seeking not only to preserve anatomic structures, but also to censerve physiologic functions. This has nowhere been more conspicuous than in the application of myomectomy in preference to hysterectomy in the treatment of fibroid tumors of the uterus, and the further it is extended the more numerous become the cases in which it is apparent that myomectomy can be applied and the uterus preserved. It has been demonstrated that when tumors are small they can be reached through the vagina, and the advantages of this route of attack secured in their removal. The bed of the tumor requires careful and delicate treatment to avoid hemorrhage and, in my experience, the anterior vaginal incision, in selected cases, offers these advantages to a most satisfactory degree. In many instances I have removed fibroid tumors in this way. If the tumor or tumors are in the anterior wall they are brought into view as the bladder is dissected from the uterus, and removed in succession, the bed of the tumor being closed with a buried catgut suture. If they are at the fundus they are brought into view and reached by lifting the bladder strongly on a retractor, the fundus being gradually brought down into the

vagina as the tumors are removed and the peritoneum closed over their site by Lembert suture. And so the uterus is rotated into the vagina as the work proceeds till the posterior aspect of the uterus is in view and tumors removed, even as low down in the posterior wall as the cervix.

Uterine polypi are as a rule removed per vias naturales, but even in cases in which the intrauterine is large and requires morcellation for its removal, the work can be greatly facilitated by performing the anterior vaginal section, thus carying the bladder high in the pelvis and making room for manipulation. There is no objection under these circumstances to splitting up the anterior uterine wall as far as may be necessary to reach the seat of the growth. After removal the uterus contracts down and can be easily restored to its normal condition. It has been found that the danger of infection from the interior of the uterus, which was formerly thought to be very great in these cases, is of no serious importance, except in cases of sloughing polypi. As an illustration of the inocuousness of the interior of the uterus I might cite the following case. In a myomectomy recently, in which a large tumor was removed from the fundus uteri by abdominal section, I broke through into the uterine cavity and, finding the mucous membrane extensively degenerated, I curretted the uterus through the opening in the fundus, swabbed it out well, and then carried some gauze down through the cervix into the vagina. There was no infection following the procedure, the patient making one of the most afebrile convalescences that I have ever seen. Dr. McCosh has made cultures of scrapings from the endometrium in a number of cases in which the uterine cavity was entered in myomectomy, but in only. one instance did he get any culture, and even that was thought to be an accidental contamination.

Martin, of Germany, is strongly in favor of the vaginal route in dealing with fibroids of the uterus. He insists that the size of the tumor is not in itself a contraindication, since growths of large size can readily be removed per vaginam by morcellation. On the other hand, in the presence of firm suprapelvic adhesions, especially intestinal, the abdomial route is preferable; but deep pelvic adhesions and intraligamentary tumors are best handled from below. Martin fears injuries to the bladder and uterus more than he does hemorrhage, especially the former. He has never injured the ureters during vaginal myomectomy, though this accident has frequently occurred in his abdominal operations. When it is possible he enuclates tumors without removing the uterus. In