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perineum has been restored. Many cases of subinvolution with lacerated cervix can only be cured by repair to the cervix (Emmet's operation) in conjunction with curettage.

The second group include a great number, the chief amongst which are:-Fixing the round ligaments in the inguinal canals or Alexander-Adams' operation, ventrofixation, ventro-suspension, and vaginal fixation.

Indications for Operation.-The number of cases requiring an operation, compared with the total number of cases of retroversion which either want no treatment or else can he relieved by some support, do not amount to many. Herman states that of 10 per cent. of all the cases that come for treatment, only about two of these need an operation. Dührssen admits to operating on one half of his cases, and Theilhaber of Munich states that retroversion causes no symptoms and needs no orthopedic treatment, and that all the co-existing troubles are due to uterine catarrh, hysteria, neurasthenia or intestinal atrophy. Most gynæcologists, however, agree that many cases cause no symptoms or discomfort, while in some serious trouble is produced, but no one is agreed as to the symptoms which retroversion may cause; reflex symptoms connected with the stomach, etc., as gastric oppression, dyspepsia, and general lassitude, headaches, and the like have been attributed to a retroversion, and by the writings of some this displacement has been adopted as a universal cause for all subjective ailments. In the matter of indications for treatment, great care must be exercised in the first place, not necessarily to hinge irregular pains in the head and stomach and other ailments on to an accompanying displacement of the uterus because it happened to occur in the same patient and was the only physical sign of anything abnormal, just as though it were the exciting cause and that the predisposing cause of neurasthenia or hysteria played no part; and, in the second place, to suppose that a correction of the retroversion will also rectify all the other troubles, but rather it should be generally stated that no case should be submitted to operation, unless the symptoms

present are clearly accounted for by the pathological condition, and failure of relief has attended the palliative treatment in the hands of an intelligent and experienced practitioner. It is frequently most difficult to decide how far the symptoms, be they local or reflex, are due to the pathological state of the uterus, and how far to a weakened nervous system, and if the latter is dependent on the former how far such is the case, and also how far correction of this displacement will relieve the general condition. Backache is a very variable symptom in these cases, and, being subjective in nature, is most fallible for estimation; again, with congestive dysmenorrhoea it is also difficult to correctly gauge its severity. As before remarked, the effect of an operation may to some extent be determined beforehand by first supporting the uterus by means of a pessary, and if this produces relief then much the same amount of benefit will result. Cases, however, of fixed retroversion with adhesions or inflamed appendages, most will agree, require an operation for their

cure.

Alexander-Adams' Operation, or the inguinal shortening of the round ligaments, has now been fully established as one of the classical operations of surgery. The operation was first successfully performed by William Alexander, of Liverpool, in 1881, and soon after followed by James Adams, of Glasgow, in 1882, and in consequence is often called after both surgeons. Briefly, the technique consists in making an incision over the external abdominal ring external to the spine of the pubes and parallel to Poupart's ligament; the external oblique fascia covering the inguinal canal is incised, and the ligament, a pinkish-white fibro-muscular cord, is isolated, pulled upon, and anchored to the fascia. This is done on both sides in turn. Many slight modifications are adopted by different surgeons, but the same object is aimed at. As an operation, it has been attended with a considerable measure of success, for Kellogg, quoted by Edebohls in 1896, writes that he has done the operation more than five hundred times, and his failures amount to less than 5 per cent. Quite as good a record as this attends other surgeons who make this

operation a routine method of practice. The arguments in favour of this operation may be stated:—(1) That, for the correction of retroversion, shortening of the round ligaments is the simplest and safest method of treatment: this is important, seeing that it is undertaken for the relief of health and not for the saving of life; the mortality may be put down at nil. (2) That the shortened ligaments will stretch and retract with pregnancy and after labour. Lapthorn Smith (Amer. Journ. Obs., July, 1898) states that in an enquiry which he had made in order to discover the experiences of American surgeons as to the influences of pregnancy and labour on this and other operations, that in no case were they unfavourably interfered with in the former, whereas, when firm adhesion had been secured by ventro-fixation and pregnancy followed, trouble of some kind, as pain, miscarriage, or difficult labour, occurred in about 30 per cent. of the cases. (3) That no band is artificially produced in the abdomen capable of producing ileus. (4) That the ligaments are strengthened at their weakest parts, whereas with intra-abdominal shortening the weak inguinal parts remain. Prof. J. W. Taylor, speaking of this operation in 1901, said "he believed it was the best for uncomplicated backward displacement. The troubles which he formerly experienced had entirely disappeared with stricter asepsis and the use of fine ophthalmic silk as a buried suture to entirely close the wound in the external oblique, and to sew the upper end of the ligament to the under surface of the aponeurosis. He had watched pregnancy come and go afterwards without any difficulty or recurrence of this displacement. Performed as he described in well-selected cases, the results were perfect, and few operations gave patient and operator more unalloyed and permanent satisfaction." Of the objections that have been raised against this operation, some may be mentioned, as the following: That two wounds are made, leaving two scars instead of one; that hernia is more likely to occur in consequence, and especially as the wounds are situated in the inguinal regions; that the operation is attended with some difficulty, either because the ligaments are not easy to find, or else when found they may be so weak as to break

