Gambar halaman
PDF
ePub

Looking at the sequelæ of laceration from another point of view, we find that carcinoma of the cervix is far more frequent in multiparæ than in nulliparæ, while carcinoma of the body of the uterus is of about equal frequency in both. And among multiparous women those with carcinoma of the cervix have had more children than those not affected, showing that labor predisposes to carcinoma. Now the common result of labor is trauma, and its most frequent effect upon the cervex is laceration. Thus we arrive at the same conclusion from another point of view.

DISPLACEMENT OF THE PELVIC ORGANS.*

BY JAMES G. LYNDS, M. D., ANN ARBOR, MICHIGAN.

THE subject of displacement of the pelvic organs is so extensive that it will be possible to consider only a small part of it this evening, and therefore I will confine my remarks largely to downward displacements, or prolapse, and include, in a general way, the ovaries, tubes, uterus, vagina, bladder and rectum.

These organs are said to be prolapsed when they lie lower than their normal position. However, just what the normal position is, in a particular case, is more or less a matter of judgment on the part of the individual examiner. In determining this one has to bear in mind the great mobility of these organs when in a perfectly healthy condition, the greater freedom of motion in some relaxed conditions, and also the marked difference in the length of the vagina and depth of the pelvis in different individuals. Beside these it is necessary to take into consideration the condition of the bladder and rectum, for the uterus will be found to occupy somewhat different positions when these organs are full, partially filled, and empty. While there may be an apparent prolapse and anteversion when the bladder is empty, when it is distended there may be ascent and a degree of retroversion, and, when there is a relaxed condition of the ligaments, the uterus may be found anteverted one day and retroverted the next, or vice versa. It is claimed by some that only when local or constitutional suffering is produced can the condition be said to be sufficiently pathologic to demand treatment. This at first thought seem to be a fair proposition, but if you will give it a moment's consideration I believe you will think otherwise. Take, for instance, many cases of retroversion occurring after confinement. The patient makes an apparent perfect recovery and leaves the bed feeling as well as one could wish. An examination reveals a retroverted and prolapsed uterus, the ovaries and tubes being dragged down more or less with it. The perineum is intact, having escaped laceration or has been properly repaired. The woman has no symptoms of trouble, and if one does not follow the routine practice of examining confinement patients after convalescence there is often no symptoms to make one suspect that displacement exists. Such a * Read before the INGHAM COUNTY (Mason, Michigan) MEDICAL SOCIETY.

patient may live weeks, months or even years before any symptoms referable to the genital organs are manifest, but soon or late they will surely appear. The simple displacement causes little if any disturbance, but there is an interference with the circulation, especially the return flow from the parts, the organs remain congested, and eventually changes take place which will produce symptoms and not unfrequently result in pathologic conditions that require the sacrifice of one or more organs. The displacement, the primary affection, becomes the least important factor to manage, but timely replacement and proper care in the direction of keeping the parts in position until the ligaments recover their tone would obviate the difficulty.

I may, as I proceed, give you further examples of this kind, but for the present consider these sufficient to demonstrate the folly of allowing displaced organs to go uncared for until serious condition. exists.

PROLAPSE OF THE OVARIES AND TUBES.

As is well known the proper position of the ovaries and tubes is at the sides of the pelvis on the posterior and superior surface of the broad ligaments, the organs being one to one and a half inches outside the uterine body, and the tubes extending two to three inches upward and outward toward the pelvic wall. While prolapse of these organs is usually secondary to retroversion or prolapse of the uterus, occasionally when the uterus is in position those on one or both sides will drop down beside or behind it and remain there, eventually sinking low into Douglas' culdesac and crowding the posterior vaginal wall forward and downward, forming what is known as a vaginal ovariocele. Often I believe a diseased condition of these organs is the cause of this prolapse; occasionally, however, we find comparatively healthy organs in this position, but, allowed to remain for any length of time they do not continue healthy. Tuberculosis is so frequently observed in these parts when chronic displacements or inflammatory conditions exist that there can be little doubt of their acting as a marked predisposing cause. Replaced and kept in position, even when considerably diseased, they often recover. Allowed to remain they invariably continue the degenerative process, become cystic, adherent, and often completely encased in an inflammatory exudate which compresses the sensitive organ, preventing the normal development and rupture of the Graffian follicle and giving rise to great suffering and disturbance of the entire nervous system, frequently, I believe, driving the poor sufferer across the borderland of insanity.

For these reasons I advocate the replacement of seriously displaced. ovaries and tubes when discovered, before they are thoroughly diseased and recovery is impossible. In young women or those under forty, who are without children, this is especially important, as by the separation of adhesions, removal of cysts, and replacement, not only is a great amount of suffernig and nervous disturbance prevented, but sterility is frequently overcome and the long cherished hope of maternity realized.

PROLAPSE OF THE UTERUS.

When the uterus becomes prolapsed the appendages are dragged along with it, and especially is this true when the fundus becomes displaced posteriorly, as it so frequently does. If the prolapse becomes marked the vagina, bladder, and rectum are correspondingly carried

[graphic][merged small]

down, and instead of having to consider and deal with one organ all those contained in the pelvis must be taken into account.

I make three divisions of uterine prolapse:

(1) Simple prolapse: When there is a simple descent of the organ in the pelvis.

(2) Prolapse with change in the uterine axis: When the fundus is displaced posteriorly and generally the cervix anteriorly.

