REPRINTED EROM AlWLSor GYN/TfoLoGV •7B12- PODIATRY A Monthly Review of Gyruecology, Obstetrics, Atxioiiilnal Surgery, and Uie Diwegiee ot Children, ERNEST w. cush:::g, U a, Bmm. Jtiau'n) g. norris. m c. Subscription Price, $a.oo a year in advance. PHILAOKLrilU UNIVERSITY OF PENNSYLVANIA PRESS PUBLISHERS SEPTEMBER, 1893 The Treatment of the Retroverted Uterus with Spe- cial Reference to the Value of Massage and the Author's Application of the Uterine Respiratory Movement. BY D. H. WILLIAMS, M.D., KNOXVILLE, TENN., s Professor oj Theory and Practice of Medicine and Clinical • Medicine and Director of Bacteriological Laboratory, Tennessee Medical College. The Treatment of the Retroverted Uterus with Special Reference to the Value of Massage and the Author's Application of the Uterine Respiratory Movement.1 BY D. H. WILLIAMS, M.D., KNOXVILLE, TENN., Professor of Theory and Practice of Medicine and Clinical Medicine and Director of Bacteriological Laboratory, Tennessee Medical College. The writer presents no disclaimer of the brilliant achievements of surgi- cal measures for correcting displace- ments. Conversely he believes that many such cases can only be perma- nently relieved by radical measures. Such cases, however, in ordinary prac- tice, aside from hospital groupings, must be exceptional and represent, firstly, a class which has not yielded to more conservative tactics, and secondly, one either the result of neg- lect or mismanaged government. Whatever arguments may be ad- vanced in favor of the non-surgical treatment, the fact remains that in a small percentage of cases, yet aggre- gating many annually, the world's record considered, the scalpel and ligature become the pis aller. After reviewing the operative ven- tures of the past, cast by their various 1 Read before the East Tennessee Medical Society, May 26,1893. 2 D. H. WILLIAMS experimenters with cloudbursts of enthusiasm upon a waiting public, one can not avoid the reminder-and 'tis admitted with great reverence- of the story of the insane astronomer in Rasselas, who is made to declare unto Imlac his possession for five years of the secret of the " regulation of the weather and the distribution of the seasons." The cases are not parallel, but the suggestion is unavoidable. 'Tis not the writer's desire to dwell upon the surgical treatment of this hitherto almost intractable bugbear of the gynaecologist, but recognizing as he does the necessity at times of such measures, mention of the more recent, and, in a manner, more ac- ceptable, operations is warrantable. Whatever difference in technique, the common aim is to restore, as nearly as possible, the normal axis of the organ even at the expense of ex- aggerating the anterior inclination, 'despite the irrational carping of a • class of delusionists, who would have us believe that every ante-flexion is pathological, and its compensatory .substitution an inglorious com- promise. Since the introduction of Alexan- der's operation-the bilateral shorten- ing of the round ligaments by extra- peritoneal incisions and stitches-less than a decade ago, many others have followed, having in view the assistance of the eye and sense of touch, resort- ing to coeliotomy and the intra- abdominal suturing so as to meet, not only the conditions for which the Alexander operation was devised, but also to correct displacement compli •cated by adhesions. To demonstrate the utility of his excellent operation, and in order to refute many objections raised, Dr. Alexander has in another recent arti- cle shown that not only does preg- nancy take place in many cases so corrected, but also that subsequent return to its pathological condition does not take place in the vast ma- jority of cases. Howard Kelly's method of hyster- orrhaphy has proven serviceable in many cases, but a large percentage has resulted in recurrence. It has the advantage over the for- mer operation of enabling the surgeon to examine the character and degree of displacement as well as to break up adhesions when possible. It has, at least, led to much specu- lation abroad, and thus resulted in causing many suggestions as to the method of applying stitches in hys- teropexy. Delageniere has well said, however, that "the point in dispute which most occupies surgeons is the question of the solidity and permanence of the adhesions created. Perhaps much may yet be expected from Dudley's method of shortening the round ligaments by folding and suturing the broad ligament on each side to the uterus, or from its modifi- cation by doubling the ligaments alone without fixation to uterus. Sanger and Leopold have each at- tested the value of ventro fixation and have shown that both pregnancy and the puerperium are not interfered with thereby. Flaischlen's method of fixation by three silk sutures only has great ad- vantage in its simplicity, and, if sub- stantiated by continued good results in all cases operated on, should be most serviceable. Not content with the fair percent- RETROVERTED UTERUS. 