COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX00039020 ^^^ tA/'^l Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/gynoplastictechnOOstur Gynoplastic Technology WITH A CHAPTER ON 'SACRAL ANESTHESIA- ARNOLD STURMDORF, M.D. Clinical Professor of Gynecology, New York Polyclinic Medical School; Visiting Gynecologist, New York Polyclinic Hospital; Consulting Gynecologist to the Manhattan State Hospital; Fellow of the American College of Surgeons; Fellow of the New York Academy of Medicine; Fellow of the American Medical Association, Etc., Etc. Illustrated with 152 Half-tone and Photo-engravings in the Text, some in Colors, and 23 Full-page Plates, with 35 Figures, all in Colors PHILADELPHIA F. A. DAVIS COMPANY, Publishers English Depot Stanley Phillips, London 1920 COPYRIGHT, 1919 BY F. A. DAVIS COMPANY Copyright, Great Britain. All rights reserved PRESS OF F. A. DAVIS COMPANY PHILADELPHIA, U.S.A. PREFACE. The evolution of technological progress, and the promulgation of its advanced basic conceptions, must of necessity contend with prevailing principles of practice, some of which are founded on theories of pathology long abandoned, some due to misdirected research or erroneous clinical deductions, while others present the mere relics of an obsolete dogma, upheld by authoritative sanction, which perpetuates surgical measures that can no longer be defended on either theoretical or practical grounds. Attempts at plastic restoration of the injured birth canal present the very genesis of gynecological sur- gery. As an art, these reconstructive procedures were developed to a high degree of perfection by the in- genuity of Sims, Emmet, Simon, Hegar, Schroeder and others, but as a science the technological prin- ciples standardized by these master-minds are no longer tenable. The present volume embodies an elaborated com- pilation of the author's previous publications on the various phases of gynecoplastic technology. Each topic is presented in monographic form, as better adapted to the exposition of its controversial aspects. (iii) iv PREFACE. The various operative procedures are detailed and illustrated to illuminate underlying principles of prac- tice rather than to standardize any individual method as one of universal applicability, while the historical data are given only where they reveal the progressive stages in the evolution of advanced gynecoplastic technology. Finally, as no modern work on regional surgery would be complete without a consideration of sacral anesthesia, a chapter on "Sacral Anesthesia" has been included. Arnold Sturmdorf. CONTENTS. Page CHAPTER I. General Principles 3 CHAPTER n. Preoperative and Postoperati\'^ Periods 11 CHAPTER III. Sacral Anesthesia in Gynecoplastic Operations 17 CHAPTER IV. Tracheloplasty 26 CHAPTER V. Chronic Endocervicitis 32 CHAPTER VI. Etiology of Endocervicitis 53 CHAPTER VII. Treatment of Chronic Endocervicitis 58 CHAPTER VIII. The Cervicoplastic Treatment of Sterility 84 CHAPTER IX. Perineorrhaphy 88 CHAPTER X. The Mechanism of Intrapelvic Visceral Support 93 CHAPTER XI. The Levator Ani Muscle 109 (v) vi CONTENTS. Page CHAPTER XII. The Pelvic Fascia • 115 CHAPTER XIII. Levator Myorrhaphy 124 CHAPTER XIV. The Retrodisplaced Uterus as a Complication in Pelvic Floor Injury ISO CHAPTER XV. Cystocele 164 CHAPTER XVI. Operations for Cystocele 174 CHAPTER XVII. Laceration Through the Anal Sphinctre 198 CHAPTER XVIII. Vesicovaginal Fistula 209 CHAPTER XIX. Operations for Vesicovaginal Fistula 212 CHAPTER XX. Functional Urinary Incontinence 234 CHAPTER XXI. Exstrophy of the Bladder 240 CHAPTER XXII. Fecal Fistula 246 CHAPTER XXIII. Cancer of the Vulva 252 CHAPTER XXIV. Elephantiasis Vulv^ 268 COXTEXTS. vii Page CHAPTER XXV. Congenital Malformations 275 CHAPTER XXVI. Malformations of the Vagina and Vulva 291 CHAPTER XXVn. Operative Correction of Congenital Malformations 309 LIST OF ILLUSTRATIONS. Fig. Page 1. Separation of spinal and sacral canals (Gray-Spitska) 18 2. Coccygeal vertebra fused with sacrum (Thompson) 20 3. Coccygeal vertebra fused with sacrum, very long hiatus 21 4. Curved type of sacrum (Thompson) 22 5. Sacral blocking, areas of anesthesia, etc 23 6. Normal cervical glands 33 7. Normal endocervical mucosa 34 8. Normal cervical gland 36 9. Normal utricular glands of the corporeal endometrium 37 10. Corporeal endometrium 38 11. Automatic contractions of uterine muscle four hours after hysterectomy (Lieb) 39 12. Automatic contractions of a muscle strip from a non-pregnant uterus three hours after hysterectomy (Lieb) 40 13. Sagittal section of the uterus (Abel) 42 14. Periadnexal lymphatics, sheep's uterus (Leopold) 45 15. Distribution and course of the periuterine and periadnexal lymphatics (Color) 47 16. Periadnexal adhesions and phlebectasia, the result of endo- cervicitis 49 17. Infantile endocervicitis — "vulvovaginitis" 53 18. Chronic endocervicitis, section from a cervix after cauteriza- tion (Abel) 54 19. Chronic endocervicitis, section of erosion of the cervix (Abel) . 55 20. Infantile erosion — "chronic endocervicitis" (Chrobak and Rosthorn) 57 21. Chronic endocervicitis 59 22. Chronic endocervicitis, round-cell infiltration in sub-epithelial layers 60 23. Chronic endocervicitis with miliary abscess 61 24. Cancerous endocervical gland (Abel) 62 25. Carcinoma of the cervix (Abel) 63 26. Advancing carcinoma of cervix 65 27. Advanced carcinoma 66 28. Tracheloplasty (author's method). Outlining the edge of the flap on the vaginal sheath of the cervix 67 29. Tracheloplasty (author's method). Elevating the flap edge preparatory to its free mobilization 68 30. Tracheloplasty (author's method). Mobilization of the cylin- drical vaginal flap 70 31. Tracheloplasty (author's method). Excision of endocervical cone 71 32. Tracheloplasty (author's method). Denuded funnel of cervical muscularis 72 33. Tracheloplasty (author's method). Silkworm strand passed transversely through the vaginal surface of the anterior flap segment 74 34. Modified Peaslee needle 75 35. Tracheloplasty (author's method). Introducing the right free suture end into and above the internal os 76 (ix) X LIST OF ILLUSTRATIONS. Fig. Page 36. Tracheloplasty (author's method). Needle emerging on the anterior vaginal fornix T] 37. Tracheloplasty (author's method). Left free suture end passed upward and forward 78 38. Tracheloplasty (author's method). Traction on the two an- terior suture ends, etc 80 39. Tracheloplasty (author's method). Anterior and posterior sutures drawn taut and tied 82 40. Normal nulliparous vulva 94 41. Normal parous vulva. Competent levator ani muscle 95 42. Parous vulva, gaping from lacerated levator ani muscle 96 43. Initial direction of intra-abdominal pressure at pelvic brim .... 102 44. Normal pressure deflection by the intrapelvic planes 106 45. Levator ani seen from below {Dickinson) 110 46. Origin of the left anterior loop of the levator ani Ill 47. The intra-pelvic line of origin of the levator ani (Haynes) . . . 112 48. Levator ani fibres normally present in the rectovaginal septum. 113 49. Anatomy of the female perineum. Superficial area 116 50. The pelvic outlet 117 51. Anatomy of the female perineum. Mid-area 118 52. The levator fascia 119 53. Anatomy of the female perineum. Exposure of the levator muscle after removal of the levator fascia 120 54. Anatomy of the female perineum. Exposure of the recto- vesical fascia after removal of the levator muscle 121 55. Perineoplasty (avithor's method) 125 56. Perineoplasty (author's method). Flap is carefully elevated from the underlying layer 126 57. Elevating the vaginal mucosa 127 58. Method of flap dissection 128 59. Fascial slits for levator exposure 129 60. Incorrect method of exposing the levator muscle 130 61. Perineoplasty (author's method). Suture traction 132 62. Perineoplasty (author's method). The levator ani partly exposed 133 63. Perineoplasty (author's method). The sutures passed entirely round (not through) the muscle-shanks 134 64. Perineoplasty (author's method). Levator sutures in. situ and tied 136 65. Perineoplasty (author's method). The elevated flap of vaginal mucosa is not ablated 138 66. Perineoplasty (author's method). The hollow cone of vaginal mucosa is inverted upon itself 139 67. Perineoplasty (author's method). Diagrammatic sagittal section 140 68. Perineoplasty (author's method). Sutures introduced to unite the musculofascial layers 142 69. Diagram of the vulvoperineal musculature 143 70. Transverse perinei often mistaken for the levator edge 144 71. Fascial layers in relation to the levator ani 145 72. Incorrect denudation 146 73. Incorrect exposure 148 74. Normal or neutral type of posture 152 75. Kangaroo type of posture 153 76. Axis of abdominal cavity, axis of pelvic cavity 155 77. Author's method of determining the lumbar index 157 LIST OF ILLUSTRATIONS. xi Fig. P-^ge 78. Diagram of relation of pelvis to abdomen 158 79. Anterior colpocele simulating cystocele 164 80. Urethrocele .• • • 165 81. Inversion of the vagina with cystocele and procidentia uteri . . 166 82. Initial direction of intra-abdominal pressure at pelvic brim . . 167 83. Misdirected pressure deflection 169 84. Perineal laceration 170 85. Procidentia uteri 171 86. Bladder pillars 175 87. Operation for cystocele. Exposure of the bladder pillars (rrank) ' 176 88. Cystocele operation. Cervical sutures tied holding bladder (Frank) 177 89. Vaginal hysterectomy, ligature of uterine artery 179 90. Vaginal hysterectomy, ligature of broad ligament 187 91. Vaginal hysterectomy, ligature of the utero-ovarian artery and tube : • 190 92. Vaginal hysterectomy, stumps of the broad ligament seen in the wound • • • 192 93. Broad ligament stumps sutured across the midline (Goffe) ... 194 94. Upper free end of ligaments tied (Goffe) 195 95. Complete laceration of the perineum through anal sphinctre (Kelly) ...199 96. Warren-Ristine operation for complete perineal laceration through the anal sphinctre 201 97. Child's outlining apron flap in the Warren-Ristine operation.. 202 98. Warren-Ristine operation 203 99. Child's sutures in the Warren-Ristine operation 205 100. Cross-section of figure-of-eight sutures (Child) 206 101. Closure of bladder fistula with buried catgut sutures (Macken- rodt) ; 213 102. Vesicovaginal fistula. Mackenrodt's operation 214 103. Lateral vaginoperineal incision ( Ward) 217 104. Schuchardt's incision outlined (Ward) 219 105. Schuchardt's incision completed (Ward) 221 106. Plane of Schuchardt's incision (Ward) 223 107. Mobilization of the bladder ( JVard) 224 108. Displacement downward of the bladder (Ward) 226 109. Vaginal suture in situ ( Ward) 228 110. Exposure and suture of sphinctre vesicae (Frank) 229 111. Operation for incontinence of urine 235 112. Operation for urinary incontinence 236 113. Kelly's mattress suture 237 114. Shortening of the vesical sphinctre 238 115. Operation for exstrophy of the bladder 242 116. Operation for exstrophy of the bladder. Uretero-intestinal anastomosis (Mayo) 243 117. Adenocarcinoma of the left vulvovaginal gland (Kelly) 253 118. Primary carcinoma of clitoris (^Taussig) 254 119. Lymphatics of the external genitalia (Crossen) 255 120. The lymphatics of the urethra and vagina (Crossen) 256 121. Regional layer dissection of vulvar structures 258 122. Regional layer dissection of the vulvar structures 260 123. Outlines for the "block excision" of the external genitals (Crossen) 261 124. First step in the "block excision'' (Crossen) 262 xii LIST OF ILLUSTRATIONS. Fig. Page 125. The block of tissue partially excised (Crossen) 263 126. Denuded area after removal of inguinal glands 264 127. Block excision, wound closed (Color) 266 128. Elephantiasis (Stein) 270 129. The rudimentary sexual ducts (Adami) 276 130. The indifferent stage in the development of the generative organs (Piersol) 277 131. Development of the female generative organs {Piersol) 278 132. Development of the male generative organs (Piersol) 279 133. Double uterus (Mann) 283 134. Bicornate uterus 284 135. Left tube, ovary and uterine nodule (Kelly) 285 136. Double uterus, 'vagina and planiform fundus (Kelly) 286 137. Pregnancy in a rudimentary left uterine horn (Color) (Kelly). 288 138. Development of the external genitals 294 139. Anus vulvalis (After Dwight) 296 140. Pseudohermaphroditism (After Poszi) 297 141. Agglutination of the labia 299 142. Atresia of the vulva (Stilton and Giles) 302 143. Atresia of the vagina (Sulton and Giles) 303 144. Feminine pseudohermaphroditism 305 145. Agglutination of the labia, after division of the membrane . . . 310 146. Widening the vaginal opening for dyspareunia (Crossen) 312 147. Forming an artificial vagina 314 148. Intestinal resection for artificial vagina 316 149. Intestinal resection, the intestinal loop in place 318 150. Artificial vagina from a section of the rectum 319 151. Artificial vagina, traction being made on the gauze strip 320 152. Artificial vagina, later steps in the operation 321 LIST OF PLATES. Plate Facing page I. Chronic endocervicitis (Palmer Fiiidlcy) 32 II. Injection specimen, normal nulliparous uterus, transverse section of myometrium (Leopold) 44 Transverse section of uterine muscle 44 III. Chronic interstitial myometritis — "fibrosis uteri" 48 IV. Histopathology of "cervical erosion" 56 V. Healed non-infected bilateral laceration 64 Mild endocervicitis, bilateral laceration 64 VI. Virginal chronic endocervicitis 64 VII. Virginal chronic endocervicitis with "erosion" 64 Chronic endocervicitis with mild manifestation at the external os 64 VIII. A. Gonorrheal condylomata 64 B. Gonorrheal endocervicitis 64 IX. Chronic endocervicitis 64 Chronic endocervicitis, mild infection 64 X. Chronic endocervicitis — "papillary erosion" 64 Chronic endocervicitis, infected laceration 64 XI. Chronic endocervicitis. infected laceration with "ulceration and suppurative nabothian folliculitis" 64 Chronic endocervicitis, infected laceration, "ectropium with follicular suppuration" ' 64 XII. Chronic endocervicitis, infected laceration with "granular erosion" and nabothian folliculitis 64 Chronic endocervicitis, with mucous polypi 64 XIII. Chronic endocervicitis, with carcinomatous papilloma .... 64 Endocervical carcinoma in the initial stage 64 XIV. Chronic endocervicitis, with carcinomatous ulceration .... 64 Carcinoma of cervix with sloughing into the posterior vaginal vault 64 XV. Carcinoma of cervix, with endocervical necrosis 64 Endocervical carcinoma in section 64 XVI. Syphilitic ulcer in angle of laceration 66 XVII. Tracheloplasty (author's method) 68 XVIII. Tracheloplasty (authors method), schematic sagittal view of the suture course in the anterior flap segment 80 XIX. Arterial supply of the perineal region 128 XX. Complete perineal laceration through the anal sphinctre, with exposure of the posterior vaginal and rectal walls. 196 XXI. Circumscribed epithelioma of the vulva 254 Diffuse ulcerative epithelioma of the vulva 254 XXII. Elephantiasis of the vulva 268 XXIII. Syphilitic gummata 272 (xiii) INTRODUCTORY. Gynecology is in the dawn of a new era; its operative technology is slowly emerging from em- pirical formularies into rational procedures based upon fundamental factors established by modern research. Current investigations of surgical "end results," while as yet in their initiative, have already demon- strated that healed incisions and purely objective restitutions to hypothetical normals do not prove the cure — plastic reconstructions as such do not restore functions, and a symptomologic nosology does not convey a diagnosis. Concept dominates practice. We were taught to see a passive retention wedge in the "perineal body" where we must recognize an active myodynamic de- flector of intra-abdominal pressure in the levator ani muscle. The "law of deflection" applied to the dynamics of that elusive force — intra-abdominal pressure — clari- fies the problems of normal and abnormal uterine poise; it reveals the nature of congenital retro-posi- tions as compensatory static deviations, normal to cer- tain types of skeletal contour in which the multifa- rious corrective operations upon the uterine ligaments should be relegated to the limbo of the obsolete. The time has passed when the term "endometritis" encompassed the beginning and end of uterine path- ologv — when "reflex neurosis" presented the shibbo- (1) 2 INTRODUCTORY. leth of its general symptomatology, and curettement the slogan of its therapy. Kundrat in 1873 exposed "endometritis" as a nor- mal premenstrual manifestation in pathological guise. Leopold in 1874 blazed the path to a rational uterine pathology by depicting the myometrial lymph course; and Henricius in 1889 unwittingly revealed a fundamental factor in uterine physiology by demon- strating that the normal no^-gravid uterus is a rhyth- mically contracting organ. More recently, Hertoghe's observations on hypo- thyroidism established an endocrine pathogenesis in the category of metrorrhagias; and Rosenow suc- ceeded in tracing the metastatic habilitation of bac- teria within the ovarian tissues from distal latent foci. The biochemic factors evolved by these latter re- searches illumine the haze of the "reflex neuroses," in which we begin to discern lineaments of insidious sepsis and toxicosis. These specific phases of established validity and far-reaching significance are elucidated in a widely scattered literature, which has not yet been correlated to that concrete homogeneity essential to their more general dissemination and practical application. This is conspicuously evident in the current text- book chapters on the cervix and perineum. CHAPTER I. General Principles. Preliminary to the special technology of the various operations about the vulvovaginal tract, it is essential to dwell upon certain general principles which apply to the preoperative, operative, and post- operative stages of gynecoplastic procedures as a class. The majority of these procedures are essentially multiple, necessitating prolonged anesthesia and ex- tensive denudations of vascular areas in a more or less contaminated field. Prolonged anesthesia and extensive denudation of vascular areas in a con- taminated field obviously embody elements of seri- ous potentialities which are too frequently disre- garded in this branch of surgery. The success of a gynecoplastic operation de- pends not only upon the technical skill of the opera- tor, but upon his clinical ability to estimate in a given case the local and systemic factors that w^ill dominate the immediate and remote efifects of his surgical procedure. Gynecoplasty is elective surgery, and, as such, affords ample time to determine the presence of the local, visceral, or systemic complications that would tend to jeopardize the operative outcome. Minor degrees of shock, hemorrhage, and infec- tion, ordinarily negligible, are nevertheless insep- arable from the major surgery of the urogenital (3) 4 GYNECOPLASTIC TECHNOLOGY. region; and while no surgeon can predicate with any approach to accuracy a patient's inherent resist- ance, he can, and should, eliminate or minimize most of the factors that tend to enhance the gravity of these morbid concomitants. Omitting a categorical elucidation of the gross organic disorders which constitute obvious contra- indications to surgical measures, it is essential to indicate the more insidious pathological factors that frequently predetermine the operative and postoper- ative morbidity. Crile states: ''A good heart and normal blood- vessels, with active innervation, and with the capa- bility of maintaining an average blood-pressure, give the patient a strong defense against operative trau- matism. With almost human ingenuity, however, disease processes strike at the strongest defenses of their intended victim, and, as a consequence, all too seldom does a patient come to the surgeon with this protective mechanism unimpaired. "It is essential, then, that we understand well the causes which may produce menacing deviations in blood-pressure, that we may be able to combat suc- cessfully these conditions by preliminary and coinci- dent measures." Hypertension may be but a temporary condition induced by a continued and intense emotion — worry, grief, or anger. It may be due to acute or chronic infection, to exophthalmic goitre, or to increased in- tracranial pressure, as well as to such more immediate causes as cardiovascular disease and physical changes in the blood-vessel walls. From this enumeration it is obvious that, while some of the causes of hypertension GENERAL PRINCIPLES. 5 are temporary and remediable, others are permanent and irremediable. In estimating, therefore, the surgical risk in a patient with hypertension, it is essential to differen- tiate the remediable from the irremediable class, elimi- nating the operative hazard in the former, and reducing it in the latter, by resort to palliation until an approximation to normal vascular tension is in- duced by appropriate measures. Gynecological patients range from the adolescent to the senile; their different disorders embody all the etiological factors of abnormal circulatory pressure — senescent arteriosclerosis; severe anemia, secondary to menorrhagia or metrorrhagia; chronic toxemia, from infectious foci in the cervix or tubes; renal involvement, especially in cases of marked cystocele with retention. The hormonic influence of the ovaries on vascular tension is clinically evidenced during menstruation and the climacteric, while emotional states and gen- eral psychic erethism are characteristic concomitants of gynecic disorders. A superposed element of danger in operating upon patients with hypertension is the anesthetic. Ether, however skilfully controlled, induces psychic stress in the primary stage of its administration. It impairs the immunity of the patient ; it retards the coagulation- period of the blood; as a fat solvent it disintegrates many of the body lipoids, especially those in the brain, the renal epithelium, and the liver, with consequent increase in waste products, and augmented tax upon the excretory organs. The strain of ether nausea and vomiting, always 6 GYNECOPLASTIC TECHNOLOGY. a disturbing feature, is especially so in cases of hyper- tension. Therefore, its administration in these cases must be reckoned as a distinct risk per se, because it injures and taxes the kidneys, predisposes to embolism and pneumonia, and intensifies the traumatic and psychic dangers, A class of patients particularly prone to shock and infection are those presenting severe secondary anemias of recent origin, frequently found among the adolescent and preclimacteric metrorrhagiacs, in none of which should any operative procedure be under- taken when the hemoglobin has fallen to 50 per cent, of the normal. As operative risks, the heart, the kidneys, and blood-pressure are so intimately correlated that they may be discussed collectively. The presence of cardiac murmurs or enlargement of the heart is readily determined. Cardiac hypertrophy with valvular lesions will withstand an operative strain better than a heart that is apparently normal in size without such lesions, but with a weakened or dilated myocardium. The relative range of the systolic and diastolic blood-pressure presents an approximate index of the myocardiac and vascular tonicity. The blood-pressure should be noted before, during, and after every extensive operation as a gauge of the patient's resistance to the anesthetic and surgical trauma. A sudden drop in the systolic pressure is a danger signal. The normal systolic pressure, taken with the 10 or 12 cm. cuff, ranges from no to 140 mm. of mer- cury, the diastolic running from 20 to 40 mm. lower. GENERAL PRINCIPLES. 7 The normal pulse may affect the normal pressure. A pulse under 65 gives about 123 mm., and over 85, 130 mm. Transitory rise may occur from apprehen- sion, requiring a second or third reading. It will rise after eating and drinking, persisting for nearly an hour. Exercise will augment it from 5 to 15 mm. A very low blood-pressure (100 mm. of mercury) in an adult denotes a weak heart. A persistent blood-pressure exceeding 140 should suggest a possible arteriosclerotic or renal menace. There are various indirect methods of testing the functional capacity of the heart; the simplest is to note the relative pulse-rate in different attitudes — sitting, standing, lying — or its increased rapidity on slight exertion. Normally, on assuming the recumbent posture, the pulse becomes slower. If the patient is recumbent, rising, or even turning, will reveal abnormal cardiac strain. If the pulse rapidity is greatly increased, and lasts more than a few minutes, the heart is defective. A m'inary examination of the twenty-four-hour specimen, with the patient on full diet, should reveal not only the presence of albumin, casts, sugar, the estimated excretion of nitrogen and the more impor- tant inorganic salts, but also the permeability of the kidneys as demonstrated by aniline tests. Under normal conditions, blue urine is excreted in ten to twelve minutes after an intramuscular injec- tion of 4 mils of a 4 per cent, indigo-carmine solution. Any marked delay in the color excretion denotes a renal impairment. If nephritis is present, or if an insidious intersti- 8; GYNECOPLASTIC TECHNOLOGY. tial nephritis is suspected, the operative prognosis, especially under prolonged anesthesia, is serious; such kidneys may readily cease functioning. If the blood-pressure, the strength of the heart, and the kidney efficiency approximate the normal, the prognosis from these points of investigation is clear. When the kidneys are but slightly involved, a short period of carbohydrate diet, with rest in bed and liberal intake of water, will minimize the danger of uremia, acetonuria, or acidemia. An equally vital consideration is the condition of the gastro-intestinal function. The presence of such conditions as dilated stomach, motor impairment, in- testinal stasis with impacted feces, may induce the absorption of putrefactive and fermentative toxins, all of which demand preoperative correction. Prolonged starving of a patient for from twenty- four to forty-eight hours, and profuse purging with more or less drastic cathartics, are not to be com- mended as rational preparatory treatment. These measures cleanse the gastro-intestinal tract, while they deplete the patient's strength and re- sistance. The preferable method is to administer mild pur- gatives of the vegetable class for several days pre- vious to the operation, thus giving the intestine time to regain its normal activity without debilitating the patient. For twenty-four hours before an operation the patient's diet should consist mainly of simple carbo- hydrates. The greater the quantity of such nutri- ment assimilated, the less danger from excessive post- operative vomiting, acetonuria, or fatal acidemia. GENERAL PRINCIPLES. 9 Hospital surgeons generally prefer to operate during the early morning; in such instances the pa- tient has probably fasted for from twelve to fourteen hours. While under ordinary conditions an individual is at his lowest temperature, lowest blood-pressure, and lowest cardiovascular tone from four o'clock to eight in the morning, there is on the other hand a decided advantage in operating upon a patient who has en- joyed a good night's sleep, free from the depressing influence of anxious anticipations. Other things being equal, it may be well in the majority of cases to operate during the morning hours, provided, however, that the patient has received some stimulating nourishment, such as a cup of coffee or tea with sugar but without milk, two hours pre- vious to the operation. The caffein in the coffee will temporarily raise the blood-pressure. This is especially desirable when the circulatory apparatus had gradually adapted itself, through a long period, to increased vascular tension, the sudden diminution of which may induce an acute cardiac, respiratory, or cerebral failure. Thyrotoxicosis, especially of the more insidious type, is a frequent complication of gynecic disorders. A rapid heart may present the only symptom of this condition, in which postoperative shock, or so-called "delayed shock," should be anticipated. In very mild or suspicious cases it may be wise to administer a hypodermatic injection of morphine before operating. As a routine practice, however, the preoperative administration of morphine or scopolamine is not to be commended. It is generally recognized that in 10 GYNECOPLASTIC TECHNOLOGY. marked hyperthyroidism surgery should be postponed until general measures have mitigated the toxicity of the excessive thyroid secretion. The sleeping habits of the patient will repay in- vestigation. A woman who, from anxiety or other cause, has not slept for days or weeks prior to an operation, will not do so without medication after such operation; a succession of sleepless nights will not tend to conserve her mental and physical stamina for the operative ordeal. A mild hypnotic is therefore indicated in all such cases during the preparatory period, and, while generally objectionable as a routine practice, it will obviate the necessity for the exhibition of stronger narcotics during the postoperative stage in women of this class. The premenstrual and menstrual period are un- favorable to gynecoplastic surgery, for, aside from obvious objections, the functional hypersemia and the presence of an active anticoagulative substance in the menstrual blood may induce a very copious oozing during operation, and enhance the possibility of post- operative hemorrhage. Finally, an active gonorrhea, cystitis, vulvar eczema, excoriations, dermatitis or furunculosis should be eliminated before attempting any plastic procedure about the urogenital canal. In all cases of complete procidentia of long stand- ing it is advantageous to replace and retain the pro- lapsed organs mechanically, while confining the pa- tient to bed for at least four days prior to operation. If the cervix presents infected ulcerations, these should be previously cauterized. CHAPTER II. Preoperative and Postoperative Periods. The older gynecologists invariably subjected their patients to a very protracted preoperative routine, ex- tending in some instances over several months, w^hile modern gynecologists generally operate within a twenty-four-hour preparatory interval. All routine practice is bad practice; protracted meddling is superfluous. On the other hand, inade- quate precautions are dangerous pitfalls. Every case presents its own specific indications, which should be met to the smallest detail. Repeated copious irrigation of the vaginal canal for disinfecting purposes should be restricted. The vaginal lining is generally regarded as incapable of absorbing pharmacologic agents ; nevertheless, numer- ous cases of mercuric chloride, zinc sulphate, iodo- form, arsenic, belladonna and phenol poisoning are recorded as the result of medicated douches and local applications. The studies of D. I. Macht ''On the Absorption of Drugs and Poisons Through the Vagina," published in the Journal of Pharmacology and Experimental Therapeutics, 1918, make it evident that "alkaloids, inorganic salts, esters and antiseptics are readily ab- sorbed by the vaginal mucosa," and he concludes "that systemic poisoning of obscure origin may find its ex- planation in absorption of toxic agents through con- tact with the vagina." (11) 12 GYNECOPLASTIC TECHNOLOGY. On the afternoon or evening before operation the external genitals and adjacent surfaces are shaved, and the patient's lower bowel irrigated. This obviates the necessity of disturbing the pa- tient's rest in the early morning. All local prepara- tions should be completed at least half an hour before operating. With the anesthetized patient on the operating table, the genitalia, the vaginal canal, and the sur- faces surrounding the operative field are scrubbed thoroughly but gently with green soap, warm sterile water, and gauze mops. The soap is rinsed off, and the surfaces thoroughly dried with sterile towels, after which the bladder is emptied with a glass catheter, the tip of which is pre- viously dipped in 20 per cent, argyrol solution. Two per cent, tincture of iodine may then be freely applied to all parts, the excess being dried by gauze sponges. Ease of accessibility and perfect exposure of the operative field must be secured as prerequisite essen- tials to accurate reconstruction, every step of which must be conducted with deliberation and painstaking attention to details. Anything like an attempt at speed in plastic work denotes the self-consciousness of the operator rather than his actual skill in this special branch of surgery. At the end of each operation the whole field should be scrupulously inspected to assure the correctness of ap- proximations, the absence of undue tension, the con- trol of all bleeding, and the obliteration of dead spaces. Bleeding vessels should be clamped without crush- PREOPERATIVE AND POSTOPERATIVE PERIODS. 13 ing surrounding tissues, the finest catgut being used for ligation. Rigid, scarred, non-vascular or inflamed and oedematous tissues are useless for plastic purposes. All flaps should consist of well-nourished segments, neither redundant nor inadequate, permitting of nat- ural coaptation without stretching. Not only tight sutures, but multiple sutures, are to be avoided. Figure-of-eight stitches are undesirable in perineo- plasty. The various layers, exhibiting diflferent de- grees of resistance, demanding different degrees of tension, cannot be controlled in any figure-of-eight stitch, the deep loop frequently proving too loose or too tight for the superficial loop. No line of union should be sewn hermetically, but minute spaces left between interrupted stitches to obviate the retention of blood-clots and preclude infection. It is safer to harbor bacteria in dry open spaces than in closed cavities filled with decomposing blood. In the postoperative stage the immediate dangers are shock and postoperative hemorrhage; the more remote danger is infection. All three are better pre- vented than cured. The anesthesia should be discontinued at the earliest feasible moment. The margin of safety in the anesthesia is frequently passed during the final stage of the operation. The proximity of the bowel and bladder complicate the problem of wound dressings about the vulvar region. All intravaginal douches are interdicted during 14 GYNECOPLASTIC TECHNOLOGY. the healing period, the parts being kept as dry as pos- sible. This is best accomplished with sterile pads dur- ing the oozing period, after which all dressings are discarded, and the parts kept dusted thoroughly with a mixture of stearate of zinc and boric acid. The great advantage of this stearate mixture is that it sheds water; and, while it may gradually become moist, it is possible, with reasonable care, to main- tain a sufficient degree of dryness and comfort. This treatment is especially advantageous in obese patients with closely apposed buttocks. Barring cases of urinary fistulse, all patients should be encouraged to void voluntarily. When necessary, the catheter may be used every eight hours, its sterile tip being invariably dipped into and filled with 20 per cent, argyrol solution prior to introduc- tion. The necessary resort to catheterization is the signal for the internal administration of urotropin, 5 to 7^ grains t.i.d. In fistula operations demanding rubber retention catheters, urotropin should be avoided, as its elimina- tion in the urine will disintegrate the catheter, de- positing particles of rubber or the entire catheter bulb within the bladder. The sovereign remedy for shock is morphine in i/^ -grain doses by hypo, every four hours, with cam- phor in sterile oil or caffein as a temporary adjuvant. Strychnine is always useless, and occasionally harmful. The amount of urine secreted is the most practical guide to the circulatory condition of the patient. The more nearly this amount approximates 150 grams per day in a previously normal condition the safer the patient. PREOPERATIVE AND POSTOPERATIVE PERIODS. 15 Albumin and casts are found in the urine so fre- quently after etherization that they may almost be expected, especially the albumin after prolonged operations. The amount varies from a faint trace to consider- able quantities. The profuse perspirations occurring during operation, the nausea, vomiting, and the small amounts of fluids ingested previously, depress urinary excretion. The greater the amount of urine excreted, the greater the elimination of toxins; hence the patient should receive water as soon as possible by mouth, rectum, or hypodermoclysis. After the effects of the anesthetic have passed, there should be no restriction as to the amount of liquid taken by the patient. A few sips of water are given at first. If these are retained, the quantity is rapidly increased, so that within twenty-four to forty- eight hours at least three pints of fluid should be in- gested daily. The necessity for fluids is especially urgent in those who have lost much blood, and in toxic patients. A cup of coffee or tea may be safely given within four hours after the operation, provided there is no nausea or vomiting. After the first post- operative bowel movement, full diet is permissible. Excessive and prolonged vomiting should be com- bated promptly by stomach lavage, which is more especially indicated in the early stages of acute gastric dilatation. Unless there is much discomfort from flatus or distention, it is not necessary to administer laxatives for the first three or four days. 16 , GYNECOPLASTIC TECHNOLOGY. Enemata are objectionable, as they tend to con- taminate the adjacent surgical area. The tendency of a deficient heart to acute post- operative dilatation should prompt caution in first directing the patient to assume the upright position. The elevation should be very gradual, approaching the vertical when the blood-pressure has resumed and maintained the level normal to the individual as estab- lished by preoperative observation. CHAPTER III. Sacral Anesthesia in Gynecoplastic Operations. Among the various methods and means for the in- duction of regional anesthesia, the one most appHcable and uniformly efficacious in gynecoplastic surgery is ''sacral blocking" or "caudal anesthesia" by extra- dural novocain injection. The epidural space surrounding the dura mater from the foramen magnum to the hiatus sacralis com- prises the area between the dura mater and the perios- teum lining the spinal canal. The sacral canal is a continuation of the spinal canal, but at the second sacral segment communication between these two parts is interrupted by the closure of the dura mater around the nerve trunks. This isolation of the sacral from the spinal canal is demonstrable anatomically (see illustration). Laewen showed that colored fluids injected into the sacral canal never appeared in the spinal canal or stained the upper part of the cord, thus proving the absolute isolation of these two sections of the dural area from one another, so that, while the nerves are transmitted from the spinal into the sacral canal, there is no other communication between the two. This marks the distinction between sacral and spinal anes- thesia; in the former, the anesthetizing fluid is in- jected through the hiatus sacralis into the sacral canal, 2 (17) 18 GYNECOPLASTIC TECHNOLOGY. while in the latter the injection is made through the lumbar origin into the spinal canal. Upon the outer surface of the dura, in the epi- dural space, especially at the sides, are extensive venous plexuses and loose adipose tissue. Fig. 1. — Showing separation of spinal and sacral canals by closure of dura mater. Sacral nerves exposed. (Gray-Spitska.) The sacral canal terminates below in the hiatus sacralis, forming a triangular opening, the sides of which are marked by the bony ridges known as the sacral cornua. This opening varies in size in different individuals. It may be abnormally large, owing to a deficiency in SACRAL ANESTHESIA. 