>:.>i':>i]/:-.';, h^^^ inti)eCitj>of jBtetogorfe Collese of ^fjpgiciang antr burgeons; ^titvmtt Hibrarp THE GYNECOLOGY OF OBSTETRICS AN EXPOSITION OF THE PATFIOLOGIES BEARING DIRECTLY ON PARTURITION BY DAVID HADDEN B.S.,M.D. FELLOW OF THE AMERICAN ASSOCIATION OF OBSTETRICIANS AND GYNECOLOGISTS FELLOW OF THE AMERICAN COL- LEGE OF SURGEONS NEW YORK THE MACMILLAN COMPANY 1915 Copyright April, 1915 by DAVID HADDEN Oakland, Cal. San Fraincisco: Taylor, Nash & Taylor Printers TO MY UNCLE WILLIAM KINGSTON VICKERY WITH WHOSE AID AND COUNSEL THE FOUNDATION WAS LAID THAT MADE THE WORK POSSIBLE I GRATEFULLY DEDICATE THIS BOOK Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/gynecologyofobstOOhadd FOREWORD The iiHijori/// of the jxilioils irlio conic to the (j//)icco//j tlie fjen- eriil j)r(ict itioner. \ot inf re(]iientt ij t/ie jxdient Inis fwen nd- rised, nnd tlint eren Ij/j men tr/iose experience shoidd dictate otJieririse, to ii'iiit until the child-l)earinc) ])eriod /.elvis and outlet than I was able to gather from vi THE GYNECOLOGY OF OBSTETRICS text-hoohs led me, when the opportunity of obtaining normal material presented itself, to take up a care fid anatomical study. I soon realised that there was no conformity hettveen the actual findings and the text-hook descriptions. The -recognized anatomies deal very superficially with the female pelvis, and the gynecologies, as a rule, copy those authorities. I hoped hy this study as well to find some reason for the generally poor understanding hy the physician of the relaxed vaginal outlet and the often unsatisfactory immediate and secondary repair. The residt is that I have written the chap- ter on anatomy wholly from my dissecting-room findings, with the main emphasis on the points that most interest the surgeon. The minutiae of muscle-fiber distribution and details of no moment to the accurate surgical correction of injuries have been omitted. This I have done with the hope of being able to present a vivid mental picture of the important relations that the operator must have while doing perineorrha'phies and other plastic work. For the opportunities to prosecute this dissection work, I desire to express my appreciation to Dr. R. O. Moody, Asso- ciate Professor of Anatomy at the University of California. The anatomical study naturally carried me into the details of histology, and thence to the pathological findings, for I felt that the average gynecology did not contain a sufficiently com- plete series of illustrations to avoid the necessity of reference to histology and pathology text-books, which, as a rule, give only a small space to the gynecological field. The illustrations are all original, from specimens selected to represent as typical a series as possible, and the micro phot o- graphs represent the main diagnostic points. For some of the slides from which these photographic reproductions are made FOREWORD vii / (]('sirc lo llidiih- Dr. Liid/cifj l^icli, of Ijri-h'ii, iriili irlioni I IkkJ llic /)/((is/irc of hihi ufi II j) some of titis ivork. The inmloiniriil fniiliiu/s, T found, were poorly port rayed by hliicl>-iiti(l-irliilc phi f is, so color pliofoyraphy tvas resorted lo. A II Hi II (lips lo color (lie slracliircs lo be empliasized were used lo (jcf llie required contrast. These color jdolcs yive niiicli (jrcalcr (lcj)Ui of focus irilli better coiilnisl tliaii ordiiiury phot Of] rii plis. Tlic ini possibilil y of ciihirf/iny sucli jdates in reproduction lias necessitated llic present size, though, I realize larger illus- t ra lions could be more easily studied. For the great interest mid care taken in the reproduction of these color photographs, as irell as in the production of the 200-mesh half-tones, I ivish to express my appreciation to Mr. E. F. Russ and his tvorkers of the Sierra Art and Engraving Company. In addition, I have taken up a comparative study of the accepted operative procedures of plastic work, discussing them irilh the data obtained in the dissecting-room as a foundation. I have eliminated as far as possible the present tendency to discuss gynecological operations under a nomenclature of sur- geons' names. While it is only just to give credit to amj indi- vidual who introduces a worthy surgical procedure, the desire of many to obtain credit for an operation which adds a modi- fication of only slight variation that in no tvay changes the principles involved must be confusing. To the student such individualization makes the average text-book of gynecology merely a mass of operations from which he }nay have difficulty in gathering the correct principles, so that he gets no appre- ciation, or at best a poor one, of the real factors at fault and to be corrected. I have no new operations of my own to discuss. I may have taken away credit due to some one; but, if so, it has only been viii THE GYNECOLOGY OF OBSTETEICS because I have attempted to take up tins narrow hut important section of gynecology and discuss it from the basis laid down iii the cliapters on anatomy and the mechanics of pelvic defects. If the effort put into this monograph tvill emphasize the greater importance that the correct trachelorrhaphy and peri- neorrhaphy have to the physical and mentcd well-heing of the mothers, I shall consider the time well spent and shall offer no apology for adding to the already voluminous medical literature. TABLE OF CONTENTS PAGE A^■A'^()M^• Di' •iiii: ( 'i:k\ix AM) I'KiJiXKr.M 1 MkCIIAXICS ol- IIIK liKI.AXKl) Ol'TM"!' 22 Etiologv and I*ki:\i:n'i'|i)n of IjAckka'I'ions 81 PATIIOLOfn' OK Tin: ( 'kkvix 40 JSV.Ml'TO.MS OK CkKXICAI. I'aI' I Io| .0(;N 66 ThKAT.MKNT ok ('KKVICAI, rATIIOLOGY 69 Immediate Hetairs . 74 Curettage 83 Cervix Operations 90 Symptoms and Diagnosis of the Relaxed Vaginal Outlet ... 97 Perineorrhaphy 105 Cystocele 121 Correction of Cystocele 127 Post-Operative Treatment 134 Prognosis and Post-Operative Complications 141 ]\[iscarriage and Sterility 152 Bladder Infections 162 Kidney Ptosis 181 Index 189 ILLUSTRATIONS IN COLORS Ol'l'OSlTK PA(JE 1*1, ATK I. A iii('(li;iii scclioii through the female pelvis a1 llic syiiipliNsis |)iil>is. The pelvic organs are in normal relation 10 I'latk 11. A median section ttironuli tlie female pelvis at 1 Ik; symphysis pubis. The ulei'us displaced, in oi'der to show 1he relalion of the ureter to the uterus and bladder 10 I'l.vteIII. Segment of the levator-ani musc](^ rutniinii' between the vauina and the rectum 14 Plate IV. The pelvic diaphragm and the attachment of the levator- ani muscle to the side of the vagina 14 Plate V. The muscles of the pelvic floor 18 Plate VI. The gland of Bartholin. The bulb of the vestibule ... 18 Plate VII. The ischiorectal fossae 20 Plate VIII. The muscles of the vaginal outlet dissected to show their relation to the vaginal outlet, with reference to episiotomy in- cisions 32 Plate IX. Dissection of a relaxed vaginal outlet to show the retraction of the levator-ani muscle 104 Plate X. ]Main nniscle structures of the pelvic floor 112 Plate XI. Blending of the levator-ani muscle with the muscles of the floor at the central tendon 114 Plate XII. Portion of the levator-ani muscle between the vagina and the rectum 116 Pate XIII. Shows the individual middle segment of the levator-ani muscle 116 Plate XIV. The ventral segment of the levator-ani nniscle .... 124 ILLUSTRATIONS IN BLACK AND WHITE PAf;E Hi'osinii (if ('('fvix (i7 Lacci'iit ioii (iF (*('i-\'i.\ . .' 'M L;i('('i';i1 iiiiiot' cci-vix IJl ('(M'vical pol.xp 85 X(inii;il N'ii'Liiii \iil\;i 20 Hcliixcd v;miii;il out let ill which IK) siipcfficinl tear oec'un'ed .... 35 Relaxed vaniiial outlet, ceatral teiidou intact 36 Kelaxetl ()utl(4 with central tendon onl>" slightly injured 115 Perineorrhaphy with poor diaphragm support 98 J*erineorrhaphy with poor diaphragm support, defect shoAvn npoji sepa- rating labia 99 Perineorrhaphy with poor diaphragm support 109 J'erineorrhaphy witli poor diaphragm support, demonstrating degree of relaxation 110 ^Method of demonstrating relaxed, outlet by finger ill vagina .... 100 ^Method of demonstrating relaxed outlet by pressure from above . . . 101 Outline of Ilegar perineorrhaphy- denudation Ill Perineorrhaphy with Somers suture 118 Graves's cystocele operation 130 Temperature curve, sho^^'ing effect of retention, the result of retrodis- placement following plastic work on cervix 148 Temperature curve, the result of retention following cervix amputation 149 MICROPHOTOGRAPHS IN BLACK AND WHITE Normal Structures Cross-section of normal cervix 2 Stratified scpiamous epithelium of cervix 4 ^lucous memlirane of cervical canal 4 Epithelial layer of mucous membrane of cervix 5 Higher magnification of same specimen 6 xiv THE GYNECOLOGY OF OBSTETRICS Inflammatory Processes Cross-section of cervical glands 5 Eroded cervix . 61 Eroded cervix, showing cystic glands 62 Eroded cervix, showing cystic glands 64 Eroded cervix — an acnte process 63 Eroded cervix in healing process .65 Higher magnification of same specimen 65 Cystic endometrinm 7 Cystic endometrinm 8 Polyp of cervix, early stage 86 Polj^p of cervix, with cyst formation 86 Cervical polyp, showing gland proliferation 87 Higher magnification of polyp, showing gland structnre ... 