PREGNANCY AND, LABOUR, AFTER v'ENTRO­FIXATION O'F THE UTIERUS (HYSTERO'PEXISHYPOGAST;RIA).

By SIR WILLIAM SINCLAIR, M.D. ABERD.

Professor of Obstetrics and Gynmcology, Victoria University, Manchester.

[Read in the Section of Obstetrics, on February 25, ]910.]

AFTEIt reviewing the palliative treatment of uterine dis­placements with pessaries and colporrhaphy, and quotingLohlein's statistics showing only 4 to 7 per cent. ofsuccesses with pessaries, the reader traced the introduc­tion of surgical operations and their results.

Alexander's operation could he useful only in simpleuncomplicated backward displacements, and it has main­tained its place as an operation of choice in the treatmentof such cases. It fell into a certain discredit owinglargely to the lack of judgment on the part of operatorswho did not recognise its limitations.

Modifications of shortening the round ligaments weregradually introduced which were more formidable thanany of the intra-abdominal operations which have everbeen practised.

One American operator speaks of his own method as" this bilateral inguinal ceeliotomy and shortening of theround ligaments via the dilated inguinal rings." Hedeclares that it has become very clear that the simpleAlexander operation without this inter-peritoneal work isgenerally too imperfect and imbecile.

Some reference was made to proceedings of Schultze,Schiicking, and Sanger merely to call attention to theirdefects.

By SIR WILLIAl\I SINCLAIR. 253

In Britain we usually associate the name of Olshausen,of Berlin, wi th the origin of ventrofixation, but the pro­fession in France claim priority for Keeberle, of Strass­burg. Howard Kelly's account or the origin of theoperation is, perhaps, a little ambiguous, but he appearsto imply that he performed the ventro-suspension opera­tion before Olshausen published his original paper on" \ientra1 Operations for Prolapse and Retrodeviation orthe Uterus."

Kelly describes in his book his operation of suspensionor the uterus. lie was much imitated in the UnitedStates by operators lacking his judgment and dexterity,and the consequence was a large amount of suffering anddanger from operative treatment in labour, including not

a few cases in which Ceesarean section had to be resortedto. Kelly's operation gives :favourable results in the pro­

portion to which the adhesions of the fundus stretch orgive way altogether. 'I'he operation, in fact, is onlyuseful if it acts temporarily as a pessary.

'I'he writer claimed. for his own operation of ventro­fixation or hysteropexis hypogastria that it had stoodcertain exacting tests and had fulfilled all his hopes andexpectations. The tests which such an operation shouldstand are: -(1) It must be devoid of danger wlien ordi­nary care is exercised ; (2) it should be easy to perform,and the operator in recorumeudiug it must feel certainthat he can complete it as planned; (0) it must relievethe symptoms Oll account of which it was uudertaken;

(4) it must not produce any new symptoms which willeven remind the patient that she has undergone an opera­tion; (5) it must leave the patient free from any remotedanger, such as ileus; (0) she must remain permanentlyfree from any sort of physical disability preventing herfrom performing all the tasks and duties of domestic

254 Pregnancy and Labour.

and social life ; (7) it must stand the strain of pregnancy,parturition, and the puerperium without apparent de­parture from the norfal ; (8) after involution the uterusmust maintain the position it was placed in by theoperation.

An operation which complies with all these conditionshas many positive merits whatever a priori objectionsmay be raised against it by preconception and prejudice.The objections usually result from accepting the term" ventrofixation" as expressing a definite procedure,however defective and even irrational may be thetechnique of some operators.

In order to obtain the desired result certain principlesmust be constantly kept in mind and complied with inevery case. It is of the utmost importance that thefundus, uteri and round ligaments are strictly safe­guarded, so that if pregnancy occurs it may run a per­fectly normal course as if no operation had ever beendone. Of no less importance is it that between a suffi­cient area of the anterior surface of the uterus and theabdominal wall complete and permanent adhesion shouldbe produced. The ideal ventrofixation is that whichresults from Ceesarean section w hen the wound islongitudinal, involving the middle third of the uterus,and complete adhesion takes place between the uterineand abdominal wounds. In such cases, when pregnancyagain occurs} there are absolutely no abnormal sensationsor symptoms, functional or mechanical, owing to theexistence of the adhesions. When Coosarean section hasto be performed for the second time it is the height offolly to break down these adhesions.