19 one or more of the vertebral arches, or it may be re- duced even to the extent of complete obliteration by ossification. Normally, the hiatus is closed by the posterior sacrococcygeal ligament, which may be recognized on palpation by passing the finger along the sacral spines from above downward. Laewen has aptly compared the palpatory charac- ter of this membrane with its bony borders to that of a fontanel. TccJuiiquc of Adiiiiiiisfrafioti. The patient is placed on her right side, on an inclined surface, w^ith head elevated and the spine flexed to the limit of com- fortable tolerance, bringing the knees and chin as nearly together as possible. The area over the sacrum and the immediate neighborhood is cleaned with benzine, dried, and painted with iodine. The sacral hiatus is located just below the rudi- mentary sacral spinous processes and above the coccyx. Having infiltrated the skin and deeper soft tissues over the hiatus with the anesthetizing solution, a long needle fitted W'ith a wire stilet is thrust through the membrane covering the hiatus. In penetrating the membrane the needle is inserted at an angle of 45 degrees to the skin surface, after wdiich its head is depressed almost to a level with the body plane, and its point diverted upward exactly in the midline following the axis of the canal for a dis- tance of 13^ to 2 inches (Lewis and Bartels). When the needle is in situ, the stilet is withdrawn. If cerebrospinal fluid appears, the needle must be 20 GYNECOPLASTIC TECHNOLOGY. withdrawn until the flow ceases, when its point will be in the sacral canal. If blood escapes through the needle, a vein has been entered, and the position of the needle must be changed to avoid an intravenous injection of the anes- thetic. It is not necessary to introduce the needle be- yond 3 or 4 cm. Fig. 2. — I. Showing- first coccygeal vertebra fused with sacrum. Upper end of hiatus low down between the fourth and fifth sacral foramina. Hiatus well formed. Margins of hiatus formed by the fused spinous processes of the fifth sacral and first coccygeal vertebrae. The fifth foramen complete posteriorly and anteriorly. H. Fusion of first coccygeal vertebra with sacrum. The fifth fora- men complete in front; represented by a fissure behind. Hiatus represented by a transverse slit at the level of the fifth sacral foramen. (/. E. Thompson.) If the needle is in the sacral canal, there is prac- tically no obstruction to the flow of fluid from the syringe. If it should lie superficial to the sacrum, there will be considerable resistance, and a subcutan- eous bulging develops over the site of the injection. SACRAL ANESTHESIA. 21 Laewen determined that less than 20 mils of a i^^ to 2 per cent, novocain solution will prove inefifectual. Anesthesia is first noted at the tip of the coccyx, from which it gradually extends over the perineum, then laterally to the gluteal region. The clitoris is the last to become anesthetized. In other words, the coccygeal plexus is first to become Fig. 3. — I. Hiatus very long, and shaped like a horse-shoe. The upper end is at the level of the third sacral foramen. The mar- gins of the hiatus are formed by two flattened ridges, in which can be seen rudiments of the spinous processes of the fourth and fifth sacral vertebrae. H. Hiatus very long, and shaped like an isosceles triangle. The upper end reaches to the upper margin of the third sacral foramen. The margins are flattened, and are formed by the fused spinous processes of the fourth and fifth sac- ral vertebrte. (/. E. Thompson.) anesthetized, followed by the hemorrhoidal, the per- ineal, and, lastly, the pudendal plexus. It is diiBcult to determine the extent of the anes- thesia, as the various operations involve more or less traction upon tissues innervated by nerves originating above the caudal region. 22 GYNECOPLASTIC TECHNOLOGY. Thompson states: "As a rule, one injection of 3 tablets, each of which contains novocain, 0.125 Gm., suprarenin, 0.000125 Gm., dissolved in 30 mils of dis- tilled water, to which 10 drops of a 50 per cent, solu- tion of calcium chloride is added, is sufficient, and at the end of half an hour anesthesia is complete in the branches supplied by the sacral nerves. Coccyx^' Fig. 4. — I. Curved type of sacrum, fused coccyx; opening of hiatus shown by a cross. II. Long flattened type of sacrum, fused coccyx; opening of hiatus shown by a cross. III. Short flattened type of sacrum;, opening of hiatus shown by a cross. IV. Curved type of sacrum; opening of hiatus shown by a cross. (/. E, Thompson.') "We have injected a second time not infrequently, and have never failed after a second injection to se- cure perfect anesthesia. The quantity of novocain used has been considerable, as much as 0.750 Gm. having been introduced into the peridural space in SACRAL ANESTHESIA. 23 two injections. As far as our experience goes, we have never seen evidence of toxic symptoms." The appended chart, designed by Prof. WilHam Keiller for Thompson's article quoted above, depicts the areas of anesthesia, the time taken for the anes- thetic to produce its effect, and the spinal segments involved by diffusion. L.I u GLANS Complete, 30 min. .■57X3.4 ..-./.y. /--yc. Partial, 15 mm. . Partial, 12 min.; complete, 15 min. Complete, la min. — Female. Perineal view. Fig. 5. — "Sacral blocking." Areas of anesthesia, time of manifes- tation, and spinal segments involved by diffusion. To Cathelin belongs the credit for first demon- strating the feasibility of producing local anesthesia by extradm-al injection through the hiatus sacralis into the sacral canal. He used cocain, but was unable to produce satisfactory results in the human subject with safe cjuantities of this drug. Stockel utilized Cathelin's method successfully in parturient women, substituting 30 mils of a 3^ per cent, solution of novocain for cocain. Schlimpert and Schneider report 34 operations, comprising perineal repairs, curettage, rectoscopy and C3^stoscopy, under sacral novocain anesthesia. 24 GYNECOPLASTIC TECHNOLOGY. Laewen gives a detailed report of 80 cases, with 7 failures, and recommends the method for forceps de- livery and repair of obstetric injuries. Schlimpert, in a second communication, enumer- ates 55 cases, with 11 failures. In 12 others, general anesthesia had to be induced, owing to the long dura- tion of the operation. Hertzler contends: "My own experience with 'sacral blocking' has convinced me of the value of the method in perineal operations. It sometimes fails more or less, but if one is ready to supplement the sac- ral blocking by local infiltration, the shortcomings of the method do not work much of a hardship. "My plan is to use quinine in the sacral canal, and novocain-epinephrin for local infiltration, or vice versa. "In this manner it is possible to meet all indica- tions without using an excess of the novocain-epi- nephrin solution. "By using this combined method, I have never had to resort to general anesthesia. "The usual cause of failure, aside from such gross errors as injecting the fluid outside the canal or into a vessel, results from the use of too small an amount of solution. "Two ounces of a ^ per cent, solution give more certain results than half this amount of twice the strength. "The large nerve trunks of the legs may become anesthetized. This may result in complete sensory anesthesia, and may alTect the motor fibres to the extent that the patient is unable to walk for several hours. This soon passes off." SACRAL ANESTHESIA. 25 In operations on the cervix, the traction pain is very marked, owing to the pull on the broad ligaments. The same holds good for the manipulation neces- sary in levator myorrhaphy for perineal lacerations, necessitating the local infiltration of the levator ani bundles prior to their mobilization and suture. When all is said and done, it must be stated that at the present writing, notwithstanding the positive claims embodied in the quoted excerpts, the region of the female genitalia and the pelvic floor do not offer an ideal field for major surgery under sacral anes- thesia. The diversity in the source, ramification, and anastomosis of the sensory innervation, added to the patient's attitudinal discomfort from a necessarily prolonged lithotomy position, constitute intrinsic ob- stacles and disconcerting factors, which to a greater or lesser degree are encountered in a large majority of cases. CHAPTER IV. Tracheloplasty. Laceration of the cervix uteri was recognized in ancient times. The textbooks on Obstetrics pubhshed during the eighteenth century refer to the "cleft condition of the cervix" as a product of difficult delivery, and to the cicatricial tissue resulting from previous lacerations as a cause of tedious labor. J. H, Bennett wrote extensively on the appear- ance and results, of the lesion under the title, "Ulcer- ation of the Cervix." This pathological misnomer established the general practice of treatment by caus- tics, in the attempt to heal the supposed ulcer. Microscopic examination of such an "ulceration," when removed intact from the living during opera- tion, will invariably disclose that the apparent ulcer is covered by a layer of normal epithelium, that its granular appearance is produced by surface corru- gations, and that its tendency to bleed on touch is due to the extreme friability of its thin epithelial covering. Modern textbooks generally apply the term "ero- sion" to these readily bleeding patches, and describe two types : (i) The "papillary erosion", in which the affec- ted surface presents a field studded with papillae, each covered with a single layer of columnar epithelium; and (26) TRACHELOPLASTY. 27 (2) "Glandular erosion", a condition where the surface is smoother, but in which many cervical glands are present. This latter form is also desig- nated as "eversion". The term "erosion", however, like "ulceration"', is inapplicable, as it suggests a solution of surface continuity, while all of these involved areas actually present an intact epithelial covering. The whole pro- cess simply represents an extension of the diseased endocervical mucosa (chronic endocervicitis) to the vaginal covering of the cervix. In this situation the tissue is subjected to friction and to the irritation of the acid vaginal secretions. As the disease progresses, the squamous vaginal epithelium proliferates over the attected surface, gradually replacing the columnar endocervical epi- thelium, and thus occludes the outlets of all subjacent cervical glands within the involved area. The resulting retention cysts finally penetrate from the inner to the vaginal aspect of the cervix as small shot-like elevations, familiarly known as "na- bothian follicles", the presence of which is invariably pathognomonic of chronic endocervicitis. Ambrose Pare first advocated amputation of the cervix. Osiander in 1802 published the first detailed treat- ise on the operative procedure, after performing it upon 2T, patients. Among the advocates of the method as proposed by Osiander appear the names of Dupuytren. Recam- ier, Lisfranc, and others of equal fame. The operation was performed by means of the bistoury, scissors, the ecraseur and galvano-cautery ; 28 GYNECOPLASTIC TECHNOLOGY. the latter method was perfected by John Byrne, of Brooklyn. All of these methods left an uncovered raw cervical stump to heal by granulation. The first plastic amputation of the cervix uteri, utilizing" a cuff of vaginal mucosa as a stump cover- ing, was practiced by Marion Sims in 1861. One year later T. A. Emmet performed his first success- ful trachelorrhaphy, the technique and results of which, however, were not published until 1874. In discussing Emmet's operation, Sims declared: "We can't modify it, we can't change it, for it is perfect — perfect in its method and perfect in its results." Emanating from so prominent a source, and en- dorsed by such authority, these operations, which embody the origin and principles of all subsequent tracheloplastic methods, found enthusiastic adoption in America, and to a large extent in England, while at the same time their introduction among Conti- nental surgeons instigated an interminable maze of controversy and modifications. Today, after a tenure of nearly half a century, the conviction is gaining ground that the reputed efficacy of these standardized operations is not sub- stantiated by final analysis. This is convincingly revealed in a recent report by Leonard, from Howard Kelly's clinic at the Johns Hopkins Hospital, who tabulated the immediate and end results of the classic cervix amputations per- formed during the past twenty years. One hundred and twenty-eight complete postoper- ative histories, from among 400 cases, forced Leonard to conclusions, which "were quite unexpected, and in many ways disappointing." TRACHELOPLASTY. 29 "Nearly 5 per cent, of the patients presented seri- ous postoperative hemorrhage, occasionally after es- tablished convalescence. "Ten per cent, of the cases suffered from decided augmentation of a preexisting menorrhagia or dys- menorrhea. "Four-fifths of the women, in whom pregnancy might reasonably have been anticipated to follow the operation, remained sterile. "On the other hand, 50 per cent, of the pregnan- cies occurring after cervix amputation terminated prematurely, while among the few who progressed to full term even a larger proportion experienced difficult and prolonged labor. "The operation in all of the cases presented con- sisted of the classic circular amputation, removing about three centimeters of the cervix above the ex- ternal OS." Actuated by these "disappointing results", Leonard next tabulated the postoperative effects of trachelor- rhaphy for comparative analysis with those of cervix' amputation^ concluding as follows: "The presence of a marked endocervicitis should be considered as contraindicating simple trachelor- rhaphy, for although trachelorrhaphy may render a mild endocervicitis more amenable to treatment, it cannot be considered, like amputation of the cervix, a curative measure for this condition. "Fertility is much more likely to follow trachelor- rhaphy than amputation of the cervix. "After amputation of the cervix, the incidence of abortion and premature delivery is greatly increased. 30 GYNECOPLASTIC TECHNOLOGY. while trachelorrhaphy has no effect upon the course of subsequent pregnancy. "Labor after cervix amputation is usually difficult, while after trachelorrhaphy it is almost always nor- mal; hence amputation of the cervix is to be avoided in the child-bearing period, trachelorrhaphy being the operation of choice in properly selected cases." Accepting these data from authoritative sources, as a correct exposition of facts, the obvious deduc- tion is, that with chronic endo cervicitis as the recog- nized pathologic indicator, trachelorrhaphy is an in- adequate, and cervix amputation an injurious, oper- ation. That it is not the tear in the cervix, but the in- duced complications, which bring the patient to the operating table, is amply demonstrated by the count- less women who bear cleft cervices, presenting un- united cicatrized edges, that are unproductive of any symptoms whatsoever, and it follows that the limita- tions of trachelorrhaphy, like the indications for cer- vix amputation, must be governed by the nature and degree of existing concomitants and not by the ex- tent of the cervical injury. A single shallow tear may initiate the most serious train of complications in one patient, while a more extensive multiple injury may prove perfectly innocuous in another; and the ques- tion naturally obtrudes itself: What factor estab- lishes the immunity from symptoms in the one and the morbidity of the other? Why is trachelorrhaphy ineffectual, and cervix amputation harmful, in so large a proportion of the cases ? The solution to these problems demands a radical revision of current elementary conceptions of cervical TRACHELOPLASTY. 31 disease, and modification in llic technique of its oper- ative cure. The fundamental dominant that estabhshes the morbidity of any cervical lesion is the incidence of infection. Clinically, the course of such infection assumes one of two types: it may reveal its initial stage as a frank puerperal sepsis of varying intensity, with a gradual subsidence of its systemic manifestations ; or, what is more common, it pursues a more or less in- sidious course from the beginning. The first type usually merges into the second, so that ultimately both types eventuate in varying degrees of the same symptom-complex, designated as "chronic endocervi- citis". CHAPTER V. Chronic Endocervicitis. Chronic endocervicitis or endotrachelitis is the most prevalent and most familiar objective manifes- tation among gynecological disorders. It constitutes a concrete clinical entity of pathogenic potentialities which may menace the integrity of the entire gynecic system. Nevertheless, it is accorded no special con- sideration as such in current textbooks, where its de- scription is scattered among numerous chapters as an incidental feature under various captions, as "cerv- ical catarrh," "simple follicular or papillary erosion," "eversion," "ectropium," "ulceration," "hypertrophy of the cervix," etc., all of which depict only different features of the same infectious process, the nature, course, and significance of which is obscured by per- petuated misconceptions and misleading dogma that dominate its ineffectual treatment. In structure and in function, a sharp line of de- marcation differentiates the cervical mucosa from the corporeal endometrium. Physiologically, the cervical canal presents nothing more than a passive communi- cating channel between the vagina and the uterine cavity proper. The cervical mucosa is composed of deeply penetrating racemose glands, which simply secrete mucus. It does not participate in the cyclic metamorphosis of the corporeal endometrium essen- tial to menstruation or deciduation. But more sig- nificant than this structural and functional con- (32) PLATE I. Chronic eiulocervicitis. "Follicular erosion." Showing sharp line of demarcation between the diseased cervical lining and the normal corporeal endometrium. {Palmer Fiiidlcy.) CHRONIC EXDOCERVICITIS. 33 trast is the striking" disparity in pathological mani- festations displayed below and above the internal os. The cervical mucosa evinces a marked suscepti- bility to infection, while the corporeal endometrium, contrary to orthodox conception, is practically im- Fig. 6. — Normal cervical glands. Note racemose outlines and depth of penetration. mune. In short, the cervical mucosa could be aptly termed the tonsil of the uterus. Kundradt first, in 1873, ^^'^^ more recently Hitsch- man and Adler, have conclusively demonstrated that all of the histologic features generally depicted as 34 GYNECOPLASTIC TECHNOLOGY. "chronic endometritis", inclusive of typical round-cell infiltration, constitute only the normal transition of the endometrium into the transudative phase of its menstrual cycle. Even that infrequent condition clin- ically labelled "hypertrophic endometritis", more correctly termed glandular hyperplasia, is never in- flammatory in character, but a functional adenoma- Fig. 7. — Normal endocervical mucosa, a. Gland opening cut obliquely in sectioning, b, Columnar epithelium (ciliated), c, Connective tissue stroma, d. Capillaries filled with blood, e, Oblique section through cervical glands. tons overgrowth, analogous to that presented by the thyroid gland in Graves' disease. While this subject is still a matter of academic controversy, the majority of pathologists concede that, clinically at least, chronic corporeal endometritis may be safely discarded. The most recent bacteriological studies fully sub- stantiate the relative immunity of the corporeal endo- CHROXIC ENDOCERVICITIS. 35 nietriuiii to ascending" surface infection from the cervical mucosa. Arthur H. Curtis, in "A Combined Bacteriological and Histological Study of the Endometrium in Health and Disease", embracing a series of ii8 cases, states: "It has 1:een my object to make a study of the en- dometrium, exclusive of the cervix, in all conditions usually encountered except those associated with pregnancy. All material has been secured from uteri removed at operation. Scrapings from the endome- trium are so liable to contamination that cultures from them are not included in this series. "The variety of media employed and other pro- cediu'es followed are in close accord with details de- scribed in the bacteriological study of uterine fibroids {I.e.). "\A'ith sterile instruments and culture material in readiness, the stump of the cervix and entire length of the peritoneal surface of the uterus are cauterized, and the anterior wall bisected. The greater part of the endometrium is excised in its entire thickness, down to the muscle layer, and is placed in sterile con- tainers to be ground and cultured. The remainder serves for immediate examination, for inoculation of culture media with imground tissue, and for micro- scopic study. "This technique affords immeasurably more ma- terial than is secured by pipette or platinum loop. Through examination of so much endometrium, in- cluding the deeper portion, it is hoped that the possi- bility of overlooking dormant infections has been re- duced to a minimum. "From this work I believe that the endometrium 26 GYNECOPLASTIC TECHNOLOGY. of nullipara, without history or gross evidence of pelvic infection, is almost invariably free from bac- teria; it is also microscopically normal. Fig. 8. — Normal cervical gland. High-power view showing racemose form, lined with a single layer of tall columnar epi- thelium, each cell with its nucleus at the base set upon a base- ment membrane. These terminal tufts extend deeply into the cervical tissues, and, once infected, nothing short of extirpation will prove curative. "Almost all women who have undergone normal presrnancy, with pelvic history otherwise negative, like\A'ise possess bacteria-free endometria. The pos- sibility of infection appears to be but slightly in- CHROXIC EXDOCERVICITJS. 37 creased 1)y |)rei;'nancy and the usual changes conse- quent thereto. "Patients with a liistory of chronic infection, from whose endometrium hacteria are ohtainahle, ahnost all have salpingitis with ecjually good growth. Pyoiiicfra and recent e.vploratiou of the uterus excepted, the eii- doijietriuiii almost never shows bacteria except zvhen there is infection of adjacent pelvic tissues. Chronic Fig. 9. — Xormal utricular glands of the corporeal endo- metrium, showing their straight tubular form. endometritis, per se, zvitJi bacteria f'rescnt in smears or cultures, is practically to be ruled out as a clinical entity. "In certain cases normal scrapings have been ob- tained from the uterus; then, several days thereafter, in the endometrium secured by hysterectomy, mixed cultures and endometritis have been found. Infection is perhaps not a customary result of curettage, but it appears not uncommon. "Some will wonder why, if curettage tends to con- 38 GYNECOPLASTIC TECHNOLOGY. Fig. 10. — Corporeal endometrium in the transudative phase ("premenstrual") of its menstrual cycle, showing the normal pre- sence of round cells and polymorphonuclear infiltration, simulating an inflammatory process. CHRONIC EXDOCERVICITIS. 39 taminate the endometrium, infection does not compli- cate hysterectomy in patients with prehminary curet- tage. Fortunately, nature can dispose of a few bacteria at the time they are introduced. But patients not operated upon until several days later, when the bacteria have had time to multiply, I believe are not ideal subjects. The problem is, in miniature, that which confronts the abortionist — he can meddle once with comparative safety, Imt if tempted to interfere Fig. 11. — Automatic contractions of a non-pregnant uterus four, hours after hysterectomy. At E, Epinephrin 1 : 2,000,000. (Lieb.) again, to complete the task, he works in a contami- nated and dangerous field." Nevertheless, the cardinal symptoms of chronic endocervicitis — namely, the disturbances in menstru- ation and deciduation — point so directly to an in- volvement of the corporeal endometrium, that their occurrence in the absence of endometritis demands elucidation. To correlate the pathology and symptomatology of 40 GYNECOPLASTIC TECHNOLOGY. chronic endocervicitis and place its therapeutics on a rational basis, we must revise some current concep- tions of the myometrial structure and its dynamics. The specific functions of the uterus in menstrua- tion and gestation demand a wide range in the control of its blood supply, and, like the heart, the uterus automatically responds to its fluctuating circulatory necessities by rhythmic contraction and dilatation, not only during pregnancy, but throughout its functional Fig. 12. — Automatic contractions of a muscle strip from a non- pregnant uterus three hours after hysterectomy. At C, Pituitrin I: 100. {Lieb.) existence (Henricius). An immobile muscle, whether in the uterus or elsewhere, degenerates. Moreover, the uterine veins, being devoid of valves, leave no pro- vision other than muscular contractions to prevent local circulatory stasis and its consequences. The myometrium is composed of smooth muscle fibres, which, like all non-striated muscle, exhibits the intrinsic phenomenon of rhythmic automatic contrac- tion independent of any neurogenic stimuli. CHRONIC EXDOCERVICITIS. 41 Two familiar clinical manifestations will serve as a practical demonstration to depict the extreme phases of this muscular virility in the non-gravid uterus. The time-honored practice of applying silver nitrate solutions on a cotton-wrapped probe to the endome- trium induces, in some patients, a most distressing tetanic response of the whole uterine musculature, which firmly clutches the probe, causes violent colicky pains, and mild but unmistakable symptoms of general shock. Xo hibernating muscle can manifest such to- nicity. On the other hand, an equally distracting moment is experienced when, during a curettage, the operator suddenly finds himself "beyond his depth,"' the curette losing contact by a paralytic dilatation of the uterine cavity, simulating traumatic perforation of the uterine wall. Only a virile muscle exhibits such absolute paralytic flaccidity. Between these two ex- tremes we will find CAxry grade of perverted mus- cular irritability, with its objective and subjective concomitants. The key to the architectural scheme of the uterine musculature is revealed in its formative, not in its matured state, and to gain a clear conception of its mechanism it is necessary to discard the accepted sub- division of this single muscle into scA'cral layers. Such a subdivision is pitrely arbitrary. There are no distinct layers, but a single muscle, presenting dift'er- ent angles in the course of its component bundles. Briefly stated, these bundles are arranged in a suc- cession of fan-shaped muscle-sprays that wind spir- ally downward from each fallopian angle throughout the whole uterus to the external os. Every muscle contracts toward its fixed point, and 42 GYNECOPLASTIC TECHNOLOGY. Fig. 13. — Sagittal section of the uterus, a, Vaginal mucosa. b. Squamous epithelium, c. Connective tissue stroma, d, External OS. e. Internal os. /, Cervical mucosa, g, Endometrium, h-h, Musculature of cervix and corpus uteri, i, Peritoneal coat. (Abel.) CHRONIC ENDOCERVICITIS. 43 for the uterine muscle such relative fixed ])oints are furnished through its fascicular prolongations in the round and broad ligaments at the pelvic brim. The rhythmical contractions of the myometrium are necessary, not only in maintaining the nutritional and functional integrity of the uterus as a whole, but they serve the equally essential purpose of drainage. The cervical secretion must find free egress from the normal, and more especially from the diseased, con- ditions of its mucosa. In the normal state, such drainage is effected, not merely by a passive outflow through a patent os, but by the active rhythmic expression resulting from uterine contractions. To comprehend this mechanism, it is necessary to dispel the anatomical myth of a cervical sphinctre. Such a sphinctre would imply the existence of a con- centrically contracting muscular ring. The structural design of the cervical musculature precludes any con- centric closure of its outlet, which dilates with every uterine contraction, because its fibres, continuous with those of the corpus uteri, do not at any point com- pletely encircle the cervix, but are disposed in serried successions of oblique circle segments, which by con- tracting spirally upwards necessarily shorten every diameter of the uterine cavity, and, by uncoiling in the cervix, widen the os like an iris diaphragm in a microscope. Cervical dilatation thus becomes an integral part of uterine contractions instead of a passive relaxation in a hypothetical sphinctre. Incidentally, this mechan- ism explains the apparent obliteration of the cervix in labor. 44 GYNECOPLASTIC TECHNOLOGY. As already emphasized, it is not the laceration as such, but the incidence of its infection that determines the morbidity of a cervical lesion. In the cervix, as elsewhere, every infection incites the greatest reaction in its lymphatic system. The enormous resorptive capacity of the uterus is displayed in its gravid and puerperal state. It is nearly fifty years since Leopold clearly demon- strated the normal uterine lymphatic circulation. Nevertheless, barring its disseminating role in malig- nancy, the domination of this element in the general pathology of gynecological infections has been prac- tically ignored. Quoting briefly from Leopold's description, which stands unchallenged to this day, the uterine lymph current may be traced from its lacunar origin in the cervical and corporeal mucosa, through minute fun- nel-shaped ostia, directly to the myometrium. Here it branches into an extensive capillary net, which, spreading on the perimysium, penetrates and en- meshes every bundle and fascicle of the entire uterine musculature to its subperitoneal surface, whence it drains into two main collecting channels that course parallel to the uterine and ovarian blood-vessels at the base and top of the broad ligament. It is this normal lymphatic envelopment of the perimysial sheaths and adnexa that determines the course of an infection from the cervical mucosa — not via the uterine cavity and tubal lumina, but along the intramuscular planes of the uterine and tubal zvalls to the ovarian tunica albuginea, as an ascending lym- phangitis whose pathological trail impairs normal uterine contractions by infiltrating the myometrial PLATE IT. 'f Injection specimen, normal nuUiparous uterus, transverse section of myometrium. A, Lj-mphatics running on the intra- muscular septa, and enveloping the muscle-bundles. B, Blood- vessels. C, Muscle-bundle. (Lcof'old.) Transverse section of uterine muscle. A, Muscle-bundles. B, Intramuscular septa carrying blood- and lymph- vessels. CIIROXIC ENDOCERVICJTIS. niiisclc sheaths, occasiDnally cstaljlishing disseminated niihary myometrial abscesses; then prog'ressing to the periadnexal lymphatic ramifications, inhi1)its tubal peristalsis, kinks the tubes and aq-.f^-lutinates their I n*^ L-1^ Fig_ 14. — Periadnexal lymphatics. Sheep's uterus. H, Left horn. T, Tube. O, Ovary. B, Broad ligament, a, Subserous lymphatics. h, Collecting lymph tube, c, Transit into broad ligament chan- nels. {Leopold.) fimbrial ostia by the production of velamentous bands, which occasionally create tubal diverticuli with ectopic possibilities; finally, reaching the ovaries, the lym- 46 GYNECOPLASTIC TECHNOLOGY. phatic infiltrate thickens their capsular tunic, impeding the normal rupture and regression of the graafian follicles, with ultimate development of retention cysts. In short, we find a chronic ascending lymphangitis, with its resultant impairment of uterine, tubal, and ovarian function — not an endometritis — that links the pathology and symptomatology of chronic endo- cervicitis. The pathological process as depicted naturally varies in extent and degree, according to the virulence of the infection and the resistance of the tissues. It may remain limited to the racemose tufts of the cer- vical mucosa indefinitely in one case, while in another it eventuates in an infectious agglomeration of uterus, tubes, and ovaries. Chronic abscesses in and about the broad liga- ments, pyosalpinx, hydrosalpinx, sactosalpinx, tubo- ovarian cysts and abscesses, ovarian sclerosis, uterine fibrosis — all of apparently insidious development and obscure source — will usually reveal their primary focus in a chronically infected cervical mucosa. The surgical bearing of this is obvious. How often is one of the adnexa removed for periadnexitis, and the other at a subsequent operation, when both could have been saved by a timely attack on the original focus within the cervix? Parallel with the pathological course, the intensity of its symptomatic manifestations will range from a simple but persistent leucorrhea to complete functional invalidism. Most important among the derangements result- ing from chronic endocervicitis are the disturbances in menstruation, fecundation, and deciduation. The periodic maturation and rupture of a graafian CHROXJC EXDOCERVICITIS. 47 follicle, the liberation of its contained ovum, the evolu- tion and involution of the corpus luteum, and the cyclic transmutation of the corporeal endometrium, consti- tute the cardinal phases essential to normal menstrua- tion, fecundation, and nidation. Fig. IS. — Distribution and course of the periuterine and periadnexal lymphatics. It is of clinical importance to note that in the pre- sence of a normal corporeal endometrium, menor- rhagia, metrorrhagia, or amenorrhea occurring in the course of chronic endocervicitis, must be inter- preted as an abnormal manifestation functional in nature, i.e., a perverted menstruation either aug- mented, protracted, or inhibited. 48 GYNECOPLASTIC TECHNOLOGY. Every menorrhagia is obviously a periodical met- rorrhagia. The same cause may be productive of ex- cessive menstruation, of intermenstrual hemorrhage, or of both; the "menorrhagia" frequently merging into "metrorrhagia," making a clinical distinction between them impossible. When a bleeding uterus presents a small fibroid, we seek no further for an explanation of the hemor- rhage; and yet no one has definitely explained why one uterus harboring a fibrous nodule bleeds exces- sively, while another bearing enormous masses of a similar nature does not bleed at all. Still less do we know why there is hemorrhage from some uteri that present no demonstrable evi- dence of any causative factor whatsoever ; and, lastly, we know nothing as to the why and how the uterus bleeds during normal menstruation. Coagulation is nature's hemostatic. The blood shed from these metrorrhagic uteri, like normal men- strual blood, is noii-coagiilahle, and the question nat- urally presents itself: What induces the normal in- coagulability of menstrual blood, and what, if any, is the relation of this incoagulability to the abnormal bleeding under consideration? The hitherto prevailing theory that attributes the absence of clotting in menstrual blood to the presence of viscid alkaline mucus secreted by the cervical glands is not tenable, for the blood shed from the cor- poreal endometrium is incoagulable before it reaches the cervical canal. Moreover, no such admixture of alkaline mucus inhibits coagulation in other coagulable fluids of the body. PLATE III. Chronic interstitial myometritis — "Fibrosis uteri." From a patient 34 years of age. Chronic endocervicitis. A, Muscle- bundles. B, Fibrous tissue, section made near the peritoneal surface. CHROXIC EXDOCERVICITIS. 49 Stripped of all intricate laboratory detail, the established premises in the problem are the following: The general circulating blood during the men- strual period and in the hemorrhagic conditions here considered shows normal coagulative properties. During menstruation and such uterine hemor- rhages the corporeal endometrium receives normally coagulable blood from the general circulation, and sheds this blood in a non-coagulable state. Fig. 16. — Thin periadnexal adhesions and phlebectasia in the broad ligament, from chronic myometrial lymphangitis, the result of chronic endocervicitis. Blood flowing from an experimental puncture or incision of the uterine tissues external to the cervical cavity promptly clots, while the simultaneous men- strual flow from the interior of the uterus fails to coagulate. The non-coagulability of normal and metrorrhagic menstrual blood discloses an identity in experimental and clinical manifestations, difl:'ering only in degree. Under the given conditions, the corporeal endo- metrium exercises a function capable of rendering coagulable blood non-coagulable. 50 GYNECOPLASTIC TECHNOLOGY. This loss of coagulability in menstrual blood is not due to the absence of any element essential to coagula- tion, but to the presence of an inhibiting substance secreted by the corporeal endometrium, from which it may be expressed during the menstrual state. The endometrium is apparently activated to the secretion of this inhibiting substance by a hormone generated in the ovary. The evidence of these established phenomena war- rants the deduction that the biochemic process thus outlined, pathologically augmented, protracted or in- hibited, constitutes an essential link between chronic endocervicitis and its menstrual aberrations. In the progressive cases of chronic endocervicitis, the ascending myometrial lymphangitis (myome- tritis) inhibits uterine contractions. The blood-cur- rent in the valveless uterine veins, thus deprived of its essential vis a tergo, is slowed. The resultant circula- tory stasis augments the menstrual flow in the non- pregnant ( menorrhagia ) . The thickened ovarian tunica albuginea (perio- ophoritis) may impede the mattiration and rupture of a graafian follicle, with consequent inhibition of men- struation (amenorrhea), or, retarding follicular con- traction and involution, protract the menstrual flow (metrorrhagia). The myometrial sensory nerve filaments penetrate the muscle sheaths; hence the normal uterine con- tractions, intensified during menstruation, compress- ing the infiltrated perimyseal areas, become painful ( dysmenorrhea ) . It is a marked characteristic of the dysmenor- CHROXIC EXDOCEKVICITIS. 51 rhea resultini^' from endocervicitis that it subsides after the inaiis^uration of a full flow. Agi^lutination and occlusion of the tuljal ostia (perisalpingitis) creates a barrier to subsequent fecundity ("one-child sterility"), while the associated iiutriiional derangements induced in the corporeal endometrium disturb or inhibit its specific decidual function, with premature blight of an existing gravidity ("habitual abortion"). The direct spermatocidal effect of a diseased cer- vical mucosa is vividly depicted by Reynolds, who, utilizing Hiihner's postcoital method for the observa- tion of spermatozoa aspirated from the cervical cavity, states: "It is extremely interesting to see how actively mobile spermatozoa progress across the field of the microscope in a cervical secretion of grossly normal appearance, until they come in contact with some clumps of pus-cells, with which the tail of the spermatozoon becomes entangled. The result then is, that it indulges in futile struggles to escape, by the violence of which it becomes exhausted, and in a few minutes gives up the struggle and lies still." The sterilit}^ of women with "conical cervix", ''cervical flexion", or ''pin-hole os" is never due to the cervical malformation as such, but to an existing endocervicitis. An OS that oft'ers sufficient egress for millions of blood-cells during every menstruation will readily afford ingress to a spermatozoon whose diameter measures less than that of a single red corpuscle. AA^e constantly encounter fecundity in cases of "pin- hole os", and sterility in widely gaping lacerated cervices, when the latter are infected. 