87 Tuberculosis of cervix 41 Higher magnification of same specimen 42 Decidual wandering cells in uterine scrapings 83 Higher magnification of same specimen 84 Inflammatory endometritis simulating malignancy 88 Higher magnification of same specimen 89 Malignant Processes Carcinoma beneath mucous membrane of cervix 53 Carcinoma beneath mucous membrane of cervix 54 Carcinoma of cervix 49 Carcinoma nodule in deeper tissue .55 Carcinomatous involvement of cervical gland 46 Extensive carcinomatous involvement of cervix 46 Type of adenocarcinoma comparatively rare in cervix . . • . .47 Higher magnification of the same specimen 48 Metastatic carcinomatous involvement of lymph gland .... 50 Chorioepithelioma of cervix 58 Chorioepithelioma of cervix 59 Higher magnification of same specimen 60 Metastatic chorioepithelioma on omentum 58 Higher magnification of sajue specimen 58 MICROPIIOTOdlJAPIIS XV .Maij(;.\.\.\"i' I'kocesses — ( 'oiil iiiiuMl Kpithclioiiia ()F cervix 43 Epitlu'lioina of ccr-vix 44 Epitliclioina of ('(M-vix HI I liylici- iiumiiifical ion of same s|)('('iin('n oi* Section of cpil liciioiiia.'sliowiim' " jx'arls '' 4.") Section sliowiiiii polyinorplioiis cliafartcr of inaliunani cells . . 45 Fibro.sarc<)nia of cervix 5t) Higher iiumnifical i(tn of same s[)eciineii 57 ANATOMY OF THE CERVIX AND PERINEUM Wlll^iX we coiisidci- llic rciiialc ix'lvic slnicliii-c and oi-- ^niis ill the li,i;iit of the I'uiictions I'oi- wliicli tlioy are (losigiie(l,the wonder is tliat any woman can i^o tliroiif^'h tlie pliysi()l()i>ic'al ordeal of cliildhirtli without liaving some untowai'd effects. The utei-us, which in its state of rest is nou lar,<>(M- than the indivichial 's fist, must increase in size and capacity sufhcicntly to retain a full-term child as well as reserve energy enough, in sjjite of its excessive distention, to expel the contents. The birth canal nmst so change its character as to accommodate a body many times the size of its caliber at rest, and yet not interfere too greatly with- the adjacent structures through and along which the canal lies. These adjacent structures have of themselves im]oor- tant duties to accomplish that require varying degrees of area. The structure of the female- pelvis is designed to permit of ex- treme distention of its contained canals without sustaining injury under normal conditions. In conditions varying from the normal, some of the structures, on account of the nature of their location and character of their duties, are more subject to strain; conse- quently, the abnormal status does not have to be marked to accom- plish some injury. While nature in all cases does its best to rem- edy any resulting defect, nature undirected often fails, especially when handicapped by mechanical interference or infections. The modern life of woman tends to cr-owd her mental culture at the expense of physical development during the period of puberty. This is associated with a type of dress that insufficiently protects the extremities and upper trunk, with a consequent exaggeration of the venous blood supply in the pelvis. These factors favor the occurrence of abnormalities before and during pregnancy and their persistence thereafter. Improper body posture, often exaggerated )3y poorly fitted or improperly adjusted corsets and defective shoes, also has its influence in the same direction. The structures that are most subject to injury, and in Avhich such injury is most likely to persist, are those of the cervix with its sur- 2 THE GYNECOLOGY OF OBSTETRICS rounding tissues, the pelvic diaphragm, and the outlet. From the nature of its structure and location, the uterus itself is only oc- casionally the site of injury. The vaginal canal, on account of its relatively large caliber, permits of fairly easy distention. With its mucous membrane arranged in columns and rugae so as to be capable of covering a much larger area, the relation between the The normal cervix at a point above the junction of the ventral vaginal wall. At this point the cavity is considerably widened, with the walls nearly in apposition. The strati- fied squamous epithelium covers the portion that is free in the vagina. mucous membrane and the deeper structures is maintained in spite of the difference in the nature of the component elements. Consequently, injuries to the vagina itself are less frequent; and, if they do occur, they tend to repair themselves, on account of the contracting power of the muscle and elastic fibers composing the wall and the mechanical arrangement of the mucous membrane. In using the term cervix throughout this monograph, I shall always refer to what should technically be known as the vaginal AXATO:yIV OF TIIK CKRVIX AX I) PKRINEUM 3 poftioii of the ('(M\ix. The line cci-vix is that portion of the uterus heyoiidthe plane at wliicli the peritoneum i-eflects upon the bladder. It is at tiiis plane that tlie constrietioii of tlie uterine cavity known as the internal os oeeurs. The cervix extends through the vaginal \ault, as it were, with a slight ventral curve to the external os. That part (»r the uterus lying in the vagina is known as the vaginal por- tion of tile cervix. Tlie os is so sitnated that it points directly to- ward the hollow of the sacrum and meets the tactile end of the su- pine examining finger. Any variation from this location indicates an abnormal position of the uterus, an al)normal relation of the true cervix to the body, a disj)lacement of the uterus from pressure by some ontw^ard mass, or a distortion of the cervix itself by scar- tissue contraction. In a retrodisplaced uterus the os, as a rule, points in the direction of the vaginal canal. By some this is given as a point diagnostic of reti'oversion, with the result that the care- less examiner is apt to overlook a condition of marked anteflexion, especially Avhere the body cannot be easily palpated. The vaginal portion of the cervix varies considerably in size in different individuals. AVe find all variations, from the small conical cervix of the girl with an anteflexed uterus to the large liypertro- ])hied cervix of the woman with a chronic endocervicitis, or vaginal prolapse. The anteflexed uterus is a persistence of what in premen- strual life is a normal flexion of the cervix and body, Init which, when inflammation is present, causes the patient to suffer from dysmenorrhea, leucorrhea, and possible sterility — an entity spoken of as anteflexion. A normal intravaginal cervix is about three- fourths of an inch in length and about an inch in breadth, tapering somewhat tow ard the truncated end, w^here the external os is situ- ated. The thickness is a little less than the breadth. The os is a circular opening about one-eighth of an inch in diameter ; and if an imaginary line be extended across the os it divides the cervix into a ventral and a dorsal lip. The ventral lip is somewhat shorter, but meets the examining finger first, on account of the relation of the vaidt of the vagina to the horizontally placed uterus. The supravaginal portion of the cervix is about three-quarters of an inch long and of slightly greater dimensions than the intravagi- nal, narrowing somewdiat at the junction with the corpus, or body, THE GYNECOLOGY OF OBSTETRICS ^9^ All i.'iilan ciiiciit of the iKii'iiial strat ili(', LFvAtof^ Ami {^^•ddlc 3£gme-nt> Under Sl;(^f^ee ofk ja/itEo VNc!f« In this section the lower portion of the vaginal wall has been par- tially cut away and pulled to the side in order to get it out of the field. The central tendon is cut through, and the segment of the leva- tor ani between vagina and rectum is intact over the strip of cloth. Aj'J Platk IV TIIK I'ELVIC DIAPHRAOM AND THE ATTACHMENT OF THE LEVATOK-AXI :\rrSCLE TO THE SH3E OF THE VAGINA ■to Pybrc A(?