Some German writers on this subject make much ofthe need for free movement of the uterus (BeweglrichlL6'it).This is a purely a priori assumption. There is not a

255By SIR V\'ILLIAM SINCLAIR.

shred or patch or evidence 01 the advantages of mobilitywhen the adhesion is on the anterior surface and does notinvolve the corpus uteri. All the evil reputation of" ventrofixation" has been the natural consequence ordystocia resuItil1g from interIerence with the fundus, or,worse still , with the posterior surface of the uterus.

The OZJeration.---The abdominal wound is reduced tothe minimum consistent with unembarrassed manipula­tion, a.nd its lower limb is as far down as possible withoutinterference with the bladrler. TIle uterus is raised upand seized at the isthmus, or just above it, with a suit­able volsella, which is held and manipulated by anassistant. If perimetritic adhesions are present they are

carefully broken down, and the ovaries and tubes in­spected. When the ovaries are found cystic withindurated tunics, they are incised and sometimespartially resected. When the tubes are sealed up, andeven when partly distended, they are laid open in somerueasure and fresh estia alrdo niiauilu; formed.

In the hysteropexis operation i tself the first step is toIntroduce a fine silk suture or two on each side, so as to

close the vesico-uterine fold. 'Then a pair of sutures ateach side, well out from the middle line of the uterus,bring the abdominal and uterine peritoneum together.Next, one or t,YO sutures on each side inc-lude the fascianperitoneum and layer of uterine margin and return, sothat the knot is outside the fascia. 'I'he last sutures aretransverse, and include fascia, parietal, peritoneum, anda layer 01 the uterine wal]. 'The uterus must be seizedjust above the isthmus, best through the puncture woundmade by the volsella. During the operation it is easy toestimate the position for the various sutures, so thatwhen they are tied and the uterus is dropped it will sinkllo\vn to its normal level.

256

The bowels are kept out of the way, and, if possible,out 01 sight, by suitable sponges. T11e abdominal woundis sutured in stages in the usual way.

The proceedings are completed by the introduction 01

a suitable size of glycerine-pad Hodge-shaped pessary to

prevent dragging on the adhesions until healing is complete.When the operation is resorted to lor prolapse it re­

quires to be supplemented by colporrhaphy.By adopting this method of hysteropexis the uterus is

brought. as nearly as possible into the normal position 01

slight anteversion, and the bladder is seldom in any "Tayembarrassed even temporarily.

It is the bringing of the Uterus into an almost anatorni­cally correct position without interference with thecorpus which is the feature of the operation. Amongthe important differences betweeu it and the faultieroperations is the avoidance of thickening of the anteriorwall of the uterus. "~Iy article on 'lfypertrophy andErosion of the Lip of the Os Uteri, a PathognomonicSign of Chronic F'lexiou ,' appears to me to furnish i rre­fragable proof . . that in chronic retroflexion thenutrition of the uteriue wal! varies wi th the relations ofthe body and cervix, and in retroflexion there is alwaysthickening of the posterior or concave wa.ll of theuterus. . If the uterus is brought into ante-.flexion to a pathological extent such thickcuing or theanterior wall and thinning of the posterior wall as tocause dystocia must be the result. All ventro­fixation operations in which sutures are introduced intothe fundus, uteri or farther back, and especially vagino­fixation operations, produce dangerous thinning of theposterior wall during pregnancy."

Many disasters during labour owing to this cause havebeen reported from all parts of Europe and America.

By SIR WILLIAM SINCLAIR. 257

"Another difference in favour of hysterapexis hypo­gastria is that it may justly claim to be an effectivemethod for the cure of sterility." No distress duringpregnancy or difficulty during. labour occurs after thisoperation. Pregnancy occurring after this operation,instead of being dreaded, should be welcomed as confirm­ing the cure, if for no other reason.