3 age of good results in cases operated on from above, and persuaded by fail- ures, we find others continuing ex- periments per vaginam, in line with the operation devised independently by Herrick and Sanger of shortening the utero-sacral ligaments. A single silver wire introduced after denudation "by means of the curved needle, passing through the posterior surface of the cervix, high up through the walls of the cul-de-sac close to the uterus, back close to the rectum, again into the vagina." The operation has not as yet met with much favor, possibly in a measure on account of the great danger of wound- ing the adjacent bowel. Schiicking, supported by Zweifel and Riihe, has practiced, and not with- out a measure of success, an operation consisting in opening the anterior vaginal cul-de-sac by vaginal incision and stitching the displaced fundus to the vagina. Mackenrodt and Diihrs- sen have each modified, but not essen- tially changed, this method. It will thus be seen to what degree investigators have gone in their zeal -and it must be called honest, since no operation as yet is free from objec- tions. Conversely much harm may result from injury to the surrounding viscera, as bowel, bladder, ureter, vessels, prolapsed ovary, etc. Such objections, in addition to other advan- tages offered, make the operation of abdominal hystero pexy, by one of the methods mentioned, first to be elected. A modification of the Howard Kelly method has, according to the writer's observations, proven more satisfactory than others, although one will occa- sionally meet disappointments in a recurrence of the trouble. The objec- tion raised that excessive hyperplastic thickening at the point of adhesion is liable to occur is not worthy of con- sideration as the converse more often obtains, and, indeed, it is a question whether or not adhesions and thicken- ing in front resulting in an elevated organ is not preferable to the first condition accompanied by all the dis- tress of pressure and obstructed cir- culation. Whatever operation may be de- termined on in any given case the fact remains that such cases are rare, and that the vast majority, perhaps 95 per cent., can be cured or markedly benefited by other measures, and not by any one, but by a combination. It is the writer's belief that in many cases operated on, either by hystero-pexy or by shortening the round ligaments, the operator has overlooked the chief underlying cause and should have directed his attention to restoring a lacerated perinaeum with its concomitant vaginal prolapse and uterine deviation, or to first re- pairing a lacerated cervix, or to regu- lating by massage and judicious local measures, in addition to general hy- giene, etc., that atonic condition of the parts, sometimes explainable and sometimes not, by which in even ex- treme cases at times is accomplished the summum bonum. Unfortunately the impatience of the woman and that combined with the waning perseverance of the medi- cal attendant often persuade us to adopt extremes not yet indicated and often in the end much less productive of good. In insisting upon the following measures the writer wishes to empha- size that they are only means to an end and in no sense exclusive. Special treatment of the specialist 4 D. H. WILLIAMS. means selective treatment and not obstinacy in empirical dogma. Com- bined agency accomplishes much and the combinations are variable. The diagnosis made in a given case, and a mental survey of all surround- ing structures taken, the conditions existing for our present consideration are, a retroverted fundus and possibly entire uterus with or without Cohe- sions, accompanying endometritis of any type, and possibly tubal involve- ment by catarrhal inflammation, the exact condition of the latter being difficult to determine and only ap- proximated by carefully observing both subjective and objective infer- ences, the activity of skill alone ren- dering conclusions valuable. Granting that the attendant recog- nizes the importance of attention to general hygiene and such details as atonic rectum, high-colored or alkaline urine,' etc., the vagina must be syringed twice daily by means of a syphon syringe, with about a 0.5 per cent, solution of potassium chlorate in very warm water, at least 1190 F. in vagina, or 1220 F. in syringe, using at least thirty two ounces each time and the woman providing free exit by means of the index and middle fingers of one hand, the exit is especially im- portant in view of the steps that follow. Any other mild agent, as a 1 per cent, solution of boric acid, may be used instead of the potassium chlorate, if preferred. Irrigations should never be used earlier than three days after cessation of menstrual flow and stopped on its advent. They should never oe used in the squatting position-a point to be em- phasized-never rapidly, but embrac- ing as much time as a continuous flow will allow. 'Tis not relevant here to define the value of this step, but its importance is not least. Free Dilatation of Cervical Canal.