(?K*' Le^/A^oR An I witti Ana evc/?eo nxeaf Coggyy All the structures on the subject's right have been removed down to the ' ' pelvic diaphragm. ' ' The relation of the muscle and the anal fascia to the median line of the pelvis with the blending into the superficial structures is shown. On the other side the dissection has been carried between the levator ani and the vagina, in order to show the attachment between the two. In this case, on the left side the separation of the sphincter vagina into superficial and deep has not been possible. ^1* 4 d.',. Antis ANATO^IY OF THE CERVIX ANM) PERTXEUM 15 tliiis (Icscrilx'S it. But under tlic licadiii.i;' of " A^ai-iatious " lie makes the rollowiii.i;' statenieiit : '"J'lie levator ani is always a well-developed musele, altliougli the extent of its attachment to the sides of the coccyx vai'ies in- versely to the attachments of the coccygeus to that bone. There is usually to be found a dividing line extending aci-oss the muscle on a level with the junction of the superior rannis of the pubic with the ilium and separating those fibers which are inserted onto the coccyx and the posterior ])ortion of the fibrous i-aplie from those which pass to the anterior part of the raphe and the rectum. Each of the portions so separated is supplied by a separate nerve, and this, combined with the results of comparative anatomy, seems to show that the posterior portion of the levator is really a muscle quite distinct from the anterior portion. It has been termed the m. iliococcygeus. Furthermore, it seems probable that the anterior portion is composed of two morphologically distinct muscles, one of which arises from the pubis and anterior part of the Svhite line ' and is inserted into the median fibrous raphe, w^hence it is termed the m. pubococcygeus, while the other, situated beneath — i. e., superficial to the pubococcygeus — consists of those fibers which arise from the pubis and are inserted into the rectum, and is termed the m. puborectalis." In my dissections the muscle has been distinctly divisible into the three segments as described, and in each case, as is well shown in the illustrations, the edge of the individual segment is distinct and overlapping, with a definite space between. In each subject the at- tachment of the ventral and middle segments to the vagina has been most marked, and yet the anatomy text-book fails to mention the fact, even under "Variations." It is extremely important to the gynecologist in accounting for the various conditions resulting from the relaxed vaginal outlet to bear this anatomical relation in mind, for upon a proper understanding of this relation will depend the correct results in plastic work. Those structures which fill in the area between the pubic arch in front and the edge of the giuteus-maximus muscles behind are spoken of as the pelvic floor. The structures composing this floor are variously described by different authorities, and in reality they vary rather markedly in different subjects. In some cases the muscles are well marked with large well-defined bellies, but rather 16 THE GYNECOLOGY OF OBSTETRICS at the expense of the fasciae. In others the fascia layers are the most prominent, while some of the mnscles are poorly defined ; but in all cases the nmscle tissue forms a large element of support. The central tendon in some women contains an excessive amount of elastic tissue, the presence of which may account for lack of injury to the pelvic floor in childbirth. This will naturally not prevent the levator-ani injury, and may deceive the obstetrician as to the ex- tent of the vital injury. This variation of composing elements probably accounts for the difference of opinion of gynecological writers as to the value of one element over another for building a perineal support. Physi- ology tells us that fasciae will alwa^^s stretch under continued ten- sion if no rest is given, and it is only by rest that they can recuper- ate ; whereas muscle tissue develops with exercise, but only within certain limits. Consequently, all over the body where strength is required but where variation in area is necessary we find both muscle and fascia closely associated and often blended. Where excessive stretching has occurred, a tearing of the fasciae has resulted, possibly without muscle rupture, and, consequently, by excessive elongation, the muscle cannot function. By shortening up the fasciae, and thus giving the muscle a new point of attach- ment, it is again set to work and develops strength, and this is the mechanism of a successfully repaired pelvic outlet. Consequently, both the surgeon who emphasizes the importance of the fascia and the surgeon who emphasizes that of the muscle are correct, but only in part. When it comes to muscle rupture as well as fascia injury, the retracted ends of the vaginal portion of the levator ani become imbedded in scar tissue. That, however, is a factor Avhich will be considered more fully under perineal repairs. The pelvic floor, ventral to the tuberosities of the ischia, practi- cally consists of three layers of fascia, between which are situated muscle layers ; and these layers, pierced by the urethra and vagina, may be considered as bridging the area within the pubic arch. Dor- sal to this line is found one layer of fascia, for here the same amount of structural support is not necessary and greater possi- bility for expansion must be allowed. The superficial layer of the outer fascia is closely blended to the skin, and cannot be considered ANA'rOMV OK TIIK CKKN'IX AND rKIMNKlM 17 of iiiucli \-alii(' rroiii llic siir,L;(M»ii 's stniidpoiiit other than in sci-viiii;- to picvcnt the movement of tlie skin on the deeper structures as well as suj)))lyiiii;' some sui)port. It is a contiimation of the superficial fascia of the tlii,i;ii and abdomen. Ontlieremovaloftlie skin witlitliis fascia, we come to the. first layer of fascia, described as one of tlie three su])port layers. This fascia is coimnonly known as ('o]l(^s's fascia. It is a (inn, well-defined layer bound down to the pubic arch. This layer is continuous niesially in some subjects with the fascia siirroundin.ij,- the vaji,ina and urethra. In other subjects the blendini;- takes phice in the median line witli the muscle tissue, and a direct connection cannot be traced with the internal fasciae. The removal of this layer exposes the first muscle structures of the pelvic floor and their central tendon attachments. This fascia is closely attached to the dorsal edge of the triangular ligament. The most important of these muscles are the two sphincter vagi- nae, or l)ulbocavernosi, which have their origin at the ventral edge of the central tendon, and thence run forward, one on either side of the vaginal orifice and vestibule, dividing into three septa, which attach themselves, one to the body of the clitoris, one to the sides of the bulbs of the vestibule, and the ventral portion running over the clitoris and blending into the fasciae and suspensory liga- ment. In most subjects it is impossible to separate this muscle from the corresponding deeper muscle called the compressor vaginae except at the attachment to the central tendon. Since surgically such a separation is of no value, from this on the two will be con- sidered as the sphincter vaginae. Corresponding to this muscle in the dorsal portion of the perineal region is the sphincter ani, aris- ing at the dorsal edge of the central tendon, running around the anus, and attached to the coccyx. The body of the muscle is well defined and inclosed in a reflection of fascia spoken of as the sheath. Both muscles depend oi; the central tendon for one point of support, and so, in cases of injury to the central tendon, the muscles retract, and thus increase the distance between the anus and vestibule. From the side of the central tendon outward, to be attached on the pubic arch a little forward of the tuberosity of the ischium, run the transversus iDerinei. The superficial are not always as well- 18 THE GYNECOLOGY OF OBSTETRICS defined muscle bodies as the deep, which have relatively the same attachments, but are situated between the layers of the triangular ligament. In some subjects the combined muscles are as much as a quarter of an inch in diameter ; and with the patient in the dorsal position, the}^ run a little upward and outward from the horizontal. Between the central tendon attachments of the sphincter vaginae and transversus perinei superficial the erector clitoridis has its origin and then continues outward at the ventral edge of the latter muscle, filling in j)artially the triangular space between these muscles and the pubic rami. It passes over the crura and is inserted into the pubic rami. The greater portion of the muscle belly is to- ward the rami, so that a considerable gap is often left between it and the sphincter vaginae. Beneath these muscles the superficial layer of the triangular lig- ament is stretched, blending, however, in the muscle gaps with Colles's fascia and the deep layer of the triangular ligament, so that in some subjects it is difficult to separate the individual layers, making it appear to be a heavy one-layer fascia that splits to in- close the muscle structures. In the median line the fascia blends with the lateral aspect of the sphincter vaginae, and this again with the rectovesical reflected layers surrounding the vaginal canal. At the bony boundary the fasciae are firmly attached, and here are readily separated into the various layers, with a considerable frac- tion of an inch gap between. At a line drawn from tuberosity to tuberosity, the superficial layer of the triangular ligament is re- flected back around the deep transversus perinei and becomes the deep layer of the triangular ligament with the same lines, of attach- ment. Between these two layers occur the deep transversus perinei, the deep sphincter vaginae, or so-called constrictor vaginae, already described, and a third muscle, corresponding to the erector clitori- dis, called variously the constrictor urethra, compressor urethra, or Guthrie's muscle, but not always well defined, especially if the superficial set of muscles are well developed. At the sides of the vagina and between the deep layer of the triangular ligament and the under layer of the anal fascia, blending with the levator ani, are situated the bulbs of the vestibule, one on either side. These Plate \' THE :\rT^l^CLES OF TTTE PELVIC FLOOR ^/ - ; In this stage of the dissection the ischiorectal fossae have