Laparotomy for Reduction of an Inverted Uterus. BY PAUL F. MUNDE, M. D., PROFESSOR OF GYNAZCOT^FY AT THE NEW YORK POLYCLINIC ; GYNAECOLOGIST TO MOUNT SINAI HOSPITAL. BEPBINTRU FROM Neto jJUeliical journal for October 27, 1888. Reprinted from the New York Medical Journal for October 27, 1888. LAPAROTOMY FOR REDUCTION OF AN INVERTED UTERUS. By PAUL F. MUNDS, M. D., PROFESSOR OF GYNAECOLOGY AT THE NEW YORK POLYCLINIC; GYNAECOLOGIST TO MOUNT SINAI HOSPITAL. When, a number of years ago, Thomas suggested and in two instances (one successful) carried out the plan of stretching the funnel of an inverted uterus with a glove- stretcher passed through an abdominal incision, the profes- sion could not but admire the boldness and originality of the idea, although it has as yet been slow in adopting and following it. But in those days (n >t so remote, either) it was considered proper to relegate laparotomy to the place of a last resort, and amputation of the inverted uterus was preferable to the dangerous experiment of attempting to dilate the constricted ring of the organ through an abdomi- nal incision. And surely the choice of the former opera- tion, mutilating as it was, could not be ascribed to its safety, since, out of fifty-eight cases collected by Scanzoni in 1 867, eighteen were fatal. With the comparative absence of danger now attending aseptic laparotomy, there seemed a chance for a revival of Thomas's operation in a favorable case. While I had seen, in all, six cases of inversion of the uterus, only two were complete uncomplicated inversions; one of these was in 2 LAPAROTOMY FOR Scanzoni's clinic in 1867, and, in consequence of a doubtful diagnosis, the uterus was ligated and amputated, with a fatal result; the other was shown me by the late Dr. Dawson in his clinic at the Out-door Department of the New York Woman's Hospital some twelve years ago, and the inversion was subsequently replaced by him, by what method I do not know. The four other cases were partial inversions pro- duced by fibroid polypi, and were easily reduced after re- moval of the tumor. Thus I had no opportunity to test Thomas's method in a case where a faithful and persistent trial of the usual rapid and gradual means of vaginal repo- sition had failed, until a few months ago. M. W., aged twenty-seven years, married, two children, the last three months and a half old, was admitted to my service at Mount Sinai Hospital on May 29, 1888, during my absence from the city. The last confinement had been easy and natural. Particulars could not be obtained as to the placenta and puer- peral state. About a month later she consulted Dr. C. Nicolai, of Harlem, for persistent haemorrhage, who detected a complete inversion of the uterus, and, as he informed me, made four distinct attempts at reduction of an hour each, twice under chloroform, but without success. The haemorrhage continued, and the patient was sent by Dr. Nicolai to my service. Dr. B. Scharlau, who acted as ray substitute during my absence, made two very determined efforts at reduction under chloroform, and, failing, employed steady pressure with an inflated air-bag for three days, until the surface of the inverted uterus became so raw and its tissue so soft as to cause fear of sloughing. Then mild carbolized douches were substituted. On June 6th a third ineffectual attempt at reposition was made under anaesthesia. On my return, two weeks after her admission, I found the excessively anaemic and emaciated patient clamoring for relief, no matter how. At the first examination 1 made a moderate attempt at reduction without anaesthesia, merely as a feeler, and easily found the reason of the failure to lie in the great mobility of the completely inverted uterus, and the apparent impossibility REDUCTION OF AN INVERTED UTERUS. 3 to secure sufficient purchase on any part of the uterus so as to be able to press it steadily against the contracted ring. The ob- struction was so easy of reach through the thin abdominal walls that it seemed to me, as it had seemed to Dr. Nicolai and Dr. Schariau, absolutely incomprehensible that it should not be overcome, and I appointed the day for the final trial, with con- siderable confidence that I should be successful. However, in case I should fail by the usual methods, I had laid down for myself the following plan of action : Abdominal section, stretching of the inverted ring with a Palmer dilator or a glove-stretcher, and then reinversion by the intravaginal hand. Should this combination fail, as I had no idea it would, then I would resort to removal of the ovaries, closure of the abdominal wound, and elastic ligation of the inverted uterus. I so confidently expected to replace the uterus by manual press- ure that I had not provided myself with a glove-stretcher, not happening to find one conveniently at hand. On June 20th, in the presence of Dr. W. H. Baker, of Bos- ton, and a number of gentlemen attending the Polyclinic, I be- gan the attempt at reduction, the patient being thoroughly re- laxed by chloroform. For fully an hour, with alternate hands in the vagina, and applying the pressure at every available spot of the uterine surface, employing the fingers of the other hand and a wooden plug as means of counter-pressure and of dilat- ing the ring, I labored to effect reduction until, from sheer exhaustion, I was obliged to desist. The contracted ring firmly resisted all efforts to dilate it. Further efforts seemed unadvisa- ble, as the uterine tissue had become so soft and pulpy from manipulation and pressure, and the wall at spots appeared so thin, as to render its perforation by the fingers probable. I could not bear to give up the reduction of the organ at that sitting, and therefore proceeded to carry out my original plan. Rapidly making a two-inch incision through the abdomi- nal wall, I pushed the uterus from the vagina upward so as to almost bring the ring into the wound, and first with my fingers and then with a Palmer's steel dilator tried to stretch it apart. Failing in this. I sent for a glove-stretcher, and procured two of ivory from the wife of the superintendent of the hospital. 