- In every case free dilatation of entire canal, vagina first cleansed, must be provided for, and repeated dilatations may be necessary during course of treatment to prevent accumulated se- cretions from being forced backward by manipulative measures. Rapid dilatation by Wylie's dilator is indicated. If carefully used no lac- eration need be produced, as the beak of the instrument is smooth and well curved. Avoid intra-uterine injections of any character, and follow dilatation with a single application to cervical canal of an 80 per cent, dilution of tr. iodine co. in distilled water. Adhesions, if present, do not con- tra-indicate dilatation. A judicious use of the curette is often indispensable when the mem- brane is unhealthy. Continued study in this line has served to confirm the writer's opinion, formed some time before reading the admirable article of Arthur Johnstone, that many, if not all, cases of displacement of the multiparous uterus when not traceable to external nor internal inflammatory conditions, nor to the existence of neo- plasmata, take their origin in congen- ital deformity, or arrested cervical development. In the "Transactions of the Amer- ican Gynecological Society," 1888, Johnstone wrote, " it is my belief that a very large proportion, if not all, so- called congenital flexions are remotely due to this early stoppage in the growth of the guardian of the uterine RETROVERTED UTERUS. 5 cavity. It is the very large number of cases in which there is a cervical arrest that has given the uterine dila- tor its deserved popularity, for I be- lieve that the prime cause of that form of dysmenorrhoea, which this instru- ment cures, is due to nothing but an arrest in the growth of the canal. " The various divergencies of this canal may be caused either by the pressure of the fully-grown organ above, attempting to force its secre- tion through too small an opening, and thus distorting it, or else the dis- proportionate weight of the fully-de- veloped body crushes down and bends the too weak support with which nature has furnished it." Especially is this condition exag- gerated when from any cause reten- tion of inflammatory products adds to the already great demand for sup- port. Manipulation Measures.-Brandt's original system has been much criti- cised-by some condemned. Damnant quod non intelligunt - may explain some opposition, certainly that of those who, like the writer of an article in a '92 southern journal, would compare uterised massage to massage of the penis, allowing, per- haps, a spirit of false modesty to govern. Whatever of special merit may be lacking in Brandt's method systematic perseverance will substantiate the principle. Let us notice superficially the vas- cular and nervous supply of uterus and vagina. Two main arteries supply the ute- rus-the arteria uterina aortica and the arteria uterina hypogastrica-both of which are exceedingly tortuous in their course and distribution, and both of which make rather sharp turns as they enter the broad ligament close to the uterus, especially the former at the lower edge of ligament. At these points the circulation is prone to dis- turbance by direct pressure, or by folding. In their final distribution we find them terminating in fine radicals rather than distinct capillaries, and connecting with diminutive corres- ponding veins, even more tortuous as they grow larger, before uniting to form the plexus uterinus and plexus, pampiniforinis, both lying largely within the folds of the broad ligament, and subject to similar pathological conditions. The vagina receives its arterial supply by communicating branches from the uterine hypogastric, pudenda and vesical, all running tortuous courses, and having corresponding veins, making a continuous and close plexus around the vagina. All of the uterine and vaginal vessels are without valves, and all communi- cate-a fortunate circumstance the latter, else the marked strangulation which exists at times would be even more disastrous. Of fully as much importance to us, and indeed more, in a sense, is the dis- tribution of the lymphatic system- unfortunately one which has not re- ceived the attention it deserves, and concerning which the meagre accounts given conflict greatly. Opportunity is not at present of- fered to discuss its probable origin and distribution, and hence this mat- ter is reserved for future reference. Probably no system, unless the in- testinal be excepted, contains larger and more numerous lymphatic vessels, having many sacculations, but few valves and no large plexuses. These ves' 6 D. H. WILLIAMS. seis pass in great numbers to the sacral or iliac glands found on each side of sacrum, below the promontory, and when enlarged capable of being felt through vagina and rectum-a point worthy of remembrance in diagnosis of malignant involvement. A few pass to the obturator, and the remainder to the glands in the Those of the upper part of the vagina are distributed similarly to to those of cervical region, while those of lower parts of vagina pass to inguinal glands. The nerve supply is derived, accord- ing to from the plexus uterinus magnus, and its division one and one- half inches below bifurcation of aorta to form the plexus hypogastrici, which latter send distributions around the rectum, some fibres going directly to the uterus, others forming the plexus cervicalis. Bearing the foregoing in mind it is easy