been cleared. The superficial and deep muscles on the left of the plate have been removed close to their attachments, exposing the crus, the bulb of the vestibule, and the anal fascia layer. The vaginal wall dissected from its surroundings dorsally and laterally has been drawn together and pushed inward. ANATOMY OF TIIK CP]RV1X AND PP^RTNEUM 21 planes (tlie (liapliraii,!!! and the floor) run ontwai'd to the i)ubic ai-('li, they become farther apart, so tliat at the pelvic wall they ai-e separated by almost the width of the pubic bone. Between these layers we iind the bulbs of the vestibule and the crura to- gether with the blood and nerve supply. The rectal area already outlined is dorsad to the reflections of the layers of the triangular ligaments over the transversus perinei, and this area can be sui)erficially defined by a line between the tuberosities of the ischia. In this region the only structures of importance, aside from the oi-ilice of the rectum, with the external sphincter ani, in the lucMlian line, are the ischiorectal fossae. These two spaces are tri- angular in base as well as in elevation. Each base area is outlined in its connnon median line by the sphincter ani, ventrally by the '' ischioperineal ligament " (as the edge of the triangular ligament is sometimes called), and on the third side by the gluteus-maximus muscle and sacrosciatic ligament. The elevation is bounded toward the me sad line by the lower surface of the rectal sling of the leva- tor ani and the anal fascia, laterally by the tuberosity of the ischi- um, and above that by the obturator fascia covering the obturator- internus muscle. These areas are filled with loose connective tissue in which is a large amount of fatty tissue, but with no structures of importance except some blood-vessels. Behind the rectimi the fos- sae are separated only by the fascia attachments of the rectum to the sacrum. The obturator fascia forming the lateral wall is a re- flection from the anal fascia, and consequently abscess formations in the ischiorectal fossa are prevented from burrowing above the pelvic diaphragm. It is these areas loosely filled that allow of the excessive distention of the vagina in childbirth and of the rectum in normal function. MECHANICS OF THE RELAXED OUTLET FROM the nature of its structure, the pelvic diaphragm, com- posed as it is of the levator ani and the rectovesical and anal fasciae, is essentially of an elastic character. In the nor- mal individual it is practically a perfect shelf, for the ca- nals that pass through it run at an acute angle to its plane, much as does the inguinal canal in the abdominal wall. It is designed, aided by the reinforcing support of the pelvic floor, to bear its share of the weight of the abdominal contents and to overcome through its elasticity the various strains. The pelvic floor aids the diaphragm as a weight-carrier, but has a more specialized function of maintaining the relation of the vari- ous outlets to one another and to the pelvic walls. The muscle ele- ments in its structure control the functions of each orifice. The blending of the diaphragm with the floor gives the former more x)oints of anchorage, since the tension and firmness of the tri- angular ligaments prevent any lateral motion. The pelvic diaphragm, being similar in structure, has the same function as the abdominal wall. Through its contraction, it has the same power of supporting the pelvic contents in cases of strain coming from above and caused by forcible contraction of the thoracic diaphragm, either under exertion or the involuntary action of sneezing or coughing. Besides the diaphragmatic action of the levator ani, this muscle has, as its name signifies, a direct function to perform in connection with the rectum. The same levator func- tion applies to the vagina in a lesser degree through the power of the fibers placed between the vagina and rectum and the attach- ment to the sides of the vagina and the urethra. In extensive injuries of the perineum, meaning thereby injury not only to the floor, but also to the diaphragm, and commonly spoken of as a relaxed vaginal outlet, a serious modification of the normal relations of the structures takes place. This abnormal rela- tion may not result immediately ujdou the production of the injury, MECHANICS OF THE RELAXED OUTLET 23 for tlio scar tissue t'oriiuMl in tli(^ attempt to repair will, through its contraction, delay tlie relaxation. The resulting but temporary support obtained is only of short duration, since scar tissue, or even fascia, will not stand any continued sti-ain without stretching, and because the important muscles have contracted and pulled back with them certain of the fascia layers to which they are intimately attached. The length of useful support from nature's handicapped method of repair depends altogether on the amount of strain ap- plied and the degree of injury. The effects are always progres- sive, and never in an injured perineum does the destructive proc- ess stand still. The ventral rectal wall has lost its support through the injury of the levator ani and its fasciae. The destruction of the central peri- neal tendon allows the retraction of the external sphincter of the anus, with a consequent increase of the distance from the vestibule to the rectum. Thus the expulsive force of the rectum acts in a ven- tral instead of a dorsal direction, and this continued expulsive pressure combined with the weight of the bowel contents stretches the rectovaginal septum, forming a rectocele. The walls of the rec- tocele thicken through unaccustomed exposure to friction, and thus more weight is added. The more this vaginal septum protudes, the less nmscular tone the rectum possesses, since the muscle layers become atrophic through excessive stretching, and thus permit of further fascia stretching. The same process goes on with the bladder in relation to the ven- tral vaginal wall, though more sIoavIj^ at first, because of the close attachment of the bladder to the uterus and the firm attachment of the urethra to the pubic arch. The ventral vaginal wall depends most largely for its vital support on the integrity of the dorsal structures, and even though only slightly injured, will quickly show the effect of the perineal defect. The cystocele and rectocele have been spoken of as hernias of the bladder and rectum, but in the majority of cases they are in reality hernias of the ventral and dorsal vaginal septa. In some cases of forceps delivery the fasciae split, and then a true hernia of the rectum and bladder ma^^ occur, and in these cases the increase in the size of the protrusion is rapid. On examination one can palpate 24 THE GYNECOLOGY OF OBSTETRICS a definite hernia ring of fascia. In ordinarj^ eystocele and reetocele, however, the fasciae are only overstretched and atrophic, and if rest be given by pntting the patient to bed or by placing a pessary to support the cervix, the recuperation and gain in tone is surpris- ing, though, of course, evanescent. The eystocele formation is at first slow, on account of the fairly firm attachments of the ventral vaginal wall and the urethra to the sides and under surface of the pubic arch, and the support of the sides of the vagina and urethra by the levator ani. Soon, how- ever, due to the hydrostatic power of its contents, the development of the protrusion is more rapid. On account of the continuedpressure of urine stretching out the vaginal septa, any marked improve- ment is imjDOssible, and in time the difficulty of operative repair is greatly exaggerated. A slight improvement results from the con- tinued recumbent posture, with its avoidance of friction, and thus the lessening of congestion. This improvement is slight, on account of the weight of urine that is always present. If a pessar^^ is ap- plicable, it can accomplish more, on account of the splintlike sup- I)ort from its rigidit}^ If the uterus were a fixed organ, probably the injurious effects might end with the production of the eystocele and reetocele, for the uterus under normal conditions lies in a horizontal position, and any pressure on its upper surface would tend to force it on the bladder in a more anteverted position. There, on account of the re- lation of the pelvic and abdominal cavities to each other and the rather firm fixation of the cervix at its normal level, it is thrown parallel with the plane of the pelvic diaphragm and acts as a valve, closing the rent in that structure as well as pressing to- gether the vaginal walls. The uterus, however, is not a fixed organ, for provision has to be made for the variation in size of the blad- der and rectum in daily life and the enlargement of the uterus itself in pregnancy. To be a fixed organ, it must have suspensory ligaments. It has ligaments, but excepting the sacrouterine they are not suspensory ligaments. Even the sacrouterine are not true suspensor}^ ligaments, though they approach nearest to that func- tion. If all the pelvic and al^dominal structures are in normal con- dition, the uterus stays in place practically without the aid of the MECHANICS OF THE RELAXED OUTLET 25 ligaments, and oiilx