52 GYNECOPLASTIC TECHNOLOGY. The cervical mucosa was characterized in the foregoing as the uterine tonsil; this pathogenic parallel finds its applicability when chronic endo- cervicitis is recognized as a primary infectious focus, and its systemic symptoms as. toxic manifestations. The ambiguous category of the "reflex neurosis" ac- companying cervical disease is thus brought within the more lucid range of the toxicoses along modern lines of clinical research. We have learned to recognize systemic manifes- tations from primary foci in the mouth, the gall-blad- der, the appendix, the urethra, etc. Why not from the cavity of the cervix ? Why term a symptom toxic there, and neurotic here? Who can continue to be- lieve that "clavus uterinus" is due to "pinching of 'nerve terminals' by cicatrices in the angle of a cer- vical tear"? Without extending this detailed analysis beyond the cardinal manifestations enumerated, it would appear sufficiently evident that the whole symptoma- tology, the complications and sequela of chronic endo- cervicitis, may be readily predicated from its patho- logical course as outlined above. CHAPTER VI. Etiology of Exdocervicitis. Infection of the cervix frequently dates back to a vulvitis in early infancy. This significant fact illu- minates many of the gynecological disturbances in viro'ins. Fig. 17.— Infantile endocervicitis — "Vulvovaginitis." Round-cell infiltration of the intramuscular connective tissue from a case of gonorrheal vaginitis. Hess reports the posf-morfciii findings in four in- fants that had the usual non-virulent form of ''vagi- nitis" during periods ranging from "three weeks to one year or more, in all of which the onlv abnormal ' (53) 54 GYNECOPLASTIC TECHNOLOGY. condition and sole lesion was an inflammation of the cervix, with round-cell infiltration of its submucous tissue." On the basis of these findings Hess con- Fig. 18. — Chronic endocervicitis. Section from a cervix after repeated cauterizations. Benign proliferation of the epithelium in the gland lumen, with epidermization of the surface. (Abel.) ETIOLOGY OF ENDOCERVICITIS. 55 eludes that "we must regard the average gonococcus infection as invohang the cervix rather than the Fig. 19. — Chronic endocervicitis. Section of a so-called "erosion"' of the cervix, showing transition from columnar to squamous epithelium, a, Squamous epithelium broken at h by vulsellum. c, Columnar epithelium proliferating over the area nor- mally covered by squamous epithelium, d, Glandular depressions extending under the proliferating squamous epithelium, e, Stroma infiltrated with round cells. (Abel.) vagina, and must consider the infection a cervicitis rather than a vaginitis." In adult females, ]\Ienge estimates that 95 per 56 GYNECOPLASTIC TECHNOLOGY. cent, of chronic gonorrheal infections are located within the cervix. While the gonococcus is by far the most frequent provocative organism in chronic endocervicitis, strep- tococcic, staphylococcic, and colon bacillus infections are not at all infrequent findings in the order enumerated. In infants, the exanthemata — and especially scar- let fever, protracted diarrheas, with probable con- tamination from soiled diapers, and general debili- tating conditions — seem to confer a special suscep- tibility to cervical infections; while in adults, con- genital maldcA^elopment of the cervix — and more especially when traumatized by cauterizations, dila- tations, curettage or birth injuries — embodies the Description of Plate IV. A, obj. 3, oc, 3, tub, 20. Heemalaun. Diagnostic excision. An area at some distance from the erosion showing an extension of the round- celled infiltration under the squamous epithelium and a death of the basal layer of cells. B, obj. 3, oc, I, tub, 20. Hsemalaun. Uterus removed because of retroflexion with adnex-tumors and adhesions. This patient had a purulent vaginal discharge. Eversion was present, and there was an "erosio-glandularis," with marked round-celled infiltration around the glands. The area shown is at some distance from the erosion and shows what might be interpreted as a beginning erosion, caused by the inflammation and round-celled infiltration excited by an infected gland. C, obj. I, oc, 4, tub, 15. Haemalaun. Showing two communications of a gland with the surface. Round-celled infiltration, though slight, is present around the openings of the glands. At one of the orifices there is apparently a destruction of the basal squamous cells. D, obj. DD, oc, 3, tub, 0. Hsemalaun. Drawing from an "erosio- glandularis" which is healing. The basal cells are shown exposed as a form of columnar epithelium. This same preparation showed true cylindric epithelium on the surface. E, obj.3, oc, T,tub, 15. Hasmalaun and muci-carmine. Nullipara. Myoma- tous uterus. Shows the squamous epithelium growing under the cervi- cal epithelium, which shows the characteristic staining with muci-carmine. F, obj. I, oc, 4, tub, 16. Hsemalaun and muci-carmine. Glandular cells show the characteristic staining reaction for mucin. The squamous epithelium has grown into the openings of the glands under- neath their epithelium. G, obj. I, oc, 4, tub, 18. Haemalaun. Diagnostic excision. Squamous epithelial plug connected with the surface. Near it is seen a small cj'st lined with low cylindrical epithelium. (Adair.) PLATE IV. T^*ffe*C--i. e^^^S^^ ^..J^ iir^'"^" '"'^*^H>' /»'»^*"'V**^ -■^•K,, - - -^O. "^^^ Histopathology of "cervical erosion." ETIOLOGY OF EXDOCERVICITIS. 57 most prolific predisposing factor to chronic endo- cervical disease. The objective features of chronic endocervicitis are typical, and plainly evident on inspection. The nullipara complaining of dysmenorrhea and sterility, with her conical cervix showing its inflammatory halo encircling a small pouting os extruding a ten- Fig. 20. — "Infantile erosion" — Chronic endocervicitis. Sharp demarcation between proliferating squamous epithelium and col- umnar cells. A, Squamous epithelium. B, Columnar cells. C, Blood-vessels. (Chrobak and Rosthoni.) acious clump of mucus; or the multipara, with lacer- ated, eroded h3'-pertrophied lips, honeycombed with nabothian cysts under a granular surface that bleeds on the slightest touch — all of these, in their varying degrees of intensity, constitute a clinical picture so familiar as to call for no detailed delineation. CHAPTER VII. Treatment of Chronic Endocervicitis. The inadequacy of prevailing therapeutic meas- ures in the treatment of chronic endocervicitis offers the most convincing evidence of misleading funda- mental concepts. Who, among the most experienced, does not realize his inability to cure permanently the ordinary leucorrhea of cervical disease? Chronic endocervicitis is primarily and essentially an infection of the deeply situated terminal tufts of the endocervical muciparous glands. These glandu- lar saccules harbor the infecting organisms for years or a lifetime. Their distention from duct occlusions may honeycomb the cervical tissues with so-called nabothian cysts, or, becoming purulent, riddle the cervix with chronic miliary abscesses, as shown in Fig. 23. It is an axiomatic surgical principle, in the control of any infectious process, to direct the therapeutic aim at the primary focus of infection. In general and specialistic practice, the escharotic, the dilator and the curette still hold sway as established routine meas- ures, especially for the chronic endocervicitis in the nuUiparous. Mild escharotics and discriminate dilatation, by promoting drainage, may prove of some benefit in very superficial infections, but curettage cannot he too emphatically condemned in any case. The curette does not and cannot reach the deeply situated infected (58) TREATMEXT OF CHRONIC EXDOCERVICITIS. 59 racemose tufts of the muciparous glands in the cer- vical tissues. Moreover, it should not injure the utricular tubules of the corporeal endometrium, which is rarely if ever involved in the disease, and whose specific functions in menstruation and gestation have been permanently vitiated by the laceration and inocu- lation incidental to this time-honored traumatism. Fig. 21. — Chronic endocervicitis. Dense round-cell infiltrations in the subepithelial layers and muscular stroma of the cervix. Tlie corporeal cndoiiictriuin is a highly specialised tissue, to be assiduously conserz'ed, and not to he har- rozved and scraped zvith impunity. The cases of posi- tive corporeal endometritis will be found among uteri that have been cauterized or scraped from one to several times. In the parous cervices with infected lacerations, the symptoms emanate from the infection, and not 60 GYNECOPLASTIC TECHNOLOGY. from the rent in the cervix. Nevertheless, surgeons usually take cognizance of the rent and ignore the infection, with the resulting proportion of ultimate failures tabulated in Leonard's statistics quoted above. Similar failures have prompted many surgeons to desist from all tracheloplastic attempts during the Fig. 22. — Chronic endocervicitis. Dense round-cell infiltration in the subepithelial layers and muscular stroma of the cervix. child-bearing period, preferring to shut their eyes to the existing condition rather than incur failure to cure, or possible aggravation, by standardized pro- cedures of questioned efficacy. To cure chronic endocervicitis, we must remove the entire infected area of the endocervical mucosa; as long as endocervicitis persists, so long will its symptoms persist. TREATMENT OF CHRONIC ENDOCERVICITIS. 61 The operation of Iraehelorrhaphy was originally evolved from the misconception that the local and gen- eral manifestations following laceration of the cervix are due solely to gaping flaps, with cicatricial dis- Fig. 23. — Chronic endocervicitis, with niiUary abscesses. Sec- tion through cervix ; subepithelial inflammatory foci ; hyperplastic lymph-vessels, with streaks of round-cell infiltration and small in- flammatory foci in the cervical musculature. A, Blood-vessel. B, Muscle-bundle. C, Lymph-vessel. D, Squamous epithelium. E, Miliary abscess. tortion, and that a cure of the condition demanded nothing more than excision of the cicatrix, and sutural closure of the gap. In other words, the operator 62 GYNECOPLASTIC TECHNOLOGY. aimed to reproduce the original area of laceration and reunite its edges. It is obvious that the airative scope of this pro- cedure is necessarily limited to the cases in which the infection has not extended beyond the lines of the Fig. 24. — Cancerous endocervical gland, a, Dark globular cell infiltrate, h, Normal columnar epithelium separated from its base at d. c, Carcinoma involving the right wall of gland. (Abel.) original tear — a rare condition, for we know to-day that the functional disturbances following lesions, which demand surgical intervention — that is, the in- fected tears — signalize the infectious invasion of the TREATMENT OF CHRONIC ENDOCERVICITIS. 63 entire length and l)rcadth of the cervical mucosa, from external to internal os, and that the conservation of the invaded area within the cervical canal beyond the lacerated edges perpetuates the whole pathological process. If this is true of single tears, it applies with pro- portionately greater force to multiple tears. But Fig. 25.— Carcinoma of the cervix. Primary stage, a. Squamous epithelium, b. Artefacts. C, Cancer nodules, dj Cancer pearls. (Abel.) whether we accept or reject the foregoing considera- tions as valid factors in limiting the scope of secon- dary trachelorrhaphy as a curative measure, a more sinister menace obtrudes itself into this question to- day, namely, the enhanced cancerous potentialities in the chronically inflamed cervical areas beyond the range of the Emmet operation. A recent publication by Ewing, on precancerous diseases, affirms that "chronic catarrhal endocervicitis precedes cancer in the great majority of cases 64 GYNECOPLASTIC TECHNOLOGY. and the cervical erosion is the most defi- nitely established lesion known to initiate cervical carcinoma." Polese demonstrated this in 34 out of 48 cases. Beckman carefully observed the develop- ment of carcinoma in an erosion which he treated for five years. Early stages of carcinoma from such lesions are described by Waldeyer, Ruge, and Veit, by Cullen, Schauenstein, Sitzenfrey, and others. Ewing studied three instances of precancerous poh^p in eroded cer- vices showing metaplastic overgrowth and beginning invasion of the stroma by adenocarcinoma. Aside from these clinical considerations, many gynecologists have for a long time discarded trache- lorrhaphy in the majority of their cases on purely technical grounds. Thus, Noble declares that "in cer- vical lacerations of long standing, with marked hyper- trophy and nabothian cystic degeneration, amputation is to be preferred, as the conditions left by trachelor- rhaphy are far from satisfactory, and, furthermore, that all cervices deficient in bulk from underdevelop- ment, irregular multiple tears, or previous sloughing present insufhcient tissue for normal reconstruction by trachelorrhaphy." The foregoing arraignment of this procedure, on physiological, pathological, clinical, and technical grounds, forces the conviction that late trachelor- rhaphy, whenever indicated, must prove inefficacious as a curative measure, and when apparently curative was probably superfluous. With the cervical lesion as the established portal of infection, simple trachelorrhaphy should find its cardinal and practically its only sphere early in the PLATE V. Healed non-infected bilateral laceration. Mild endocervicitis. Bilateral laceration. PLATE VI. V^irainal chronic endocervicitis. Conical cervix. PLATE VII. Virginal chronic endocervicitis with "erosion." Chronic endocervicitis, with mild manifestation at the external os (leucorrhea). PLATE \'III. A, Gonorrheal condylomata. B, Gonorrheal endocervicitis. PLATE IX. y Chronic senile endocervicitis. Infected bilateral laceration, with extreme relaxation — "eversion" — of the cervical wall. Chronic endocervicitis. Mildly infected. Stellate laceration. PLATE XI. Chronic endocervicitis. Infected laceration with "ulceration and suppurative nabothian folliculitis." Chronic endocervicitis. Infected laceration. "Ectro- pium with follicular suppuration." PLATE XII. ) Chronic endocervicitis. Infected laceration, with "'gran- ular erosion" and nabothian folHcuIitis. $y Chronic endocervicitis, with mucous polipi. Pr.ATE XI IT. Chronic endocervicitis, with carcinomatous papilloma. -Stf Endocervical carcinoma in the initial stage. PLATE XIV. Chronic endocervicitis, with carcinomatous ulceration. Carcinoma of cervix, with sloughing into the posterior vaginal vault. PLATE XV. m Carcinoma of cervix, with endocervical necrosis. Endocervical carcinoma in section, showing its tendency to progress along the uterine musculature, rather than by way of the corporeal endometrium. TREATMENT OE CHRONIC ENDOCERVICITIS. 65 puerperiuni, Avhen "iinniediatc," or, still better, the ''intermediate" operation represents an efifort of the highest prophylactic potency. In thus restricting- the applicability of trachelor- rhaphy to the puerperium, we necessarily augment the Fig. 26. — Advancing- carcinoma of cervix. Note involvement of the uterine musculature. range of cervix amputation as the reparative method of choice for all chronic cervical lesions; and it now remains to elucidate and obviate as far as possible those derangements noted after this more radical operation. In the light of the normal and pathological funda- mentals at hand, both cause and prevention of these 66 GYNECOPLASTIC TECHNOLOGY. postoperative disturbances are revealed as inherent in the technique of the prevaihng methods of cervix amputation. A low amputation of the cervix is a partial ampu- tation, and can only eliminate a part of its diseased Fig. 27. — Advanced carcinoma. mucosa, while a complete or high amputation is an unwarrantable mutilation of its muscular mechanism. When a cervix tears during labor, the rent extends practically in the direction of its muscle-fibres. On the other hand, when the cervix is amputated in the usual manner, the muscle-fibres are severed transversely. The spontaneous tear, unless infected, exercises but PLATE XVT. Sj'philitic ulcer in angle of laceration. TREATMENT OF CHRONIC EXDOCERVICITIS. 67 Fig. 28. — Tracheloplasty (author's method). Outhning the edge of the flap on the vaginal sheath of the cervix along the demar- cating line between the normal vaginal and diseased endocervical mucosa in a case of infected bilateral laceration. 68 GYNECOPLASTIC TECHNOLOGY, Fig. 29. — Tracheloplasty (author's method). Elevating the flap edge preparatory to its free mobilization by blunt dissection from the subjacent musculature. PLATE XVII. Tracheloplasty (author's method). Outlining the edge of the flap of the vaginal sheath of the cervix along the demarcating line between the normal vaginal and the diseased endocervical mucosa in a case of nuUiparous chronic endocervicitis. TREATMEXT OF CHRONIC EXDOCERVICITIS. 69 little influence upon the muscular mechanism of the cervix, while the transverse ablation detroys it completely. Circular amputation of the cervix, and union of its vaginal and endometrial mucosa, according to standard methods, defeats its own purpose by dis- regarding the physiological and textural characters of the cervical tissues. According to an established law^ in myodynamics — "the extent of contractile shortening in a given muscle depends upon the arrangement and number of its contractile tmits" — the longer the muscle, the greater the number of its contractile units. Conse- quently, a long muscle-bundle will contract through a proportionately w"ider interval than a similarly ar- ranged short one. In the uterus the peripheral fibres traversing the greater circumferential area are necessarily much longer than the central fibres that entw'ine the uterine cavity. It follows, therefore, that on ablating the cervix in the usual manner, all the muscle stumps are made to terminate at the same level. The longer peripheral fibres, contracting to a higher plane than the shorter central fibres, tend to pull the vaginal and endometrial margins of the stump asunder. Further- more, the extreme friability of the endometrial edge renders its sutural retention purely transitory, so that sooner or later the flaps separate and expose a raw beveled cervical stump. These exposed stump surfaces heal by granulation. Some never heal completely; but when they do, and the patient comes to child-birth, the annular cicatrix, incapable of physiologic retractile expansion, presents 70 GYNECOPLASTIC TECHNOLOGY. Fig. 30. — Tracheloplast)' (author's method). Mobilization of the cylindrical vaginal flap to the vaginal fornices. TREATMENT OF CHKOXIC ENDOCERVICITIS. 71 Fig. 31. — Trachcloplasty (author's method). Excision of endocer- vical cone, the knife directed towards the internal os. 72 GYNECOPLASTIC TECHNOLOGY. Fig. 32. — Tracheloplasty (author's method). Denuded funnel of cervical muscularis, excised cone of endocervical mucosa, and loose cylindrical flap of vaginal mucosa. TREATMENT OF CHROXIC EXDOCERVICITIS. 7Z the dystocia noted in Leonard's tedious deliveries. The cases that do not heal present a raw area, which, becoming- infected, practically re-establishes the origi- nal lesion, with the whole train of objective and subjective disturbances that first prompted our sur- gical intervention. Realizing- some of these operative shortcomings, Karl Schroeder excised the cervical mucosa separ- ately from the anterior and posterior lip as a trans- verse wedge. Then he folded each lip upon itself, and sutured its vaginal margin at or near the internal os, while the redundant lateral edges were sutured to each other. Commenting on this modification, Noble states : "Schroeder's operation accomplishes the purpose of removing the glandular portion of the cervix, but it is difficult of performance, and yields inferior results." Howard Kelly removes a wedge of tissue from each lateral angle after amputating, aiming to produce "a wide, smooth os." The method is comparable to the cupping of the cervix after supravaginal hysterec- tomy. The ultimate outcome of this method, as already cjuoted in our introductory statistics, was declared by Leonard as "quite unexpected, and in many ways disappointing." The difficulty in all the prevailing methods of cervix amputation is encountered when suture of the vaginal to the endometrial edge is attempted, the extreme friability and inaccessibility of the latter fre- quently rendering- accurate approximation and per- manent retention quite impossible. Briefly stated, the cure of a chronic endocervicitis, whether in the nulliparous or multiparous cervix, demands : 74 GYNECOPLASTIC TECHNOLOGY. Fig. 33. — Tracheloplasty (author's method). Silkworm strand passed transversely through the vaginal surface of the anterior flap segment, Vs of an inch from the edge, embracing yg of an inch of tissue. TREATMENT OF CHRONIC ENDOCERVICITIS. /o S H. 3 ^ 5 ^ O (J -^3 -J ^ '-' ™ a; u ''3 ^ o ^ Ph u^ ( 1 ) Complete enu- cleation of the entire endocervical mucosa, from external to inter- nal OS, with preserva- tion of its muscular structure. (2) Accurate re- lining of the denuded cervical canal by a cy- lindrical cuff of its vagi- nal sheath. The following me- thod fulfills the physio- logical demands, meets the pathological indica- tions, and obviates the technical shortcomings enumerated. The pro- cedure is applicable to infected nulliparous or multiparous cervices alike, and comprises: ( 1 ) Outlining and free liberation of an ample cuff of mucosa from the vaginal sheath of the cervix. (2) Enucleation of the entire endocervical mucosa to the internal OS, with preservation of its surrounding muscu- lar layer. 7(i GYNECOPLASTIC TECHNOLOGY. Fig. 35.— Tracheloplasty (author's method). Introducing the right free suture-end into and slightly above the internal os on a double curved needle, v^^hence it is passed upward, forward and slightly to the right through the musculature to emerge at the base of the flap in the anterior vaginal fornix, % of an inch from the median line. TREATMENT OF CHRONIC ENDOCERVICITIS. 77 Fig. 36. — Tracheloplasty (author's method). Needle, carrying the right free end of the anterior suture, emerging on the anterior vaginal fornix at the base of the flap. 78 GYNECOPLASTIC TECHNOLOGY. Fig. Zl . — Tracheloplasty (author's method). The left free suture-end passed in a direction iTpward, forward, and to the left. Both ends emerging on the anterior vaginal fornix at the base of the flap, Yz of an inch from the median line. TREATMENT OF CHROXIC EXDOCERVICITIS. 79 (3) Sutural inversion of the vai^'inal cuff into the denuded cervical cavity. The main object in the first step is the formation of an ample cuff of mucosa from the vaginal sheath of the cervix. With this in view, an outlining incision is made to encircle the eroded area around the external OS, closely skirting the demarcation border between the healthy vaginal and the diseased endocervical mucosa, running parallel to any indentations that mark the lines and angles of laceration. The cylindrical flap thus outlined is freely liber- ated from the anterior and posterior surface of the cervix to the level of the internal os. The eroded external os, with its everted hyper- trophied lips, and the entire cervical lining up to the internal "os, are now cored out of the surrounding- muscular bed as a complete cone. In congenitally deformed nulliparous cervices, chronicall}^ infected, the muscular framework thus exposed may now be advantageously reshaped by appropriate incisions on the lines established by Sims, Pozzi, or Dudley, according to indication or predilection. The vaginal flap is not included in any of these muscle incisions, to which no individual stitches need be applied. The cervix now presents a muscular funnel within a deep cylindrical sheath of vaginal mucosa. The inversion of the cylindrical sheath of vaginal mucosa into the muscular funnel,' and its sutural coaptation at the correct level, is accomplished in the following manner : Beginning with the anterior segment of the circular flap, a long strand of heavy silkworm gut is 80 GYNECOPLASTIC TECHNOLOGY. Fig. 38. — Tracheloplasty (author's method). Traction on the two anterior suture ends draws the anterior vaginal flap segment into the cervical cavity, and approximates its edge to the circum- ference of the denuded internal os. PLATE X\'Iir. Tracheloplasty (author's method). Schematic sagittal A-iew of the suture course in the anterior flap segment. A, Edge of the cyhndrical vaginal flap. B, Edge of denuded cervical cavity. C, Course of suture through the musculature to the base of the vaginal flap. The suture of posterior flap segment runs parallel to that of the anterior, but in a correspondingly posterior direction. 82 GYNECOPLASTIC TECHNOLOGY. Fig. 39. — Tracheloplasty (author's method). The anterior and posterior sutures drawn taut and tied, flap in place, lining the cer- vical cavity to the internal os. TREATMENT OF LllKUXIC EXDOCERVICITIS. 83 cavity will foreshorten the anterior vai2;'inal wall, and tilt the uterus backward. To lengthen a congenitally foreshortened anterior vaginal wall, as suggested by Reynolds, it is only necessary to incise the anterior flap segment trans- versely and pull this transverse incision into a longi- tudinal slit before passing the main sutures, which, emerging at the sides of the slit, coapt and retain its edges in the longitudinal axis. Additional sutures are usually imnecessary. The silkworm ends are left long to facilitate their removal, and tucked into the vagina. A narrow strip of iodoform gauze introduced into the cervix, with the object of maintaining flat coapta- tion of all raw surfaces, completes the operation. This gauze is removed on the third or fourth day, when the patient is permitted to walk about. The stitches are removed at the end of the third week, when they will be found loose and accessible. The specific features of the operative method thus outlined efl:"ect the complete elimination of the infec- tious focus by extirpation of the diseased cervical mucosa; preserve the normal arrangement, contour, and functions of the cervical musculature ; obviate the mechanical difficulty, and secure the permanency of accurate sutural coaptation of flap to stump. I do not claim an ideal restitution to the normal in all cases. So perfectly a balanced mechanism as the uterus, when once deranged, cannot be perfectly re- stored by surgery. But I may contend that the pro- cedure here advocated obviates in the greatest number of cases the detailed shortcomings in the prevailing tracheloplastic methods and results. CHAPTER VIII. The Cervicoplastic Treatment of Sterility. In its clinical designation, the term sterility is purely relative, necessarily implying in a given case the presence of approximately normal anatomic and physiologic essentials to conception, without the consummation of offspring. Physiologically, every woman who menstruates, ovulates. Biologically, ovu- lation predicates potential fecundity. The virgin ovary harbors from forty to sixty thousand ova. Ovulation, fertilization, and nidation constitute the chronological cycle of conception, and any perversion in their normal concurrence determines sterility. We cannot create a function; we can only attempt to activate one existing in a dormant state, stimulate one deficient, or, possibly, mobilize one tentatively in- hibited. The maturation of a graafian follicle and liberation of its contained ovum, the evolution of the corpus luteum, the endometrial transmutation essen- tial to deciduation, the subtle biotactic elements that dominate ovular fertilization and nidation, are all sus- ceptible to inhibiting influences, temporary or per- manent, local or systemic, most of which involve problems far beyond our present diagnostic horizon and therapeutic scope. Who can explain why the conjugation of a per- fectly normal female with an equally normal male proves sterile, while the subsequent union of each with another demonstrates the fecundity of both? To (84) CERVICOPLASTIC TREATMENT OF STERILITY. 85 apply the serological hypothesis of "a selective ovular immunity to certain strains of sperma" in explanation, is mere terminological juggling. Fecundity is a ques- tion of seed and soil. We cannot control the seed; we can onl\- enhance its viability by correcting a defi- cient soil. W't cannot control the ovule; we can only aim to correct certain endometrial abnormalities in- imical to its fertilization and nidation. The endometrium must provide a medium condu- cive to the virility and progression of the sper- matozoon in its fertilizing mission, and must respond normally to ovular fertilization, with a concurrent activation of its decidual potentialities essential to normal nidation. According to established modern conceptions, chronic corporeal endometritis is extremely rare. Our former acceptance of the condition was based upon misinterpretations of the normal endometrial changes characteristic of its menstrual cycle, as already eluci- dated above. But for this relative immunity of the corporeal endonietriiun, the extreme prevalence of chronic endocervicitis would render the largest majority of women sterile, for a diseased ccrvieal mucosa is capable of iuunohilizing and destroying spermatozoa. But beyond the direct devitalization of sperma by the diseased cervical mucosa, other factors, of equal and greater potency in the causation of sterility, may be incited through the influence of cervical disease upon the functions of the uterus as a whole, for, zi'Jiile chronic endocervicitis never extends to the corporeal endonietriuni by direct continuity, a sterility accom- panying the former ls' due in large part to the 86 GYNECOPLASTIC TECHNOLOGY. functional derangements induced in the latter. (See chapter on Endocervicitis. ) Crystallized into a concrete postulate, chronic endocervicitis presents the key to the therapeutic problem in sterility of cervical origin, and the success of any curative attempt upon the cervix will be pro- portionate to its elimination of an existing endo- cervical infection. The question as an abstract proposition, whether a tracheloplastic widening of the cervical canal cures sterility by facilitating the ingress of spermatozoa, or the egress of deleterious secretions, would appear of more academic than practical interest, but applied to the individual case it acquires the significance that dis- tinguishes between rational procedures and empirical practice. Every curative attempt should be based upon a correct perception of indications, and a definite realiza- tion of its aim and scope. Wo. must know why we operate, in order to determine when and how to operate. Boldt states : ''Next to curetting, dilatation of the cervical canal, principally to overcome sterility, is the operation most frequently done without proper indica- tion. Those who have made observations will prob- ably concede that in 75 per cent, of patients so treated the intervention is unwarranted." The cervicoplastic operations in vogue for the cure of sterility comprise the so-called discission and amputation — that is, the cervix is either split or ablated. ]\lany women undoubtedly conceive after one or other of these operation, as they occasionally do after CERVICOPLASTIC TREATMENT OE STERILITY. 87 dilatation and curettage, but to attribute an eventual fecundity to the curative effect of this or that pro- cedure is an obvious "post hoc" interpretation; for it must be conceded that, on the one hand, many women presenting- operative indications ultimately conceive without anv intervention w^iatsoever, while on the other hand a very considerable number of operations prove utterly futile of results. One hundred and twenty-eight complete post- operative histories from among 400 recorded cases tabulated by Leonard in Howard Kelly's clinic re- vealed 80 per cent, of sterility after low amputation for cervical lacerations. In other words, 8 out of 10 women of established fecundity are sterilized by prevailing methods of cer- vix amputation ; and while we recognize an occasional postpuerperal sterility as a possible sequel of birth injuries ("one-child sterility"), its occurrence never attains to such proportions. The normal cervical lining is not essential to con- ception or gestation, but a diseased lining is inimical to both, and should be removed by the method advo- cated in the chapter on the treatment of endocervicitis. I would not dogmatically attribute the cure of sterility to this operation any more than to other pro- cedures, for there is too much that is unknown and unknowable involved in the problem; but I may as- sert, after a very extensive and critical trial, that the method as outlined radically eliminates chronic endo- cervicitis — the one established causative factor in the sterility of cervical origin. » CHAPTER IX. Perineorrhaphy. The practice of perineorrhaphy dates from the middle ages. Tradition points to one Trotula, a woman attached to the school of Salernum in the eleventh century, as the first to suture a lacerated perineum: ''Post modinn rupturam intra anuni et vulvan tribus locis vel quatuor suimus cum Mo de sericej" From this remote record to the present time, a span of nearly one thousand years encompasses the evolution of perineorrhaphy, every phase of which is linked with names of the most illustrious surgical ex- ponents, and with a literature which offers the most ancient, the most voluminous, and yet the most in- complete theme in modern gynecology. ''To no department of gynecology," wrote Thomas thirty-five years ago, "does there attach more surgical rubbish which needs a thorough clearing away than to perineorrhaphy." Three years later Emmet inaugurated what may be termed a renaissance in perineorrhaphy, by demon- strating the significance of the musculofascial ele- ments in the nature and repair of perineal injuries. Nevertheless, while thus among the first to recognize correct anatomic essentials for a reparative method, he devised an operation the ultimate results of which have not tended to sustain that prestige among con- temporaneous procedures bestowed upon it by the (88) rERlNEUkkiiAl'ilY. 89 authoritative name of its advocate, for, after a vogue of nearly three decades, Jewett in 1905 characterizes ''the female perineum with its surgical problems" as the "pons asinoruui of the gynecologist" ; adding that "the surgical anatomy, the nature of obstetric injuries and the rationale of their repair, are cjuestions long in dispute, and their solution still remote." Irving S. Haynes, on "The Anatomic Basis for Successful Repair of the Female Pelvic Outlet," as- serts that "the treatment of pelvic lacerations is in sufficient chaos to justify a reasonably careful review of the salient features of the subject." In the same vein, W. W. Babcock pointedly de- picts the practice of perineorrhaphy in 1909 as fol- lows: "The methods of perineorrhaphy that have been chiefly employed for the last twenty-five years suggest more of a mathematical than an anatomic basis for their existence. For the most part, they have consisted of excisions of mucous membrane from the posterior vaginal wall, having geometrical pat- terns that vary as do the fancies of the dift'erent surgeons. "In support of the various operations, much has been written about the laceration in the muscular and fascial planes, and of the effectiveness of particular operations; yet one who studies the work of various gynecologists will be impressed by the thought that usually the precise anatomic restoration of the peri- neum occurs only in the theory of the operator, for the operation as a rule consists of little more than the removal of an area of mucous membrane and the union of the wound edges. . . . If at times the operator's needle is made to sweep in various direc- 90 GYNECOPLASTIC TECHNOLOGY. tions, with the specification that certain muscles are caught in its grasp, the precise evidence that such muscles are included, and especially any evidence that the important fascial planes of the perineum are re- stored, is rarely observed." The veteran Henry O. Marcy concludes one year later that "the basic principles of the operation are still in a measure misunderstood." C. M. Watson tersely epitomizes the sum and substance of the whole problem by stating that "the classic operations for the secondary repair of the torn or relaxed perineum have been successful only to a degree; the more extensive the injury to the levator ani muscle, the less effective these operations." The recognition of the levator ani as the func- tional dominant and surgical objective in perineal in- juries is not of recent date. In 1884, B. E. Hadra, of San Antonio, Texas, first propounded the operative problem as it presented itself to him at the time, in the following: "It will be hazardous to cut through the posterior vaginal wall in order to seek the levator muscles and to sew them together; still something of this kind must be done. "I have in view an operation which was devised by my deceased friend. Dr. Dowell, of Galveston, for hernia. I believe that it will prove to be the correct procedure, as it promises reunion of the separated muscles, and narrowing of the slit, without any in- jury to the surrounding organs and tissues. "I will at the proper time report more fully on this point, but for the present would ask the profession to take the whole subject under consideration, and seek PERINEORRHAPHY. 91 sonic method to remedy evils which as yet are beyond onr control." Again, in 1887, lladra, after experimental at- tempts on the cadaver, and a critical scrutiny of con- temporaneous methods, stated: "A little reflection will at once demonstrate that it is not the perineum which the operation aims at, but the posterior vagi- nal wall. . . . Wylie's operation, like Emmet's, is not a perineorrhaphy. . . . It is only the effect of both operations on the patulency of the vaginal out- let that makes them appear a remedy in a ruptured perineum. . . . Very likely a sewing of the margins of the levator shanks sometimes happens without our knowledge in operations where the sides of the vagina are extensively denuded, so as to lay the muscles bare. ... I am confident that, in all the colporrha- phies which have given permanent relief, the shanks of the levator were united to each other on the sides of the vagina. When the vaginal wall is fully lifted, these muscles may be fully exposed, and when the cor- responding surfaces of both sides are well brought together the brims of the levators must be sewn to each other. I do not doubt that in Hegar's, in a high Tait's or Fritsch's operation, as in all others in which the vagina is posteriorly extensively denuded, the narrowing of the levatoric slit by these processes is the main part of the permanent success." In 1900, Ziegenspeck first recorded the direct suture of the levator ani in perineorrhaphy on the living, while Duval and Proust published an elabor- ately illustrated monograph on "Levator JNIyorrha- phy" in 1902. These early publications, which practically embody 92 GYNECOPLASTIC TECHNOLOGY. the origin and principles of all subsequent levator operations, instigated a flood of technical propositions and academic controversy which to the present time display a striking diversity in conceptions of the anatomy, topography, and dynamics of the levator ani muscle. CHAPTER X. The Mechanism of Intrapelvic A'isceral Support. The keynote in the clinical significance and surg- ical indications of perineal lacerations is the loss of gynecic support, and the study of its problems must be centered in the myodynamics of the pelvic floor and its function in the control of intra-abdominal pressure. Studies of normal visceral support have been con- fined laro-elv to the limits of anatomical detail. Anatomy, however, has not fully revealed the true mechanism of this support. It is a gross miscon- ception of function that attributes visceral support to the textural strength of ligaments or muscles. The ligament or muscle does not exist that can perman- ently withstand the continuous force of intra-abdom- inal pressure. The muscular and ligamentous elements serve to support the pelvic contents, not by virtue of their textural resistance to displacement, but by deflecthig the displacing force of intra-abdominal pressure. Moreover, the perineal musculature should not be conceived as a diaphragm, passively bearing the weight of its superposed organs, with a sphinctre action at the pelvic outlet. It is an active integral part in a complicated deflecting mechanism that dom- inates the topographic stability of all the abdominal viscera. (93) 94 GYNECOPLASTIC TECHxNOLOGY. The influence of pressure and its deflection find familiar exemplification in the mechanism of labor when the initial direction of the expulsive force be- comes deflected by the pelvic planes, and thus impels the fetal ovoid through the different axes of the parturient canal. Fig. 40. — Normal nulliparous vulva The radical cure of inguinal hernia became possi- ble only with the realization of its two essentials, namely, the apposition of contractile muscular resist- ance to the hernial area, and the obliteration of its peritoneal funnel. In other words, the muscular and serous planes are so reconstructed as to re-establish the normal deflection of intra-abdominal pressure, thus causing the intestine to glide oz'er instead of into the hernial gap. MECHAXISM OF LXTRAPELVJC SUPPORT. 