to understand the cause of dis- turbance by pressure, both upon blood vessels, lymphatics and nerves, which is so often found in posterior devia- tions. Again, not only does it cause disturbance, but the condition grows greater according to impeded circula- tion and innervation, and the uterus enlarges or fails to undergo involu- tion, following parturition. A lacer- ated perinaeum existing, a new condi- tion is added, support being removed descent takes place, and hyperplasia of the walls of the vagina is found, sooner or later, with all the disturb- ance of increasing prolapse. With such conditions massage seeks to restore not the uterus alone, but normal tone to a chroniqally asphyx iated vaginal wall, obtiundd Oih hyper aesthetic nerves, over-distended blood vessels and lymphatics, which, while they may be sufficiently able to con- vey, no longer receive the normal amount of matters from the uterine and vaginal membranes, thus result- ing in increased discharges from a source which should secrete and not excrete. As to the technique of uterine and pre-vaginal massage cases differ since some uteri are reducible with the woman in the dorsal position, others only in the genu-pectoral, and still others at first not at all, though in many cases later. In all cases one of the first steps is to promote this reduction before be- ginning manipulations-the reasons are obvious. The writer has never found it nec- essary to use a sound to cause reposi- tion, for in cases where it cannot be done by careful bimanual means it should not be done at all, and the sense of touch is the best criterion of the permissible amount of force used. If it can be done, no adhesions ex- isting, solution becomes relatively easy; if not then the most delicate judgment is needed in subsequent management, and the operator should be content with slight manipulation, and possibly without appreciable change for many times subsequently. The woman may be treated with most comfort to herself and ease to operator in Sim's position for a vari- able number of times. Adhesions being present, especially if thicken- ing is greatest on one side, ' t is always best to treat the patient on the side, and if the thickening is greatest on the left side the patient should be placed in Sim's position reversed. The mat- ter of position, however, is of no very great importance, provided the dorsal position is not chosen. The index and middle fingers of one RETROVERTED UTERUS. 7 hand should be well oiled with steril- ized vaseline, and introduced high in posterior fornix, with or without suc- cess in reposition, gentle stroking with the rounded ends of fingers of the whole upper vaginal vault poste- riorly should then be practised. The anterior vaginal wall from labia to full extent of vagina, if one is careful, need not undergo friction, though in some cases this is needed in front of cervix to hasten absorption. This stroking should be done from the uterus toward the middle of sac rum on either side, bearing in mind the anatomical relations ; lymphatic circulation is hastened, venous tur- gescence relieved, and diseased or benumbed nerves stimulated. Such cases are apt to suffer from constipation, and 'tis sometimes won- derful to note the stimulating effect of such measures upon the rectum alone without special medication. It is needless to say that the rectum should always be evacuated before beginning treatment. Only slight, if any, pain should be caused, and manipulations stopped on its inception if traceable to the massage. One need not expect here even absolute freedom from pain in every case. The duration of each treatment is variable, and subject to the degree of reaction in individual cases. Continued longer than two or three minutes, it is questionable whether any further good is done. Mild attempts at reduction should be made each time, and should be re- peated not oftener than once in four days. Following each manipulation a me- dium-sized soft tampon of borated absorbent cotton, not sponge, should be introduced posteriorly, moderately saturated with a solution composed of the following: B. Acidi borici, Acidi tannici, aa §ss Glycerini (Price's), Sviij M. The mixture should be heated to promote solution and to render it thoroughly aseptic. The tampon to be removed at the end of twenty-four hours. One should be content for several weeks, or even months, with the above measures only, until tenderness is moderated, the vault hardened and free dilation effected. Later, uterus replaced, the organ may be contracted by fingers of left hand in vagina, with woman on the side and right hand over lower abdo- men, and gently massaged by vibra- tory motion of the hand on abdomen, preferably using the bdhe of thumb. The fingers of hand in vagina remain relatively passive, little motion being needed to secure control. If force is used the uterus will sometimes eject its contents in considerable quantity, but this should be avoided and mild stimulus only applied, for with small doses of fluid extract of ergot twenty drops every four hours following, for four to six doses, the action begun will be continued. In some cases the