On Operation for Fracture Extending into Joints

W. W. Cheyne
1891 BMJ (Clinical Research Edition)  
Nor'tlherni Dispensary. THE practical requirements for successful ventral uterine fixation are -to heal erosions and ulcerationis, and reduce the size and weiglt of the uterus before attempting fixation. So far as practicable, vacginal prolapse must be corrected by astringent douches-for example, oak bark, quebracho, etc. The uterus slhould be temporarily supported by a pessary; above all, lhyperplasia miust be corrected by rest in the hiorizontal positioni. As a lesser operation,
more » ... tion, perineorrhaphy, withl or witlhout colporraphy, may be first tried, especially in cases wlhere rectocele or cystocele is a miarked complication. Despite all these measures, a few cases will be fouind to require sometlhing more. Unless a trial of shortening the round ligyaments is mnade, ventral fixation of the uterus is the only radical cure. For clhronic senile procidentia, the followiing procedure seems to me likely to become niore gesnerally used thaln ally hiitlherto employed: Operotion.--T'he uterus is well returned witllin the vagina; thlen, by means of a broad-pointed sounid-like repositor, it is l)ressed up against the abdominial peritoneum. A slhort inCi--sion is made in the imnd-line tlirough the suiperficial and deep -abdominal layers down to, but not through, the peritoneum. A niarrow curved needle, with a fairly large eye, of Ilagedorni's pattern, and fixed in a long firm handle, is iiitroduced per vaginam, and brought out tlhrough thle riglht side of the -uterus and through the exposed abdoominal peritoneum. The ineedle is threaded with strong silkworm gut or reindeer ten(lon, or silver wire, froIIi the abdomin-ial side: the needle is witlhdrawn tlhrouighi tihe same ptunceture, the tlhread is drawn througlh. and the lower end brought iiito the vaciiia. The ends of the sutture are fixed witlh catch forceps. Tlhe needle is disinfected, then reintro(luced, anid made to pass througlh the left side of the uterus anld tIme abdominal pl)ritoneuin coveringit tlhe needle is threaded as before, an(l, onl beingTwithdrawn brings the left side thread inlto the vaginia. There are inow two single threads or two free ends infe-riorly, witlh a loop on the abdominal aspect; the latter slhould be divided, and the ends fixed witlh forceps. Thle forceps on the vaginial ends of the sutures are removed, and on eachl suture a small, stout tlattened ovoid glass disc, wvithl roun(led edges, or a plate ,of decaleified chickenl bone is slipped. A little manipuila-Ctionl iay be needed to get the discs through tlhe cervix. As a rule this can l)e maniagaed by steadying the uterus, ;if nieed be, by volselhl, and(I tlhen guidingr the discs side-,ways by forceps, or by gentle tractioni on the abdominal -enlds of the sutures. Before tightening the sutures, care Ilmust be observed that the intrauterine repositorimaintainis the fund(ulls uteri in close appositioin to the abclominal -peritoneunm. The sutur'es are nlow (Irawnl tight fromli the abdo--miiial enids till both discs are closely applied to the inner uterine wall; the operator slhoulcd be able to lift up the uterus by means of the threads. If the uterus is unduly large, or if there is any dolubt about the positioni or streingthl of the sutures, a tlhird or fourth dise inay be introdlice(l in the mann)ner already dlescribed, but this will seldom be necessary. The abdominal ends of the sutures are nlow threaded in an ordinary Ilagedorni's needle, amid passed tlhrouhcl the muscular layers of the abdomeni; discs of bone or glass maybe slipped on.1 antlte sutures secured and buried. At times the sutures from the opposite sides are tied together and theni buried. The intrauterine rel)ositor is withdrawni. (Two deeply buried silkworm gut stitchles, including the wlhole thickness of the uterine wall, but not passing through the endomnietrium, may be used to further coinInect' the uteruis with the abdominal muscles. These latter stitches are only to be used wlheni the nfeius' is large anid heavy). The abdominal wound is closecl. The vaginial ends of the sutures are n-ot cut slhort, but allowed to remaini as drainage tubes for ten davs. The vagina is )acked witlh antiseptic tamponis for a fortn;ight. If the sutures 1 Read in the Seetion of Obstetrics at the Anniual MTeeting of tlle British Medical Association lheld inl Biriinghiliamii, July, 1i90. are not loosened by the enld of a fortnight, they are cut off at the level of tlhe os. Tlhe patient slhould be kept in bed for three weeks after operation, and, in a considerable proportion of cases, it nlay be desirable that a pessary should be worn for two or three moniths after getting up. In event of retro-uterine adhesions, it may be necessary to open the peritoneal cavity and break these down. If this lhas to be done, a strip of uterine peritoneum slhould be dissected off by scissors and the uterine surface stitchled to the parietal peritoneum, as practised by Caneva, of M1ilan, and maniy others.2 Tllis slhould be done after the intrauterine sutures lhave been passed, but before they are tightened. The advantages claimed for this operation are-(1) It gives more secure and reliable fixture tllan any other. (2) Thle time occupied in performing the disc operation is much shorter than in plastic metlhods. (3) Sufficient adlhesive peritonitis is induced to warrant belief that, after the absorption of sutures (if destructible sutures are employed), the uterus will retain its relations to tlle abdominal wall. (4) Tlle risks of bleeding are nil. The risks of septic absorption from the thread passing througlh the uterus are practically nil; fluid matter will come down into the vagina, and the sutures, passilng through the substance of the uterus with the closely applied discs, block the uterinle end of the suture tract, and prevent passage of fluid inito the peritoneal cavitv. (5) The operation is much easier than a plastic method. Any overator conversant withl the uterine sound can do all that is needed.
doi:10.1136/bmj.1.1575.516-a fatcat:yhvqulambbaevmvz3sraarnp6y