95 In inguinal herniotomy, the freely mobilized con- joined tendon with its contiguous muscles is deliber- ately displaced by suture to Poupart's ligament; and yet the analogous interposition of the mobilized leva- tor, essential to a successful perineorrhaphy "(which is practicall}' a vaginal herniotomy), is stigmatized as "unanatomic." Fig. 41. — Xormal parous vulva. Competent levator ani muscle. The really valid objections to some of the levator myorrhaphies in vogue — namely, the isolation of the muscle ''through a slit in its fascial covering," "in- juries to the rectovaginal plexus, with possible throm- botic sequela in residual dead spaces" — are inapplic- able to a technique which circumvents these deleteri- ous features by approaching the levator bed bluntly along a direct plane of cleavage existing normally be- tween the vae'inal mucosa and the levator fascia. 96 GYNECOPLASTIC TECHNOLOGY. The evolution of levator myorrhaphy, like that of every other surgical procedure, has afforded a fer- tile field for attempts at originality and modification, some of which, losing sight of fundamental principles, necessarily defeat their own ulterior purpose. It is a significant fact that the most pernicious of these ''simplified" methods emanated from the ranks Fig. 42. — Parous vulva, gaping from incompetent lacerated levator ani muscle. of the general surgeons. To "plunge a scissors" blindly through the perineal tissues, "tease out a few levator fibres on each side and sew them together," all "done within five to six minutes," is levator myor- rhaphy in name only, and nothing more. No corrective procedure in all gynecology exacts a more intimate regional knowledsre and greater MECHANISM OF INTRAPELVIC SUPPORT. 97 technical skill than a properly executed sutural re- adjustment of the levator ani in perineorrhaphy. The morbidity of a ])erineal injury manifests itself by palpable evidences of impaired support at the pelvic outlet. Every perineal laceration that im- pairs a previously normal intrapelvic support has partly or completely severed the junction of the an- terior levator segments on one or both sides of the median raphe; the resultant "relaxed vaginal outlet," the "colpocele," "rectocele," "cystocele," and "decen- v^ sus uteri," present only different degrees and succes- sive stages in the ultimate development of a complete prolapse, each stage being proportionate to the extent and duration of the muscular lesion in the pelvic floor. The restoration of the impaired visceral stability within the pelvis demands a readjustment of balance between an expulsive force and its counteracting re- tentive elements — that is, between intra-abdominal pressure and its deflecting mechanism. Paradoxical as it may appear, both maintenance and disturbance of visceral equilibrium are the resultants of one and the same force, namely, intra-abdominal pressure under the influence of its balanced or unbalanced deflection. The conditions causing and modifying intratho- racic pressures have been the subject of exact re- search, and the conclusions offered meet general acceptance. This is not the case with intra-ahdoininal pressure. In the general and special literature, the subject is treated under discussions of splanchnoptosis, ascites, and circulatory conditions. ]\Iost of the textbooks on 98 GYNECOPLASTIC TECHNOLOGY, physiology omit the topic entirely, while the standard works on Obstetrics, Gynecology, and Surgery allude to intra-abdominal pressure so sparsely and inaccur- ately that very little is to be gleaned from them. Martin (1885), in discussing the causes of uterine displacement, states that intra-abdominal pressure is the essential factor, and that failure of the pelvic floor induces a diminution of this pressure and a descent of the uterus. Hegar (1886) asserts that the pelvic viscera are dislocated, not only by relaxed ligaments, but by diminution of intra-abdominal pressure. The fallacy of these interpretations becomes ap- parent when it is recalled that the abdominal and pelvic cavities present one continuous chamber, and that pressure recorded at any one point within this chamber is equivalent to the pressure at the same moment at any other point in the chamber; conse- quently, if diminution of pressure as such induced a descent of the pelvic organs, it should constitute part of a synchronous descent of all superposed abdominal organs, which is contrary to clinical experience. Much of this confusion is due to the misapplica- tion of hydrostatic principles to intraperitoneal con- ditions. These principles, when applied to homo- geneous fluids under pressure in a retainer of uniform outline and resistance, permit of exact observations and calculation; but the abdominal cavity is neither uniform in outline nor resistance; its walls are bony here and muscular there, while its contents are not homogeneous, but solid, semisolid, fluid, and gaseous. To quote further from a few of the more extensive treatises on physiology : MECHANISM OF INTRAPELVIC SUPPORT. 99 Du Bois-Reymond (190S) merely states that there is a variation in intra-abdominal pressure due to the action of the diaphragm. Hall ( 1900J considers intra-abdominal pressure at zero when the abdominal muscles are at rest, but illustrates the rise above that on descent of dia- phragm and contraction of the abdominal muscles. Although his tracings are probably correct, he gives neither base-line nor statement as to what fluid he used in his manometers to obtain the pressure records. He notes the effect of abdominal pressure on venous and lymphatic flow. Landois (1900) refers to Hamburger's work of 1 895- 1 896, and makes the curious statement that ex- piration causes a rise in intra-abdominal pressure in man and dogs, but that inspiration has this eft'ect in guinea pigs. A slight increase in abdominal pressure causes increased heart action and arterial pressure, but excessive pressure in the abdomen decreases both. Luciani describes the use of rectal and esophageal bougies, and gives tracings of intrathoracic and in- tra-abdominal pressures, but no figures as to the facts observed in etherized dogs. The essential fallacy of testing such pressures through a contractile hollow organ he does not observe. He finds that the abdomi- nal pressure varies with the descent of the diaphragm and contraction of the abdominal walls. Schaefer (1900), after noting the efifect of ab- dominal conditions on the circulation, points out the very important fact that the tone of the abdominal w^all muscles is maintained by the respiratory centre. The abdominal pressure as maintained by the ab- dominal walls is of the utmost importance, as it tonic- 100 GYNECOPLASTIC TECHNOLOGY. ally maintains the calibre of the great veins, and can compress them or allow them to expand. Tigerstedt (1906): "By abdominal pressure we mean the pressure on abdominal viscera produced by the simultaneous contraction of the diaphragm and 'the abdominal muscles." He gives no figures or trac- ings, and considers the pressure of importance only in relation to defecation and in labor. Briefly stated, intra-abdominal pressure — or, more specifically, intraperitoneal pressure — is the result- ant of several components, the most potent of which are muscular contractions, gravity, intravisceral ten- sion, and atmospheric pressure. Intraperitoneal pressure, while continuous in ef- fect, varies in intensity with the necessarily diverse activity of its muscular component. For practical purposes, these pressure variations may be defined as presenting a passive and an active phase. The passive phase is the state of normally bal- anced minimum intraperitoneal tension which prevails under the ordinary conditions of functional activity. This phase is of physiologic interest only. The active phase is a superinduced condition of hypertension, resulting from augmented eflr'orts that incite the abdominal and thoracic muscles to sudden or sustained maximum contractions, as coughing, sneezing, straining, lifting, etc. It is this phase of pressure which tends to extrude the pelvic viscera in the direction of least resistance. When a perineal laceration involves the sphinctre ani, prolapse rarely ensues, because ever}^ sudden augmentation of pressure in this condition is promptly MECHANISM OF INTRAPELVJC SUPPORT. 101 reduced by the involuntary emptying of the lower bowel contents through the gaping anal orifice before the increased tension can exercise its displacing force upon the pelvic viscera. It is a fundamental law in dynamics that the direction of a given force or body impelled by such force, impinging against a resistant plane, becomes deflected in a fixed and definite direction, the degree of deflection being governed by the angle of the re- sisting or deflecting plane. The same law is dominant in establishing and maintaining visceral equilibrium against the displac- ing force of gravity and intra-abdominal pressure. But for the influence of deflecting planes, every erect female would prolapse her abdominal contents into the pelvis and out through the vagina. As the result of normal deflection, a pressure of 80 mm. in the abdominal cavity is reduced to 60 mm. at the cervix, 40 mm. in the vagina, and 20 mm. at the introitus (G. H. Noble), thus resembling a placid pool along the edge of a rapid vortex. The entire abdominal cavity constitutes a com- pound deflecting chamber presenting multiple planes, some fixed and others mobile, that deflect pressure at various and varying angles to each other. In the pelvis, the fixed or bony planes may be designated expulsive planes, inasmuch as they tend to deflect the direction of pressure into line with the axis of the pelvic outlet. They are practically iden- tical with the established obstetric planes, among which, however, the sacral hollow is the most potent, as exemplified in its dominance on the final course of 102 GYNECOPLASTIC TECHNOLOGY. the fetal head; any viscus that falls into the line of this expulsive plane must eventually prolapse. In the same sense, the mobile planes are retentive planes, in so far as they deflect or disperse pressure Fig. 43. — In an abdominal cavity of normal skeletal configura- tion a true vertical in contact with the sacrolumbar angulation will impinge against the inner face of the symphysis pubis at its lower border. This vertical represents the initial direction of intra- abdominal pressure at the pelvis brim. in directions that tend to preserve the topographic stability of the pelvic contents. These are presented by the mobile uterus, with its broad ligament exten- sions, and the levator ani in the pelvic floor. MECHANISM OF JNTRAPELVIC SUPPORT. 1(33 In an al^dominal cavity of normal skeletal config- uration, a true vertical, in contact with the centre of the sacrovertebral promontory, will impinge against the inner face of the symphysis pubes at its lower border. The sacrovertebral promontory is situated y/2 inches above the symphysis, so that the vertical line which represents the initial direction of intra- abdominal pressure at the pelvic brim passes over, and not into, the pelvic cavity. In other words, the posterior abdominal wall ter- minating at the sacrovertebral angle is 3^ inches shorter than the anterior, which ends at the symphy- sis pubes. Dynamically the pelvic cavity thus pre- sents a separate communicating chamber or elbow, hollowed out of the posterior abdominal wall, with the sacrum as an inclined roof, from which the uterus is suspended by its sacro-uterine ligaments. Accordingly, under ordinary conditions, the di- rection of intra-abdominal pressure within the pelvis is such as to fall upon the posterior surface of the uterus and broad ligaments. In deflecting the direc- tion of this pressure to maintain its equilibrium, the normally anteverted uterus may be compared to a lever of unequal arms, poised over a fulcrum pre- sented by the intravaginal crest of the perineum. This intravaginal crest is formed by the junction of the pubococcygeal levator segments to the median raphe. The longer fundal arm of the uterine lever, which rests upon the subjacent bladder and pubic surface, is movable upwards, extreme movement in this direc- tion being limited by the round ligaments, which, up to a certain point, prevent tilting of the uterus into 104 GYNECOPLASTIC TECHNOLOGY. the axis of the sacral expulsive plane. The shorter cervical arm of the uterine lever projects free into the vaginal fornix. By this adjustment intra-abdominal pressure at first tends to depress the normal level of the uterine plane as a whole, until its anterior pole is arrested by the resistance of the subjacent bladder and upper pubic surface; augmentation of the pressure at this stage acts upon the free posterior cervical pole, forc- ing it upon its perineal fulcrum. Were this pressure to continue undeflected, the round ligaments would yield, and the progressive descent of the cervical pole, with its corresponding elevation of the fundus, would gradually tilt the uterus into retroversion. In this position it sustains the pressure impact upon its anterior instead of its posterior surface, and is thus crowded into line with the axis of the vaginal outlet. Under normal con- ditions, it is this last phase of the pressure that is counteracted by the deflecting function of the levator ani muscle. The stimulus which incites the abdominal mus- culature into activity, and thereby augments intra- abdominal pressure, induces a simultaneous contrac- tion in the levator ani. The elements of this muscle are so arranged that their contraction elevates the level and the angle of the pelvic floor. This elevation lifts the intravaginal crest or fulcrum up to the uterine lever, raises the depressed cervical pole of the lever to the level of its fundal pole, thus restoring anteversion; at the same time, the elevation of the perineal plane narrows the essential uterovaginal angle, preserves the potenti- MECHANISM OF INTRAPELVIC SUPPORT. 105 ality of the vagina by converting its actual canal into a valvular slit, and mechanically closes the pelvic outlet. Every augmentation of pressure demands a pro- portionate increase in resistance, which demand is promptly met by a synchronous countercontraction of the levator ani. Accepting the principle of deflection as funda- mentally applicable to the problem of visceral support, it follows as a natural corollary that every deviation from the normal, in the angle and resistance of the perineal deflecting plane, must necessarily induce a corresponding deviation in the direction of intra- abdominal pressure, with resulting topographic disturbance. The normal contours and topographic arrange- ment of the pelvic floor and its superimposed organs all conform to subserve this deflecting function. A sagittal section of the pelvic floor, wath the body in the erect posture, shows the cutaneous perineum extending horizontally from the posterior vulvar com- missure to the coccyx, while the upper or intra- abdominal surface, conformable with its function as a deflecting plane, slopes obliquely from the pubes, downward and backward, in a line parallel to the axis of the pelvic inlet. This divergence of the upper from the under sur- face outlines the triangular configuration of the pelvic floor. Its apex at the coccyx is less than half an inch in thickness ; its base at the pubic arch occupies a space of over 3 inches. The vagina, bladder, uterus, and rectum rest upon and constitute part of this inclined plane, the whole 106 GYNECOPLASTIC TECHNOLOGY. Structure being swung in the muscular hammock formed by the levator ani loops, which, by their con- tractile response to pressure, maintain its form, level, incline, and topographic relations. Contrary to general impression, the direction of the vaginal canal is practically horizontal. It is inter- Fig. 44. — Diagrammatic scheme of normal pressure deflection by the intrapelvic planes, and the direction of levator contraction. posed between the muscular layer in the pelvic floor and the superimposed pelvic viscera, the disposition of its walls being superior and inferior, not anterior and posterior. Its orifice is held in the most anterior of the leva- tor loops (pubo-coccygens), in a plane just posterior to that of the pubic arch. MECHANISM OF INTRAPELVIC SUPPORT. 107 Normally, the uterus lies nearly parallel to the puborectal segment of the levator ani, which, on con- tracting, draws the perineum forward and beneath the bladder, thus covering the outlet like a sliding floor. Every augmentation of pressure that forces the uterus downward stimulates the levator to lift the vagina upward, constricting its orifice against the pubic arch and closing the uterovaginal angle; the greater the pressure, the narrower the angle and the firmer the resulting vaginal closure. Concisely stated, the levator ani diminishes the force of intra-abdominal pressure upon the pelvic contents by deflecting the direction of that pressure, augments the resistance to the pressure by closing the uterovaginal angle, and obstructs the pelvic outlet against the pressure by compressing the vaginal canal. It is the tensor of the pelvic fascia, the antagonist of the diaphragm and abdominal muscles, contract- ing when these opposing muscles contract, and re- laxing when they relax. When intact, it maintains the equilibrium of the pelvic organs ; when its integrity is impaired, equilib- rium is disturbed and displacement ensues. Finally, in disorders of the lower spinal segments, especially in Spina hiiida and Spina hiUda occulta, involving the fourth sacral nerves, prolapse ensues as the result of levator paralysis, and this notwithstanding that the ligaments and fascia are intact. Such is the function of the perineum, and such the measure of its importance as a visceral support. It follows that the gravity of perineal lacerations is 108 GYNECOPLASTIC TECHNOLOGY. proportionate to the resulting impairment of its mus- cular element, such impairment inducing a tendency to prolapse, not because any direct support to the viscera is severed, but because the equilibrium of in- trapelvic pressure is deranged and its expulsive force undeUected. CHAPTER XI. The Levator Ani Muscle. In 1889 Robert L. Dickinson wrote: 'T venture to affirm that there is no considerable muscle in the body whose form and function are more difficult to understand than those of the levator ani, and about which such nebulous impressions prevail. The draw- ings of it are complicated, the impressions of its strength and importance are conflicting, and the knowledge concerning it is fragmentary and not readil}^ accessible. . . . One commonly meets with the idea that the levator is a kind of muscular funnel tapering to the anus, and serving to pull it directly upward after defecation. This is absolutely tmtrue. The muscle rather resembles a horseshoe — a sling attached to the pubes in front, its sweep reacting horizontally backward, to circle like a collar the rectum and vagina. Its action in woman is to drag the lower ends of the vagina and rectum forward, level to the symphysis." This statement in its entirety holds good at the present time. The levator ani is not a single muscle, but a radially disposed plexus of flat muscle segments, en- closed and separated by fascial investments, and com- posed of striped and unstriped muscle-fibres. AA'hile its individual segments may be separately demon- strated at their origin, they become intimately and inseparably blended with each other and with the (109) no GYXECOPLASTIC TECHNOLOGY. aponeurotic tissues in the perineal centre and ano- coccygeal raphe. Functionall}^, a sharp demarcation characterizes the coccygeal and pubic divisions of the levator muscle. The coccygeal division comprises the thin pos- terior semi-membranous segments that are inserted Fig. 45. — The levator ani seen from below. The cut ends projecting upward are those fibres which run into the recto- vaginal septum. (Dickinson.) into the sides and tip of the coccyx. These are de- void of special function, representing vestigial struc- tures, homologous with the caudal flexors in the lower animals, and are of anthropologic interest only. The functionall}' essential elements of the levator ani are the pubic bands commonly designated "pubo- vaginalis," "puborectalis," or "pubococcygeus." The bulk and strength of these muscles are much THE LEVATOR AXI MUSCLE. Ill greater than current anatomic descriptions and post- vwrtcni appearances would indicate. Their hnes of origfin extend for i and ilA inches on either side of the posterior surface of the pubic symphysis, thus equalhng in width the average ster- nomastoid : they are twice as thick as the diaphragm, Fig. 4o. — Origin of the left anterior (pubococc3-geal) loop of the levator ani from the posterior symphyseal surface (the right loop removed). S, Symphysis. U, Urethra. V, Vagina. P, Peri- neum. 1, Pubovesical ligament; 2, Origin of pubococcygeus ; 3, Iliococcygeus ; 4, Internal pudic vessels ; 5, Urethral plexus ; 6, Upper (inner) surface of the pelvic diaphragm; 7, Pubococcygeal loops of the levator ani muscle. weigh one-fourth as much as the external oblique, altogether presenting a muscular support exceeding that guarding the inguinal ring. Their dynamic energy, as developed by Dickin- 112 GYNECOPLASTIC TECHNOLOGY. son's experiments, ranges from lo to 27 traction pounds. These pubic segments course almost horizontally backward and inward along the lateral vaginal walls. . Fig. 47. — The intrapelvic line of origin of the levator ani. (Haynes.) They converge rapidly toward each other to be- come inserted into the rectovaginal septum, the perineal centre, the rectal walls and the anococcygeal tendon, encircling the vagina and rectum in distinct loops. THE LEVATOR ANI MUSCLE. 113 Their median borders, which are plainly palpable through the lateral vaginal walls, a half-inch or less behind the plane of the hymen, form a V-shaped in- terspace which embraces the introitus under the pubic arch, and is termed the levator cleft. Fig. 48. — Levator ani fibres normally present in the rectovaginal septum. A study of the vaginal extrusions resulting from perineal lacerations reveal elements closely analog- ous to those of inguinal hernia. Both conditions result from muscular insufficiency over a vulnerable intra-abdominal site, tunnelling their outward course along potential channels be- tween the muscular and fascial layers of the abdom- inal walls. 114 GYNECOPLASTIC TECHNOLOGY. The levator ani embracing the abdominal floor is as much an abdominal muscle as the obliquus, trans- versalis, or rectus. Furthermore, the form and nature of the muscular arrangement guarding the inguinal openings above the pubes is the exact counterpart of the levator arrangement beneath the pubes. The lacerated levator shanks retract upward and outward behind the pubic rami towards their para- symphyseal origin, widening the introitus, with re- sulting eversion and ultimate protrusion of the vagi- nal mucosa through the gaping orifice. The cleft created by the separation of their median borders gives vent to the anterior rectal wall in the formation of rectocele. The vaginal floor, thus deprived of its muscular crotch, and shortened to the extent of its laceration, exposes the upper vaginal wall and leaves the bladder base unsupported. The entire vaginal canal, with its superimposed viscera, descends to a lower level. The prolapsed vaginal pouches, with their hernial contents, gradu- ally drag the anteverted cervix toward the yielding outlet. The uterovaginal angle becomes widened, the uterus telescopes the vagina, and the prolapse is complete. CHAPTER XIT. The Pelvic Fascia. The levator ani, like all skeletal muscles, is in- vested with fascial sheaths whose relative function in the mechanism of intrapelvic support presents a topic of unsettled controversy. The study and de- lineation of this fascia, like that of the levator, aside from its intrinsic difficulties, is encumbered by a di- versified terminology, which depicts a confusing mul- tiplicity of subdivided layers. In the pelvis, as elsewhere, the muscular domin- ance in visceral support, direct or indirect, accords with the established morphological law, that "all weight-bearing function is essentially muscular in nature, clonic in rhythm, and continuous in efifect." With the assumption of the erect attitude by man, the pubic levator segments developed their support- ing function, while the coccygeal or caudal segments degenerated into thin membranous expansions. In the biological scale, the tailless anthropoid apes present a well defined levator ani, similar in form and function to the human muscle. This evolutional transition of the levator, from caudal flexor to perineal contractor, oflfers a key to the complicated topographic arrangement of the pelvic fascia along the following lines : The fibres of the primitive pubic muscle-bundles (pubo-coccygens), proliferated around the pre-exist- ing vaginal and anal canals, between the lavers of (115) (116J THE PELVIC EASCIA. 117 the deep pelvic fascia, which thus constituted the levator sheath ; the upper layer of this sheath is known as the ''rectovesical fascia", while the lower is termed "levator fascia". Concisely stated, the pelvic fascia, the rectovesical fascia, and the levator fascia, like the iliac and ob- turator fascia, are all in reality but one stratified ^ Antfpu6ic ^t'^^^ u»crMffj^ Fig. 50. — The pelvic outlet. sheath, practically continuous with the transversalis fascia, thus lining the abdominal muscles above and enveloping the levator muscles below. The rectoves- ical and levator fasciae fuse in the levator cleft. Topographically it is essential to note: — That the origin of the levator ani and its fascial sheath are on a level with the internal or upper sur- face of the pubic arch. ^ ^cref ^ 2 ^/^p^ . \ u \ "i \^ X \ 1^ if 8^ bo (118) (iiyj (120) (121) 122 GYNECOPLASTIC TECHNOLOGY. The pelvic outlet in the lithotomy position is lozenge-shaped, consisting of two triangles, base to base. The apex of the anterior triangle is at the symphysis ; that of the posterior at the sacrococcygeal joint. The anterior triangle presents the vaginal and urethral openings; the posterior triangle presents the anus. The common base-line between the two extends just anterior to the ischial tuberosities, correspond- ing to the direction and position of the deep trans- versus perinei muscle. The surgical path in the pelvic floor from the vulvar outlet to the ■ levator fascia traverses two thin, indistinct fascial planes — first, the "superficial perineal fascia," composed of two layers directly con- tinuous with the general subcutaneous fascia, con- taining a layer of fat only; the second fascial plane is attached to the anterior or lower surface of the pubic arch; it envelops the "superficial transversus perinei," the "bulbo-cavernosus ;" the "btilbus vesti- buli," and the "bartholinian glands." The deep transversus perinei occupies the cleft between this second plane and the levator fascia. These lower fascial planes and their muscles are isolated with difficulty in the cadaver, as they are in- timately blended along their lines of contact, while in the living their definition is blurred by cicatricial distortion and attenuation. Surgically, they are of secondary importance. The two transversus perinei are at best very weak subordinate adjuvants in intrapelvic support, while THE PELVIC FASCIA. 123 the "bulbo-cavernosus," sometimes misnamed "sphinc- tre vagiiice" or "constrictor cimi," simply controls the turgescence of the erectile tissue in the vulva and clitoris, exercising" no supporting function what- soever. CHAPTER XIII. Levator jMyorrhaphy. The musculofascial elements located in the leva- tor plane, constitute the surgical objective point in perineorrhaphy. Before denuding the seat of lesion it is essential to locate the two levator shanks, each being distinctly palpable through the lateral vaginal walls, behind the h3^menal border, where they converge downward to- ward the perineal centre, and may be followed up- ward and outward to their parasymphyseal origin on the posterior plane of the pubes. The primary laceration separates the tissues at the levator junction on one or the other side of the median line, with subsequent retraction of both mus- cle shanks. This alters their normal relation to each other and to their surroundings. Instead of forming an acute angle, with its apex fixed in the perineal centre, they run nearly parallel throughout their course. The normal intravaginal perineal crest formed by this apex of the two muscle shanks, and constitut- ing a fulcrum to the uterus, is obliterated, while the posterior vaginal wall is foreshortened. Contrary to general impression, the torn levator muscle is more frequently hypertrophied than atro- phied, especially in its upper portion, owing to its augmented compensatory function, due to its mal- position. (124) LEVATOR MYORRHAPHY. 125 Fig. 55. — Perineoplasty (author's method). OutHning incision on the vulvar mucosa from corresponding points just outside the lateral hymenal edges to the cicatricial mucocutaneous centre of the posterior commissure. 126 GYNECOPLASTIC TECHNOLOGY. Fig. 56. — Perineoplasty (author's method). The outHned flap is carefully elevated from the underlying cicatricial and fascial layer by feather-edge dissection up to its base, as the thinnest possible (almost translucent) flap consisting of vaginal mucosa only. LEVATOR MVORRIIAPHY. 127 Atrophy of either nmscle shank occurs only as the resuU of direct destructive traumatism to the muscle belly hy crushing with obstetric forceps. To correctly expose the seat of lesion and the levator shanks, it is necessary to recall that the up- per and under fascial sheaths enclosing the levator ani — namelv, the rectovesical and levator fascia — Fig. 57. — In elevating the vaginal mucosa, the flap is steadied by the left hand, the index finger exercising counter-pressure, con- trolling the course and progress of the denudation. blend in the median triangTilar space between the inner muscle borders known as the levator cleft, the contiguous fascial surfaces being held in apposition by a sparse reticular layer, which offers a natural line of cleavage directly to the muscle. The essential steps in the operative technique that demand detailed elucidation are: — L Elevation of a thin, almost translucent trian- gular flap of mucosa from the posterior vaginal wall. 128 GYNECOPLASTIC TECHNOLOGY. Fig. 58. — The flap dissection is necessarily sharp through the dense cicatrized area, until the uninvolved yielding reticular struc- ture at the lower pole of the rectovaginal septum is reached, whence it is continued bluntly on either side of the centre to the crest of the rectocele. X I — I X w < S « 2 o ~ So cj » o o r. 3 LEVATOR MYORRHAPHY. 129 TT. Exposure and mobilization of the puborectal levator shanks. III. Sutural readjustment of the muscle. IV. Coaptation of the vai^inal Hap. V. Closure of the superficial perineal layers. Fig. 59. — Fascial slits for levator exposure, necessitated by improper denudation. Preliminary to the first step, any concomitant displacement of the uterus or bladder, as well as pathological condition of the cervix, must be cor- rected by measures which will be considered under their respective captions. 9 130 GYNECOPLASTIC TECHNOLOGY. Fig. 60. — Incorrect method of exposing the levator muscle by slitting the fascia. LEVATOR MYORRHAPHY. 131 The delineation of the flap is faciHtated by hook- ing a tenaculum on each side of the vaginal orifice into the labia majora, and a third into the centre of the posterior mucocutaneous margin. A very superficial outlining incision is carried by light strokes of the knife on the vulvar mucosa from corresponding points just outside the lateral hymenal edges to the mucocutaneous centre of the posterior commissure. This constitutes a triangular area, with its apex and base just the reverse to that of Hegar. The lowest hymenal caruncles are too frequently situated at different levels to be standardized as fixed starting points in all cases. TJie triangular surface thus outlined must he carefully elevated from all underlying tissues by feather-edge dissection up to its base as the thinnest possible, almost translucent Hap, consisting of vaginal mucosa only. The flap dissection at first is necessarily a sharp one, through the dense cicatrized area until the un- involved yielding reticular tissue in the lowest pole of the rectovaginal septum is reached, when it may be continued bluntly upward to the natural point of con- tact between the anterior and posterior vaginal wall, commonly designated as the "crest of the rectocele." Owing to the proximity of the rectovaginal venous plexus, it is neither advisable nor necessary to continue the cleavage of the tissues upward in the median line above this point of the rectovaginal septum at this stage of the procedure. If a sufficiently thin flap of mucosa has been sepa- rated from the posterior vaginal wall, at the correct anatomical level, the exposed submucous surface will 132 GYNECOPLASTIC TECHNOLOGY. Fig. 61. — Perineoplasty (author's method). Suture traction on the retracted upper part of the levator ani, and blunt mobilization of its left shank by a gauze-covered finger. LEVATOR MVORRIFAIMIY. 133 Fig. 62.— Perineoplasty (author's method). The levator ani partly exposed, covered by a thin perimyseal sheath. 134 GYNECOPLASTIC TECHNOLOGY. Fig. 63. — Perineoplasty (author's method). The sutures passed entirely round (not through) the muscle-shanks, encircling them so as to secure the broadest possible side-to-side surface contact under the vaginal floor. LEVATOR MYORRHAPHY. 135 lead directly into the normal line of cleavai^"e between the two levator sheaths, where the finger tip may be insinuated and pushed gently in a direction outward and upward, on each side of the median line, toward the posterior surface of the pubic rami, and expose the muscle near its origin. Here it is necessary to observe that the pull on the flap during its elevation imperceptibly drags the submucous tissues forward in a manner to overlap the essential plane of cleavage to the levator ani. This overlapping tends to divert the further course of dissection into the lower fascial and cicatricial planes, which blurs the definition of the muscle, and necessitates supplemental fascial incisions for its ex- posure and mobilization, all of which are circum- vented by frecjuently releasing the pull and carefully grasping and clipping all attached reticular meshes with mouse-tooth forceps and scissors, as close as possible to the under flap surface. Barring the penetration of an occasional trau- matic varix in the reticular structure, which is easily controlled by pressure, and a small spurting branch of the internal pudic artery, no bleeding of import is encountered in this procedure. The vaginal Hap is not excised. The upper pole of the muscle, exposed by the blunt penetration, with the finger tip between the levator and rectovesical fascia, is found completely enveloped in a hitherto undescribed thin, smooth perimyseal membrane, which for convenience may be termed the surgical sheath. Neither this sheath nor its contiguous fascial coverings should be per- forated during any step in the operation. At times 136 GYNECOPLASTIC TECHNOLOGY. ?^ r' ~^«^.'^;;#i^'^'i -.J <*wi:*aH*»WMa«!;fr/> J5*^^ii^«^?ediss-* LeVu Fig. 64. — Perineoplasty (author's method). Levator sutures in situ and tied. LEVATOR MYORRHAPHY. 137 the digital retraction of the wound edges creates deep fascial folds which may simulate the levator shanks so closely as to confuse the operator. This is averted by palpating the exposed muscle to its posterior pubic origin. The identity of both muscle shanks thus estab- lished, their outer borders should be mobilized along their entire length to an extent permitting of their median approximation without tension. The method practised by a number of surgeons, in which a thin edge of muscle is drawn through a slit in the lateral fascia on each side and sutured without previous mobilization, is not to be com- mended, as it results in the formation of a thin cre- scentic diaphragm behind the introitus, productive of disagreeable sequellse. On the other hand, the muscle must not be enu- cleated or dislocated from its normal bed; its natural mobility is simply amplified by gently stretching its connections to contiguous structures. The operative field, correctly exposed before suture, should present a denuded irregular triangle, with its base line at the junction of vaginal flap and rectovaginal septum, its sides the inner borders of the levator shanks, edged by the furled layer of the levator fascia. From three to four interrupted, forty-day chromic gut sutures coapt the muscles and close the intermus- cular gap in front of the rectocele. Each suture is passed from side to side, not tJi rough but entirely around both muscles, encircling them so as to secure their broadest possible surface contact under the vaginal floor. 138 GYNECOPLASTIC TECHNOLOGY. Fig. 65. — Perineoplasty (author's method). The elevated flap of vaginal mucosa is not ablated. Its edges are sutured from its central tip downward to form a hollow cone. LEVATOR MYORRHAPHY, 139 Fig. 66. — Perineoplasty (author's method). The hollow cone of vaginal mucosa is inverted upon itself, tucked into the vagina, and snugly applied to the posterior surface of reunited levator ani muscle. 140 GYNECOPLASTIC TECHNOLOGY. The rectocele should not be caught in the suture nor pinched between the muscles, the uppermost suture being inserted just high enough to normally appose the lower to the upper vaginal wall when the flap is replaced. Fig. 67. — Perineoplasty (author's method). Diagrammatic sagit- tal section, showing the inversion and application of the inverted flap of vaginal mucosa to the posterior surface of the reunited levator ani. A, Inverted flap. B, Levator ani. C, Superficial perineal coverings. In adjusting the superficial coverings no vaginal mucosa is removed. The transverse wound is con- verted into a perpendicular slit by properly applied LEVATOR MYORKIIAIMIY. 