(3) Procidentia, partial and complete: Complete when straining or the erect position causes the entire uterus to lie outside the vulva, the vagina being inverted. Partial when a portion of the uterus is outside with partial inversion of the vagina, the fundus lying correspondingly low. I mean here to differentiate between a prolapsed and an hypertrophied organ in which we find an elongated cervix protruding from the vulva with or without partial inversion of the vagina, but where the fundus is found in practically its normal position. The uterus is usually retroverted, retroflexed, or a combination of each exists, but it is important to bear in mind that it sometimes occurs

when the normal or even an abnormal anteversion or anteflexion is present.

Etiology. On this part of the subject I will say little more than remind you of the three general causes, namely, decreased support, increased weight, and increased abdominal pressure. Considering the supports, there are below, the perineum and vagina with its lateral attachments to the pelvic walls, and above, the uterosacral, uterovesical, broad and round ligaments. Personally, I give these ligaments more credit for supporting the uterine and intraabdominal organs than they generally receive. It is a well-known fact, and one I have no doubt many of you have observed, that when these ligaments become relaxed and weakened the uterus will sag even in young women in whom the supports below are perfect, and in elderly nulliparous women I have seen both incomplete and complete procidentia a number of times. On the other hand, I have seen the uterus and its appendages remain in perfect position for years when a complete laceration of the perineum and prolapse of the lower part of the vagina were present. Understand me, I do not mean to belittle the sustaining power of the perineum and vagina, for I fully appreciate their great importance and am thoroughly convinced that a large majority of the cases of procidentia are due primarily to a weakened condition of these parts and could be prevented if they were properly strengthened at the right time. The supports below, the ligaments, and the so-called retentive power of the abdomen above, are all necessary in the majority of cases to properly support these organs; and the weakening of any one of them is likely to result in a downward displacement soon or late unless the uterus be correspondingly light and easy of retention. It must not be forgotten that a large, heavy uterus will of itself overcome all ordinary supports and become prolapsed. Thus we observe a very fine and equalized adjustment between the strength of the supports and the parts to be supported.

A study of the different ways in which a prolapse begins will demonstrate what factor of support has been at fault. The sagging begins either at the vault or outlet of the vagina. When at the vault the uterus settles down and inversion of the vagina begins above. This may occur when the pelvic floor is intact, and is due to a weakened or relaxed condition of the ligaments, an unusually heavy uterus, or the retentive power of the abdomen is replaced by an expulsive power so great as to overcome the supports and force the organs down. When the sagging begins about the vaginal outlet it is due to a weakened condition of these parts. The vaginal wall sags through the vulva together with the bladder and rectum, giving rise to cystocele and rectocele. The inversion of the vagina begins at the vulva, and upper portions of the vagina and uterus are dragged upon, the uterine ligaments are called upon to support this extra weight and generally are unable to do so, consequently all the organs are dragged down together. Montgomery calls. the former uterovaginal, the latter vaginouterine prolapse. In the first

the causes are in the pelvis, where the prolapse begins, in the latter at the vulva.

Diagnosis. In simple prolapse the diagnosis is made by digital examination, the uterus being found nearer the vaginal outlet than normal, the cervix frequently resting on the perineum. In prolapse with change in the uterine axis the cervix generally lies close to the anterior vaginal wall and the ostium vaginæ, the body back against the bowel either in retroversion or retroflexion.

The diagnosis of procidentia while apparently very simple is frequently made when it is not present. It is necessary to differentiate from tumors of various kinds, enterocele, rectocele, cystocele, urethrocele, inversion of the uterus, and, more than all else, elongated or hypertrophied cervix. A very superficial examination is generally all that is necessary to differentiate these conditions, yet mistakes are frequently made. The most common probably is that of mistaking an elongated cervix. When one sees a cervix protruding from the vulva it seems quite natural to call it prolapse or procidentia, when it is quite as likely to be an elongated cervix. I call attention to this error especially because it has a very important bearing on treatment and prognosis. The cervix is divided anatomically into three portions, namely, the vaginal, the intermediate, and the supravaginal. You will note the attachment of the anterior vaginal wall at the top of the vaginal portion and of the postvaginal wall at the top of the intermediate portion. In procidentia the entire uterus, appendages, vaginal vault, and bladder descend together. In elongation of the cervix the body remains in practically its normal position. If the vaginal portion alone hypertrophies the vaginal vault is not disturbed, neither is the canal shortened. If the intermediate portion elongates the anterior vaginal wall and usually the bladder is carried down with it and this portion of the vaginal canal is correspondingly shortened. If the supravaginal portion elongates the entire vaginal vault is carried down exactly as in procidentia, but the uterine body, its attachments, and appendages remain in their normal positions practically undisturbed.

Now, note that in complete and partial procidentia the support of the pelvic floor, be it little or great, is overcome, the lateral attachments of the vagina and bladder are destroyed to greater or less extent according to amount of inversion, and the uterine ligaments and pelvic peritoneum are stretched so that they lie outside the vulva. (The photoengraving illustrating this paper will demonstrate to what extent this condition may occur). This differential diagnosis is of the greatest importance in giving a prognosis and deciding upon treatment, as in hypertrophy the treatment is simple, safe, sure, and involves the loss of none of the organs, while in procidentia the prognosis is uncertain and anything that promises a cure more difficult and dangerous.

Tumors protruding from the vulva are sometimes mistaken for procidentia, but by locating the body and cervical canal there is no occasion for this error. In inversion of the uterus the fundus is likely

« SebelumnyaLanjutkan »