writer has used, after free dilatation when much dis- charge existed, the application H2O2, full strength, for a single application. It should never be injected. Its effi- cacy is undoubted. He has long since discarded strong applications to the endometrium, and believes that his percentage of recov- eries has doubled. Some cases demanding curetting and draining with iodoform gauze, 8 D. H. WILLIAMS have done excellently on the com- bined treatment, the operator desist- ing from manipulations during treat- ment unless needed in selected cases. Although the interior of the uterus is never, perhaps, pathologically lined with a pus membrane in the sense of a suppurating sinus, yet in some cases the analogy is approximated, and Polk has even pointed out the value of such drainage. From galvanism the writer has never been able to derive much, if any, benefit in such conditions, and as for intra-mural injections, he believe the practice reprehensible. A suitable pessary, during the in- tervals of treatment, often affords much comfort, especially if prolapse complicates. In selecting one, avoid that having a very sharp curve. Emmet's-Smith's is an excellent one, and the same may be said of Tait's wedge pessary. Of those cup-shaped, Fowler's is prob- ably the best. The point to be borne in mind is that support, in the vast majority of cases, is to be given through distending the vaginal vault. No pessary simply lifts the fundus. Intra-uterine pessaries in version may do harm-seldom good. Uterine Respiratory Action.-It may be that much lack of research is shown, but the writer has been unable to find any literature upon this meas- ure as a therapeutic agency. Noting the marked rising and fall- ing of the uterus and appendages dur- ing examination of women in the genu-pectoral position, it has seemed to him that we have in that fact a measure of great importance. The intestines have their peristaltic ac- tion, and so have, practically, all the other abdominal viscera respiratory movement, as well as those of the tho- rax. The brain, in its almost closed surroundings, may or may not have or need any special movements, but it is certainly true that the uterus and appendages, in the pathological state under consideration, with the great superimposed weight, and in an almost fixed condition below, with vessels engorged, does not, when the body is erect, have much change of position, and must necessarily suffer. The vis-a tergo, in normal conditions, is sufficiently able to maintain equable circulation in valveless vessels, but it is certainly not, when change of axis and loss of support has gradually led to material changes; it may be that other vessels have compensated largely, but the points of impinge- ment and flexion at least do not re- ceive their normal supply. The argument that nature provides for all contingencies is not rational. With this idea in mind, the writer instructs each patient to place her- self in the knee-chest position nightly, just after retiring, and take deep, reg- ular inspirations, twelve to fifteen per minute for a variable period, and then assume a lateral position opposite to any adhesions, knees comfortably drawn up and sleep invited. Improvement seems to be aided, and the morning heaviness in back is not nearly so marked. This exercise may be repeated for a few minutes every morning before rising. No attempt has been made in this article to elaborate the treatment of posterior displacements, and hence any failure to mention the investiga- tions of others is not intentional. Especially would the writer like to dwell upon the great benefit derived from hydrotherapy, particularly as ap- plied to the spinal column. He has found, clinically, much of RETROVERTED UTERUS. 9 value from adopting the above roughly sketched measures, and has purposely omitted many details for lack of time. He wishes to push with much em- phasis the fact before stated, that operation may often be deferred with benefit, in a given case, if not entirely left out of consideration. Again, while disease of the uterus and appendages as produced by dis- placements, and displacements as oc- casioned by disease, in a large meas- ure, but not absolutely, are indicated by a derangement in the performance of uterine functions, conversely any condition departing from the normal unaccompanied by any evidences of perverted functions attributable solely to the uterus and appendages, should be carefully studied before local inter- ference or even suggestion is indulged in ; or, to state it differently, derange- ments are not always in direct ratio to the extent or condition of tissue involved. LITERATURE REFERRED TO. Dudley.-Amer. Jour. Obs., p. 1336, 1890. Delag£niere.-Annales de Gyn., p. 447, 1890. Sanger.-Cent, fur Gyn., s. 317, 1891. Flaischlens.-Zeitschrift fur Geb. and Gyn., Bd. xxii. Herrick.-N. Y. Med. Rec., Vol. xli, No. 6, p. 152. Herrick.-Amer. Jour. Obs., p. 314, 1891. Schiicking.-Cent, fur Gyn., s. 689, 1890, and s. 251, 1891. Riihe.-Cent, fur Gyn., s. 916, 1890. Diihrssen.-Zeit. fur Geb. und Gyn., Bd. xxiv, s. 368. Johnstone.-Trans. Amer. Gyn. Soc., 1888. Year Book of Treatment, 1892, 1893.