141 traction, and the edges united side to side by con- tinuous or interrupted suture. The proper adjustment of the flap is clearly indi- cated by observing" the normal vaginal contours. In sagittal section, the edge of the posterior vagi- nal wall presents an undulating line running con- vexly in front over the eminence of the intravaginal perineal crest, concave posteriorly where it dips into the declivity of the posterior vaginal cul-de-sac. In the lacerated perineum, on the other hand, the intravaginal crest is obliterated by the diastasis of the levator junction, the posterior vaginal wall plus its mucosa is foreshortened, and the undulation is levelled to a flat surface. The sutural reunion of the levator junction re- stores the intravaginal crest and the natural undula- tion of the posterior vaginal wall. The area of an undulating surface is greater than that of a flat surface. It follow^s that the vaginal floor thus requires more iiiitcosa after its restoration than before. Moreover, the normal vagina is not a canal of smooth bore, but rugous. To ablate the flap is not only unanatomical, but unsurgical ; for, the remaining mucosa, too short to adapt itself in lining the posterior or descending sur- face of the intravaginal crest, must span the hollow at its base, creating a dead space of variable depth and pathological potentialities. To secure a normal adjustment of the flap, its median edges are brought together by a thin catgut suture extending from the central tip to the lower- most hymenal caruncles, which are thus brought into their natural apposition, where the suture is tied. 142 GYNECOPLASTIC TECHNOLOGY. Fig. 68. — Perineoplasty (author's method). Sutures introduced to unite the musculofascial layers superficial to the levator suture. These sutures do not include the levator muscle. LEVATOR MVORRHAPin'. 143 The resulting hollow cone of vaginal mucosa is turned inside out, thus inverting its apex and exposing its entire raw surface; this is tucked into the vagina, and snugly applied against the posterior surface of the reconstructed crest down to the Jiollow at its base, P"ig. 69. — Diagram of the vulvoperineal musculature. Note the position, relation, and origin of the transversus perinei as com- pared with the levator ani. where it is retained by a small packing of iodoform gauze. The entire vaginal canal is thus completely re- stored, and it remains to readjust the levator fascia and superficial layers to the cutaneous perineum. The very extended controversy on the relative importance of fascia and muscle in gynecic support 144 GYNECOPLASTIC TECHNOLOGY. - — Cenrrum. tendi/ieufn Sphincter ej^t Fig. 70. — The transverse perinei here depicted is often mistaken for the levator edge. Isolated suture of these bundles give a weak, insufificient perineum. {Doederlein and Kroenig.) LEVATOR M^'ORRHAPHV. 145 has only tended to obscure the sahent fundamentals of the question. Physioloi^ically and dynamically, fascia and muscle constitute a functioning unit. The -elastic resiliency of the former is complemental to the con- tractility of the latter. The direction and arrangement of the muscle- fibres determine and limit con- Fig. 71. — The fascial layers in relation to the levator ani. tractions, which are amplified and extended radially by its fascial sheaths. The exploitation of the fascial to the exclusion of the direct levator suture in perineorrhaphy on the parallel of its utility in ventral hernia ignores the textural and topographic contrasts presented by the two areas. The abdominal fascia ordinarily ofl:'ers the neces- sary strength and redundancy essential to successful 10 146 GYXECOPLASTIC TECHNOLOGY. Fig. 12. — Incorrect denudation, leading into wrong cleavage lines, and necessitating additional incisions into the levator fascia to expose the muscle. LEVATOR MYORRHAPHY. 147 overlapping in ventral hernia, while the pelvic floor fascia does not. The torn levator fascia, limited in extent by its firm attachment to the pubic arch, attenuated by re- traction, and partly obliterated by cicatricial fusion, does not oflfer the reconstructive essentials to per- manent support. This is substantiated by the short- comings in the functional results of the classic fascial perineorrhaphies. Efficient overlapping is impossible. ''A chain is as strong as its weakest link." Fascial suture can- not reproduce fascia, but only an edge-to-edge cica- tricial junction at best. An unbiased criticism of the results following the classic fascial methods of perineorrhaphy in vogue will concede a more or less perfect cosmetic restora- tion of perineal contours and bulk, in which, how^- ever, the all-essential physiologic muscular element in pelvic support is supplanted and immobilized by a vicarious cicatricial plug at the vaginal outlet. Such result fulfills all the indications for those who continue to see a "perineal body forming a tri- angular wedge, composed of fascia and areolar tis- sue," instead of a muscular pelvic floor, and who still adhere to the theory that ascribes the role of the perineum in the co-ordination of gynecic support to form rather than function. Obstructive retention at the vaginal outlet can- not permanently replace normal physiologic support, and the aim in perineorrhaphy must be the restitu- tion of such anatomic relations as to restore, as far as possible, physiological as \vell as mechanical support to the pelvic contents. 148 GYNECOPLASTIC TECHNOLOGY. Fig. 72>. — Inporrect exposure and improper suture of the levator ani. The levator edges are here drawn through a slit in its fascia, resulting in a thin cicatricial crescentric diagram at the vulvar outlet. ■■ LEVATOR MYORRHAPHY. I49 The original perineal rent is anteroposterior. Subsequent levator retraction converts this sagittal rent into a transverse slit. The operative denuda- tion and properly applied anteroposterior traction by tenacula reconverts the transverse wound into a perpendicular slit, which thus restores the original relations of the fascial edges for suture in the median line. Whether the fascial structures and skin are finally united by one or two rows of interrupted sutures is simply a matter of individual preference, the main object being accurate layer coaptation. The interposed levator muscle in the rectovaginal septum provides contractile resistance over the two hernial areas in the vaginal canal — namely, the uterovesical above and the uterorectal below — ful- filling its function in gynecic support, and restormg the anatomic contours of the lacerated perineum. CHAPTER XIV. The Retrodisplaced Uterus as a Complication IN Pelvic Floor Injury. The development of uterine prolapse consequent upon a perineal laceration is invariably preceded by a stage of retroversion. On the other hand, every retroverted uterus does not necessarily prolapse. A concomitant cervical laceration, chronically infected and pro- ductive of adnexal disease with peri-uterine adhe- sions, may suspend the uterus and prevent its ultimate descent. The treatment of retroversion is the correction of its cause. The cause may be congenital or acquired. Our fundamental conceptions of uterine poise, normal and abnormal, have not as yet attained to any concrete finality, and, barring the occasional allusion to the existence of congenital retrodisplace- ments and their probable dependence upon conditions of general visceroptosis, the clinical significance of such displacements, and their diagnostic, etiologic, and therapeutic contrast to the acquired form, find no elucidation in the literature on the subject. The wide diversity in the nature of the two con- ditions, presenting practically identical symptoms, demands their clinical differentiation. Such differ- (150J THE RETRODISPLACED UTERUS. 151 entiation necessitates a differentiating factor of pa- thognomonic constancy. A uterus congenitally retroposed before impreg- nation will resume its retroposition after delivery, whether the pelvic floor is lacerated or not. Loss of perineal support in the congenital class is more prone to the development of procidentia than in the acquired form. The correction of congenital retroposition as such is essentially orthopedic, while that of the acquired form is gynecologic. Hence this differentiation is important. Approximately, i8 per cent, of all gynecological patients present a retrodisplaced uterus. Barbour and Watson estimate one-fifth of this number as congenital in origin, qualifying their statement, however, by admitting that "it is difficult to establish the congenital nature of these cases; but should a uterus be found retroverted in a nulliparous patient, without any history of inflammation or other cause sufflcient to produce retroversion, should it measure only 25^ inches by sound, and on being re- placed show a tendency to resume its retroverted poise, we are justified in assuming that it has de- veloped in that position." These admittedly vague differential criteria em- body in their very paucity the crux of the clinical problem presented by uterine displacements in gen- eral to-day. In the first place, a retrodeviated uterus, whether in a nulliparous or multiparous patient, "without evidence of inflammation or other cause sufficient to produce the displacement," would be classified as a 152 GYXECOPLASTIC TECHNOLOGY. Fig. 74. — Normal or neutral type of posture. Distinguishing features are: (1) Line of gravity of body passes through impor- tant pivotal points; (2) the pelvis is balanced in equilibrium on the heads of the thigh bones; (3) this relation of important pivotal points with the line of gravity and this balance of the pelvis prevents muscle and ligament strains ; and (4) the rear perpen- dicular touches the middle back and the buttocks. (Modified from Dickinson and Truslow.) THE RETRODISPLACED UTERUS. 153 Fig. 75. — A, Kangaroo type of posture. Distinguishing features are: (1) Most pivotal structures of the trunk are carried in front of, and those of the lower extremities behind, the line of gravity ; (2) the pelvis rotates forward downward; (3) the forward carried trunk puts strain on the spinal and pelvospinal ligaments and muscles, and tends towards forward displacement of abdominal and! pelvic viscera. Wavy lines indicate muscles relaxed; double lines, muscles in action. B, Gorilla type of posture. Distinguish- ing features are: (1) Most of the pivotal structures of the trunk are carried back of, and those of the lower extremities in front of, the line of gravity; (2) the pelvis rotates backward downward; (3) the backward carried trunk puts its own variety of strain on the spinal and pelvospinal ligaments and muscles, and tends toward backward and downward displacement of the abdominal and pelvic viscera. Wavy lines indicate muscles relaxed ; double lines, in action. (Modified from Dickinson and Truslow.) 154 GYNECOPLASTIC TECHNOLOGY. simple or uncomplicated malposition, regardless of its probable congenital nature. Such classification has a most significant thera- peutic bearing, for, accepting the clinical postulate, that all uncomplicated uterine retrodisplacements are devoid of symptoms or clinical significance, it follows that to differentiate the congenital from the acquired retrodisplacements is to exclude any attempt at cor- rection of the displacement as such in over one-fifth of the cases. On the other- hand, a congenitally retrodisplaced uterus is not necessarily "nuUiparous," nor immune to "inflammatory and other complications capable of producing retroversion." It may, like any other uterus, measure more than ''2)4 inches by sound," so that the congenital origin of its retroposition must be established through existing diagnostic factors that are constant and remain unaltered by complicating elements which tend to efface the characterizing syndrome formulated by Barbour and Watson. As a matter of fact, it is that very class of pa- tients, with their congenital deviations obscured by superposed parturitional and infectious complications, in which differentiation is most essential. In seeking to establish such a constant pathog- nomonic factor it is necessary to recognize that the malposition does not represent simply a congenital uterine retroversion, but a congenital retroversion of the entire pelvis, with resultant compensatory dys- topia of its contents. Dickinson and Truslow characterize the general skeletal poise of these cases as "the gorilla type," in THE RETRODISPLACED UTERUS. 155 which "the pelvis is rolled or rotated backward and downward, the plane of its inlet making with the horizon an angle more acute than that of the normal type." In other words, with normal spinal contours, the axes of the abdominal and pelvic cavities form al- Fig. 76. — A, Axis of abdominal cavity. B, Axis of pelvic cavity. most a right angle, while in the stature under con- sideration there is a marked flattening of the sacro- vertebral angle, resulting in an approximation of these axes toward the vertical, so that the thrust of intra-abdominal pressure is expended in a more direct line on the pelvic viscera. This flattening of the sacrovertebral angle, is 156 GYNECOPLASTIC TECHNOLOGY. regularly evidenced by a corresponding obliteration of the normal lumbar curve, and the measure of its resultant approximation to the vertical constitutes a diagnostic index in differentiating congenital from acquired retrodisplacements of the uterus. To obtain this measure, the patient, with back exposed, assumes her natural standing attitude, while the edge of an ordinary 1 8-inch desk ruler, held vertically in contact with the most prominent spinous processes of the dorsal and sacral convexities, spans the intervening lumbar hollow. The distance in millimeters from the deepest point of this hollow to the edge of the ruler presents our index. The spinous processes of the dorsal and sacral convexities are invariably and distinctly palpable under all degrees of adiposity and statural deviations, while the extreme simplicity of the method and means enables anyone to substantiate the uniform accuracy of the index, and elicit the significance and indications of its clinical bearings. In an extensive series of observations, the index ranged from 12 to 45 millimeters. An excess of 45 millimeters indicates pathological lordosis — a con- dition the opposite to that under consideration, of more obstetric and less gynecological importance. An index of 30 millimeters marks the extreme minimum compatible with normal anteversion of the uterus. From 25 millimeters down, the exist- ence of congenital retroversion may he positively predicated in nearly every case prior to its biman- nal verification, and this regardless of multiparity THE RETRODISPLACED UTERUS. 157 1/ Fig. 77. — The edge of an 18-inch ruler held vertically in con- tact with the most prominent spinous processes of the dorsal and sacral convexities spans the lumbar hollow. The distance in millimeters from the deepest point of the hollow to the anterior edge of the ruler presents the '"lumbar index." (. Author's method.) 158 GYNECOPLASTIC TECHNOLOGY. and the other complicating factors that obliterate the differentiating criteria formulated by Barbour and Watson. A uterus congenitally retroverted before concep- tion will invariably resume its retroverted position after delivery, when the demonstration of a minus index will reveal the congenital nature of the dis- placement, to the exoneration of the accoucheur. Fig. 7S. — Diagram of the relation of pelvis to abdomen. A, Sacrolumbar angle. B, Upper sacral vertebra. D-E, Line extend- ing from the upper symphyseal border to the sacrococcygeal joint. The application of the lumbar index will establish over one-half of all retroversions, complicated and uncomplicated, as congenital, instead of one-fifth, as hitherto accepted. The rare exceptions to the rule will, on closer in- vestigation, reveal an exostosis of the sacral promon- tory; a recession of the pubes which foreshortens the conjugate diameter; a strained and deceptive pose assumed by the patient during measurement, or an THE RETRODISPLACED UTERUS. 159 acquired autcz'crsion from pathological concomitants, for it is only reasonable to suppose that, just as a normally poised uterus may be retroverted, so a con- genitally retroverted one may become anteverted without invalidating the utility of the index. It must be emphasized, that congenital retrover- sion, as such, is essentially only a part of a compen- satory adaptation of the pelvic contents to abnormal static conditions through unstable spinal poise; that the depth of the lumbar hollow is the relative measure of the sacrovertebral angle ; that the degree of sacro- vertebral angulation determines the dip of the pelvis, and that a certain degree of such pelvic dip is essen- tial to the normal topography of its contents. A fiat sacrolumbar angle with vertical pelvis is normal in early childhood, but abnormal in the adult. If an infant be placed on its back, and its legs be drawn down from their habitual attitude of semi- flexion, it will be noticed that the range of extension is limited by the absence of the lumbar curve and pelvic incline. When gain in muscular development enables the infant to stand, the erector spinse draws the trunk upward against the resistance of the ilio- psoas group and ligaments of the hip-joint, bending the lumbar spine into its physiological curve. In other words, under normal development, the erect attitude is attained by flexure of the lumbar spine, the pelvis maintaining an incline of 60 to 65 degrees, the tip of the coccyx being on a level with the lower border of the symphysis pubes. Under ab- normal developmental conditions, the upright pose is induced principally by an upward and backward rota- tion of the pelvis on the hip-joints, carrying the axis 160 GYXECOPLASTIC TECHNOLOGY. of its inlet toward a vertical from a horizontal line. In such a vertical pelvis, the only tenable position for the uterus is one of retroposition. The upward and backward rotation of the pelvis elevates the pubes and lowers the sacrum, which lat- ter, thus forming the posterior instead of the upper wall of the pelvic cavity, necessarily alters the mech- anism of the sacro-uterine ligaments, their horizontal pull tending to hold the uterus backward against the depressed sacrum, instead of suspending it from above, as in the normal. Furthermore, intra-abdomi- nal pressure, inadequately deflected, thrusts the loose intestinal coils into the pelvic cavity and against the anterior surface of the uterus, crowding it into the space of least resistance offered by the sacral hollow. To put it tersely, every fixed abnormal pelvic tilt must create a correspondingly abnormal uterine tilt. The whole clinical import of congenital retro- versions is centered in their intra- and extra-pelvic complications, not in the uterine displacement as such. The continuous attitudinal strain on the sacroiliac joints, the erector spinse and iliopsoas muscles, in- duces pelvic symptoms that simulate and are gener- ally attributed to the retroversion. Operative gynecolog}^ to date records over lOO detailed methods for the correction of uterine retro- displacements. Every one of these methods, at the hands of its promulgator, will undoubtedly convert the retroposed into an anteroposed uterus; but not- withstanding their faultless uterine poise, many of THE RETRODISPLACED UTERUS. 161 these patients will continue to suffer as before opera- tion — and some more so. Baldy states: "In my opinion nine-tenths of the operations performed on women for retrodisplace- ments are uncalled for; and, further, the possible number of retrodisplacement operations performed in this country is limited only by the number of females in existence." We have already stated that congenital retrover- sion is a compensatory necessity, and it follows that any procedure which converts such a retroversion into an anteversion converts a compensated into a decompensated visceral equilibrium within the pelvic cavity. Clinically, the lumbar index will reveal two classes of congenital retrodisplacements, namely, the com- plicated and the uncomplicated. Leaving the retroversion, as such, unmolested, the gynecologist should aim to eradicate all coexist- ing intrapelvic complications, thus converting the complicated into an uncomplicated case. It cannot be overemphasized that patients with uncomplicated congenital retroversion suffer through a constant attitudinal strain in maintaining their unstable skeletal poise within the lines of gravity, the congenital retrodisplacement of the uterus being an accompaniment and not a cause of the suffering. These cases must be treated on purely mechanical and orthopedic principles, the details of which find full elaboration in the appended literature. The normal uterine poise is necessarily oscillat- 11 162 GYNECOPLASTIC TECHNOLOGY. ing, the fundus traversing an anteroposterior arc whose normal Hmits extend from the symphysis pubes to the sacral promontory, with its axis of oscillation at the cervicocorporeal junction, its pivotal fixation secured by the so-called "cardinal ligament." The round ligaments tend to subserve uterine support only in so far as they limit its essential mobility to a normal range. They maintain poise, hut not support. They cannot lift the uterus, because their insertion at the fundus is normally above their pelvic attachment; hence their pull on the fundus is downward and forward. Whether the uterus oscillates from promontory toward symphysis, as in congenital retroposition, or vice versa, as in the normal, is a phenomenon of clinical indifference so long as the elevation of the pivotal point, which is determined by the plane of the levator junction, is at the normal level. Poise is unimportant; elevation is essential. Every uterus freely movable at the normal pelvic level is in normal poise at any point in its arc of transit from the symphysis to the sacral promontory. Briefly summarized, congenital retropositions should not be corrected. Acquired retroversions without descensus, result- ing from levator impairment, are corrected by levator myorrhaphy. Acquired retroversions with descensus should be corrected by levator myorrhaphy plus a vaginal shortening of the round ligaments, which pulls the uterus forward out of the sacral hollow and upon its re-established levator fulcrum. Finally, all adherent THE RETRODISPLACED UTERUS. 163 retroversions should be attacked through the abdom- inal route. As the vaginal shortening of the round ligaments should constitute a part of every cystocele operation, it will obviate repetition to detail the method under the latter caption. CHAPTER XV. Cystocele. Clinically, it is essential to differentiate the simple ectopia of the vaginal wall, known as anterior colpocele, from the condition of true cystocele. Fig. 79. — Anterior colpocele simulating cystocele. Dotted line indicates the redundant anterior vaginal wall, with the bladder and urethra in normal position. Anterior colpocele occurs as a result of certain obstetric complications that lead to separation and prolapse of the vaginal v\^all from the vesical base without disturbing the musculofascial planes that maintain the anatomic position and topographic re- lations of the bladder. (164) CYSTOCELE. 165 The abnormality, with but few exceptions, occurs in parous women during the first and second decades of the child-bearing period. A coexisting lesion of the pelvic floor may or may not be present, although a lacerated or relaxed state of these structures al- ways aggravates the condition, and in exceptional cases bears a causal relation to its development. P'ig. 80.— Urethrocele. B, Bladder. U, Urethrocele. First among the distinguishing features between anterior colpocele and true cystocele is the absence of uterine ptosis; in fact, the uterus bears no relation w^hatever to either the production or maintenance of an existing colpocele, while, on the other hand, a true cystocele without uterine descent is anatomically in- conceivable. Such a uterine descent may not be evident unless the patient is examined in the erect posture. 166 GYNECOPLASTIC TECHNOLOGY. True cystocele dififers from colpocele as a loose fold of hypertrophied skin or relaxed abdominal wall differs from ventral hernia. The prolapsed vaginal wall is usually hypertro- Fig. 81. — Inversion of the vagina, with cystocele and pro- cidentia uteri. Catheter in bladder. phied and rugous, while the vaginal covering of a cystocele, especially when distended, is smooth and thin. Furthermore, careful palpation will disclose the mobiHty of the simple vaginal protrusion on the firm CYSTOCELE. 167 subjacent vesical floor. In cystocele a catheter passed into the bladder can be directed so that the vesical end of the catheter may be felt in the prolapsed blad- der, where it protrudes throu.^h the vaginal outlet. Residual urinary retention and its possible se- quella are conspicuously absent in colpocele. Fig. 82. — Initial direction of intra-abdominal pressure at the pelvic brim. Anterior colpocele, involving the vaginal mucosa only, is curable by any of the standardized colporrha- phies that simply ablate a varying patch of the vagi- nal mucosa, and reef the wound edges by suture. ^ A herniated bladder, however, cannot possibly be restored and retained by any such procedure, which only substitutes a yielding temporary occlusion for the mechanism of physiological support. 168 GYNECOPLASTIC TECHNOLOGY. Notwithstanding these dinical, pathological, and surgical contrasts between the two conditions, the term cystocele is still generally applied to all pro- trusions of the anterior vaginal wall regardless of the structures involved. Thus we find (Kelly and Noble's Gynecology) "anterior colporrhaphy or re- section of the anterior vaginal wall is indicated for the cure of cystocele, or of cystocele complicated by prolapse of the uterus;" and again, "anterior colpor- rhaphy is the only satisfactory treatment for cys- tocele." More recently, Robert Frank epitomizes the sub- ject to date in the following: "The writer has seen individual operators who, through long years of ex- perience, or by reason of special gifts and dexterity, have acquired the necessary skill, but who were quite unable to teach to the spectator, or even transmit to their regular assistants the method by which they ob- tained their good results. This inability to teach is due to the fact that these operators, although by nicety of judgment, by precision of execution, by unconscious visualizing of reconstruction, and by proper extent of denudation they obtained good re- sults, did not expose the field anatomically, and did not perform an anatomical repair, such as is done as a matter of course in inguinal herniotomy, for example. . . . For a number of years the so-called interposition operation has been employed in the treatment of cystocele. This procedure is anatomical in so far as its execution is concerned, but the result- ing repair distorts natural conditions to a degree which necessitates sterilization, if performed in the child-bearing period, and is unsatisfactory when ap- CVSTOCELE. 169 plied to cases of prolapse. . . . The majority of operations devised for cystocele and rectocele depend upon ingenious denudation, complicated application of sutures, etc., rather than upon a firm anatomical basis." Fig. 83. — Diagrammatic scheme of misdirected pressure deflec- tion by deranged intrapelvic planes, due to incompetent levator contraction resulting from perineal injury. The same occurs as a result of levator paralysis in Spina bifida occulta, or lesions of the fourth sacral nerve producing a "virginal uterine prolapse," notwithstanding intact fascia and ligaments. First stage in the development of cystocele and procidentia uteri. A rational operative procedure for the cure of cystocele must be evolved from a clear conception of the disorder in the supporting mechanism resulting in prolapse. Although descriptive anatomy enumerates five 170 GYNECOPLASTIC TECHNOLOGY. ''true" and five ''false" ligamentous supports, the bladder is actually swung at its base on a thin fascial hammock, which extends from the posterior surface of the symphysis and pubic rami to the cer- vicocorporeal junction of the uterus. Fig. 84. — Perineal laceration, with rectocele leucorrhea, from chronic endocer\-icitis. The anterior or pubic extremity of the bladder base thus presents a fixed point, while its posterior or cervical segment naturally participates in the mobility of the uterus. Uterine poise thus dominates bladder poise; the free span of bladder base between the pubic and cervical attachment and its subjacent CYSTOCELE. 171 anterior vaginal wall being supported by the mus- culofascial mechanism of the pelvic floor. In applying the principle of deflection to the problem of intrapelvic visceral support, as elucidated Fig. 85. — Procidentia uteri. A, Cystocele, showing transverse rugse, the lowermost of which indicate the position of the lower bladder pole. B, Endocer^'ical ulceration. C, Rectocele. in the chapter on perineorrhaphy, intra-abdominal pressure is defined as the initial force to be deflected, the mobile intestinal coils as the medium through which this force is manifested, and the muscular 172 GYNECOPLASTIC TECHNOLOGY. mechanism of the pelvic floor plus its superposed bladder and uterus as the deflecting plane. A transverse section of the empty bladder is Y-shaped, due to the cupping of its summit in con- traction. "As the bladder empties, the upper, more mov- able portion, covered with peritoneum, settles down into the lower and relatively more fixed portion, un- til it comes to lie within it as one saucer rests in another. During respiration the free upper half may be seen (through the cystoscope) moving on the lower half, as if hinged, the line of demarcation be- tween them being distinctly visible. "At the edges where the two saucers meet, three folds are formed — the right, left, and posterior. The posterior fold stretches from side to side in front of the uterus; it is gently convex forward, following the contour of the uterus, and ends in front of each broad ligament, where each lateral fold begins and extends horizontally around toward the urethra. These folds represent the physiological hinges on which the bladder moves in expanding and collapsing. "The apices, where the posterior fold joins the lateral fold in front of the broad ligaments, are called the right and left vesical cornua" (Howard Kelly). This is significant, for under normal conditions the concavity of its intraperitoneal aspect, induced by this cupping, is filled by the convex uterine fundus like a ball in a socket, which thus maintains the con- tours and incline of the plane for the deflection of pressure from above. On the other hand, where the uterine fundus is retroverted and prolapsed, the CYSTOCELE. 173 cupped bladder area affords a potential peritoneal pouch for the herniation of its superposed intestine.^ Observing the distorted topography of the pelvic viscera from above in a case of marked cystocele, the first abnormality to obtrude itself is the absence of the uterine fundus from its normal situation, and the presence in its place of intestinal coils. On clearing these coils, the essential incline of the pelvic floor is found converted into a hollow declivity formed by the distended uterovesical space, with the uterine fundus posteriorly, and the bladder at the bottom. The crippled levator ani permits the anterior part of the pelvic floor to sag, levelling its incline; the direc- tion of intra-abdominal pressure, no longer deflected, falls upon the vesico-uterine space, which, deprived of its musculofascial buttress at the perineal crest, becomes pouched and distended with intestinal coils. Thus the fully developed cystocele represents not merely a prolapse of the bladder, but a complete hernia, equipped with its peritoneal sac containing intestine, differing from an inguinal hernia only in that the bladder and vaginal zvall enter into the for- uiation of its coverings. CHAPTER XVI. Operations for Cystocele. The surgical object in the cure of cystocele and procidentia should not aim to create merely a cica- tricial retention of the prolapse at the vaginal outlet, but to reconstruct the mechanism which exercises physiological support from below and deflects pres- sure from above the pelvic organs. That this object is not uniformly attained is ap- parent in the diversity and multiplicity of prevailing methods. The procedure of Bumm, Liepman, and Martin, which consists of a simple anterior colporrhaphy re- inforced by separate suture of the subvesical fascia, after mobilizing the bladder, is advocated and de- tailed by Frank in the following : — "The cervix is grasped with a vulsellum forceps, and forcibly pulled downward. A small forceps (Ochsner) is applied to the mucosa Yz centimeter be- low the urethra. A vertical incision, just penetrating through the vaginal mucosa, is made between the two instruments. Starting from below upward, the vag- inal mucosa is separated from the underlying bladder for a distance of only )4 centimeter along the entire edge on both sides of the incision. The vaginal flap is made as thin as possible. To each edge two Ochsner forceps are applied as tractors. At the very bottom of the incision a few snips of a blunt scissors (174) OPERATIOXS FOR CVSTOCELE. 175 cut across the so-called 'vesical ligament,' which serves to attach the bladder to the cervix. "The gauze-covered finger, by stripping upward and backward, strictly in the median line, now frees the lower margin of the bladder from the cervix. As this is done on each side, fascial fibres running upward and inward become apparent. These are the Fig. 86. — "Bladder pillars." A, Pubocervical ligament. (From life.) 'bladder pillars' (the pubovesical ligaments), which are invaluable in the repair. "Not until this dissection has been completed is it wise to separate the vaginal mucosa to the neces- sary distance laterally, because it is extremely easy to stray into a deeper layer, and thus either destroy or repeatedly buttonhole the 'pillars' and the thin fas- cia which covers them, or to detach them from their 176 GYNECOPLASTIC TECHNOLOGY. continuity with deeper structures (anterior part of cardinal ligament). "After the vaginal flaps have been reflected, and the bladder pushed up well above the peritoneal re- flection, especially at the sides (behind the pillars), Fig. 87. — Operation for cystocele. Exposure of the "bladder pillars" (pubocervical ligament) and insertion of the cervical sutures. (Frank.) interrupted sutures of chromic gut are passed from side to side, entering one pillar, then catching the cervix, and again taking in the pillar of the opposite side. "The upper suture must be passed with care, and not too deeply, as the ureters are in close proximity. OPERATIONS FOR CYSTOCELE. 177 ''When these sutures are tied, the bladder is held well up and back, and is prevented from descending. "At the upper end of the denudation, close to the urethra, a strong inverted V-shaped fascia will be noted. This forms part of the anterior layer of Fig. 88. — Cystocele operation. Cervical sutures tied, holding back bladder. Insertion of more anterior suture. (Frank.) the triangular ligament. AMien this is approximated by transverse or mattress sutures of chromic gut, only a small portion of the bladder between the upper and lower sutured areas lacks reinforcement. This weak spot can now be closed, as the fascial edges, which have become demarcated far laterally by the 12 178 GYNECOPLASTIC TECHNOLOGY. traction of the tied sutures (and which draw the anterior fibres of the cardinal hgament toward the median Hne), are in turn drawn together by inter- rupted sutures. ''After resecting a sufficient area of vaginal flap on each side (the amount, if not excessive, is of little importance), so as to leave an oval denudation, the mucosa is approximated with interrupted silk sutures. ''By following the above directions closely, suffi- cient fascial structures will be found in almost every case, especially in large cystoceles found in conjunc- tion with prolapsus. "The fasciae are most often destroyed or lost by operators who form large vaginal flaps or broadly denude, as their first step in cystocele operations. Other gynecologists deliberately cut through the 'pillars' 'in order to free the bladder edges.' "The bladder can be fully freed behind (i.e., cephalad) to the 'pillars.' These structures are espe- cially valuable, not only because they afford good material for suture, but also as they serve both as guide and tractor to the deeper parts of the anterior portion of the cardinal ligaments." Frank prefaces the above technique with the claim that it is "applicable to all but very large cystoceles, that it is always the operation of choice, and only to be abandoned if absence of fascial structures is encountered." He concludes by stating that "in the few cases in which no 'pillars' and no fascia can be isolated, large cystoceles may be held back by the operation of vaginal interposition (Schauta, Wert- heim), which is simple, but the disadvantages of which (necessity for sterilization, bladder symptoms. OPERATIONS FOR CYSTOCELE. 179 Fig. 89. — Extended operation for postclimacteric cystocele, with complete procidentia. {Goffe.) Vaginal hysterectomy — ligature of uterine artery. 180 GYNECOPLASTIC TECHxNOLOGY. recurrence of protrusion after operation for pro- lapse) have become increasingly apparent." It will be recalled that the claim of general effi- cacy and wide applicability for the procedure advo- cated by Frank in the cure of cystocele was likewise advanced with equal confidence for the simpler col- porrhaphy. Moreover, Frank vaguely concedes that "recurrence must be expected in i to lo per cent, of the cases." A closer pre- and post-operative scrutiny of the cases operated upon successfully by this method, will attribute the curative result, not to the suture of the suhvesical fascial "pillars," upon which so much stress is laid, but rather to the elevation of the blad- der, the partial obliteration of the uterovesical space, and the efficacy of the concomitant perineoplastic reconstruction. This operation is undoubtedly beneficial in what may be termed borderline conditions, where the pro- trusion constitutes a maximum of colpocele and a minimum of cystocele. These cases never present residual urine. The floor of the bladder never projects beyond the nor- mal plane of the vulvar cleft, in addition to which they display one anatomic feature of almost pathog- nomonic differential significance not heretofore noted, namely, a deep transverse sulcus in the anterior vaginal wall, at the site of junction between the urethra and vesical neck, directly under the apex of the pubic arch. This transverse sulcus is due to the competence of the pubovesical fascia. It maintains the normal t OPERATIONS FOR CYSTOCELE. 