()f the 300 odd patients that had undergone the opera­tion about one-sixth had borne one or more childrensince. The process of parturition was not distinguish­able from ordinary labour, and involution of the uteruswent on normally.

"'

Illustrative cases were mentioned concisely.1. Cure of sterility in patients with retroflexed uterus

at time of marriage.2. Cure or one-child sterility owing to retroflexion of

sub-involution uterus after septic endometritis withmetritis.

3. Pregnancy occurring after the operation for retro­flexion with complications affecting tubes and ovaries,even to the extent or breaking down adhesions, resectingovaries, and forming fresh ostia abtlomirialia;

4. Labour and use of forceps, normal involution, and"normal position of uterus at last examination.

DR. J ELLETT said they were under a double debt of gratitudeto Sir William Sinclair, first, for the trouble he had taken incoming over, and, second, for declining to avail himself of theprivilege of having his paper left undiseussed. He was surethat the paper would lead to a most interesting discussion.

SIR WILLIAM SMYLY said he had come to the conclusion thatthe very best operation for cases such as had been referred to wasventro-suspension, but through his attendance at the Academyhe had been so much impressed with Dr. J ellett's results with the

VOL. XXVIII. R

258 Pregnancy and Labour.

Alexander Adams' operation that he had recently been trying it.He believed that one should give a woman a chance with a pessarybefore resorting to operation. His own experience of ventro­suspension had been a very happy one. If he were to read adescription of Sir William Sinclair's operation of ventro-fixationsimply in a book, he would not think very much of it, but tohear Sir William Sinclair's experience of it put the operation in.a very different light. On theoretical grounds it did not seemto him to be physiological to bring the lower uterine segment.right up against the abdominal wall; but that did not make the'least difference if the results were good.

PROFESSOR ALFRED SMITH agreed that there was a large­number of cases in which excellent results were got by the useof a pessary. If every case of displacement was to be treated byventro-fixation they could not supply the patients with beds inDublin. The type of case that seemed to him to be most suitable:for the Alexander Adams' operation was a simple backward dis­placement that reduced easily, and was found to have gone backagain next day. The aim of operation should be to leave theorgan as nearly as possible in its normal position. There was no

organ so mobile as the uterus, and he thought its fixation a verygreat objection. Still they could not overlook the brilliant,results in the cases mentioned by Sir William Sinclair. His own.practice in cases where he had satisfied himself that the organs.were capable of performing their functions was to thrust aforceps through the rectus muscle, and seize the round ligament.on either side, and draw them right out through the muscles andsuture them there to the aponeurosis. The operation was simple,and the results were excellent; patients returned with the uterusin situ without pessary or support. He must, of course, beinfluenced by the excellent results obtained by Sir WilliamSinclair from ventro-fixation.

DR. HORNE said he had a patient who had gone through tenconfinements who suffered from retroflexion of the uterus, andwho had to wear a pessary between the pregnancies. The resultof ventro-fixation in 800 to 1,000 cases in America, when thewomen became pregnant, was that 10 per cent. aborted, and themortality of full-time pregnancy was 2 per cent. and 3 per cent.In view of such results one felt some hesitation in tying up theuterus. He thought the brilliant results' obtained by Sir William.

By SIR WILLIAM 8INCLAIR. 259

Sinclair were due to the method by which he performed theoperation, in suturing. above the isthmus, so that dragging on theposterior ligaments did not take place, and abnormalities didnot occur when the women became pregnant.