wlicii tlic distcMitioii of the ])ladder and rectum occurs do we find the ligaments placed under any tension. The intact pei'iiieum keeps the abdominal and pelvic cavities closed. Thus, under balanced opposing forces and in the resulting closed chamber, the uterus practically floats with even pressure on all sides except what may bo exerted by the variation in cavity con- tents and respiration. Any injury to the levator ani and its inclosing fasciae that de- stroys the function of the diaphragm permits the entrance of air within the vagina, and thus this uterine balance is immediately dis- turbed and the structures supporting the cervix are compelled to bear the strain intended for the diaphragm. These structures, while firm enough to be most important in maintaining the position of the uterus under normal conditions, are only of fascia composition and are bound to stretch. Combined with the injury to the relaxed vaginal outlet, more or less relaxation occurs at this plane, so that the cervix sinks somewhat, and as it does the body becomes more perpendicular. This position, known as the first degree of retro- version, compels the fundus to bear the brunt of the now most ac- tive force, designated as intra-abdominal pressure, and, with the uterus sinking lower in the pelvis, the uterine ligaments begin to act as suspensory. The circulation is interfered with, the body be- comes heavy and congested and flexes on the cervix, giving a retro- flexion. Now, the uterus has no tendency to return to the normal position by itself, for all the pressure from above is on the caudal surface and the pressure of the bowel contents makes a valve of the fundus. For a time the uterus remains stationary at the same level, except as it varies within minor limits with the changes in pressure in the abdomen from respiration and straining and the weight of the bowel contents, for the ligaments are suspensory, and only as they stretch does prolapse occur. When we consider the strength of the cervical supports and the comparative inf requency of severe degrees of prolapse in premeno- pause life, it is hardly justifiable to consider prolapse wholly as a sequence of retrodisplacement. From the nature of the mechanics, a retrodisplacement is bound to be a forerunner of procidentiae, but ]irolapse as a sequel is not of sufficient frequency to retrover- 26 THE GYNECOLOGY OF OBSTETRICS sion to wholly account for its prodnction. In young women, when prolapse occurs, it comes on after precipitous, severe, prolonged, or instrumental deliveries. Its onset is usually rapid, so it seems more rational to explain the condition by acknowledging extensive injuries to the ligaments and attachments of the cervix and upper vagina than wholly bythe conditions producing retrodisplacements. In women beyond the menopause, complete prolapse frequently occurs suddenly, and this is due to the rapid giving way of the same structures grown atrophic with age and continued strain. Prolapse operations, then, which will take into consideration the strengthening of the tissues at the cervical level as well as the associated relaxed vaginal outlet, will be the most successful, and failures may be due to overlooking these factors. The uterus, having sunken to the point where the upper supports are on tension, remains there just as long as these supports can resist the pull from below and the pressure from above. While the pressure downward is practically a non-increasing force within certain limits, the pull from below increases, as has been shown, by the increased weight of thickened mucous membranes and the increase of the residual capacity of the bladder and rectum. This unaccustomed pull of the rectocele and cystocele on the already en- larged and softened cervix results in a gradual stretching out and further hypertrophy of that organ. The greater the friction exerted by the vaginal walls on the displaced cervix, the greater this hypertrophy, so that in some severe forms of cervical elongation, in which the cervix reaches the vulva or protrudes from the vaginal canal, the elongated and hypertrophied organ may be four and five times the normal width. The size of the hypertrophied cervix in this class of cases may be even longer than twice the length of the uterine body. The cases of excessive elongation of the cervix in which the uterine body remains in practically normal position are still another reason for assuming injuries at the cervical attach- ments as the controlling cause for uterine procidentia. The cases of elongated cervix are not as a rule associated with as severe grades of rectocele, for the cervix by its splintlike sup- port to the dorsal vaginal wall takes much of the brunt of the pressure of the fecal contents, and as the fasciae gain strength by MECHANICS OF THE RELAXED OUTLET 27 sui)))()rt tlic iiiusc'lo eleiiuMits in botli tlie walls of* tlie va<2,iiia and the rectum also dcNcloi) tlii()ii,ii,li the relative shortening between their attachmeiit i)oiiits. In cases of uterine prola])se we also find the conii)aratively smaller rectocele throngh this same support by the uterine body. AVhat is true of the rectocele is not true of the cysto- cele, for, witli tlie stretching- of the cervix, the ])ladder, through its attachment thereto, is also stretched out ; and correspondingly, in cases of elongation of the cervix or uterine prolaj^se, the cystocele l)ecomes a most ])rominent protrusion. in this discussion of uterine pathology that is secondary to the relaxed vaginal outlet, we have referred to the force that acts from al)ove in helping to produce the abnormalities. Casual considera- tion might result in the conclusion that gravity was the greatest factor involved, and that in time it could produce the hernia of the pelvic contents. Tn reality, gravity directly plays only a moderate ]iart, for when the patient is erect the center of gravity of the ab- domen, on account of the relation of the abdominal to the pelvic cavities, falls well out of line of the true pelvis, directly upon the bony walls and the lower abdominal muscle wall. The direct force of gravity becomes indirect in the pelvis and is decreased by the friction of the abdominal contents against the lower abdominal wall, especially in women with enteroptosis. The force from above that exerts the greatest power is in reality a combination of forces, and for convenience has been designated intra-abdominal pressure. The question of what intra-abdominal pressure really is, in fact the existence of such a factor at all, has occupied the attention of many, and vain attempts have been made to get some measure of its poAver. Gravity plays a most important part, but directly counteracting that force is a factor that was very frequently discussed by the older writers, and designated by them the '" retentive power" of the abdomen. This " retentive power " of the abdomen is practical- ly the condition so frequently found in attempting to deliver a pelvic tumor situated low in the pelvis and in close relation to its walls. Not until we can admit air beneath the mass does the groA\i:h come up easily. This condition, of course, is due to the lack of dead spaces within the abdomen, and is nothing more than the effect of 28 THE GYNECOLOGY OF OBSTETRICS air pressure. The more or less elastic character of the abdominal contents and the containing abdominal muscle makes more effective the relative vacuum and prevents the displacement of the abdomi- nal contents. In a normal closed abdomen, the pelvic cavity also included, the pressure on any one j)oint of the internal wall must be a component of at least three factors. The first of these factors is the weight and pressure of the contents of the hollow structures, these contents being either solid, liquid, or gaseous, or a combination, according to the nature of the function of the organ. But this internal force is held in restraint and somewhat counteracted by the second force, the contractile power of the muscle and elastic fibers composing the containing walls, aided by the ligamentary supports of the various organs. If the contents of an organ are solid or liquid, gravity alone is involved in the production of excessive distention. But in those organs where fermentation may give rise to gas formation the laws of gas x)ressure and expansion come into play. Over these two forces the individual has no voluntary control. The third force, on the other hand, is almost wholly a voluntary one and exerted through the contractile power of the thoracic and pelvic dia- phragms and the containing lateral muscle walls. The abdominal walls and the thoracic diaphragm act largely in conjunction, where- as the pelvic diaphragm is more of an antagonist, and in its con- traction bears the strain of the force applied by the thoracic dia- phragm in normal respiration or involuntary actions, as in hic- coughing, vomiting, etc. It is the component of these three forces, then, that determines the character and degree of any internal abdominal pressure, and these forces can in many wa^^s be modified; for instance, excessive pressure of the internal contents of an organ will cause a relative