181 direction of the urethra, and is always obliterated in marked cystocele. The futility of fascial suture as such in pelvic visceral support, and the reasons therefor, have been fully discussed in the chapter on perineorrhaphy. In addition to the arguments set forth there, which apply with equal force here, it must be recalled that, unlike the perineal fasciae, the subvesical fascia is seldom if ever directly torn. In short, the normal subvesical fascia sags, not because of any direct in- jury, but primarily as a result of the levator tear in the perineum plus uterine descent, the former de- priving it of its fundal support, the latter carrying its cervical attachment downward; and it follow^s as a logical corollary that the reefing of this fascia, more especially in the attenuated condition encountered in advanced cases of cystocele, must prove illusory as an element in the restoration of permanent support to the bladder. The essential operative phases in the radical cure of cystocele with uterine procidentia demand: — I. Ample separation of the bladder base from the abnormal uterine and vaginal attachment acquired in its descent. II. Correction of the uterine malposition by vagi- nal reefing of the round ligaments. III. Reattachment of the bladder to the anterior surface of the uterus at the normal level (Goffe). IV. Reconstruction of the musculofascial support in the pelvic floor. To expose the base of the bladder, the cervix is forcibly drawn down with a vulsellum; its anterior vaginal coat is incised transversely just below the 182 GYNECOPLASTIC TECHNOLOGY. level and parallel to the lowest of the transverse rugae, which, in the relaxed state, invariably desig- nates the limit of the vaginocervical attachment of the bladder. From the center of this transverse slit, a superfi- cial median longitudinal incision is made, extending for a sufficient distance upward toward the external urinary meatus, the junction of the two incisions thus forming an inverted T. The mobilization of the bladder is begun at the lower extremity of the longitudinal incision by sepa- rating the two central flap tips in the angles of the inverted T from the underlying tissues for a distance sufficient to expose and sever the cervical attachment to the bladder base, after which the bladder is readily brushed bluntly from the uterus by a gauze-covered finger, up to the vesico-uterine peritoneal reflection. The separation of the bladder from the anterior vaginal wall is materially facilitated by attention to certain technical and anatomical details. In picking up the edge of the flap incision the underlying tissues should be severed with a few strokes of the knife, so that the T-forceps grasps the vaginal tissues only. Then by gauze dissection the bladder is separated on each side as far out as neces- sary for its free mobilization. The safety of this rapid blunt dissection lies in rolling the yielding connective tissue from the raw upper surface of the firm vaginal flap by the gauze- covered finger working against counter pressure ex- ercised by the fingers of the opposite hand applied to its under surface. Furthermore, it is essential to note that there are OPERATIONS FOR CVSTOCELE. 183 two planes of cleavage between the vaginal mucosa and the base of the bladder proper, separated by the pubovesical fascia. The lower cleavage plane lies between the vaginal mucosa and under surface of the fascia, while the upper separates the bladder from the upper fascial surface. The longitudinal arm of the outlining flap incision should penetrate this fascia to the upper plane of cleavage {i.e., between the bladder base and upper (cephalad) fascial surface), in which the bladder may be readily mobilized without undue traumatism or bleeding. The lower plane of cleavage must be avoided, as it leads directly to the under surface of the pubovesi- cal fascia, the pubic attachments of which may offer considerable resistance, necessitating their discission in freeing the lateral aspects of the bladder wall. The freely mobilized bladder is elevated on a flat speculum held against the pubic arch. This stretches and exposes the uterovesical fold of peritoneum, which is gently drawn down by blunt forceps and grasped between the fingers like a hernial sac to ex- clude the possible presence of omentum or intestine, after which it is opened widely to the base of the broad ligament on each side. In stout patients, and in those with deep pelves, a slight Trendelenburg incline at this stage of the operation will facilitate the location of the uterovesi- cal fold, and tend to cause the intestines to gravitate from the operative field. No gauze packing should be used for the latter purpose. Difficulty is sometimes experienced in identifying 184 GYXECOPLASTIC TECHNOLOGY. the uterovesical fold. It may be recognized by a dif- ference in color from the surrounding tissues, its translucency, smooth surface, and respiratory oscil- lation. In the anxiety to avoid injury to the bladder, con- fusion is sometimes caused by dissecting too close to the uterus. At the cervicovesical junction, it is necessary to hug the cervix closely, carefully brush- ing all loose tissue with the bladder wall; but once the bladder wall begins to peel freely, and the loose connective tissue between the cervix and bladder is clearly defined, the remaining attachment is simply wiped off the cervix in the line of least resistance, which always carries the separation direct to the uterovesical peritoneum. In the cure of a complete procidentia the operative aim is not only an elevation of the prolapsed organs to their normal level, but the equally essential restor- ation and maintenance of normal uterine- poise by vaginal shortening of the round ligaments, which is best accomplished b}^ bringing the exposed fundus to the vulva, doubling each ligament upon itself, and sewing the loop to the cornual area at the fundus. These sutures should be inserted at the correct distance, and in proper alignment, but not tied until after the fundus is replaced within the pelvic cavity; or, each ligament may be caught in a chromic gut loop, introduced one inch from the cornua, the loose strands of each loop passed separately through the respective vaginal flap, one-quarter of an inch apart, and tied. (Vaginal fixation of the round ligaments.) The fundus uteri should be brought to the vulva by manipulation with a finger hooked behind one OPERATIONS FOR CVSTOCELE. 185 or other broad ligament, and n(A Ijy traumatizing tenacula, the dehvery of the fundus being facihtated by first pushing the cervix far 1)ack into the vagina. Dr. J. Riddle Goffe secures the elevation of the bladder by suturing its base to the anterior uterine wall as follows: — "Three chromicized catgut ligatures (No. 2) are passed, one through the anterior wall of the uterus at its midpoint, and the other two through the an- terior walls of the broad ligaments, just outside the lateral margins of the uterus. These are left long, and protrude through the vulva. A point is now selected in the base of the bladder, at such a distance from the urethra as, when carried up to the point of insertion of the first of these three ligatures, will cause the base of the bladder to make a straight line from the urethra to the uterus. "Through this point in the bladder wall the suture is passed, catching up in its course the bladder attach- ment of the peritoneum, where it was separated from the uterus. Two points in the base of the bladder are now selected, at either side of the first selected point, and distant from an inch to an inch and a half. Through these points the lateral sutures are passed respectively. The three are then tied, beginning with the middle one. The first takes up all the slack in the line from the uterus to the urethra, but makes a ridge in the interior of the bladder, with a sulcus on either side. By tying the lateral sutures, however, these sulci are obliterated, and the base of the bladder is spread out upon the anterior face of the uterus and broad ligaments. "The overstretched fascia and hypertrophied an- 186 GYXECOPLASTIC TECHNOLOGY. terior vaginal wall are trimmed to fit snugly under the bladder base, then sewed together, and to the lower anterior surface of the uterus." As an aid in the identification of the round liga- ments, when these are not clearly definable as the re- sult of the inverted fundal position, three distinct ridges may be noted, continuous with and extending outward from the uterine cornua. In tracing these ridges backward, the anterior will be found continu- ous with the round ligament, the middle with the fal- lopian tube, and the posterior with the utero-ovarian ligament, the tubal ridge being the highest and most prominent, the utero-ovarian the lowest and posterior. When the round ligaments are identified, they are grasped in holding forceps, and the fundus replaced within the pelvis. This relaxes the ligaments, and enables the operator to estimate the necessary extent of shortening, and to insert the sutures, all of which is impossible with the fundus and ligaments on the stretch at the vulvar outlet. There are cases in w^hich the round ligaments and tubes, especially near their uterine extremity, occupy practically the same compartment in the top of the broad ligament. Here the looping and suture of the round ligament would necessarily kink the tube with pathological possibilities. This condition may be recognized after reposition of the fundus by observ- ing the outlines of the tube on pulling the round liga- ment loop before suturing. If tubal kinking is in- duced, the peritoneal investment along the round ligament should be incised for a distance sufficient to liberate the tube. OPERATIONS FOR CYSTOCELE. 187 Fig. 90. — Extended operation for postclimacteric cystocele, with complete procidentia. (Goffe.) Ligature of broad ligament between the uterine and ovarian artery. 188 GYNECOPLASTIC TECHNOLOGY. In trimming the redundant vaginal flaps, there is a general tendency to remove too much mucosa rather than too little, with a consequent shortening of the anterior vaginal wall. This will tend to pull the cervix toward the vulvar outlet, and thus pro- mote the possibility of a recurrence. Vaginal hysterectomy, as a routine measure for the cure of complete procidentia, cannot be too em- phatically condemned. The advocacy of this illog- ical empiricism has been perpetuated in standard publications to the present time. Thus, E. E. Mont- gomery asserts : — "Even in women during the child-bearing period, any operation for the successful retention of the pro- truding uterus and vagina is inconsistent with the continuance of procreation. No operative procedure has been devised for such a condition which will suc- cessfully endure the mechanism of a subsequent labor. "Indeed, the changes produced in the uterus are such as to render conception improbable, and to make the uterus unable to develop in such a way as to oflier a reasonable probability that the fecundated ovum shall find a proper soil and secure habitation to en- sure completion of the pregnancy. The uterus in such cases is a needless organ — yea, worse than needless, a diseased organ." This is fallacious dogma, based upon premises not substantiated by either clinical, pathological, or surgical facts. In the chapter on the dynamics of intrapelvic vis- ceral support, the uterus is depicted as constituting a lever, with a fundal and a cervical arm, swung upon a fulcrum formed by the projection of the levator , OPERATIONS FOR CYSTOCELE. 189 junction, which latter constitutes the "intravaginal perineal crest." Hence, to remove the uterus, or ablate its cervical arm, is to remove an integral part in the mechanism that prevents prolapse by deflecting the course of intra-abdominal pressure. For the same mechanical reason, permanent fixation of either uterine pole is contraindicated. The cervix sJiould not he amputated, its bulk be- ing- reduced to normal, when necessary, by the method detailed in the section on "Tracheloplasty.'' A prolapsed uterus is a dislocated uterus, and dis- location as such is not an indication for its removal, notwithstanding an existing menopause. Further- more, hysterectomy does not ensure the permanency of the retention, as the bladder and vagina may even- tually protrude in the absence of the uterus — a condi- tion presenting an extremely doubtful prognosis as to the probability of an ultimate cure. The indications for the removal of the prolapsed uterus should be identical w-ith those in the non-pro- lapsed organ, namely, irremediable pathologic alter- ation from chronic infections or neoplasms. This applies particularly to the aged, who, as a matter of fact, suflr'er more from anxiety than from the actual discomfort induced by the existence of the prolapse, both of wdiich may be effectually and safely relieved by a properly applied ^lenge pessary. In the presence of definite indications, a vaginal hysterectomy should be performed by extending the primary transverse incision on the vaginal mucosa completely around the cervix, severing the vaginal and bladder attachments of the uterus, which is then brought completely to the vulva and removed after 190 GYNECOPLASTIC TECHNOLOGY. Fig. 91. — Extended operation for postclimacteric cystocele, with complete procidentia. (Goffe.) The fundus uteri delivered through the anterior vaginal fornix. Ligature of the utero-ovarian artery and tube. OPERATIOXS FOR CYSTOCELE. 191 clamping each broad ligament from top to bottom as far ontward as possible, leaving or removing the adnexa according to indications. A continuous suture or chain ligature controls bleeding from the raw edges of the broad ligaments. ''In order to provide a support for the bladder, and also a surface to act as a deflector of intra-ab- dominal pressure, the broad ligament edges are sutured to one another, from the round ligaments down to their bases, taking in sufficient slack to make them draw taut across the pelvis" (Goffe). "The bladder is spread out on the anterior (un- der) surface of the broad ligament plane thus con- structed (which takes the place of the uterus), and is attached at three points corresponding to those designated for the cases with the uterus in situ, after which the pubovesical fascia and trimmed vaginal walls are sutured in separate layers, or in bulk" (Goffe). The operation is completed by the method of leva- tor myorrhaphy in the pelvic floor, as detailed in the chapter on the perineum. It is a significant fact, of direct bearing on the extended controversy as to the relative merits of the numerous procidentia operations and their technical variants, that none omit, and all stress, the import- ance of an efficient pelvic floor restoration. The technique, as outlined here, readjusts the normal bladder topography, obliterates the hernial pouch of the distended uterovesical peritoneum, aug- ments the resistance of this area by superposing the uterine fundus, and, finally, by restoring the poise and elevation of the uterus essential to its function 192 GYNECOPLASTIC TECHNOLOGY. Fig. 92. — The stumps of the broad ligaments, with their respec- tive ligatures, seen in the depth of the vaginal wound. (Goffe.) Introduction of broad ligament suture to form a new base of sup- port for the bladder in place of the uterus removed. OPERATIONS FOR CYSTOCELE. 193 as a lever in the deflecting" mechanism, it diminishes pressure from above the vesico-uterine space. This operation does not hazard the result upon the precarious support offered by the subvesical fascia. It creates no malinterposition of the bladder, and de- mands no sterilization of an otherwise normal woman. From a prognostic and technical point of view, the preoperative differentiation of three types among procidentia patients is essential, namely: — I. Procidentia as an ultimate result of birth trauma in previously normal women. II. Procidentia following birth injury in women presenting the skeletal and static deviations pathog- nomonic of congenital uterine retroposition. These cases are recognized by the sacrolumbar index de- scribed in the chapter on retroversion. III. Cases of so-called "virginal prolapse," which may manifest itself before or after parity. Weinberg asserts "that prolapse of the uterus in the new-born and in nulliparae constitutes 3.45 per cent, of all cases of prolapse. Nebesky, in a series of 232 cases of procidentia, reports 16 as occurring in nulliparous women." The majority, if not all, the virginal cases are due to the existence of an unrecognized Spina bifida oc- culta, which involves the fourth sacral nerves, with consequent paralysis of the levator ani. The bony cleft of Spina bifida occulta in the lum- bosacral region is usually closed by a dense mem- brane; a characteristic hairy patch may be the only local indication of its existence. The cleft can usually be felt, but in some cases only the X-ray reveals its presence. The hair has a typical concentric arrange- 13 194 GYNECOPLASTIC TECHNOLOGY. ment over the centre of the defect. After puberty it may grow to 25 or 30 cm. in length, resembling a tail. Local hypertrichosis is usual in all SpincB biMce. Cicatricial changes in the skin over the defect are common, and are always present when tumors exist Fig. 93. — Broad ligament stumps sutured across the midline. Suspension ligatures, 1, 2, 3, are passed from the centre and sides of the upper broad ligament border through corresponding points at the centre and sides of the bladder base, and are drawn taut. (Goffe.) within the canal. Lipomata, fibromata, myomata, angiomata and dermoids are frequently found inside or outside the vertebral canal, or occupying the bony cleft. OPERATIONS FOR CYSTOCELE. 195 Fig. 94. — The upper free end of each suspension ligament is passed from its insertion in the broaCd ligament border (Fig. 93) through corresponding points in the subvesical fascia. Each upper free end is then tied with its respective lower free end, c, a, b, and drawn taut, bringing the base of the bladder snugly against the anterior face of the united broad ligaments. (Goffe.) OPERATIONS FOR CYSTOCELE. 197 Discrimination before operating upon these cases will obviate many difficulties and disappointments. Let the operator fully realize what he sets out to accomplish, and he will readily adopt the simplest, easiest, and surest method to this end. Let him, on the other hand, clog his mind with details and special plans of this and that operator, and he will follow an uncertain mixture of complicated and often futile procedures. CHAPTER XML Laceration Through the Anal Sphinctre. One of the most distressing phases of pelvic floor lacerations is fecal incontinence from injury to the anal sphinctre. In the immediate operation after injury, the indi- cation to reunite the several tissues is plain. When, however, the repair is to be undertaken, after healing by granulation with subsequent cicatricial distortions, the problem presents technical difficulties. '■]\Iany and varied methods are still advocated that should, by reason of general surgical advance, have been discarded, while those appearing worthy of more extended trial have not been accorded the prominence they are entitled to" (C. G. Child). The degree of sphincteral incompetence and the technique of the repair vary with the extent of the laceration into the anterior rectal wall. In all cases of complete tear involving the recto- A^aginal septum, lateral cicatricial retraction shortens the anterior rectal wall, and buries the retracted sphinctre ends on either side of the anus. In some cases these ends are caught in a bridge of cicatricial tissue spanning the anterior edge of the anal opening, thus maintaining a partial fecal control. But, as a rule, the sphinctre ends are so widely separated as to expose the eroded rectal mucosa. The technical dominants in the operative cure of these iniuries comprise two objectives: — (198j LACERATION TlfROUGlI THE ANAL SPHINCTRE. 199 I. Elongation of the shortened anterior rectal wall by utilizing an "apron flap" of vaginal mucosa, thus obviating the liability to infection by suture of the anterior rectal wall (Warren, Ristine). Fig. 95. — Complete laceration of the perineum through the anal sphinctre. Rupture of the rectovaginal septum, with retraction of the anterior rectal wall. Sph, Sphinctre pits over the location of the widely separated sphinctre ends. (Kelly.) II. Isolation and direct sutural reunion of the retracted sphinctre ends. Laceration through the sphinctre ani constitutes a complete perineal tear, and the operative cure of 200 GYNECOPLASTIC TECHNOLOGY. the former comprises an extended procedure for the restoration of the latter in the following order: — I. Outlining the area of denudation and mobili- zation of the vaginal "apron flap" from the recto- vaginal septum. II. Liberation and isolated suture of the retracted sphinctre ends. III. Levator myorrhaphy. IV. Sutural readjustment of the superficial peri- neal planes. With the patient in the lithotomy position, the vulva is retracted laterally by tissue-hooks, inserted as for incomplete tear. A transverse outlining incision is then carried completely across the posterior vaginal wall, one inch to an inch and a half above its anal margin. From each lateral extremity of this transverse incision a longitudinal incision is directed to the pits on either side of the anus which mark the location of the retracted sphinctre ends. The three incisions thus outline a square flap on the rectovaginal septum, the vaginal layer of which is carefully dissected downward to the anal margin from the rectal layer, liberating an apron of vaginal mucosa attached at the anovaginal junction. The base of this apron retracts into the rectum, automatically filling the defect in its anterior wall, thus substituting a curtain of the posterior vaginal wall for the deficient anterior rectal wall. The apron or flap is liberated from above down- ward. In this way normal tissue is entered first, cica- tricial last, making the dissection easier. As the proper line of cleavage between the rectal and vagi- LACERATION THROUGH THE ANAL SPHINCTRE. 201 nal layer is entered, the splitting of the septum pro- ceeds with little difficulty, until the cicatricial junc- ture of the vaginal and rectal outlets is encountered. Here the greatest care must be taken not to button- hole the apron or perforate the rectum. As the Fig. 96. — W'arren-Ristine operation for complete perineal lac- eration through the anal sphinctre, with retraction of the anterior rectal wall. Outline of apron flap on the posterior vaginal wall. margin of the septum consists of cicatricial tissue, it requires skillful dissection to preserve a properly nourished flap. After turning the flap down over the anal orifice like a curtain, the exposed tissues in the sphinctre pits are grasped and drawn forward by small trac- 202 GYXECOPLASTIC TECHNOLOGY. tion forceps, and the retracted sphinctre ends are freely liberated by clipping their cicatricial envelope with knife-tip or curved scissors. When both sphinc- tre ends are freely mobilized, they are united by interrupted buried chromic gut or thin kangaroo sutures. After trimming the apron flap to necessary di- mensions, the levator myorrhaphy and the sutural Fig. 97. — Child's outlining apron flap in the Warren-Ristine operation for complete perineal laceration. A, Sphinctre pits. B, Upper extremity of outlining incisions. C, Crest of the rectocele. readjustment of the superposed perineal tissues is carried out as described under Perineorrhaphy. Sloughing of the apron edge sometimes occurs, but as a rule does no harm, as the necrosis is superficial. Child claims 90 per cent, of cures by primary union after the following modification of this method : LACERATION THROUGH THE ANAL SPHINCTRE. 203 "The apron dissected from the posterior and lat- eral vaginal walls is clamped at three points and al- lowed to hang down over the anus, where it remains until the completion of the operation. The incision in the vagina is closed with a continuous suture of No. 4 Fig. 98. — Warren-Ristine operation for complete perineal lac- eration through the sphinctre ani, with retraction of the anterior rectal wall. Suture through the exposed sphinctre ends. Apron flap from the posterior vaginal mucosa drawn over the anal defect by a tenaculum. forty-day chromic catgut, beginning at the apex of the denuded area on the posterior vaginal wall, and continued down to the outlet, thereby bringing the caruncula together in the middle line to mark the 204 GYNECOPLASTIC TECHNOLOGY. highest point on the new perineum, as they originally marked the highest point on the old perineum before it was torn, "In uniting the muscles in the perineum, the method that I first described in 19 13 of figure-of- eight sutures of large-size silkworm gut is used. These are introduced as follows: The first suture is passed through the ends of the sphinctre muscle; the free ends are then crossed and introduced in the raw area close to the sheaths of the sphinctre, and brought out through the skin on either side, about one-quarter inch from the wound margin. These are then clamped, but not tied. In like manner three or four figure-of-eight silkworm sutures are passed through the edges of the levator ani muscles, crossed, and made to include in their second bite all intervening tissue. A thorough irrigation of the wound area is now given. All blood-clots that may have formed during the operation are carefully removed, and all bleeding points tied with fine-size kangaroo tendon, "The sutures are now tied in the following man- ner : Beginning with the one that unites the ends of the sphinctre, the free ends are drawn on until the first bite of the figure-of-eight is tightened sufiiciently to bring together the muscle ends within its grasp. It is then tied by a square knot, just tight enough to snugly approximate the tissues, which it holds. The remaining sutures, uniting the levator muscles, skin, and subcuticular tissues, are tied in the same manner, "The sutures should never be tied so tightly as to cause cutting or strangulation, and the second knot of each suture should not be tied tight enough to splinter the silkworm, or to interfere with untying it LACERATION THROUGH THE ANAL SPHINCTRE. 205 later, should occasion arise. The wound is now com- pletely closed, and if at its summit, the highest point on the perineum, any gaping is present, an extra silk- worm suture may be introduced. ''A careful survey of the field of operation will Fig. 99. — Child's method of introducing figure-of-eight sutures in the Warren-Ristine operation for complete perineal laceration. now show that the apron of Ristine has already to some extent been drawn up into the rectum, thereby lengthening out the previously shortened anterior rectal wall, thus relieving all tension at the anovagi- nal juncture. A small strip of iodoform gauze is in- troduced into the vagina to facilitate drainage for the first few days. 206 GYNECOPLASTIC TECHNOLOGY. ''The patient should be catheterized every eight to twelve hours for the first three days, after which the perineum is irrigated during micturition. The wound is inspected daily, and if any of the sutures have been tied too tightly the tension should be re- lieved. The bowels are moved on the third day, castor oil being the laxative of choice, assisted by an enema when necessary. If an enema is given it should be under the doctor's supervision, unless the Fig. 100. — Cross section of figure-of-eight sutures tied. {Child.) nurse is thoroughly familiar with this class of cases. After the third day, when the vaginal gauze is re- moved, a daily cleansing vaginal douche of normal saline is given. The patient is kept in bed for two weeks. After the fourth or fifth day the apron of tissue over the anus may begin to slough; this will have no bad effect upon the healing of the wound, but the sloughing area should be clipped off with scissors. If the line of demarcation is carefully followed, this will cause no pain. LACERATION THROUGH THE ANAL SPHINCTRE. 207 "The silkworm .i^ut sutures are removed between the tenth day and the end of the second week. As a rule, the end of the second week, when the patient is ready to get up out of bed, is the preferable time. Should infection occur in the wound, the sutures, several or all, are untied and loosened, so as to allow of free drainage and daily irrigation. Later, when the infection is over, and union begun, the sutures are again drawn tight and tied, as at the time of their introduction. During the third week after operation the patient is allowed up in a chair, the bed-pan is discarded, and she may move slowly about her room each day." Child concludes: "So far as I have been able to determine, the operations for this condition per- formed by other methods are far from satisfactory, yielding a very small percentage of successful re- sults. By the Warren-Ristine technique, with certain modifications described, I have reported the results of lo consecutive cases. In only one instance was vmion by first intention in the least interfered with, and in 90 per cent, the cure was absolute. Once only, in case No. lo, did we fail to restore perfect control of the sphinctre muscle; yet as the patient's condition was very materially improved, even this case cannot be classed as a failure." In rare instances, the sphinctre ani is torn subcu- taneously, causing fecal incontinence without ex- ternal evidence of the lesion. In such cases, there is also a submucous laceration of the levator ani, wnth resulting relaxation of the vaginal outlet. j\Iost fre- quently, how^ever, this condition is due to an unsuc- cessful operation for complete perineal rupture, in 208 GYXECOPLASTIC TECHNOLOGY. which union of the perineum is obtained, but with failure to restore the sphinctre ani. To repair such a sphinctre, Kelly makes a "horse- shoe incision on the perineal surface, extending from one sphincteral pit to the other, parallel to the an- terior anal border." The flap of the skin thus out- lined is turned down over the anal opening, similar to the apron flap described in the preceding section. The ends of the incision should extend down on either side to expose the sphinctre muscle, which is readily palpated between index finger and thumb. After liberation of the sphinctre, its ends are united by two or three interrupted catgut sutures. It is advisable at this juncture to introduce a re- tention stitch of silkworm gut, transfixing the skin from just behind the ends of the incision, the sphinc- tre ends, and the rectovaginal septum. Before tying this stitch, the cutaneous sutures are inserted. CHAPTER XVIIL Vesicovaginal Fistula. In the entire evolutional progress of gynecoplastic technology no single phase presents a more striking contrast between past and present methods and re- sults than the operative cure of vesicovaginal fistulae. In 1663 H. V. Roonhuysen first suggested the closure of such defects by suture. Following this suggestion, J. Fatio operated successfully upon two cases — one in 1675, the other in 1684 — by the method published in 1752: "With the patient in the lithot- omy position, a speculum exposed the fistula, the edges of which were freshened with a delicate pair of scissors, and held in apposition by means of a quill suture." A. J. Jobert de Lamballe (1850-1852) published the first elaborate monograph on the subject, based upon an extensive series of operated cases, many of them successful. His method consisted in exposing the fistula by speculum and traction on the cervix with forceps, denudation of the fistulous margin, and approxima- tion by suture. In very extensive defects, he relieved tension by vaginal incisions running parallel to the edges of the fistula, which permitted closure {''par glissement"). An incision through the vaginal vault, detaching the cervix for this purpose, is still known as "Jobert's incision." 14 (209) 210 GYNECOPLASTIC TECHNOLOGY. G. Simon (1854) discarded the lateral vaginal in- cisions of Jobert, substituting tension sutures at a distance from the wound. The suture securing ap- proximation of the denuded fistula margins he termed ''suture of union," and the one relieving tension "suture of detention." In 1852, J. Marion Sims, working independently of the above, devised the duck-bill speculum and its use in the left semiprone (Sim's) position of the patient for the better exposure of the fistula. He bevelled the denudation of the fistular margin, and closed it with silver wire. Sims' results in the cure of vesicovaginal fistula had not been equalled in his time, but, notwithstand- ing the brilliant success following upon his original innovations and manual skill, there still remained a large class of cases that proved intractable to prevail- ing curative methods, and in which surgery could offer nothing save a complete occlusion of the vagi- nal outlet, i.e., colpocleisis (Simon). The first attempts to obviate the necessity for so mutilating a procedure were those of Rydygier (1887), and of A. Martin (1891), who planned to cover the fistulous defects with pediculated flaps from contiguous vaginal mucosa. Trendelenburg (in 1890) and L. Von Dittel (1893) departed radically from all precedent by ap- proaching the lesion through an abdominal incision, separating the bladder from the uterus, thus expos- ing and suturing the fistula. The suture included only the bladder wall, and was covered by the utero- vesical peritoneum. VESICOVAGINAL FISTULA. 211 An epochal advance in the operative cure of vesi- covaginal fistula was inaugurated by A. Mackenrodt in 1894. This consisted in the complete moljihzation of the bladder base from its vaginal and uterine at- tachments, and the separate suture of the vesical and vaginal margins of the fistula. In very large defects, he interposed the uterine fundus to occlude the opening in the bladder or vagi- nal wall (vagino-fixation). Mackenrodt's operation embodies the modern principle of flap splitting and cleavage, the practical application of which has brought the closure of many otherwise intractable fistulse of all grades, form, size, and position, within the range of curability, and has well-nigh relegated the pioneer work of Sims, Simon, and Emmet, as well as the numerous complex modifi- cations of their denudation methods, to the rear. This method secures the essential laxity of vesi- cal structure in the immediate vicinity of the fistula, and the free mobility of the vesical base, necessary to effect permanent closure without incurring risk of failure from undue tension. All subsequent contri- butions present only auxiliary aids and modifications, adapted to isolated conditions, that exercise no domi- nant influence on the outcome of the procedure in general. CHAPTER XIX. Operations for Vesicovaginal Fistula. The anterior vaginal wall is fixed and put on the stretch with two tenacula, one catching the cervix and the other the tissues below the external urinary meatus. A straight incision is now made from one tenaculum to the other, across the fistula, through the entire thickness of the vaginal wall to the connective- tissue layer separating it from the bladder. Mackenrodt splits the edge of the fistulous margin, cleaves the entire bladder base from its vagi- nal and uterine attachments in all directions, up to the vesico-uterine peritoneum if necessary. The dissection is carred out with knife, scissors, and gauze brushing. Free mobilization of the blad- der, especially its base, is the aim. The edges of the bladder opening are trimmed of scar tissue, and brought together without tension by a Lembertizing continuous or interrupted mattress suture of fine forty-day chromic gut, care being taken not to pene- trate the intravesical surface. The vaginal flaps are finally pared and approximated by soft silkworm strands. In general, it will be found much more expeditious to begin the separation of the vaginal from the vesi- cal wall in the normal tissues at either extremity of the outlining incision, i.e., below the meatus, or at the cervical attachment. The normal line of cleavage is readily located at these points, from which it is (212) OPERATIONS FOR VESICOVAGINAL FISTULA. 213 easily extended on all sides toward the cicatrized margins of the fistula, the mobilization and splitting of which is thus facilitated. In very extensive tissue defects, the uterine fun- Fig. lOL — Closure of bladder fistula with buried catgut sutures, without penetrating the vesical mucosa. (Mackenrodt.) dus is interposed between the bladder and vagina, its posterior surface thus filling the bladder gap, while its anterior bridges the vaginal opening. In 'Vesico-uterine" and "vesico-uterovaginal" fistulse, the application of Mackenrodt's principle — 214 GYNECOPLASTIC TECHNOLOGY. namely, isolation and separate suture of the vesical, uterine, and vaginal tissues — offers the most certain means to successful repair. Only in those cases, fortunately rare, in which a Fig. 102. — Vesicovaginal fistula. Mackenrodt's operation. Approximation of vaginal flap. vesico-uterovaginal fistula is complicated by very ex- tensive intrapelvic disease, with firm fixation at the vaginal vault, does an attack by the abdominal route with possible hysterectomy for access to the fistulous tract come under consideration. OPERATIONS FOR VESICOVAGINAL FISTULA. 215 U refer ovaginal fistula should be operated intra- abdominally, as a rule. Vaginal plastic efforts to im- plant the ureter end or the fistulous tract into the bladder, converting the ureterovaginal into a uretero- vesical fistula, are not to be commended, as a prob- able stenotic contraction at the site of union invari- ably eventuates in destructive degeneration of the corresponding kidney. In ureterovesicovaginal fistula, the simplest and surest course is to implant the ureter into the bladder by the abdominal route, and repair the vesical open- ing through the vagina. Exceptionally favorable cases of this class, in which the ureteral and vesical openings are small, very close to one another and imbedded in lax, acces- sible surroundings, may be operated entirely by the vaginal route in one of several ways. An oval denudation, at least one-third of an inch wide, is made to encircle, like a ring, a small island of vaginal mucosa, the centre of which presents the fistulous openings of ureter and bladder. The marg- ins of the denuded circle are united by suture in the line of least resistance, thus turning the ureteral ori- fice into the bladder (Schede). Where the ureteral orifice is readily located, it may be split on its vesical aspect to the extent of half an inch, making its opening continuous with that in the bladder. The object in either of the above proce- dures is to eliminate the ureteral opening as a compli- cating factor, and reduce the condition to one of simple vesicovaginal fistula. Sampson, in a study of 158 total hysterectomies for carcinoma, performed at Johns Hopkins, records 216 GYNECOPLASTIC TECHNOLOGY. 19 cases, or 12 per cent., of bladder injuries with resulting fistulse. These fistulse usually present a small opening, which is buried in the rigid, firmly adherent vault of an atrophied and contracted vagina. Every fistulous defect of the bladder, that is freely and completely mobilized from its vaginal and uterine attachments, and properly sutured without tension, will heal promptly. The technical difficulty presented by postoperative vesicovaginal fistulse is their inaccessibility. To overcome this difficulty, Kelly incises the pos- terior vaginal fornix at the site of the cul-de-sac, and opens the peritoneal cavity. This tends to lower and partially liberate the plane of the fistulous area, which may thus be drawn down within reach. But an aid of wider scope, affording much greater accessibility, is offered by the paravaginal incision devised by Schuchardt, to which Ward redirected attention in the following: — 'Tt is rather strange that in America a correct conception of this incision, and appreciation of its value, is rare. In the minds of many operators con- fusion exists between Schuchardt's incision and the ordinary lateral vaginoperineal incision, which is similar to a simple episiotomy. The two incisions are totally different, and there is no comparison as to their effectiveness in procuring accessibility. The simple straight vaginoperineal incision is superficial, and much less extensive, as compared to Schuchardt's. Its length is limited by the pelvic wall, and it is usually necessary to make one on each side of the perineum. OPEkATlOXS FOR VESICOVAGINAL FISTULA. 