DR. TWEEDY said that Howard Kelly popularised many opera­tions, and gynrecologists owed him and the J ohns HopkinsHospital a considerable debt of gratitude. The operation describedby Kelly was the one which he (Dr. Tweedy) personally performedin the vast maj ority of instances, and he did ten ventro-suspensionsto one of all the other methods combined. Excellent results weregot by all the methods. He had done ventro-suspension at least300 times, and in Dublin during the last fifteen years it hadprobably been performed well over a thousand times. AsMaster of the Rotunda he saw a number of women, who had beenoperated on by himself and others, delivered, and he had neveronce seen a single case that required operative treatment afterventro-suspension. A patient of his had had six normal deliveriesafter ventro-suspension, forceps or other instrumental delivery wasnever found necessary, and the uterus was in as good a position ason the first day it was fixed. As he conceived the operation, theuterus was fixed down to the empty bladder, and rose or fell as.the bladder filled and emptied. In every instance he had foundlong adhesions lying directly on to the bladder, so that no intes­tines could fall beneath them. The adhesions were macroscopicallyidentical with the round ligaments. There was plenty of space:for development in pregnancy. He was convinced that after atime, even if these ligaments were severed, the uterus wouldremain in position, as Kelly's operation was a curative one. Sir­William Sinclair's results were brilliant, but Kelly's operationwas hard to beat; he supposed its failure did not amount toanything like 5 per cent.

DR. FITZGIBBoN said he still believed in the use of the pessarYe.Women in the child-bearing period were entitled to a period oftrial with it. He believed that a large number of cases wouldbe cured of uncomplicated retroversions by wearing a pessary,particularly in those cases where the displacement commenced.after child-birth and was probably associated with subinvolution..These cases, if treated with pessary shortly after confinement,frequently ended in six or eight months in complete cure. Anda large number of those cases which did not receive treatment

260 P1~egnancy and Labour,

for a year or so after the beginning of the retroversion, if thentreated by pessary, and this was followed by pregnancy, wouldbe cured of the retroversion by wearing a pessary for a few monthsafter delivery, and thus allowing the uterus and ligaments toinvolute fully. In cases of long sterility one was justified insupposing something more than retroversion, and in opening theabdomen to see what was preventing pregnancy. The operationhe generally did was Kelly's operation. When a woman waspast, or near the end of, the child-bearing period, he did not thinkit mattered whether they fixed the uterus firmly or not.

SIR CHARLES BALL said that in the treatment of extensiveprolapse of the rectum they almost always resorted to colopexy.Earlier operations had failed largely because a peritoneal surfacewas stitched to a peritoneal surface. Such adhesions stretchedrapidly, and disappeared in a great many cases after a short time.They had therefore to do something more extensive, and toinsure that the stitches included the muscular coat of the intes­tines, and that this was stitched down firmly to the iliac fascia.In the case of a lady on whom he had to do a colopexy, andwho had had a retroflexed uterus stitched to the front abdominalwall, he saw no trace of adhesions of any kind, or any mark onthe surface of the uterus.

DR. SPENCER SHEILL said that, in adding a few words to express.his indebtedness to Sir William Sinclair for his excellent paper,in which he had so clearly set forth powerful arguments advocatinga most valuable operative procedure, he would like to point outthe necessity of approaching any discussion upon the merits ordemerits of any particular operation with an open mind. Hebelieved the reason that so many operating gynsccologists weredivided in their opinions respecting the advantages of one methodof operating for the cure of retro-deviations of the uterus over

.another method, was because, when a man begins to perform onevariety of operation, and becomes expert at it, his cases beinguniformly successful, he rarely gives up" the bird in the hand forthe two in the bush," and so he views the question with a notimpartial mind. He said Alexander Adams is one of the mostvigorous opponents of the operations of ventra-suspension andventro-fixation of the uterus, the reason being quite apparent,80 it was pleasant to hear from the distinguished guest of theSection the opinion of one who by actual operative ex-