paralysis of that organ's muscle fibers and prevent emptying, thus doing away with the controlling second force and allowing great in- crease of the first. A poison acting on the sympathetic nervous system ma^^ also result in a x)aralysis of the muscle fibers pro- ducing the same results. Peritoneal inflammation or irritation by direct action may also produce paralysis. In a normal abdomen gravity is largely a potential and not so much an active force. It MECHANIC'S OF TWb] HKI.AXKl) OUTLET 29 is ('\'('i't(Ml a(*ti\'('l\' witliiii llic <'a\it\' upon tlic soIkI coiitoiits of tlie coiitniiiiiiii,' or,i;'aiis, and upon an oi-,i;an itself that has h)st its suj)- poit, sucli as we find witii a movable kidney; ])ut upon the contents of tile abdomen as a whole it is practically non-active, l)ein<>- dis- tril)iited evenly upon tiie intact containing' walls. Undci' iioi-nial conditions tiiesc forces are practically balanced and concern us little, but when a break occurs in either the abdomi- nal wall or })elvic dia])hra^ii,ni this balance is disturhed, and the nor- mal forces, meaning therehy gravity, gas distention, and pressure from forcible contraction of the diaphragm and abdominal walls, produce serious conditions where the defect is not remedied. These normal balanced forces can hardly be designated by a specific name, but when the balance is disturbed we are justified in defining the abnormal relation of pressure by some specific term, and it is to this abnormal relation that the name ''intra-abdominal " pressure applies. "Intra-abdominal" pressure, then, is the comi)onent of the three forces found in the normal closed abdomen, with an in- crease in the force of gravit}' the lower the artificial ox^ening in the retaining walls, but again restrained somewhat and in the same increasing ratio by the so-called "retentive power" of the ab- domen, or, in other words, air pressure. When it comes to the pel- vic diaphragm, the gravity of the abdominal viscera is lessened, as has been explained, by the change of direction of the force and by friction, but the weight of the bladder and rectum contents is added. In the case of each individual organ having suspensory liga- ments the sum total of gravity does not vary, but, on account of the upper i)oints of attachment, the place upon which it acts with a static force will be modified. Xow, while as a rule an abdominal hernia unrestrained will in- crease in size more rapidly than the pelvic hernia, this is not wholly due, as might be supposed, to the greater force of gravity exerted on the lower abdomen over the pelvis, on account of the body con- struction. In the pelvis are the cervical and uterine supports bear- ing the strain, and only as they stretch does the greater degree of procidentia develop. Consecpiently, the development of the end con- ditions of the relaxed vaginal outlet is of insidious onset, but al- ways progressive, and the rai)idity of the progression depends on 30 THE GYNECOLOGY OF OBSTETRICS so many factors in the life of the individual woman that a prog- nosis of the time required is impossible. What may occur rapidly in a hard-working individual may take years in one of sedentary habits, though in each case the primary pathology may have seemed to be identical. But neither is it alone the individual's activities that hasten the process, for other factors concerning the resistance of fasciae and scar tissues have to be considered. The woman's correctness of car- riage, the proper application of corsets, the care during subsequent pregnancies, and the control of all those other conditions favoring pelvic congestion have a very significant bearing on the final out- come. "While prophylaxis in all those things which favor pelvic congestion has its influence on the final outcome, yet the process goes on progressively until the repair of the pelvic diaphragm and outlet is accomplished. ETIOLOGY AND PREVENTION OF LACERATIONS To THE ([uestioii of ctioloi^y and |)r('veiiti()u of eliil(n)irtli injuries very little attention is ])ai(l in the obstetrical text- book outside of the consideration of the perineum and the means reconnnended to prevent injuries there. The meth- ods advised are pretty well stereotyped, and practically all discus- sions consider the technique of the most normal presentation, the abnormal cases being acknowledged to result almost invariably in injury. On the prevention of cervical tears little is said. Regarding the pi-evention of perineal injuries we have different methods advocated. Varnier teaches that it is the child's forehead that is liable to cause injury. He recommends holding back the fore- head so as to prevent extension until the parietal eminences and neck are delivered under the pubic arch, and then allowing the slow appearance of the forehead, nose, mouth, and chin successive- ly, and that preferably in the interim between pains; this he ac- complishes by pushing back the vulvar parts, and, if possible, is aided by the voluntary expulsion on the mother's part. He thus acknowledges that it is the rapid expulsion of the head Avhich causes the greatest danger. If delivery is accomplished as he ad- vises, he states that there is no fear of perineal tear. Such may be true if the relation of child to mother is not abnormal as regards size. Hartmann advocates Varnier 's method and rather belittles the frequently recommended supporting of the dilating perineum by the obstetrician's hand, "for the perineum will tear under the hand supporting it. " Peterson says: "In spite of the greatest care, lacerations will occur in certain cases, but if the obstetrician is skillful, the tear will be of mininmm size. There is seldom any excuse for the exten- sive rupture upon which the gynecologist operates later." The fact remains that the more skillful the obstetrician the less severe the injury, but that there is no excuse for the extensive 32 THE GYNECOLOGY OF OBSTETRICS relaxations found later is not true. From the hands of the best ob- stetricians often come some of these same extensive relaxations, and the reason for this has been shown in the chapter on the results of perineal injury. All such injuries are progressive, and many re- sults seemingly good shortly after labor lead to a marked degree of relaxation as the scars stretch and muscles atrophy. The in- juries which are the result of the giving way of the muscles and fascia beneath the uninjured mucous membrane also take time to develop. The use of the rubber water-filled bag has been recommended by Macomber as a method of dilating not only the cervix, but also the perineum, and thus avoiding excessive injury. He advises placing the largest bag possible, preferably of the Voorhees type, within the vagina during the first stage of labor. He claims that thus the transmission of pressure from the uterine contraction helps the perineal softening, and the presence of the bag with its weight upon the outlet stimulates the uterine pains. After the first stage is over, the descent of the child pushes the bag ahead, giving a more gradual and even dilatation than would be accomplished by the ver- tex, and the bag's presence still acts as a stimulator of uterine con- tractions. In the opinion of some obstetricians, it is held that the degree of injury can be more readily controlled with the patient in the lateral posture rather than the dorsal. In the lateral position it is easy to demonstrate that the tear begins within the vagina, and that in most cases the diaphragm gives way beneath the superficial structures, an occurrence it is impossible to prevent. Another method advocated for the prevention of injuries is the incision of the vulva, or episiotomy. According to Berkeley and Bonney, "In exceptional instances, when it appears certain that the head cannot be born naturally without a severe rupture of the perineum, deliberate incision of the latter should be performed. The division should not be made in the middle line but to one side of it. Bilateral incision is preferred by some authorities." Hartmann, already quoted, says : " The little incisions in the vul- va are useless and only lead to tears. If the central tear is feared, make an oblique incision backward and outward ;. a median section Plate VIII THE MUSCLES OF THE VAGINAL OUTLET DISSECTED TO SHOAV THEIR RELATION TO THE VAGINAL OUTLET, WITH REFERENCE TO EPISIOTO:\IY INCISIONS U\|eK3 Tr^n^u/ar l.is'vnet^t' REMevco (£'Vv;mult>o -CAveRNy>tJs Vagina! waI/ On the left side the superficial muscles with the superficial layer of the triangular ligament have been removed. The well-devel- oped deeper muscles are shown running into the central tendon. On the right side the superficial muscles are still present and dissected from the deeper layer only in the ventral portion at the pubic arch. The sphincter ani is separated from its sheath and is shown in its attachment to the central tendon and the coccyx. The anal fascia is exjiosed over the dorsal portion of the levator ani. ETIOLOGY AND PREVENTION OF LACERATIONS 33 increased by the passage of the fetal liead risks the iiipture of the nmseulai- tissue ol* tlie amis." Peterson sums up the question of episiotomy as follows: ''1. Many cases in which a tear of the perineum seems innninent escape without any lesion whatever if the obstetrician takes time and pains in the management of the delivery of the head. 2. There are two incisions, while a tear in the perineum may be single. 