217 '^JLi^^RmhI HSksV^v ~~ % ^^m ■_{ \ ^ ^^^^r ttyj ^^^^^^^^Hs . '^ 1 W 1X9 ^Bm^^^ks^^^^^HPsT^ I a^l^H ^^^^1 ^B^^^- - J^^^^^^K ' 'i^^^^wi^^ < \ 'i^l^H^^^HHK ■ .:: M ■■ '^*::'y -t'.; ">'"i^^^^^^BBhteis 5. Fig. 103. — Lateral vaginoperineal incision as made by Duehrrsen and others. (Ward.) 218 GYNECOPLASTIC TECHNOLOGY. Schuchardt first described his incision in 1893 for the radical vaginal extirpation of the carcinomatous uterus, and Schauta and others have adopted it in their vaginal operations for cancer. In 1896 he advocated its employment for other conditions besides carcinoma of the uterus, and re- ported a case of its successful use in rendering acces- sible a double vesicovaginal fistula which was fixed in scar tissue high in the vagina. In 1901 he con- tributed a further study of his incision, with an anatomical report by Waldeyer. Vaginoperineal incisions have been employed by many operators prior to Schuchardt's description of his operation in 1893, notably Duehrrsen, Leopold, Chaput, Picque, and others ; but, as Sinclair remarks, it is not fair to speak of Schuchardt's method as a mere extension of these incisions; it is a distinctly beneficial addition to the resources of operative gyne- cology. Sinclair made Schuchardt's incision on the cadaver, and had the anatomical relations studied by Young. Gellhorn says: 'The effect of the paravaginal incision is surprising. In place of a vaginal tube we have before us a shallow excavation not deeper than one inch." Duehrrsen claimed that he had recommended the same incision three years prior to Schuchardt, but a study of his paper shows that he described the straight vaginoperineal incision, which is directed to- ward the ischium, and is but 2 to 3 centimeters in depth. In 1892 Chaput described an incision similar to that of Duehrrsen, before the Congres Frangais de OPERATIONS FOR VESICOVAGINAL FISTULA. 219 Fig. 104. — Schuchardt's incision outlined. (IVard.) 220 GYNECOPLASTIC TECHNOLOGY. Chirurgie, which he designated as a ''colpoperineoto- mie laterale," and in the discussion Picque stated he had utihzed it several times for high vesicovaginal fistulse. The vaginoperineal incision of Duehrrsen, as de- scribed by him in 1889, commenced 6 to 7 centimeters within the vagina, at the junction of the posterior with the lateral wall, and extends in a straight line for a similar distance on the skin toward the ischium. Schuchardt, in his later description of his opera- tion, describes the site of the incision as a triangle, one side of which is on the vaginal wall, the other on the skin from the junction of the middle and lower third of the labia majora to a point a finger's breadth posterior to the anus, near the middle line, and the base forms a line extending obliquely from the upper end of the incision on the vagina to a point just pos- terior to the anus. It lies from within outward, partly in paravaginal and in pararectal tissue, the fat of the ischiorectal fossa, and in the subcutaneous tissue. The surface of this triangle is curved on its long axis, with its concavity toward the rectum. The incision is made preferably on the left side, as it is easier for right-handed operators. The left labium is put on the stretch, and is divided at the junction of its middle and posterior third. The in- cision is then extended up the whole length of the vaginal tube at the junction of the posterior and lateral walls, completely splitting the vaginal canal. It is next continued on the cutaneous surface in a curve outside of and encircling the sphinctre ani, the integrity of which is preserved, and terminates a finger's breadth posterior to the anus near the median OPERATIONS FOR VESICOVAGINAL FISTULA. 221 , LEVATOR \ y\Ni r^ECTUMDl^AWN TO ONE SIDE Fig. 105. — Schuchardt's incision completed. (Drawn from life, Ward.) 222 GYNECOPLASTIC TECHNOLOGY. line. The entire incision is then deepened in a curved direction, enveloping the rectum, without injuring it, until the inner surface of the canal of the levator ani and coccygeus muscle and the depths of the ischio- rectal fossa are plainly exposed. If the incision has been correctly made — that is, with a sufficient curve — the levator muscle will not be cut, except the super- ficial fibres near their insertion into the coccyx and sphinctre ani. It will then be seen that the incision, while com- mencing laterally on the vaginal surface, terminates at its base near the median line, posterior to the rec- tum, encircling that organ, and consequently mobiliz- ing it, so that it may be displaced to one side. Thus the incision, for all practical purposes, becomes a median one, lying in the longest diameter of the pelvic outlet, thereby obtaining the maximum amount of space. The incision divides the whole vaginal canal, the labium, the skin of the perineum and lateral anal region down to the coccyx, the superficial fascia, the bulbocavernosus and transversus perinei muscles, the lower part of the triangular ligament, the paravagi- nal and pararectal tissues, the outer fibres of the levator ani near their sphinctre ani and coccygeal attachment, and the cellular tissue of the ischiorectal fossa. It passes below the vestibular bulb and Bar- tholin's gland. Only the superficial branches of the perineal and inferior hemorrhoidal vessels and nerves are divided, and hemorrhage is readily controlled with a few ligatures. In spite of the extent of the incision, no tissue of importance is injured, and the wound unites readily OPERATIONS FOR VESICOVAGINAL FISTULA. 223 if closed with a layer of buried and external sutures. A rubber tissue drain should be placed at the lower angle of the incision, extending into the ischiorectal fossa. The wide separation of the bladder from the va- gina is practically that of the modern operation for Fig. 106. — Geometrical figure of the plane of Schuchardt's incision. (IVard.) cystocele, with a more extensive dissection at the vaginal vault. In cases in which the bladder is ex- tensively adherent to dense cicatricial tissue, a trans- verse incision extending the full width of the vault is essential in order to free it sufficiently. I would not hesitate to freely open the peritoneal cavity, as recommended by Kelly, but so far I have not found it necessary. It is wise to bear in mind 224 GYXECOPLASTIC TECHNOLOGY. the possibility of the proximity of an adherent loop of intestine where the uterus has been removed. The point in the technique which I wish to empha- size is, that in separating the bladder base from the vagina the dissection should commence at the outer ^^ M ^ ■i fe |E J™" I^H HH^I ^B ^^^HBlrf^ 1 ft ■ 1 ^H BBBg* ''^-y i 1 ^H ^^^^1 ' i % -? ^^^^1^^^^ pp^ ipV' ' ■■Jl^ --<«[ ^^^^HP^ Fig. 107. — Commencement of mobilization of the bladder. {Ward.) end of the anteroposterior incision near the meatus urinaris, where there is an absence of scar tissue, and where it is a simple matter to find the line of cleavage between the bladder wall and the vagina. This having been established, the separation is carried upward and outward until the cicatricial tissue in the region of OPERATIONS FOR VESICOVAGINAL FISTULA. 225 the fistula is encountered, when the dissection pro- gresses, partly Ijy the use of the gauze-covered finger, and partly by snipping with round-pointed scissors, with a fair degree of safety, by reason of the line of cleavage having been first determined, and by the use of a sound in the bladder as a guide. If care and patience are exercised in freeing the bladder laterally to the utmost limit, not only at the vault, but also throughout the length of the anterior vaginal wall, the next procedure (that of dislocating the bladder wall downward so as to bring the site of the fistula wathin easy reach) will be greatly facili- tated. The employment of an instrument introduced into the bladder through the urethra for this purpose, and to act, as a counterpoint, has been advocated by Pas- teau, of France. He has devised a special instrument for the purpose, but I can see little advantage in it over a sound. I consider that the employment of an instrument in the bladder, used as a lever and counterpoint, is a decided aid, and I have found a straight male sound (No. 28, French scale) to be most satisfactory for this purpose. Catgut should be used for closing the opening in the bladder wall. I have found No. i. chromic gut suitable for this purpose. The needles should be very short, curved, round-pointed, and strong. These sutures should penetrate the muscular coat of the bladder only, and have the effect of turning in the edges of the fistula. A second layer may be used to advantage in some cases. The vaginal incision at the vault should be closed 15 226 GYNECOPLASTIC TECHNOLOGY. with silkworm gut sutures, an important point being to catch with each stitch the base of the bladder to one side and beyond the fistula, so that when tied the lines of suturing will be brought in different planes, and will avoid dead spaces. Fig. 108. — Displacement downward of the bladder by means of a sound. Sutures embracing fistular margins in place. (Ward.) The bladder should be drained with a self-retain- ing catheter, or be frequently catheterized for a period of six days. Nothing serves more to signalize gynecoplastic progress during the past fifty years, than the state- OPERATIONS FOR VESICOVAGINAL FISTULA. 227 nient, llial, not one of the indications postulated by Simon for colpocleisis, with its morl)id sequella, is vaHd at the present time. No case of vesicovaginal fistula, whatever its extent, should be considered hopeless from a reparative standpoint, provided the vesical sphinctre and adjacent portions of the ure- thra are intact. Surgery can repair, but cannot create, a sphinctre muscle. To restore a sphinctre that is partly lacerated or completely severed, as after pubotomy, the bladder should be completely liberated, as for vesicovaginal fistula. The urethra and bladder are then sutured over a rubber catheter with interrupted sutures of chromic gut, which grasp the muscular but not the mucous coat. At the bladder neck, the sphinctre fibres, together with a delicate but distinct fascia, are caught in the sutures, or sewn separately, just as the sphinctre ani is reunited in complete perineal tears. The torn and retracted sphinctre ends must be sought and isolated close to the edges of the pubic rami. As an aid in locating these fibres, Frank sug- gests ''passing a traction suture about i centimeter from the pubic ramus, at the level of the vesical neck ; when this traction suture is pulled upon, the stronger and deeper fibres are broug-ht into view." Whenever the vesical sphinctre has been com- pletely destroyed in consequence of excessive trauma and sloughing no effort should be expended in plastic attempts to restore the urethral canal, which can at best yield but a cosmetic result, not urinary contin- ence. The only feasible expedient in this lamentable and otherwise intractable condition is the direct 228 GYNECOPLASTIC TECHNOLOGY. Fig. 109. — Vaginal sutures in situ. (Ward.) OPERATIONS J'OK VIiSICOVAGINAL I-ISTULA. 229 drainaj^-e of the Ijladder into the rectum by establish- ing" an ample communication between the bladder and rectum via the vagina. This secures a tolerable urinary continence by means of the anal sphinctre. While this exj)edient may a])])ear objectionable on theoretical grounds, its practical utility has been Fig. 110. — Exposure and suture of (lacerated) sphinctre vesicae. Vaginal flaps (F) have been liberated and retracted. The bladder (Bl) has been freed and pushed upward, exposing the supra- vaginal part of the cervix (C). On each side the pubocervical liga- ments (P-C) have been exposed. The sphinctre fibres are shown partly approximated by traction on two untied sutures. (Frank.) amply demonstrated by clinical and experimental re- sults, which tend to prove that the rectum can be used as a substitute for the urinary bladder without giving rise to rectal irritation. Peterson, in a recent article entitled, "Substitu- tion of the Anal for the Vesical Sphinctre in Certain Cases of Inoperable Vesicovaginal Fistul?e", which embraces the entire literature of the subject to date. 230 GYNECOPLASTIC TECHNOLOGY. States: "According to Lipinsky, the first utilization of the rectal sphinctre for the control of the urine after the formation of a vesicovaginalrectal fistula and closure of the vagina (colpocleisis) or the vulva (episiocleisis) is to be credited to Maisonneuve. . . . The operation had been suggested, but not practised, by Jobert in 1836, and Berard in 1845." Commenting upon 41 recorded cases, inclusive of his own, Peterson concludes: "Most of the opera- tions were performed for conditions where restora- tion of function — i.e., urinary continence — was hope- less from the start, because of loss of the vesicle sphinctre. In a way, every case of the operation we are considering is a confession of failure. It is not, and never will be, an ideal procedure. At the most, it is merely a way out of a serious difficulty." As the peritoneal cavity is not invaded by this operation, there should be no primary mortality. This is borne out by Peterson's study. Maison- neuve's case in 185 1 died directly from the operation, but as a result of septic phlebitis. Morisani lost one patient, on the eighteenth day, from pneumonia. One of Rose's patients died ten months after the opera- tion from nephritis, while another operated upon for malignant disease died nine weeks later from metas- tatic occlusion of both ureters. Among the successful cases, urinary control was maintained for from one to eight hours. In 12 cases, the women menstruated through the rectum without apparent inconvenience, while 9 pa- tients ceased to menstruate after the operation with- out obvious cause. Infection of the uterine cavity from contiguity of rectal contents was not observed. OPERATIOXS FOR VESICOVAGINAL FISTULA. 231 The most important fact established by these cases is, that ascending renal infection was absolutely excluded, which is undoubtedly due to the preserva- tion of the normal ureteral orifices and ample drain- age at the lowest point of the bladder base. In performing the operation for the establishment of a permanent vesicovaginorectal fistula, it is essen- tial to bear in mind, that the vesical and rectal open- ings must be made large enough to allow for post- operative contraction, which occurred in 9 out of the 41 recorded cases. The rectal opening should be made just above the internal sphinctre muscle, large enough to admit two fingers. The edge of each fistulous opening should be whipped over by a running suture, but the two fistu- lous openings should not be anastomosed. It will obviate the tendency to cicatricial recon- traction to excise an ellipse from the anterior and posterior vaginal mucosa, and simply incise the un- derlying bladder base and rectal wall longitudinally for i^ to 2 inches. The hemming of the fistulous edges thus advantageously everts the vesical and rectal mucosa, which acts as a valvular curtain, pre- venting the regurgitation of feces into the bladder. In 15 of the reported cases, the operation w^as performed in two stages, the fistulae, vesical, and rectal being made first, and the vulva subsequently closed. In the majority of the cases, however, the operation may be completed in one sitting. The closure of the vagina (colpocleisis-episioclei- sis) is performed by removing a wide collar of tissue 232 GYNECOPLASTIC TECHNOLOGY. from the circumference of the vulvovaginal outlet, and uniting the denuded surfaces with interrupted silkworm sutures. This converts the perforated blad- der and vagina into a common reservoir for urine and menstrual blood, which drains through the recto- vaginal fistula into the rectum, from which it is dis- charged at intervals through the anus. The urethral canal should either be extirpated in denuding the vulvovaginal outlet, or its canal obliterated by a Paquelin cautery. It is difficult to secure a primary union of the en- tire vulvar cleft. In only two instances of the series reported by Peterson was this attained. The small resulting fistulse, however, heal very readily on the application of caustics, only 6 of the 41 recorded cases having proved intractable. As already indicated, this operation has no direct mortality; there is no danger of renal infection; there is no regurgitation of feces into the vagina; there is no irritation of the rectum. It precludes copulation, which, however, is equally interdicted by the eroded tissues and vaginal defects in the unoperated con- dition. It is a mutilation of the genitals, but it substitutes a very tolerable state for an intolerable condition. Keen, the first among American surgeons to ap- ply this procedure in a case resulting from typhoid sloughing, comments upon the result as follows: "It is an encouraging fact that in any case requiring similar treatment, the later history of the patient shows that for twenty-one years she has only twice had the least trouble — once from a small calculus forming in the vagina, and once from a small abscess OPKRATIOXS V()\i VESICOVAGINAL FISTULA. 233 forming in the cicatrix, which abscess spontaneously closed. Instead of being a constant source of disgust to herself and everybody about her, a hospital patient dependent upon charity, and a pariah, cut off from all society, she has been enabled to become self-sup- porting as a nurse, and to enter freely into her wonted social relations." CHAPTER XX. Functional Urinary Incontinence. There is a class of climateric multiparse, with a record of difficult and prolonged labors, who suffer from a relaxed and incompetent vesical sphinctre. Their involuntary urinary discharge varies from an occasional ejection on coughing or other sudden exertion to a constant dribble. In the surgical correction of this condition, vari- ous urethroplastic operations are advocated, namely, narrowing, lengthening, twisting, or displacement of the urethral tube, all of which can at best only miti- gate the incontinence by establishing an artificial im- pediment to the urinary escape in the place of its sphincteral control. The rational operative indication in urinary in- continence, due to widening of the sphincteral open- ing from relaxation, is to contract such openmg by sutural furling of its muscular ring at the vesical neck in the following manner: — The anterior vaginal wall is divided by a median longitudinal incision extending well over the pos- terior part of the urethra and vesical neck. The vaginal flap on each side is caught by forceps- and separated from the underlying tissues for an ample distance outward. The vesical sphinctre should be accurately located by a bulbous sound, which is passed into the bladder and withdrawn until its head engages in the vesical (234) FUNCTIONAL URINARY INCONTINENCE. 235 neck. "Jlic sphinctre tlicn lies just in front of the bulb, which is identified ])y ])ali)<'ilion. The muscle may now be exposed by deeper dis- section, and furled by direct suture; or the sphinc- teral openin,"' may he narrowed indirectly by the in- Fig. 111. — Operation for functional incontinence of urine, due to relaxed sphinctre. The vaginal mucosa has been reflected ex- posing the sphinctre area and the course of the constricting sutures. folding" of its enveloping tissues with mattress sutures of silk or linen thread, after the method suggested by Kelly, as shown in the illustration. The mattress suture, when correctly placed, em- braces the region of the sphinctre muscle, narrows its 236 GYXECOPLASTIC TECHXOLOGY. Opening, elevates the vesical neck, and restores the essential angle of the urethrovesical junction. The vaginal wall is finally reunited in its normal relations. In the majority of cases a relaxed vesical sphinc- tre is part and parcel of a generally relaxed pelvic Pig. 112. — Operation for urinary incontinence due to relaxed vesical sphinctre. The second line of buried sutures and union of the vaginal flaps. outlet consequent upon birth-injury to the levator ani muscle, with partial or complete descent of the blad- der, rectal wall, or uterus, all of which must be cor- rected coincidentally with the above procedure to assure permanency of result. FUNCTJOXAL URIXARV JXCOXTJNENCE. 237 Incontinence from a Paraurethral Opening of an Abnormal Ureter. — An anomalous type of perma- nent urinary incontinence, congenital in nature, is due to a minute ureteral opening in the vaginal vesti- Fig. 113. — Kelly's mattress suture for shortening the relaxed vesical sphinctre. The sphinctre is located by the bulb of a re- tention catheter drawn into the vesical outlet, as shown by dotted lines. bule, just lateral to the edge of the external urinary meatus. The clinical vicissitudes of such a patient are typi- fied by the following case: — 238 GYNECOPLASTIC TECHNOLOGY. Miss D., nurse, 23 years old, single, suffered from incontinence all her life. During childhood she was treated for "enuresis," then for a "weak bladder." Later in life she was pronounced a "neurotic." One Fig. 114. — Shortening of the vesical sphinctre for functional incon- tinence. Baldy's re-enforcing suture over the repaired area. surgeon attributed her incontinence to a "floating kidney," and performed a nephropexy on the right side. The persistence of the condition prompted another surgeon to remove her left kidney for "tubercular FUNCTIONAL URINARY INCONTINENCE. 239 nephritis." The leak continuing-, a third surgeon sub- jected her to a urethroplastic procedure, four months after which the patient came under the author's observation. On distending her bladder with methylene blue solution, the total absence of the coloring substance in the leaking urine at once established both the in- tegrity of the vesical sphinctre and the ureteral source of the incontinence. The anomalous opening was exposed, after a pro- longed and tedious search, as a very minute orifice, concealed by a minature contractile valve of mucosa, located just within the right lateral margin of the ex- ternal urinary meatus. This diminutive opening contracted periodically like a normal ureteral orifice within the bladder. The patient was cured by dissecting the para- urethral ureter from the para-urethral tissues on an inserted probe, and implanting its free end into the base of the bladder. These cases are not as rare as the paucity of re- ports would indicate. Anomalous and supernumer- ary ureters are quite common, and when such aber- rant ureters open into the urethra or vaginal vestibule a permanent incontinence must ensue, which can be corrected onl}^ by a ureterovesical implantation, which, in most of the cases, may be successfully ac- complished per vaginum. CHAPTER XXI. Exstrophy of the Bladder. ' This is a congenital deformity in which arrested fetal development resulted in a diastasis between the two lateral halves of the anterior bladder wall and of all the tissues in front of it, including the abdominal parieties, the pubic bones, and the roof of the urethra, the gap being filled by the forward bulging of the bladder base. The clitoris is cleft, and the labia majora and minora are widely separated, while the urethra as such is totally absent. Up to recent years this most deplorable affliction defied all corrective efforts. Much zeal and inge- nuity were expended in repeated futile attempts to bridge these extensive defects by various plastic methods, the best results of which were a small uri- nary sac, chronically inflamed, and subject to recur- ring calculus formation, demanding constant treat- ment. In a number of cases such plastic procedures secured a covering for the protruding vesical cavity, and thus converted the bulging mass of bladder wall into a closed urinary reservoir, but no method had established the sphincteral retentive function essen- tial to the cure of the condition. The ver}^ operations that secured the most com- plete closure of the defect were farthest from afford- ing relief to the -patients, as in just these instances (240) EXSTROPHY OF THE BLADDER. 241 decomposition of urine, phosphatic incrustations and irritating secretions from the inner surface of the artificial bladder wall, almost invariably necessitated a reopening of the cavity for free drainage and cleansing purposes. In 1894 Maydl first introduced the modern prin- ciple of diverting the urinary flow by transplanting the bladder trigone, with both ureters intact, into the sigmoid, then dissecting out the remainder of the bladder, and closing the abdominal aperture by an autoplastic method suitable to the case. He thus preserved the essential controlling mech- anism of the ureterovesical orifices. Hartley collected the results of 46 cases operated upon by this method, with an ultimate mortality of 15 per cent. The principal danger of Alaydl's operation lies in its transperitoneal course. Moynihan obviates this danger by first catheterizing the ureters, then excis- ing the entire bladder wall, and, after stripping the intact rectovesical peritoneum upwards, he incises the rectum and implants the bladder base into the rectal lumen. As Maydl's original operation and Moynihan's extraperitoneal modification are anatomically im- practicable in the female, George A. Peters, of Toronto, elaborated the following method of extra- peritoneal transplantation of each ureter into the cor- responding side of the rectum, taking with the ureter enough of the bladder wall to preserve the uretero- vesical musculature : — With a guiding catheter in each ureter, the ex- cision of a button of bladder wall is begun on the 16 242 GYNECOPLASTIC TECHNOLOGY. lower or pubic side of the ureteral orifices, thus avoiding the peritoneum. A finger in the cellular space thus opened contin- ues the dissection bluntly to the peritoneal reflection. When the button of bladder wall is entirely free, the ureter is readily brushed from its loose surround- ings and carefully followed back without traction Fig. 115. — Operation for exstrophy of the bladder. Uretero- intestinal anastomosis (Mayo.) Ureter ready to be drawn through incision into the lumen of the large bowel. until enough is mobilized to secure an approximately straight course from the brim of the pelvis to its new location in the lateral rectal wall. The transplantation should be made just above the internal rectal sphinctre. A forceps is carried through the anus into the rectum and pressed against the selected spot, where a slight incision enables the forceps to penetrate when it is spread just sufficient EXSTROPHY OF THE BLy\DDER. 243 to make an opening that will hold the ureter snugly by means of one or two sutures. After drawing the button of bladder into the rec- tal opening, the catheter is removed from the ureter, and when both sides are completed, Peters leaves a small drainage-tube in the rectum. The latter is unnccessarv. Fig. 116. — Operation for exstrophy of the bladder. Uretero- intestinal anastomosis. (Mayo.) Ureter infolded into large bowel, similar to gastrostomy. Peters cured each one of his 5 original cases, 4 of which are still living and well. They retain their urine from one to four hours during the day, and from six to eleven hours during the night. Lendon, of Australia, performed an exactly simi- lar operation May 22, 1899 — two months before Peters' first operation — and another in July, 1901, 244 GYNECOPLASTIC TECHNOLOGY. but his two cases were not published until 1906. In the same issue (Brit. Med. Jour., April 28, 1906) Newland, of Australia, records a case, and in the same journal of May 19, 1906, is the report of a case by Bond, of England. Sherman, of San Francisco, reports a successful case done by the Peters method, and quotes one of Pye Smith. This makes 10 cases, with two deaths — a record that will be improved upon with greater per- fection of technique. Peters' operation preserves the ureterovesical mus- culature, as do the Maydl and Moynihan procedures. It is entirely extraperitoneal. Its simplicity and ease of execution result in a minimum of trauma, and therefore in greater likelihood of a proper immediate ureteral function. The infection of the peritoneum is eliminated, and ultimate contractures and strict- ures about the ureters obviated. The remainder of the bladder should be removed at a subsequent operation, when cicatricial contrac- tion and the dry state of the tissues offer more favorable conditions for autoplastic closure of the residual abdominal defect. In a recent article reviewing the subject to date, Charles H. Mayo discards Peters' operation, and questions the competence of the ureterovesical im- plant to prevent ascending renal infection. Mayo contends that "Nature's method of empty- ing a duct is always by indirection. Thus, the sali- vary ducts, the common duct of the liver, and the ureters pass through the muscularis, and continue for a distance between the mucous membrane and the firmer outer wall of the cavity. Pressure from within EXSTROPHY Ui' THE BLADDER. 245 compresses the ducts, and blocks against dilatation and ascending' infection. The fact seemingly was not recognized that the mechanical principle of the passage of the ureter through the wall of the bladder and its mucosa could not be retained after the loss of its innervation. . . . The secret of successfully an- astomosing the ureter into the bowel is to tubularize the ureteral entrance for i}i inches." On the basis of this contention, he reverts to the transperitoneal implantation of the ureters into the sigmoid. The inherent dangers of this formidable procedure, as compared with the Peters operation, are in no measure offset by the purely theoretical ad- vantage as set forth. Mayo's record of 13 successful cases, with only one operative death, attests the tech- nical skill of the operator rather than the safety of the method employed. CHAPTER XXII. Fecal Fistula. The fecal fistulse within the range of gynecoplas- tic operations comprise: — I. Enterogenital. II. Enterovaginal. HI, Rectovaginal. IV. Rectoperineal. V. Postrectal (congenital cysts). An enterogenital fistula communicates between some part of the intestinal lumen (not including the rectum) and the generative organs. The condition is not common. Lieblein and Hilgenreimer found only 122 cases in the entire literature of the subject. These fistulse may be congenital or acquired. The latter result from traumatism during attempted abor- tion, parturiental accidents or injuries, and extra- uterine pregnancy. In 28 cases of enfero-nterine fecal fistula collected by Neugebauer, one-half were due to retained ne- crotic foetal parts ; the remainder followed forceps application, or rupture of the uterus during delivery. The uterus or vagina may be perforated; a loop of intestine protruding through the rent becomes strangulated and sloughs. The puerperal uterus may be penetrated by the curette or finger in removing placental remnants. In postpartem sepsis an adherent coil of intestine may be invaded by suppuration of a pelvic exudate, (246) FECAL FISTULA. 247 or punctured by an incision in the posterior vaginal fornix for the evacuation of pus. Among the estabhshed non-puerperal causes of enterogenital fistulse are forcible dilatation of the ^ cervix; pessaries; clamping and injudicious gauze- packing during vaginal hysterectomy. Such fistulae may also originate from primary in- testinal conditions, as tuberculosis, syphilis, appendi- citis, diverticulitis or malignant growths. Congenital Fistulas of Genital Origin Intestinal origin Unknown origin Total Puerperal Post- operative Other 1 47 47 12 5 13 125 The order of frequency in the occurrence is: I., enterovaginal ; II., entero-uterine ; III., enterotubal. Among I02 cases, 59 were vaginal, 41 uterine, and 2 tubal. No. of Cases No. of Fistulous Openings Total Varieties Small Intestine. Large Intestine Large and small Intestine No. of Fistulae Entero- vaginal 57 46 10 3 59 Entero- uterine 37 25 13 3 41 Enterotubal 2 2 2 Postoper- ative 26 24 3 •• 27 Total 122 95 28 6 129 248 GYNECOPLASTIC TECHNOLOGY. The location of the fistulse (as shown in this table, from Lieblein and Hilgenreimer) is in the small bowel, and, as a rule, in its movable segments. It follows that all plastic attempts through the vagina are attended by technical difficulties that jeopardize the outcome by enhancing the possibility of infection and disaster, the abdominal route offering greater access, facility, and safety for any indicated entero- plastic procedure, which, when successful, is invari- ably followed by a spontaneous closure of the vaginal opening. While some of the cases may heal spontaneously after a varying period of time, the majority demand operative intervention, as shown in the following table : — Variety- No n- operated Cases Operated Cases O o u & a -a 2 ft a 5 3 o -a u 3 O •a > o ft a a 5 CO o Post- operative FistulEe 11 •• 2 13 3 • • • • 3 Other Fistulse 15 12 1 20 48 12 1 3 6 22 Total 26 12 1 22 61 15 1 3 6 25 The mortality in these patients is materially aug- mented by delay in operating. Rectovaginal Ustiila is a direct pathological com- munication between the vagina and rectum. Surgic- ally, this variety should be classified as follows : — I. Openings into the upper region of the recto- vaginal septum. FECAL FISTULA. 249 II. Openings involving the more central zone. III. Those presenting in the sphincteral region. The first and second class are most frecjuently due to malignant or syphilitic ulceration, more rarely to trauma; while the third class almost invariably re- sults from parturiental or operative injury. Rectoperineal fistulse frequently follow unsuccess- ful attempts at repair for complete perineal laceration extending into the anterior rectal wall. A fistulous tract connecting the rectum and one of the labia presents an extension of burrowing ab- scess formation from the ischiorectal fossa, usually tubercular in nature. Rectovaginal fistulse of cancerous origin are in- curable. An operation for fistula resulting from syphilitic or tuberculous ulceration will fail unless preceded by appropriate constitutional measures. The same technical principles that govern opera- tions for the cure of vesicovaginal fistulse apply to the treatment of rectovaginal fistulse. In all cases, when the patient is anesthetized, the anal sphinctre should be incised or properly stretched as an essential preliminary. To secure ample mobilization and redundancy of the involved tissue layers, the mucosa of the posterior vaginal wall should be incised like that of the anterior vaginal wall in vesicovaginal fistula, and the rectum dissected from the vagina for at least i^ inches around the fistular margins. Firm closure of the rectal defect without undue tension should be secured by interrupted absorbable Lembert sutures, introduced from the vaginal aspect. 250 GYNECOPLASTIC TECHxNOLOGY. SO as to extend to, but not through, the rectal mucosa. Before suturing the vaginal mucosa, the levator ani should, if possible, be interposed between the vaginal and rectal wall, as described in the chapter on Peri- neorrhaphy, thus securing an additional barrier against recurrence. A rectoperineal fistula demands complete division of the perineum through the sphinctre ani along the course of the fistulous tract to its origin in the rectum. The fistulous tract should be exsected, and the tissues accurately reunited, as in cases of recent complete perineal tear. Fistulae situated high between rectum and vagina, like the inaccessible vesicovaginal fistula, may neces- sitate the paravaginal incision of Schuchardt, already described. In large rectal defects extending laterally, it is sometimes advantageous to liberate the anterior rec- tal wall for from 2 to 3 inches above the upper margin of the fistula. This is drawn down and at- tached to the cutaneous anal margin, and the split sphinctre ani united over it by a buried suture (Noble). The most frequent cause of failure in rectovaginal as in vesicovaginal fistula is, deficient liberation of the fistular layers from one another. Postrectal FistulcB (Cysts; Congenital Fistulse). — These infected congenital defects result from fail- ure of embryonal occlusion of the neuro-enteric canal. There may be simple pilonidal cutaneous involucra (dermonidal cysts), or postrectal dermoid pockets communicating wnth the rectum (mucous exclusion). FECAL FISTUL.^. 251 or a fistula may lead from the skin to the mucosa of the bowel. The variety which concerns us here is the post- rectal fistula communicating with an epithelium-lined pocket behind the rectum. A retrorectal dermoid may become infected and rupture into the rectum, discharging pus and dermoid debris for months or years. A sinus or opening in the postrectal region discharging pus, hair, or debris would, of course, lead to a diagnosis, but the surgeon rarely sees the case in this condition. He finds merely an opening leading to a suppurating cavity, or the patient complains of a periodical discharge of pus from the bowel, the source of which may not at the time be apparent, owing to intermittent closure of the fistulous opening. The afTected parts may be reached by a sacro- iliac incision close to the margin of the sacrum and coccyx, or by a Kraske incision. On reflecting the bony flap, the wall of the sac can be freed from all of its attachments, severed from the rectum, and removed. A mural and an extramural double row^ of ab- sorbable sutures should close the rectal defect; the bony flap is replaced, and the postprocteal space drained. This class of fistulse is generally mistreated, since neither simple incision and drainage nor cauteriza- tion can efifect a cure. The cavity is lined with epi- thelial cells presenting essentially an organic secret- ing tissue curable by nothing short of radical extirpation. CHAPTER XXIII. Cancer of the Vulva. The records of primary vulvar cancer to date embrace about 271 reports (Stein). Among II 77 cases of malignant disease involv- ing the female genitalia, tabulated by Schwarz, 30 were of primary vulvar origin. While primary vulvar cancer, like cancer in gen- eral, is a disease of advanced life, youth is by no means exempt. A number of cases are recorded that developed in women under 30 years of age. Ossing refers to a case in a girl of 20. Primary cancer of the vulva almost invariably originates from the squamous epithelium of the af- fected area, and thus presents the clinical and histo- logical features of tegumentary epithelioma, although a few scattered instances of adenocarcinoma origi- nating in the vulvovaginal and Skenes glands are recorded. The most frequent starting-point of the disease is the inner aspect of the right labium minus, below the clitoris, the other sites of origin in their order of occurrence being: the sulcus, between the labium minus and majus ; the anterior and posterior commis- sures; the clitoris; the urinary meatus; and the vulvovaginal glands. Papillary excrescences at the mucocutaneous margins, and other local irritative processes in el- (252) CANCER OF THE VULVA. 253 derly women, manifest a decidecl predisposing tend- ency to the development of malignant disease, which ordinarily begins as a circumscribed superficial infil- tration, gradually developing one of two distinct clinical types in its progress : — Fig. 117. — Adenocarcinoma of the left vulvo- vaginal gland. (Kelly.) I. A more or less prominent nodular or papillary outgrowth, with a tendency to the formation of "epithelial pearls" and cornification. The outgrowth may attain the size of an orange; its surface becomes excoriated, and sooner or later breaks into necrotic ulcers. 254 GYNECOPLASTIC TECHNOLOGY. 