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Of the different operations, probably that of shortening the round ligaments externally, the original Alexander operation, has better stood the test of time and experience than of any of the others, and there is no doubt but that in a suitable case the operation will yield good results. However, the force exerted by the round ligaments in the suspensory process of the uterus is not great, and in most cases where there is much resistance caused by inflammatory thickening in the posterior ligaments, or where the uterus is unduly heavy from hypertrophy or hyperplasia, the operation is likely to fail. Then it will be seen that this operation is only indicated in detrodeviations of the virgin uterus uncomplicated with adhesions, and it is in this class of cases that pessaries yield such brilliant results. What has been said of Alexander's operation applies with equal force to the several operations for shortening the round ligaments internally.
Ventral fixation is not, in my judgment, justifiable. The operation is illogical and unsurgical. It is uncertain in its results, and even if the womb should remain anchored in its new situation, it is but the substitution of one abnormality for another whose disadvantages are too apparent to call for detailed recital here.
I have had no experience with vaginal fixation methods and can only express an opinion based upon the theory that any operation which fixes the uterus, and does not permit a fair range of motion, can only be detrimental.
That measure will succeed best which not only restores the truant organ to its proper position, but maintains it with the least interference with the performance of its physiological functions. Mechanical supports effect a result which more nearly approaches the normal condition of the womb than any other method, since they do not limit its movements, do not interfere with the pelvic circulation, and in no way abridge the natural functions.
I have recently read an article by a distinguished surgeon, in which he gives five reasons why pessaries should not be used in uterine malpositions, and as these embody in substance the sum of contraindications which have been urged against this method of
treatment, I take the liberty of reproducing them here. They are as follows: First, the possibility of retaining the uterus by the aid of tampons; second, existence of inflammations, as salpingitis, metritis, vaginitis, etc.; third, ruptured perineum; fourth, bending of the uterus when the pessary is in place; fifth, pain produced by the pessary.
These objections, when critically analyzed, are easily demolished, since there is no single one of them which is tenable. With reference to the first, the possibility of retaining the uterus by means of tampons, I will say that a pessary creates no more pain or irritation than a tampon, corrects the deformity better, and has not the disadvantages of having to be frequently removed and replaced, thus permitting the uterus, unsupported, to resume its old abnormal situation. Existence of inflammation is no more of a contraindication to the use of the pessary than to any other method.
The third reason, ruptured perineum, is not an argument against their use, for the reason that the rupture should be repaired as the first step in any method of treatment. The fourth reason, bending of the uterus when the pessary is in place, is merely a condition which calls for extreme care upon the part of the physician, and its importance has been emphasized in a former paragraph. And the fifth objection, pain produced by a pessary, does not hold, for the reason that a pessary properly fitted does not produce pain.
If I should attempt to define the indications for operation and mechanical supports in the abstract, I would say that surgical measures are designed to restore the uterus to its proper place, and mechanical methods to maintain it. Then operations would be reserved for those cases of displacements complicated by adhesions wherein the uterus can not be replaced by ordinary methods, and where the displacement provokes sufficient discomfort or disability to render its victim unfit for the ordinary duties of life.
After the adhesions are broken up and the uterus restored to its proper position, a suitable pessary should be used to retain it. This will, in my judgment, yield better results than any of the operative methods yet designed to fix or suspend it. If the opera
tion would in truth suspend, and not fix, the uterus, the use of a pessary as a supplementary measure would not be needed, but this happy result can be expected only in a very limited number of
I have no doubt that ligamentous bands sometimes form after the suspension operation of Kelly, but this takes place too infrequently to be relied upon as a justification for the operation.
It is presuming too much upon the reparative power of nature to expect her to construct adequate anchors in even the majority of cases. I am aware that in making this statement, I express an opinion distinctly at variance with men of recognized authority, with some of whom it would be considered almost a sacrilege to differ, yet this opinion is the derivative of my experience amplified by observation and supported by the views of many conservative practitioners.
After all, therapeutics, in its most comprehensive significance, is but the application of the plain elements of common sense to the treatment of disease, and he will succeed best who has the keenest scent for the intricate trail between cause and effect, and the wisest judgment in adapting his methods to meet the exigencies of individual conditions.
THE TREACHEROUSNESS OF CATGUT IN ABDOMINAL SURGERY, WITH REPORT OF CASE.
M. SMITH, M. D.,
SULPHUR SPRINGS, TEXAS.
I appreciate the inelegancy of the title of my paper, but it so lucidly expresses the conditions that I wish to speak of that I prefer to use it. I know of no other word or term that can express or convey to the thinking, investigating mind such an impression as the word treacherous. It carries with it the very essence of disappointment, and having had just such an experience with catgut as a suture material in some abdominal cases, I was tempted to give my paper this title, "The Treacherousness of Catgut in Abdominal Surgery."
I am fully aware of the fact that the question of suture material is one of varied experiences-one operator using silk, and claiming its advantages over all others; another operator using catgut, advocating it to the exclusion of all other material except in exposed surfaces.
I am sure that all will agree that catgut is the most used material of any and has grown in favor because of the modern methods of sterilization having been almost perfected, or at least to such an extent as to be considered safe to use as buried sutures anywhere in the body. With all this before us, we know, from perhaps a sad experience, that it is not all rendered aseptic, and just at the time when we most need pure, good suture material we get the unpleasant results, hence I still cling to the title treacherousness.
I will not burden you with the detailed description of the many ways of preparing catgut for surgical use, but will say that all of it that claims to be sterile has been subjected to a temperature of from 130° F. to 212° F. from thirty minutes to three hours, each thread is then examined microscopically, afterward being immersed in various solutions, hermetically sealed and sent out for use.
I noticed in one of the April numbers of the Journal of the American Medical Association an article written by Dr. Senn, of Chicago, on the sterilization of catgut, as follows: "Immerse the twisted threads in a 1 per cent solution of iodine for ten days, the container being a small mouth jar or bottle." He claims to have been using catgut sterilized by this method for the last six years in his clinic at the Rush Medical College with uniformly good results. Others have tried it with disastrous consequences. "The advantages of absorbable suture material is of the greatest importance. We can gauge the time we wish for a suture to be absorbed by using catgut. The plain is absorbed in about seven days, the chromacized in from two to three weeks-Oschner." Silk is never absorbed, and when used to tie off the pedicles of ovarian tumors becomes encysted and frequently becomes the source of all kinds of reflexes caused by the constant irritation of the nerve tissue embodied within its grasp, from which patients complain more than before operation-a condition exceedingly troublesome to the patient and extremely so to the surgeon.
The case in point was operated upon March 4, 1903, for a bilateral intra-ligamentous tubo-ovarian cyst. I was nearly two hours in completing the operation, so fearfully dense were the adhesions. I used No. 1 formaldehyde catgut in closing rent in broad ligaments, and in closing parietal peritoneum No. 2 pyoktanin was used by tying blood vessels and closing muscle fascia in abdominal wound, using silkworm gut for closing the skin. The patient did nicely, bowels moving every day, no temperature, no nausea from chloroform, skin healed perfectly and stitches removed on eighth day, appetite good, sleeping well, free from pain, could move to any position in bed alone by the eighth day. On afternoon of the eleventh day she developed a temperature of 102, and upon examining closely I found a little mass on the right side of abdominal incision. Vaginal examination revealed quite an extensive mass in right iliac region, extending down on the right lateral side of the uterus, till bulging in vagina was plain. On the twentieth day I noticed a little separation of the skin in the lower and upper angle