4 LAPAROTOMY FOR These were disinfected, and first one and then both were in- serted through the abdominal wound into the uterine ring down to the very bottom of the inverted uterus and gently separated to their utmost. The ring was thus completely dilated and I expected an immediate reduction. But as the glove-stretchers were slowly withdrawn to allow the pari passu reposition from the vagina, at the instant the stretchers slipped out of the ring, the latter closed like a vise ; and, although the attempt was re- peated again and again, no rapidity or concurrence of action in pressing the fundus upward succeeded in anticipating the con- traction of the ring. It seems almost incredible that it should have been impossible to so dilate and keep open the ring, when it was not only easily accessible, but even visible at the abdomi- nal incision, as to enable me to slip the fundus back through it. But such was nevertheless the case, and my spectators will, I think, give me credit for having tried faithfully to save this woman's uterus. As a last resort I followed a suggestion of Dr. Lilienthal, iny house surgeon, who assisted me (before the op- eration, while discussing the possible necessities of the case, I had rejected this plan as ingenious, but scarcely likely to be re- quired), and passed a Peaslee's needle from the vagina through the firmest portion of the fundus uteri and out of the ring and the abdominal wound, attached a long loop of the thickest silk to it, drew the loop out of the vagina, and tied a piece of large, doubled, vulcanized rubber drainage-tube to it, as a ful- crum upon which to exert traction. I chose the flexible tube in preference to a flat button of horn or metal, which were at hand, because I feared the latter might prove an obstacle at the contracted ring. Then dilating the ring with the glove- stretcher, I tried to draw the fundus up through it by making steady traction on the loop of silk. But the pulpy uterine tis- sue gave way and the drainage-tube suddenly appeared in the abdominal wound. Realizing that this uterus was beyond sav- ing, I quickly removed the drainage-tube and silk loop, pushed the perforated fundus down into the vagina, and tied an elastic ligature tightly about the body of the uterus as near the vaginal vault as I could reach. Having thus sealed off the peritoneal cavity from below, I proceeded to remove both ovaries and REDUCTION OF AN INVERTED UTERUS. 5 tubes in the usual manner, and, after thoroughly cleansing the abdominal cavity with warm Thiersch's solution, closed the wound. The vagina was irrigated with bichloride solution (1 to 5,000) and loosely packed with iodoform gauze. The operation had lasted an hour and forty minutes, the oophorectomy and closure of the abdominal wound occupying but ten minutes. The patient bore the severe handling better than her anaemic state would have led one to expect; there was but moderate shock, and no local inflammatory reaction what- ever. Afterthe first forty-eight hours, when the iodoform gauze was removed, the vagina was irrigated every three hours with warm Thiersch's solution, bringing away for nearly two weeks quantities of black offensive shreds. The temperature for nine days varied between 101 + ° and 102 + ° F., the pulse between 100 and 130 beats; after that both became normal. The frequency of the pulse was no doubt due to the excessive anaemia, and the slight rise of temperature to absorption of septic matter from the sloughing uterus by the abraded and torn vagina. On the thirteenth day I made an examination with the Sims speculum and found the elastic ligature loose in the vagina, and the body of the uterus entirely absent, the stump of the cervix being almost on a level with the vaginal vault and the cervical canal apparently closed. The abdominal sutures were removed on the ninth day, and a small mural abscess was found which may have caused some of the temperature, for it immediately fell, and remained down. From that date recovery was uninterrupted, and on the fif- teenth day the patient sat up in an easy-chair. I am thankful that in this case I followed the old rule to " let well enough alone " and did not interfere with the sloughing process of the ligated inverted uterus by cutting off the sloughing portion, as is advised by most authors, and as the fear of septic infection might have induced me to do. But more than the danger of septic infection I feared the retraction of the edges of the cervical canal and a communi- cation with the peritoneal cavity. I had once seen this oc- cur after immediate amputation of the inverted uterus after 6 laparotomy for an inverted uterus. ligation (Scanzoni's case), and the autopsy showed the gan- grenous border of the cervix turned into the peritoneal cav- ity, and I did not wish to risk a similar occurrence in my case, if the elastic ligature was removed too early or chanced to slip off after amputation of the sloughing uterus. Besides the practical point to be learned from the treatment of the ligated uterus, the chief lesson taught by this case seems to me to be the failure of the effort to dilate the cervical ring through an abdominal incision sufficiently to permit replace- ment of the fundus. My hopes had been so unbounded in the easy success of Thomas's ingenious plan that I was and still am intensely diappointed at its failure, the more so as I fancy whatever chance it had of being adopted in suitable cases in the future may be shattered thereby. I am aware that I may be criticised for not having per- severed still longer with gradual pressure, and I confess that, had I doubted for a moment that Thomas's method would succeed, I should have felt it my duty to subject the uterus and vagina to still further distension and taxis, which they might ill have borne. A REASONS WHY ^^e^ans Shoidd Subscribe for The New York Medical Journal, Edited by FRANK P. FOSTER, M. D./ Published by D. APPLETON & CO., 1, 3, & 5 Bond St I. BECAUSE : It is the LEADING- JOURNAL of America, and contains more reading-matter than any other journal of its class. 2. BECAUSE : It is the exponent of the most advanced scientific medical thought. 3. 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