11. is the more virulent, and presents a diffuse surface infiltration rather than circumscribed tumor formation, characterized by a flat elevation of the deeply infiltrated area, in which early necrobiosis re- sults in sloughing patches, with typical irregular, Fig. 118. — Primary carcinoma of clitoris developing on a basis of condjdomata acuminata. (Taussig.) indurated edges, and a grayish, friable, coarsely granular base, exuding a foul discharge. Involvement of the inguinal lymphatics occurs early in the latter form of the disease, and contact implantations have been noted. PLATE XXI. Circumscribed epithelioma of the vulva. / Diffuse ulcerative epithelioma of the vulva. CANCER OF THE VULVA. As a rule, ihc process extends toward, but not into, the vagina, usually advancing" upward into the groin and down over the perineum. Fig. 119. — The lymphatics of the external genitalia. (Crossen.) The average duration of life in unoperated patients is about two years. In no class of cancer cases, wnth the possible ex- ception of primary adenocarcinoma of the corporeal 256 GYXECOPLASTIC TECHXOLOGY. endometrium, is early radical extirpation so uni- formly curative as in primary vulvar epithelioma. Such an extirpation implies a total exsection "en hloc" of all the involved vulvar structures, including the inguinal lymphatics on both sides. Poirier and Cuneo give the following account of the vulvar lymphatics, quoting in part from Sappey's older work: — Fig. 120. — The lymphatics of the urethra and anterior part of the vagina pass directly backward to glands in the interior of the pelvis. (Crossen.) "The lymphatics of the vulva arise from a net- work, the extremely close meshes of which are super- posed in several planes. This network covers the fourchette, the meatus urinarius, the vestibule, the clitoris, the labia minora, and the internal surface of the labia majora. It is so loose and close throughout that when it has been well injected it presents at first sight merely an ashy-gray appearance. To dis- CANCER OF THE VULVA. 257 tinguish the innumerable silvery filaments of which it is composed, we must use a magnifying glass. On the external surface of the labia majora the network composed of smaller and larger branches becomes sufficiently distinct to be recognized by the naked eye" (Sappey). "From the periphery of this network of origin run the collecting trunks. The direction of these trunks varies according to their point of origin. Those which come from the anterior third of the vulva run directly upward and forward toward the mons veneris ; there they turn sharply and run trans- versely toward the superficial inguinal glands. The trunks which come from the posterior two-thirds are directed upward and outward, and directly reach their terminal glands. The majority of the lym- phatics of the vulva terminate in the glands of the internal-superior group. Some of them may end in the internal-inferior group. It is even possible, though much more rare, to see some of these vessels reach a gland belonging to one of the two external groups. The vulvar lymphatics are far from being confined to a perfectly definite glandular group. When injecting one-half of the vulva the mass may frequently be seen to reach the glands of the opposite side. The injection of these glands may take place by a double process. Sometimes it is effected on ac- count of the continuity of the network of origin of the two sides of the vulva in the middle line ; at others it is due to the fact that some of the collecting trunks cross the middle line and end in the inguinal region of the opposite side. In all cases, when dealing with an epithelioma of the vulva, the inguinal glands of both sides should be regarded as liable to infection. 17 258 GYNECOPLASTIC TECHNOLOGY. urcS V-. - dans clitoriUi^ Heep dor-sot Its cZcfarii^rJ'lf- ' '' " cere. ■ Uee-p ifors. c/ito/-ic(i V n ctrmar'ict^ A.rtjl>f6u/// Vuii^&-voc^erta/ Levator fascia^ Tendinous centra of the perineum — J'roZia 7 ^ ^€. t./^ iit/'"', re/'/ecfeeC y•e/'^ectea Fig. 121. — Regional layer dissection of vulvar structures. CANCER OF THE VULVA. 259 Surgical interference in epitlielial tumors can be effi- cient only when combined with radical extirpation of the glands, for the lymphatics are invaded from the very beginning, and, although sometimes apparently intact, are always altered histologically." The lymphatics of the clitoris, instead of passing into the superficial inguinal glands, like the other vulvar lymphatics, pass from the primary plexus in several collecting trunks along the dorsal surface of the clitoris to the front of the symphysis, where they anastomose, forming a plexus which gives oft* two sets of collecting trunks. One lymph-vessel, passing along the inguinal canal to the external retrocrural gland, is usually encountered beneath the round liga- ment, while other lymphatics pass toward the crural to their termination in a deep inguinal gland, the internal retrocrural gland and the so-called gland of Cloquet. The urethral lymphatics in the female drain into the middle and outer chain of the external iliac glands, the hypogastric glands, and the glands of the promontory. The practical application of these anatomical find- ings is very clearly and concisely summarized by Crossen ("Operative Gynecology," 1915, p. 476) as f ollow^s : — I. "From a cancer of the labium majus or minus all the lymphatic distribution in the early stage is likely to be to the inguinal glands. II. "This distribution may extend not only to the side on which the lesion is located, but also to the opposite. Hence the glands on both sides should be removed. 260 GYNECOPLASTIC TECHNOLOGY. T 'W~,^ ,i&i 'cxm % r T^^n dZTi oi^j- t treofthejyer-fTt - Fig. 122. — Regional layer dissection of the vulvar structures. CANCER 01' THE VULVA. 261 III. "In cancer of the clitoris, a very early dis- tribution to the glands inside the pelvis is probable. IV. "In cancer of the urethra also, invasion of the interior of the pelvis is favored by the lymphatic distribution." Technically, the operation for cancer of the vulva should conform strictly to the established modern Fig. 123. — Outlines for the "block excision" of the external genitals. (Crossen.) principles of radical cancer extirpations "en bloc" , that is, commencing with the exsection of the ingui- nal lymphatics and ending with that of the vulva, the whole involved area is removed from above down- wards in its entirety, as one unbroken block, which includes the glands, the lymph-vessels and the vulvar tissues, with an ample margin of uninvolved skin. To obviate dissemination, this entire dissection is conducted through the surrounding healthy tissues. 262 GYNECOPLASTIC TECHNOLOGY. as wide of the disease as feasible, and all rough ma- nipulation of the cancerous structures is scrupulously avoided. In the following adaptation from Crossen, Stein summarizes the stages in the operative technique as follows : — First step: "Circumferential skin incision of the Fig. 124. — First step in the "block excision." The inguinal gland-tissue dissected out. (Crossen.) surface to be removed, including a wide margin about the lesion, extending outward over the lym- phatics on each side. Where the vulvar lymphatics are more deeply situated a linear continuation of the incision and reflection will be sufficient." As some of the lymph-vessels run upward for a considerable distance before turning outward, while others decussate, it is necessary to excise the super- ficial tissues well up over the pubes. CANCER OF THE VULVA. 263 Second step: "Block dissection of the gland- bearing area on each side, including the adjoining tissues and the contents of the saphenous opening, where injury to the deep veins must be carefully avoided/' From being skin deep at first over the gland areas, the incision, as it approaches the vulva, penetrates the structures down to the muscles and fascia. Fig. 125. — The block of tissue partially excised. {Crosseii.) Third step: "Removal of the tissue block 'en masse/ guarding against injury to the urethra." Enough of the vestibular mucosa should be left intact to cover the urethra and prevent cicatricial dis- tortion of the urinary outlet. This strip of mucosa may be safely preserved, as its lymphatics terminate in the excised glands of the groin. Fourth step: "The large raw area left by the ex- cision is covered as far as possible by sliding flaps, 264 GYNECOPLASTIC TECHNOLOGY. by tension sutures, and relaxing incisions, the details of which will necessarily vary in different cases. It is preferable to leave parts of the wound to heal by granulations than to incur sloughing by overten- sion. ..." Fig. 126. — Denuded area and flap outlines after the removal of the clitoris, vestibule, anterior part of the urethra, and labia, with extension of the incisions for the removal of the inguinal glands. The absolutely fatal prognosis in advanced cases should prompt early intervention. The inguinal glands must invariably be extirpated on both sides, whether demonstrably involved or not, and the whole region of the groin thoroughly cleared CANCER OF THE VULVA. 265 of all lymph-carrying structures, similar to the clear- ing" of the axillary space in mammary cancer. The extraperitoneal extirpation of deep glandu- lar involvement, according to Stoeckel, begins with an incision parallel to Poupart's ligament, extending from the inguinal ring to the anterior-superior iliac spine, and along the anterior third of the pubic crest. The parietal peritoneum is reflected toward the median line, exposing the ureter in its entire course, as well as the large iliac vessels, when the deep and superficial pelvic l3anphatics with their enveloping connective tissue are removed in continuity with the deep and superficial inguinal glands. A more extended radical operation by an intra- peritoneal method was again advocated by Stoeckel in 19 1 2, aiming to extirpate the hypogastric glands in addition to the iliac, the superficial, and deep in- guinal. The intra-abdominal glands are removed through a median laparotomy incision, which is then closed, and the inguinal glands removed by way of two oblique incisions above the inguinal ligaments. At the point where the laparotomy incision and the curved incision from one iliac spine to the other meet, a vertical incision is applied, which passes downward over the symphysis encircling the vulva. Next, the vulvovaginal tissue is detached from the bone, together with the tumor. This is followed by suture of the wound and permanent catheterization of the bladder. Routine laparotomy, in Stoeckel's opinion, is a very desirable preliminary, and improvement of the operation, and he recommends its performance as a valuable first step in all operations for cancer of the 266 GYXECOPLASTIC TECHNOLOGY. vulva. A patient recently operated upon by him ac- cording to this plan made a good operative recovery. In another case which was operated upon according to the customary method — namely, extirpation of the total lymph gland apparatus from the anterior-super- ior iliac spines in connection with the entire vulva — Fig. 127. — Wound closed. the wound healed by first intention, but a small nodule developed in the vaginal cicatrix on the right side, evidently an inoculation-recurrence, as it was found on examination to be carcinomatous. It is doubtful whether such extensive and formid- able operative invasions are justifiable, more espe- cially as the conviction generally prevails that in CANCER OF THE VULVA. 267 cases where the disease has actually extended to the intrapelvic lymph-nodes the extended radical proced- ures offer a forlorn hope. Ordinarily, the neighboring healthy tissues are sufficiently mobile to permit of wound closure by direct suture of the skin and vaginal mucosa. In very extensive denudations it is necessary to secure sliding skin flaps from the corresponding thighs to cover the defect. By means of circumferential relaxing incisions, it is usually possible to approximate all the margins without injurious tension. If at any point this can- not be accomplished, the intervening gap may be left to heal by granulation. A considerable amount of scar tissue is tolerated in this region without disturbance, provided the urethra is not distorted by cicatricial contraction. Hence, accurate coaptation, especially about the urinary meatus, should be secured. CHAPTER XXIV. Elephantiasis Vulv^. In its clinical application, the term Elephantiasis vulvce designates a generic group of local manifesta- tions, linked by a similarity in objective features, but differing in their etiology. These objective features are characterized by hy- perplasia and hypertrophy of the vulvar tegumentary and subjacent connective tissue layers, concomitant with local lymph stasis and dilatation of the lymph- channels. The clitoris, labia minora, labia majora, and peri- neum, in the order named, present the initial focus from which the process extends, rapidly or slowly, involving the whole or part of the vulvar region in a growth that may reach to the knees and weigh 30 or more pounds. The surface of such growths may be smooth, rough, warty, polypoid or ulcerated. It presents macules, papules, and cysts, very large masses being invariably fissured and lobulated. Negresses are more prone to the disease than white women. The disease is endemic in the tropics, as a result of filarial infection, while the non-parasitic form, which may occur in any climate, is most frequently due to syphilis or tuberculosis. But there are many cases, of obscure etiology, that develop in the course (268) PLATE XXIL Elephantiasis of the vulva. ELEPHANTIASIS VULV^. 269 of various chronic inflammatory lesions, productive of local lymph stasis. In an article on ''Esthiomene and Elephantiasis Vulvae", A. Stein reports a case, and reviews our present knowledge of this indeterminate class as follows (see Fig. 128) : — ''During recent years publications upon this sub- ject have been very few. This is probably due to the fact that our knowledge of maladies of the vulva is growing clearer, and we can distinguish ulcerative, tubercular, or luetic processes from those of an in- determinable etiology. Under the latter heading, however, there is a small group of diseases — better, perhaps, a clinical picture — to which we can apply no better appellation than that of 'Esthiomene.' This term was employed for the first time about sixty years ago by Huguier. He, like his contemporaries, knew no methods of differentiation among luetic, tubercular, and simple ulcers of the external female genitalia. Chronic inflammatory processes due to chemical and other non-specific agents could not be separated from those caused by specific organisms. It is possible, however, to reopen this question, and to analyze it more accurately, since our conception of the nature of syphilis and tuberculosis is no longer vague, as in the days of Huguier. ... It seems clearly established that we are dealing with a con- dition the etiology of which is still obscure. ... It may be argued that the overgrowth presents a type of true lymphangioma. It will not be diflicult, how- ever, to show that this is not so. "Our conception of lymphangioma is not a per- fectly clear one, for the simple reason that it is 270 GYNECOPLASTIC TECHNOLOGY. - / '-^""^m j ^Hh 'm 1 bIw ■ f ^^^%^jrJ^S^N j v^M :lJlmJ^^B» •*^ ■ ♦ii.' "l uU^^ai^^lHl' 4^B^HHHv »'^^^B9HHH|piV '^^PIRIliP t Fig. 128. — Elephantiasis. "Esthiomene" of the anovulvar region. (Stein.) ELEPHAXTJASIS VULV^. 271 difficult clinicall}' and pathologically to distinguish between a lymph-vessel new growth and a lymph- angiectasis. Winiwarter, Wagner, and Unna have attempted rather unsuccessfully to clear up this sub- ject, but have succeeded mainly in splitting hairs. One very readily recognized disease coming under this caption, which deserves closer scrutiny, is 'lym- phangioma circumscriptum cystoides cutis.' "Clinically, this is characterized by the appearance upon the skin of small, clear cysts from i mm. to ^ cm. in circumference, occurring in groups over an area of from i to 4 inches. These cysts contain clear serum, and have non-inflammatory bases. Occasion- ally in the subjacent skin teleangiectases are found. At times the blood-vessels rupture into the cysts, causing their contents to become hemorrhagic. The disease is one of youth. It is usually found about the neck, shoulders, upper thorax, lips, and even the tongue. "Strange to say, the first case in the literature, de- scribed by Tilbury and Calcott Fox in 1879, ^^'^^ one in which the lesions were located upon the perineum and thighs. In no case recorded since then has this been observed. The patient was a young man of about 20. Fox designated the disease as lupus lym- phaticus, and we cannot evade the suspicion that this case may serve as a connecting link between the true circumscribed lymphangioma and esthiomene. A further point of similarity is furnished by Freud- weiler, whose good fortune it was to observe a case from its inception. The earliest manifestations he noticed consisted of small yellow spots, which, becom- 272 GYXECOPLASTIC TECHNOLOGY. ins: raised, were ultimately converted into cvsts. In our patient all of these stages of development were present, the flat lesions being situated upon the mens veneris, the others further backward upon the labia. In no case in the literature was any reference made to ulceration or polypoid formation. ''Histologically, the lesions have been described as clefts corresponding to lymphatic spaces in the con- nective tissue of the papillary body and cutis. Some were pear-shaped, with the apex pointing downward,, and connected by strands of cells with the cutaneous blood-vessels. All contained lymph-cells; all were lined with endothelium, sometimes several layers deep. Freudweiler found no evidence of inflamma- tion. AA'aelsch, on the other hand, did. All other investigators agree with Freudweiler. "Concerning the etiology, opinions are evenly di- vided as to whether the disease is caused by prolifer- ation of the lymph-vessel endothelium per se, or whether it is due to lymph-vessel dilatation. With- out entering into this discussion, it seems unlikely that a new growth in the true sense of the word can depend for its origin upon a process commonly re- garded as inflammatory. In comparing our case, then, to cvstic lymphangiomata, we note the following points of similarit}^ viz., the presence of macules, pap- ules and cysts. T^Iore striking, however, are the pro- nounced dift'erences. In lymphangioma cysticum, ulcerations, hypertrophies, elephantiasis are entirely lackinsf, and there are no ascertainable mechanical grounds for cyst formation such as are present in this case. Obviously, then, we must rule out the pre- PLATE XXIII. Syphilitic gummata. ELEPHANTIASIS VULV^. 273 sumption that our case is one of lymphangioma cys- ticum, and seek another diagnosis. This we beheve to be the one ah'eady mentioned, namely, esthiomene." While elephantiasis of the vulva is not a malig- nant disease, the intense pruritus, the painful excori- ations, and the eventual impediment to urination, defecation, and copulation, compel the patients to seek relief, which is afforded only by a total extirpa- tion of the tumefied areas. The operation must be guarded by the strictest aseptic and antiseptic measures, to avoid infection and its rapid dissemination through the dilated lymph-vessels. Before incising the tissues, all ulcerated sur- faces should be thoroughly seared with a thermo- cautery. The mass should be enveloped in moist bichloride gauze thus securing a firm hold for fixation and trac- tion, while the tissues about its base are incised from above downwards. In very extensive extirpations, Kelly grasps the gauze-covered mass with the left hand, and by trac- tion ''forms a distinct pedicle where none exists naturally." This pedicle is transfixed with successive silkworm ligatures, and the mass excised from above downwards, tying each ligature before incising the next section of pedicle. The amputation is thus continued, excising and closing area after area, until the whole mass is re- moved and the wound completely closed. By this method of sectional successive transfixion and closure, the ligatures serve the double purpose of hemostasis and coaptation. 18 274 GYXECOPLASTIC TECHXOLOGY. These hypertrophies should be removed as early as possible, before they have attained to the septic and excessively vascular stage, in which the opera- tion is at best an extremely dangerous under- takinsf. CHAPTER XXV. Congenital Malformations. The congenital malformations of the female re- productive organs constitute a sharply defined clinical group of anomalies, in which surgical intervention aims to correct defective menstrual and procreative functions. These anomalies are, almost without exception, instances of arrested development. The fallopian tubes, uterus and vagina represent the normal end products in the developmental trans- mutation of the two embryonic Miillerian ducts. Lying on either side of the Wolffian body, and ex- ternal to its duct, the Miillerian ducts, consisting at first of solid strands, pass downwards into the allan- toic portion of the cloaca. At a later stage each duct acquires a lumen, the lower portion of which, by fus- ing with its fellow of the opposite side, forms the uterus and vagina, while its upper part, remaining separate, forms the fallopian tube. Certain deviations from the normal sequence in this developmental chronology, such as irregularities in the fusion of the lower parts of the Miillerian ducts, in their mode of termination, their partial or complete absence, or their imperforate condition, will account for the various congenital atresias, abnormal fistular communications, partial or complete duplications and other defects, that may involve different segments or the entire srenital tract. te (275) 276 GYNECOPLASTIC TECHNOLOGY. The development of the vulva and external gen- erative organs is more complicated and less clear than that of the vaginal canal and uterus, with its adnexa. V. Aberrans Paradidymis or JNephric pt. of Wolffian Body. II III. Fig. 129. — Relationship of the sexual ducts and their rudiments in the two sexes. I, The indifferent primary type. II, The differ- entiation in the female. Ill, The differentiation in the male {Adami.) At the posterior or lower end of the embryo an invagination of the ectoderm occurs, by which the cloaca is brought into communication with the ex- terior, thus forming the cloacal opening or primitive CONGENITAL MALFORMATIONS. 277 anus. This is followed by an indifferent stage, dur- ing" which sex distinction is impossible. The anterior part of the anal plate becomes thick- ened, and gives origin to a projection known as the "genital tubercle", which is the "anlage" of the penis in the male, and the clitoris in the female. Endof Mul- J\ Genital process {fienis or clitoris). Fig. 130.— The indifferent stage in the development of the gen- erative organs (diagrammatic). {Piersol, after Thompson, "Ameri- can Textbook of Obstetrics.") On the under surface of the genital tubercle ap- pears a groove — the "genital groove" — which passes backwards into the cloaca. In the female, the edges of this furrow become the labia minora, and the in- tegument external to these develops into the labia majora. In the next stage, the cloaca is divided by a partition — the rudimentary perineum — into an an- 278 GYNECOPLASTIC TECHNOLOGY. terior and posterior cavity, the former, termed "the urogenital sinus," gives vent to the urinary and sexual duct terminals, while the latter constitutes the permanent anus. In the female, the sinus urogenitalis persists, forming the vestibule, the external urinary meatus, the vaginal introitus, and the hymenal fold. Simbria. l/rackus Bartholin's gland. Fig. 131.— Changes that take place in the development of the female generative organs (diagrammatic). {Piersol^ after Thomp- son, "American Textbook of Obstetrics.") Omitting the more involved phases of academic teratology, these brief embryological outlines will serve to reveal the complicated segmental transmu- tations which must be visualized in the elucidation and attempted correction of any congenital defect. Not all such defects, however, can be satisfactorily explained on the basis of developmental arrest, and in these latter other pathologic factors more or less conjectural, such as amniotic compression, amniotic CONGENITAL MALFORMATIONS. 279 adhesions, fetal peritonitis, infantile vulvitis, adhe- sive colpitis, etc., have been invoked. While it is generally accepted as a clinical axiom that congenital malformations and defects are usu- ally multiple and diverse, they may for practical pur- poses be enumerated under the following pathological grouping. Epididymis. Urachvs Fig. 132. — Changes that take place in the development of the male generative organs (diagrammatic). (JPiersol, after Thomp- son, "American Textbook of Obstetrics.") GROUP A. Aplasia and Hypoplasia of the Fetal Rudiments. 1. Absence of the uterine appendages. 2. Absence of the uterus. 3. Absence of the entire genital tract, with or without — 4. Pseudohermaphroditism. 5. Uterus unicornis. 280 GYNECOPLASTIC TECHNOLOGY. 6. Atresias, which ma}^ be cord-hke or diaphrag- matic, existing in the cervix, vagina, hymen or vulva. 7. Congenital rectovaginal or rectovulvar fis- tulse; atresia anivaginalis or hymenalis, cloaca vagi- nalis, or fistula rectovestibularis. 8. Feminine epispadias or hypospadias. GROUP B. Hyperplastic Anomalies of Formation. 1. Duplication of entire segments: Uterus di- delphys. 2. Uterus et vagina duplex. 3. Duplication of the uterine appendages; ova- ries; tubal ostia. 4. Uterus bicornis. 5. Duplication by a septum: Uterus bicornis septus, or bicollis, and subseptus or unicollis, all of which may be combined with vagina septa or subsepta. GROUP C. Arrested Development and Anomalies of Infancy AND Puberty. 1. Uterus foetalis. 2. Uterus infantilis and uterus membranaceus. 3. Anteflexio uteri infantilis. 4. Stenosis cervicis et orificii externi. 5. Stenosis vulvovaginalis or hymenalis. 6. Evolutio prsecox. 7. Oligomenorrhea and amenorrhea. 8. Dysmenorrhea. 9. Menorrhagia. . 10. Sterility. CONGENITAL MALFORMATIONS. 281 Of clinical import in the foregoing" enumeration are : — Absence of the Uterus ("uterus deficiens seu clefectus uteri"). — Complete absence of the uterus, its adnexa, and (to some extent also) the external genitals is usually encountered in the acardiac twin and in sympodial fetuses; but its occurrence in the adult and otherwise normal individual is extremely rare. Only post-mortem evidences can establish the non-existence of the uterus and its adnexa, and in most of the reported cases such evidence is wanting; hence it is more logical to assume that in the majority of these cases the individual was a male with unde- scended testicles, not a female without a uterus. A woman without a uterus, or with merely a rudimentary organ, may present all the secondary characters of her sex. She may have a high-pitched voice, rounded contours, and an absence of facial hair. Amenorrhea is necessarily constant. Never- theless, ovulation may occur, and molimina become manifest, which occasionally assume an intensity that demands removal of the ovaries. The shallow vesti- bular vaginal pouch may be deepened by repeated attempts at coitus, which in most of the cases is un- consciously practiced through the gradually dilated urethral opening. Uterus unicornis is an organ in which one horn alone is well developed. There are two varieties — that in which the second horn is altogether absent, and that in which it persists as a solid or hollow^ rudi- ment. In the first condition there is complete, in the latter partial, defect of one of the Aliillerian ducts. 282 GYXECOPLASTIC TECHNOLOGY. The uterus unicornis has no fundus. The single horn, incHning to one side of the middle line, tapers to a point at which it is continuous with the fallopian tube and the origin of the round ligament. The cer- vix is usually small, and the vagina narrow, absent, or septate. The single horn may also be solid or partly excavated. The concomitant defects noted are, absence of the fallopian tube, round and broad ligament on the de- . ficient side,, as well as the corresponding ureter and kidney. Only half of the bladder may be developed, while the ovaries, when present, are rudimentary. A patient with a uterus unicornis commonly gives a history of amenorrhea, but it is well to bear in mind that menstruation and fecundation have oc- curred. Gestation in such a rudimentary uterine horn is practically an ectopic gestation, with all of its attendant dangers and indications. The uterus didelphys, diductus, or separatus, exhibits the maximum degree of separation between its two laterally placed halves, which normally fuse into the single viscus. There appear to be two single uteri lying side by side, each, however, possessing unl}- one ovary, tube, and round ligament. There may also be complete or incomplete dupli- cation of the vagina, or this canal may be single. The two uteri are rarely of equal dimensions, and one of them may be imperforate — a condition giving rise to h^ematometra at puberty. Xot uncommonly this uterine malformation is as- sociated with deformities of neighboring parts, such as ectopia vesicae and atresia ani. CONGENITAL MALFORMATIONS. 283 Since it is impossible to differentiate cases of uterus didelphys from the more frequent uterus bicornis, the two will be considered together. Uterus bicornis denotes the condition in which the two halves or horns are not entirely separate, as in the didelphous organ, but are united more or less intimately at their lower end, that is, in the region of the cervix or lower part of the corpus uteri. Fig. 133. — Double uterus (uterus didelphys). a, Right cavity; b, left cavity; c, right ovary; d, right round ligament; e, left round ligament; f, left tube; g, left vaginal portion; h, right vaginal portion; i, right vagina; j, left vagina; k, partition between the two vaginae. (Mann.) The mid-portions of Miiller's ducts had evidently begun to fuse, but coalescence ceased short of the normal limits, and a uterus is produced exhibiting clear external evidences of its two-horned origin. The bicornate uterus is the connecting link be- tween the uterus didelphys, which presents two un- united halves, and the uterus septus or bilocularis, in which outwardly the organ gives no indication of duplicity. 284 GYNECOPLASTIC TECHNOLOGY. The uterus bicornis also shows all possible tran- sitions from the form in which the two horns are fused in the cervical area only to that in which the malformation is merely indicated by a shallow de- pression or notch at the fundus. Fig. 134. — Case of bicornate uterus, with carcinoma of both ovaries. Septum seen running down to the single cervical canal. The depression at the fundus is characteristic. The two horns may be of equal size, or one, being retarded in development, approximates to the type of uterus unicornis. The extent of bifurcation varies greatly. In the most marked, the two segments present a considera- ble interval superiorly, bridged by a band or frenum passing from the bladder to the rectum. In less CONGENITAL MALFORMATIONS. 285 evident cases the horns he close together, Init are not united. The cervix may 1)e l)road and large, showing a double orifice (uterus bicornis duplex; septus or bi- cameratus); it may be double, with but one orifice, or entirelv normal. Fig. 135. — Left tube, ovary and uterine nodule. Tube and ovary normal in size. The membrane below, with parallel folds, occupies the position of the uterine body and upper vagina. Natural size. (Kelly.) The vagina may be septate^ subseptate, or single, the external genitalia usually presenting a normal appearance. The menstrual function may be variously affected by the presence of a didelphous or bicornate uterus. 286 GYNECOPLASTIC TECHNOLOGY. Fig. 136. — Case of double uterus, double vagina and planiform fundus. The uterine cavities are shown in double lines. Natural size. (Kelly.) CONGENITAL MALFORMATIONS. 287 Menstruation may occur every two weeks, every month, or once in every two niontlis. In the first in- stance, the menstrual flow comes from each uterine cavity alternately every two weeks, there being no coincidence of function ; each side menstruates inde- pendent of the other. In the second case, both sides menstruate simultaneously, or each side functionates alternately every other month. In the third instance, there is a bimonthly flow from one half, whilst on the other side there is an imperforate condition of the horn, vagina, or hymen which obstructs the egress of the discharge. Pregnancy may occur in one horn, and menstrua- tion from the other — a circumstance which possibly accounts for the continuance of menstruation during gestation in many unrecognized cases. Decidua may form in the empty horn or each horn may harbor an ovum, pregnancy occurring in both horns simultaneously or at diflferent but not far distant dates, thus explaining some instances of anomalous superfetation. The bicornate uterus may abort from one horn, foetation going to full term in the other. When, as sometimes happens, the preg- nant horn is obstructed by a septum, gestation be- comes practically extra-uterine. Even in cases in which there is no unilateral atresia, rupture of the uterus, or of the septum between its horns, may occur (see Fig. 137). Uterus Foctalis. — The anatomical uterine charac- ters normal to the foetus may persist as an abnor- mality in the adult. The cervix is longer than the corpus; its walls are thick, while those of the corpus > > o .2 a> " is Os o — ■ j^ ^? o 'l' " TO ^ "^ 3 re t_, a^^ -JJ ^ J- m ^ ^ f- :n ^ M o 13 M.2^.2 Si5.2-S ^^°|;*«^ ^ ao a • 2 3^ > c 3 02 3 ?■ -a 1 § ^ C a o o ^ -B ■~ ^^ ij .^ r3 e G cs3 -tJ X ^ £ ^ C ■^ 3 a r- < o o o o _2 ^' :3 p •-^ CD d i o 3 s be -a o H o 3 %^ t« ^ *m m O ^J ri ;ii M S 11 o s B 3 ■a a c -H O o P be _in g o CB o ^ 'C ■d ^ ■3 J3 O ^ o 3 3 2 5 Q. m S3 > ? ■a o o >> m o 2 C. 5 =« -5 o o 5 *" o o o o ci " tc O m a i o ■a t- 3 O 3 O o o 1 3 Z) ^ ^ tn ^ p ^ ___ d © a) s -1 >; ^ m — t_i — ' 1 2SS , CONGENITAL MALFORMATIONS. 289 arc thin. It is conical in shape, with a so-called "pin-hole os." The whole organ is cylindrical in form and small in size, the length of its cavity rarely exceeding i]^ inches. The term "infantile uterus" is practically synonymous with foetal uterus. The endometrium is poorly developed, and may present an absence of utricular glands. The vagina is short, especially its anterior wall, usually narrow, but may be normal. Ovaries, tubes, and external genitalia are infantile in contour, and deficient in function. AA'ith a uterus fetalis there is usually amenor- rhea, or at most a scant, irregular, and painful men- struation. Sterility is constant. Chlorosis, a small heart, small aorta, and general hypoplasia of the vascular system are frequent concomitants. All attempts at treatment of the fetal uterus are futile, while in the pubescent uterus a small propor- tion attain some approximation to normal functions later in adult life. Uterine Atresia and Stenosis. — The uterus may be congenitally imperforate — an anomaly w^hich finds its explanation in the originally solid condition of Miiller's ducts, from which it is developed. Uterine atresia is not so much an independent malformation as a complication of other defects. The whole cervix may be solid or present a septum at the external or internal os. At puberty hematometra may develop, which may be unilateral in bicornate cases. The symptoms of uterine atresia are mainly those of hematometra, and as these are also encountered 19 290 GYNECOPLASTIC TECHNOLOGY. in vaginal atresia, their further consideration will be deferred to the chapters on the latter anomaly. Infantile or Congenital Anteflexion is in reality an anteflexion of the cervix only, which usually is conical in shape with a minute external orifice, and foreshortened anterior vaginal wall. Dysmenorrhea and sterility are the rule, the more direct cause, however, being a chronic endocer- vicitis, to which these cervices are especially prone. CHAPTER XXVI. Malformation of the Vagina and Vulva. Vaginal malformations present many charac- ters in common with those of the uterus — a circum- stance readily understood when we recall that both vagina and uterus are derivatives of the Miillerian ducts. Moreover, vaginal and uterine defects frequently coexist, and in many instances combine to establish a clinical complex. While abnormal communications between the uterus and contiguous viscera are rare, the congenital fistulas between the vagina and its neighboring organs are relatively frequent. Double Vagina (YRgins. septa). — A double vagina in the literal sense can only be said to exist in cer- tain double terata, such as the pygopagous twins; but it has become customary to apply the term to cases in which the two Miillerian ducts, which nor- mally fuse into one canal, have remained separate, the residual septum persisting along a part or the entire extent of its vaginal course. In the great majority of cases this septum runs anteroposterior^, and the vaginae are situated later- ally. More rarely it extends transversely, when the vaginal canals lie in front of one another. In the latter instance, the two unfused ducts must have undergone a partial rotation. (291) 292 GYNECOPLASTIC TECHNOLOGY. The two canals are never perfectly symmetrical in position or calibre. Ordinarily the left lies a little in front of the right. The septum is composed of muscular tissue covered by mucous membrane, and has the consistency of the rectovaginal septum. It varies, however, in thickness, and may be perforated. It may be absent at the introitus, and present at any point above, and z'ice versa. Its remnant may be in- dicated by a ridge or cock's-comb elevation on the vaginal wall. In the majority of cases the uterus is double, i.e., didelphous, bicornate, or septate, present- ing one cervical orifice in each vaginal compartment. In a few recorded cases the uterus was single, its cervix projecting into one or other of the vaginal lumina. In atresia of one or both vaginal tracts, uni- lateral or bilateral hematocolpos will develop in adult life. It is claimed that during pregnancy the septum may be absorbed, but should it persist to term, de- livery may be impeded. When one canal is imper- forate, the condition may simulate a vaginal cyst. Atresia Vagiuce implies any defect of the vaginal canal, from its complete or partial absence to a simple membranous obstruction or perforated diaphragm existing at some part of its lumen. When the upper two-thirds of the vagina are oc- cluded, the patulous lower third is not vaginal in nature, but represents an enlarged vestibular canal, the vestige of the sinus urogenitalis. Through the arrest in the downward progress of the Miillerian ducts, the vestibular canal has retained its early dimensions, its depth being increased by coital attempts. When the central vaginal zone is atretic. MALFORMATION OF VAGINA AND VULVA. 293 it may be assumed thai the n])])er canal is Miillerian or truly vaginal, while the lower part is vestibular. The uterus, adnexa, and vulva may be normal, rudimentary or absent. If the uterus and ovaries are present, the condition reveals itself at puberty by hematocolpos, hematometra, and hematosalpinx. The surgical indications will be entirely domin- ated by the extent and position of the defect, by the presence or absence of the internal generative organs, or by the accumulation of retained menstrual blood. Patients with extensive defects of the vagina and uterus, in whom severe menstrual molimina indicate the presence of functioning ovaries, may demand oophorectomy for relief. Hematocolpos and hematometra invariably call for operative intervention. It is not correct to leave such blood accumulations to nature. Spontaneous rupture, even when it occurs through the vaginal tract, is seldom safe in its immediate, or satisfactory in its ultimate, results. Dyspareunia, as such, in the absence of uterus and ovaries, and without other subjective manifesta- tions, is a questionable indication for the operative construction of an artificial vagina — a difficult and dangerous procedure, the results rarely justifying the means especially in very extensive cases. Abnormal Coinmunications of the Vagina. — The vagina may open into the rectum through a develop- mental defect of the rectovaginal septum, or it may communicate by a small orifice with the urethra. Most of the abnormal clefts between the vaginal canal and its contiguous viscera are in reality vulvar 294 GYNECOPLASTIC TECHNOLOGY. A B Fig. 138. — Development of the external genitals (after Ecker- Ziegler models). A, Indifferent stage (eighth week) : gt, genital tubercle ; gr, genital ridge ; gf, genital fold ; gg, genital groove. B, Female type: cl, clitoris; /. m