3. A tear in the perineum, if properly sutured, unites as well as the wounds in episiotomy. Rui)tures of the perineum may involve the levator- ani muscle or anal sphincter and are in a location more difficult to kee]) clean than the posterolateral wounds which involve no im- portant structure. Episiotomy seems justifiable only when the oper- ation is certain to substitute two slight w^ounds for a serious peri- neal laceration ; the less experienced the obstetrician the more like- ly is he to x^erform episiotomy." What does episiotomy as ordinarily advised accomplish, and does it by any chance prevent the injury of the deeper structures or direct the injury in the desired direction? The operation is done when the head is beginning to distend the vaginal outlet excessively. Surrounding the protruding head then are the vaginal-sphincter muscles, with the inner edge of the tri- angular ligaments markedly on stretch. The elastic central tendon to which these structures as w^ell as the transversus perinei and sphincter ani are attached is stretching across the bregma, which is putting excessive strain on these muscle attachments and the in- closing fasciae. It is practically impossible to determine the amount of room required, and there is no way to check the tear once started in the incision lines or to control its direction. The majorit^^ of the episiotoni}^ incisions probably sever only the stretched-out labia minora or fourchette, and possibly the edge of the fascia shelf, for it has been estimated that the skin and mucous membrane, when the perineum is in full extension, extend two to three centimeters be^^ond the muscle. When one realizes from dis- sections how comparatively deep the vaginal sphincters are placed beneath the labia, it is easy to see that the average incision would not involve that muscle. If the incision is only deep enough to cut through the superficial structures and Colles's fascia, its location 34 THE GYNECOLOGY OF OBSTETRICS is of little importance, provided that location does not involve the portion of the mucous membrane overlying the orifice of the gland of Bartholin, which, if involved in the resulting scar, might favor a cyst development. To be sure of saving the portion of the perinemn most important, such incisions must be carried through the pelvic floor, for a tear that is not going to involve that structure should need no episi- otomy. If the incisions are placed laterally in no matter what radial direction and deep enough to accomplish the desired purpose, they are bound to cut across some portion of the muscle sling around the vagina. The more downward and outward they are from the horizontal line, the less of the total width of this muscle sling they separate on account of the radiation at the central tendon attach- ment, but the greater the chance of separating the transversus- perinei attachments. AYith the severance of these muscles, the fibers immediately re- tract, for they are not sufficiently attached to the fascia laj^ers to be held thereby. The incision is probably repaired by uniting the fasciae and the mucous membrane, the retracted muscle being overlooked. The chances are that, lacking the support of the floor, the portion of the pelvic diaphragm between the vagina and the rectum has given way, but exposes no injur}^ superficially. The lateral attachment of the levator ani to the sides of the va- gina pulls forward the segment ventral to the incision ; the contrac- tion of the sphincter ani, the dorsal portion. The consequence is that immediately following the closure of the incisions where the muscles have been ununited the results look good, but all the fac- tors are present for the later development of a relaxed outlet. If it seems mse to guide the injury that it is impossible to pre- vent, I prefer to incise the apex of the stretched-out fourchette through the central tendon as far as it appears necessary. If the injury promises to be so excessive as to involve the sphincter, it is possible to direct the cut to one side or the other, though such pro- cedure is almost out of the possibility of requirement, as careful delivery will save the sphincter almost invariably. Injury of the i^Tioi.odv Axi) nn<:\'Kx^n()X ok lackuatioxs :]5 spliiiictci- is almost without (lucstioii tlic result of too hasty de- livci'W though thci-c ai'c occasioiuill)' suhjccts where the tissues seem to melt a\\a>- uudei- pi-acticall)' no strain. I prefei- this median incision, knowin.i;- that, witli the method of i-e|)air advised, it is ])ossihle in the majority of eases to ^-et fi,-ood results. With a direet median ineisiou tliere is no danger of indi- vidual nmsele i-etraetion, foi- at this point the fasciae and muscles are intimatel_\' associate(l. it is also easy to follow up the exten- sion of the injury if it has gone beyond the range of the incision. There is then also no unsuspect- ed subnuieous tear overlooked, and, moreover, it is possible to adjust the size of the incision to the size of the head. Tn cases in which the dia- phragm has given way beneath the uninjured mucous mem- l)rane, and even beneath tlie central tendon, some authorities advise cutting through the bridge of tissue so as to be able to approximate the retracted structures. Tf, according to Hartmann, " in spite of all prevention the This patient has been twice coufiueil. In neither case was there any tearing of the mucous membrane. The degree of relaxation is very marked, but on the ventral wall the rugae are still prominent. If a patient is confined in the lateral posture, such an in- juiy to the levator ani may be more readily observed during its occurrence. ]ierineum is torn, the rupture is lateral always, the posterior column of the vagina, fil)rous and re- sistant, remaining intact. The vagina, skin and vulvar constrictor being torn tlirough, on se])arating them, we get a lozenge-shaped wound which left to itself to cicatrize results in a ]ierineum which no longer plays its role as a supporting agent." It is true that in the majority of injuries the tear is lateral, not, however, because of the resistant dorsal vaginal wall. The greater numlier of tears are unilateral, with probably a larger per cent on the left, but wlietlier this is due to the preponder- 36 THE GYNECOLOGY OF OBSTETRICS ance of left presentations, as claimed by some writers, is question- able. It is probabl}^ true that some of the tears are caused by the de- livery of the shoulders rather than the he^d; or, at least, we can perhaps more safely say the shoulder deliveiy increases the degree of injury, for it is impossible to determine the extent of the tear re- sulting from the birth of the head, especially where the central ten- don has not been excessively injured. The injuries produced by the shoulders are more often than not due to the greater haste of the obstetrician in their deliver}?- or are a result of the method used to extract the arm. If the central tendon only is involved, and the structures are of equal strength on either side, the tear is alwa^^s in the median line, for that is the point at the apex, as it were, where the greatest ten- sion comes. If the central ten- don is not involved, but tearing of the pelvic diaphragm occurs, it is always situated laterally. Tears of the vaginal mucous membrane may occur in any di- rection if the stretching is too severe, but the tear in the dia- phragm always runs to the side in the plane of the levator ani, and this is accounted tor by the anatomical relations. A combina- tion tear involving both the floor and diaphragm is a " Y "-shaped injury if both sides of the vagina are involved, though only one arm of the " Y " is present when the injury is not bilateral. We must bear in mind that if the diaphragm is injured, no matter in what direction the mucous-membrane tear occurs, we can demon- strate the defect by careful palpation. The very presence of a lat- eral tear running from inside the central tendon indicates a rup- tured pelvic diaphragm. A relaxed vaginal outlet in which the cen- tral tendon and median raphae have not been injured. The injury to the levator ani has permitted the development of a rectocele. This patient had had an abdominal oper- ation to correct a retrodisplacement, but with no improvement to her symptoms. A perine- orrhaphy cleared up the physical condition. KTIOLOUY AXI) PRKVKXTIOX OF LAC'KHATIOXS 37 Upon the I'datioii ot* tlic s(',<;-ni('iits of the Icvatoi' aiii to each otlici* and upon tlicir attaclmiciits in tlic median line depends tlie C'oui'se of injury to llic pcKic diaplii'a,i;in. 