NOTES ON A CASE OF PROLAPSUS UTERI

"WITH PYOSALPINX.

By R. F. STAND AGE,

CAPTAIN, I.M.S.,

Residency Surgeon, Bangalore.

Nursamah, a Hindu, aged 40 years, was ad- mitted to the Lady Curzon Hospital for Women on 25th February 1903, complaining of reten- tion of urine for nearly two days. A catheter was passed quite easily and a very large quanity of urine drawn off. Her immediate distress being relieved, the patient then complained of constant severe pain in the hypogastric and right iliac regions. She stated that for three months she had suffered severely from aggravation oi this

pelvic pain during menstruation, which had of late been very scanty. She also stated that she had suffered, lately, from attacks of fever and shivering.

She was married 20 years ago, had only one child, 15 years ago, and had no miscarriages or abortions. On examination P. V there was a well-marked

prolapse of the uterus, the cervix being visible in the vulval opening close against the sym- phisis pubis. The os was directed to the right and a hard, ill-defined mass was felt behind and to the right. Owing to the resistance of the abdominal muscles the bimanual examination was difficult, but under chloroform the following additional facts were observed :?The body of the uterus, which could be clearly differentiated from the tumour behind, was pushed away to the left and forward against the pubic base, the sound passed the normal distance to the left. In an upward and downward direction the uterus was moveable upon the tumour, to which it was loosely connected by an easily palpable band. The tumour was situated in Douglas's pouch and extended to the right be- hind the right broad ligament. It was about the size of the head of a" baby six months old, was irregularly round in shape and was slight- ly movable in an upward direction. It was

very hard, but on very firm pressure with both hands a sense of elasticity was elicited. Per rectum, bands of adhesions could be felt, passing from the tumour to the uterus and the pelvic walls. The ovary on the left side could be made out, and was normal in size and position. The prolapse of the uterus, b}^ the gentle traction with a volsellum forceps, could be made com-

plete, and the uterus returned to its original position by gentle upward pressure. The patient was put to hed and systemati-

cally nourished for the operation, which took

place on 14th March, 1903. A median incision of 3^ inches long was

made, extending downwards to 1 inch above the

symphisis pubis. On opening the peritoneum omentum presented, which, it was found, could not be pulled up to clear the SeW ot operation. On passing the hand down towards the pelvis over the tumour, it was found that the omen-

tum was intimately adherent to it in its entire

breadth. Two Doyen's clamps were placed across the omentum close to its attachment to

the tumour, and a row of fine silk ligatures an inch higher than the clamps, the omentum being divided right across between the ligatures and

clamps. The hand was then passed down be- hind the left hand ligament to the back of the

uterus and carried to the right on to the

tumour, which was found to be intimately ad-

herent to the uterus, the rectum, small intes-

tine (ileum), posterior surface of the broad liga- ment, and to the vermiform appendix, which closely adhered to its superior and posterior surface. By manipulation with the fingers, the connections with the uterus were separated, the adhesions to the rectum and sacro-uterine liga- ments were very lax and easily broke down, but the small intestines was very tightly adherent, and some part of the wall of the tumour had

to be peeled off with the gut before it could be

set free. The appendix also gave considerable trouble and ruptured while being set free from the tumour, a small, hard stercolith shaped like a date-stone (but about half the size) escaping. The appendix was therefore clamped and put aside for treatment at a later stage. Freed from

these connections, the tumour was easily shelled out from its bed on the posterior wall of the

broad ligament, and was brought out through the external wound. It was found to be an

enormously thickened and dilated Fallopian tube, the ampullar end being the size of a foetal

head, and containing nearly six ounces of

greenish, odourless pus. No trace of the right ovary could be found, and it was afterwards

discovered flattened out on the wall of the tube.

The thickened meso-salpinx was transfixed and the tube ligatured and removed close to

the right corner of the uterus. The appen- dix was then dealt with, being ligatured close to the caecum, and cut oft with the

meso-appendix, which was separately ligated. The peritoneal coat of the stump was carefully brought together by a gossamer silkworm gut stitch. There still remained the prolapse of the uterus to be dealt with, and it was decided, as the operation had already occupied nearly an

hour, not to employ the method of Stanmon-

Bishop, and shorten the sacro-uterine ligaments, though there was ample space to perform it. The uterus was therefore brought into the abdominal