By SIR WILLIAM SINCLAIR. 261

perience has made himself an authority competent to expressviews upon the subject worthy of closest attention. Dr. Sheillsaid it appeared to him that there was a place for all theoperations-fixation, suspension, and shortening of the roundligaments-and that each had its own special indications. Heconsidered Alexander Adams' operation as useless for the cure ofretro-deviations when complicated by prolapse, as ventra-fixationis undesirable in a simple case of backward displacement in ayoung married woman. As to the respective merits of the externaland internal methods of shortening the round ligaments, it wasworthy of note, he said, that Adams recommends the former,because he considers the portion of round ligament in the externalabdominal ring to be the weakest part, and it being cut awaywill not permit of recurrence as after the internal operation.It was said that a grave danger of ventra-fixation was " too largean area of adhesion." Dr. Sheill believed the causes of this to betoo much injury to the uterine peritoneum, and slight infectionof the abdominal sutures, the remedies being obvious. Dr.Tweedy (the Master of the Rotunda) described two thick rope­like ligaments-" in appearance very like normal round liga­ments "-as being the ideal result following ventra-fixation; buthe (Dr. Sheill) could not agree with him, as he held that thereshould be a vertical line of adhesion from the base of the anteriorcul-de-sac to above the isthmus of the uterus, and not distinctligaments which were liable to cause strangulation of intestine.He believed 'the dangers of ventra-fixation in the child-bearingperiod were dependent upon the placing of sutures too near thefundus in front, or even in the fundus or posterior to it, as hasbeen advocated, as well as upon the adhesion, whether it wasperitoneum to peritoneum or peritoneum to fascia. Dr. Sheillsaid he reported to the Section some years ago a case ofhis in which he performed ventro-suspension and myomectomy,the patient having previously aborted four times. Again becom­ing pregnant after the operation, she aborted a twin at twomonths, carrying to term the other, when she had an uneventfullabour. The note of the case was as follows :-" With regard tothe operation itself, it is interesting to note that suspension inthis case caused no pain, unusual vomiting, or frequency ofmicturition during gestation, and no dragging or alteration inshape of the uterus other than a slight dimple at the fundus.

262 Pregnane!.! and Labour.

Vaginal examination a month later showed the uterus normallyinvoluted and in perfect position." Since then he had deliveredher of a second child, and this pregnancy was uneventful in everydetail. Dr. Sheill has performed the operation of ventro-fixationon other cases of displacement and descent since then. Onepatient became pregnant, and labour was normal in every way;in none of the others has there been any recurrence or complicationso far.

DR. JELLETT said that he wished to convey to Sir WilliamSinclair the thanks of th e Section for the paper he had read.The fact that it was so fully discussed showed how muchthe Section appreciated his kindness in coming over to Ireland;he personally thought the use of the pessary a procedureof necessity, but not of choice, and that consequently opera­tion was in most cases preferable. He wished to draw a clearline of distinction between ventral suspension and ventralfixation, as several of. the speakers had used the terms assynonymous. Kelly's operation was one of ventral suspension,and it created a bond of union that would give way in pregnancy,or probably without it. In either case it had probably firstdone its work and enabled the uterus to gain its normal tone.Ventral fixation was an operation intended to create a positiveunion which would not give way under any circumstances. Theabsence of trouble during pregnancy after the operation recom­mended by Sir William Sinclair, which was essentially one ofventral fixation, was due to the fact that he fixed the uterus verylow down. Some time ago he (the President) reported some 400cases of the Alexander Adams' operation from different sources.His statistics showed that there was a return of the displacementin about I per cent., while Sir William Sinclair's showed 20 percent. This showed what an effect the collecting of statistics hadon the morality of the compiler. He had personally done somesixty cases, and had only had a recurrence in one case in whichhe had shortened one of the ligaments only. Kelly's operation,so far as recurrence of displacement or difficulty was concerned,might be put in an almost similar category.

SIR WILLIAM SINCLAIR, in reply, said that the remark made bySir Charles Ball confirmed him in the belief that it was only tothe extent to which the adhesions gave way that Kelly's operationwas a benefit to the patient. The additional ligaments were not

By SIR WILLIAM SINCLAIR. 263

imbedded, and were not muscular, and would not contract whenthey relapsed, and to that extent were in the way. He had notdiscarded the pessary altogether, but statistics over a long seriesof cases showed that they succeeded in only 11 per cent., and thetime the pessary was worn for was varied from a year toseventeen years.