with the pulling of them up; and, finally, that adhesive cases or those with extensive inflammation and fixity of the displacement are excluded, so that the operation is strictly limited to the mobile organ. Except for the last point, which refers to the limited applicability in the scope of the operation, the above arguments will not carry much weight and do not need much explanation: Two wounds are made, but generally the scars are partly hidden and are not disfiguring; hernia, when the fascia has been carefully sewn up and the wound is aseptic, is less likely to occur, as the inguinal canal is strengthened by the firm scar; difficulty in the performance of the operation is not experienced by those who do it constantly, and frailty of the ligament, Alexander himself states that it occurs in only about 3 or 4 per cent. of the cases. Dr. Lapthorn Smith, speaking at the annual meeting of the British Medical Association in 1898, said that Alexander's operation was ideal if it was absolutely certain that no adhesions were present and that the tubes and ovaries were healthy. That the operation is contra-indicated when the uterus is fixed by diseased appendages is admitted by Alexander himself, who has recently advised and practised a preliminary colpotomy in order to include these cases within the scope of his original operation. Alexander, by vaginal incision, opens Douglas's pouch, passes in his finger, and breaks down adhesions, until the uterus can be pushed forward easily into anteversion; he then packs the vagina with gauze and shortens the round ligaments; he states that if any lesion is found in the pelvis it can be removed by the vaginal opening. In some cases, no doubt, by posterior colpotomy as a preliminary measure, we can satisfactorily do all that is required, but in many of these cases it will be difficult to separate the adhesions and remove the diseased appendages by feel only when the work lies out of sight, and furthermore, portions of intestine may be adherent, which will run great risk of damage, and the control of hæmorrhage may be difficult, which may require a secondary abdominal section.

Other modifications than posterior colpotomy have been practised in order to apply Alexander's shortening of the

round ligaments to cases of fixed retroversion. It has been said that what Alexander originally devised should not be taken for what can be done by any modification that he or anyone else should subsequently propose; for instance, it may be found that the operation of shortening the round ligaments combined with cœliotomy through the internal abdominal rings as carried out by Dr. Goldspohn, of Chicago, may come to embrace many, if not, all those cases of fixed retroversions which would otherwise have been excluded. This author (Goldspohn) publishes (in the Trans. Amer. Assoc. Obs. and Gyn., in 1902) a record of 105 operations of shortening the round ligaments combined with what he calls a bilateral inguinal cœliotomy via the dilated internal inguinal rings; by this means he claims that he can treat not only a small number of unimportant uncomplicated cases where an absolute diagnosis is necessary before the round ligaments are pulled upon, but also a larger number of aseptic cases with adhesions where the infective agent has died out; on the other hand, he distinctly states that the treatment of pus tubes, tubercular disease, or conditions other than those mentioned do not come within its indications, for he describes how, owing to mistaken diagnosis, he came upon a pus tube which he enucleated and removed from one side in three cases, and also in another case tubercular tubes containing cheesy pus, and in another an early unruptured tubal pregnancy, all of which would have been treated by a median ventral cœliotomy had they been correctly diagnosed.

Another modification has been suggested for these cases where adhesions exist, and that is that a small median abdominal opening should be made to separate the adhesions prior to the drawing up of the round ligaments.

In conclusion, it would seem that Alexander's operation is the one of choice in the mobile retroversion of the childbearing period of life, as the mortality is practically nil and the dangers connected with a pregnancy non-existent; but, whether with a fixed displacement or one with accompanying disease of the tubes and ovaries which requires separation or resection, any modification of this operation will become popular is open to doubt.

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