Feb. 1904.] PROLAPSUS UTERI WITH PYOS \LPINX 59

wound, and attached by its posterior surface t(> the parietal peritoneum by three fine silk sutures (Kelly's method). The uppermost suture passed through the uterine muscle a line behind the Fallopian tubes, and the sutures in the parie- tal peritoneum took up also some of the sub-

jacent muscle. The left ovary and tube having been found

normal, were returned to the pelvis, the pelvic cavity was irrigated thoroughly with warm, weak boric solution, the suspending sutures on

the uterus were tied up snugly, the peritoneum was drawn together by a continuous fine silk ligature, and the parietes united by interrupted stout silk worm gut sutures. The operation lasted one hour and a quarter. I had the great advantage, throughout the operation, of the

assistance of Dr. (Miss) Niebel, the Lady Doctor ?f the hospital, to whom I am also indebted for the notes of the case. Miss M. de Lemo.s, As-

sistant-Surgeon, gave chloroform most skilfully. The patient was somewhat collapsed after the

operation, but rallied well, and made an unin- terrupted recovery. All she stitches were re-

moved by the 14th day, and she left hospital a month after the operation perfectly well and with the uterus in good position. Remarks.?I have drawn attention to this

case, as it forms one of a series treated by me in the Lady Curzon Hospital, in which prolapse of the uterus occurred together with pyosalpinx. Some cases have been double, others, like this

one, single, with one healthy tube, and all, of

course, presented differences in the number and extent of the adhesions found. The one similar feature was the prolapse, and I am convinced that this condition is the cause of the tubal

infection. It would be difficult to imagine how the

prolapse of a uterus, so surrounded by inflam-

matory adhesions, could happen after those adhe- sions had formed, but, granted that the prolapse occurred before the spread of infective inflam- niation to the tubes, and through them to the peritoneum, it is easy to imagine many sources ?f infection from the fact of the os uteri being in the outer world. When we reflect on the insanitary clothes

worn by the lower class native, or the dirty floors on which they sit, and the many other

opportunities for the infection of an exposed Mucous orifice occurring in their daily life, the

Wonder is that every case of prolapse is not

accompanied by tubal trouble. In this case the

P"s in the tube was sterile, so no direct evidence of infection by an organism, which could be

assumed to have invaded the uterus from its

contact with outside dirt, was available. 1 hope, however, in some future case to get bacteriologi- cal evidence of a continuous infection starting at the exposed os. This case I report to draw

attention to the condition and in the hope that other operators may record their experiences of a similar nature.

It is unfortunate that in such cases the history is of 110 assistance. Those acquainted with the difficulties of case-taking in a native ward will bear me out when I say that such matters as the occurrence of prolapse of the uterus before the onset of pelvic pain, or vice versd, create so trivial an impression on the average lower class native mind as to be entirely unrecorded by the memory.

Prolapse of the uterus is common among native women, and I attribute it to weakening of the utero-sacral ligaments during pregnancy, and to the strain placed upon those ligaments after child-birth by the dragging of the non-involut- ed uterus 011 them, when the woman resumes her ordinary life too soon. The yielding of these ligaments allows the uterus to fall, and the subsequent course of events, to produce the condition described in this case, is the infection of the exposed os uteri and the extension of the infection to the mucous membrane of the uterus and Fallopian tubes.

Convinced as I am that an exposed os uteri is a danger to the health and possibly the life of a woman whose condition of life does not admit of her continually wearing a pessary after a colporrhaphy. I advise all native women applying for relief of their condition at the Lady Curzon "Hospital to submit to operation. The operation I advise is either a ventro-fixation, after the method of Kelly, somewhat modified, or the operation described by Stanmon-Bishop in the Lancet of March 14th, 1903. The latter appears to me to be the more scientific procedure and has the additional advantage of not embar- rassing subsequent pregnancies. I cannot speak definitely from my own experience of its results, but I have performed the operation of suspen- sion (or rather, fixation) twelve times, complete relief of a very distressing condition having been <nven in every case, except one, a very old woman with very lax parietes, in whom Yielding or rupture, of the suspending adhesions must have taken place shortly after leaving hospital The others have reported themselves from time to time at hospital, and the os uteri in each case has remained in good position, well protected from the invasion of any infective organism, with the lamentable exception of the gonococcus.

Apart from the question of the origin of the pus in the Fallopian tube, this case is of interest ovvinc to the variety and extent of the adhesions met ?with during the operation, presenting ms it did, an object-lesson on the method of dealing with each in turn. The presence of a smalT stercolith in the appendix is interesting, too, and might suggest that the appendix was the'orcan first diseased. I think, however, that it is not unlikely that an appendix, firmly anchored in the pelvis by adhesions, would more readily receive a foreign body than one whose movements were not hampered.