'riic Ncnti'a! se<;'nient of the muscle, hy its linn attachment to the si(h'S of the vaj^ina and its fascia layei-s attached under tlie pul)ic ai'cli, together witli the firm triangular ligaments, -prevents any chance foi- much freedom of play, and practically fixes the ventral and side walls of the vagina. AVhen the excessive dilatation comes, the picssure is conseciueiitly exerted most markedly in stretching out the parts dorsal to these structures. The dorsal edge of the triangular ligament, which has heen called the '* ischioi)erine,al " ligament, for all ))ractical pur- poses may he considei'ed as defining the fixed portion of the pelvic diaphragm fiom the more readily distensible portion dorsally. The pressure of the child as it comes from the hollow of the sa- crum under the pubic arch is directed, against the dorsal two-thirds of the pelvic diaphragm. The portion behind the rectum, on ac- count of its protection b}^ the two firm fascia layers and the elas- ticity of the rectum itself, bears the strain best, and is also well ])rotected from sudden force by the central portion of the muscle with its fascia reflections situated between the vagina and the rec- tum. Xaturally, this portion between the vagina and the rectum, w liicli is })ractically a separate segment, is the one first to give way to dilating forces. Having given way, it is on account of the firm fixation of the vaginal canal ventrally and laterally and the greater elasticity of the dorsal segment that the tear extends up the vagina in the plane paralleling the segment division. This same injury can happen without any superficial tearing in cases where the disten- sibility of the vaginal canal is possible on account of well-defined rugae. As a rule, in such subcutaneous ruptures, the central tendon is elastic enough to stretch Avithout tearing. Thus, the most careful palpation is necessary to define such an injury, as superficially there is no evidence. Lacerations of the cervix are even more frequent than perineal injuries. Some men write of jDhysiological lacerations of the cervix, thus acknowledging the fact that in practically every case we get some degree of injury. Many are shallow enough to involve the mu- cous membrane only, and these naturally are of little pathological THE GYNECOLOGY OF OBSTETRICS consequence. What concerns us in the later plastic work is the tear that is deep enongh to injure the circular muscle fibers, and which in the process of healing gives the round-cell infiltration and later the scar-tissue formation in the angle of the wound. It is true that we may prevent the formation of extensive injury by avoiding the too early application of forceps or too strenuous forcil)le dilatation. The more severe cervical injuries probably occur from forceps deliveries, and especially in those cases where the undi- lated ring is carried down Avith the head, pinching the ventral lip between the head and the pubes. It is probabh' true, too, that the shoulders may produce injuries or in- crease those alread}^ pro- duced by the head where ex- traction is too rapid. The text-book advice is to leave cervical injuries alone unless the need of control- ling hemorrhage arises. The difficulty of the work, the in- creased risk of infection, the rapid involution of the tis- sues in the first days, which tends to leave the stitches too slack to approximate the torn edges, and, finally, the fact that the majority of tears heal kindly without intervention, give us the authority for this stand. However, a large number of cervical tears do not thus heal by first intention, and the formation of scar tissue, with or without the turning out of the cervical mucous membrane, gives rise to the secondary symptoms. There can be no doubt that many miscarriages are due to the persisting deep clefts in the cer- vical tissue, even when not associated with endocervicitis, which alone is enough to prevent pregnancy or favor miscarriage. Lacerated cervix. The greater injury is on the left side, extending as high as the internal os. This patient miscarried twice before operation, but since then has been confined at term. ^7l^l()IJ)(i^' AXI) IMJKN'KXTIOX OF LACERATIONS :;9 The usual trcatincut of the pai'luriciit woman lias kept her lii-ni- ly baiula^-ed and lyin.ii,- on liei- hack. During the (ii-st twenty-four liours after eonrnieuuMit, a siiu.i;ly littin.ii,- hinder with a fii-ni pad, so placed as to keep the fundus against the puhes, favors tlie contrac- tion of the uterus and the prevention of liemorrha^-e. After tlie dan- ger of i-elaxation has- passed, anythin,!;- hut a loose binder is not only usek'ss, ])ut may be injuri()uic in charactei", and, lik<' all eiiibrNonic cells, have ^•i-eater power of reproduction and t;ro\v at the expense of the nor- mal elements. Most pathologists l)elieve tJiat the cancer cell is a " weak cell" and less resistant to destructive agents than the normal tissue ele- ments. For this reason radiotherapy, either witii the X-ray, radi- mn, or mesothori- um, has the ])()wer to injure the can- cer cell more rajnd- ly than the normal tissue. The cancer cell thus can be considered as hav- ing a greater ac- tivity of growth, which is a positive powder, but as lack- ing tlie negative faculty of resist- ance, Avhich is a (juality of normal tissue. Theoretically, it would be more nat- ural to expect the malignant growth to have its origin in the ven- tral oi- dorsal lip rather than at the site of the tear, for the normal 1)1()0(I supply runs around the cervix from its lateral origin, and the scar-tissue contraction at the angles of the tear w^ould decrease the supply there, but tend to increase it in the normal tissue through interference with the return flow\ It w^ould also be more natural to expect the stimulation by the circulation, with the in- creased growth in the cells that are free from the cicatricial tissue found around the angles of the tears. The much more frecpient per- A section of an adenocarcinoma of the cervix. The more marked stroma, with the proportionally less heaping of the the epithelial cells, indicates a hard, slow-growing tumor. The malignancy is marked by the usual characteristics. Such a growth, while relatively common in the uterine body, is comparatively rare in the cervix. 48 THE GYNECOLOGY OF OBSTETRICS sistence of the lateral clefts in injuries of the cervix over those in the ventral and dorsal lips tends to make us overlook the fact that injuries do occur and persist as well in the median line of the cervix, and in those cases we should rather expect the degeneration to begin laterally. The early manifestations of the disease differ little in appear- ance and character from Nabothian cyst formation, but the greater induration, the solid and less translucent character, the single nod- ule, the location in the ventral or dorsal lip, usually at the mucous jmicture, tend to aid in the differentiation, and, fortunatel}^, in the mi- croscopical examination lies our method of posi- tive diagnosis. It is in this stage that its recog- nition is difficult, and that its removal by high amputation, as advised by some men, by actual cautery, or by carbon- dioxide freezing is pos- sible. Later it is only from more extensive procedures, such as hys- terectomy, that we can expect a radical cure. In the late stages, when operation is impossible, the only hope lies in the cautery, the X-ray, or the newer applications, such as meso- thorium. That the recent excessive enthusiasm over radium in the treatment of malignancy is not well founded is the opinion of men most qualified to pass upon the subject. In the beginning of the growth the only symptom present may be increased leucorrheal discharge. By the time blood-streaked mu- cus and bladder irritation and pain have supervened ulceration has A highly magnified reproduction of a portion of the preceding section, showing a single gland. The char- acteristics of malignancy are well shown — the meta- morphous character of the cells, the irregular heaping, with the destruction of the basement membrane. I>ATTK)L()(JV OF TlIK (M^RVIX 49 ()('cuii(mK and the alaiidiilar cxtciision, and thus offers greater hope for complete ex- tii-|)ati()ii. 'i'lic cai-ciiiomatous type havini;- its origin on tlie surface of the cer\'ical canal mucous meinhrane, oi' witliin the g'lands them- A malignant tumor of the cervix in which the growth has pene- trated deeply into the tissues. Some of the finger-like projec- tions are here shown in cross-sections. Not only the squamous cell, but also the cylindrical growths, tend to this arrange- ment. This section is from glandular carcinoma, judging by the character of the cells and the fact that the masses of cells are growing toward their center. selves, is more rapid in growth, especially in younger individu- als, and, if not accompanied by ulceration, may progress within the canal to serious involvement without producing sufficient symptoms to cause its recognition. It will, on account of its mor- phology and situation, involve the lymphatics earlier than the epithelioma. Cervical curettage and microscopical examination aid in the 50 THE GYNECOLOGY OF OBSTETRICS earl}^ recognition, and, if malignancy is proven, should be followed immediately b}^ radical treatment. Cases have been reported in which the clinical symptoms pointed toM^ard malignancy, while the tissue examination had negative find- ings; but, as Dr. Rodman, of Philadelphia, in reporting a case of lip ulcer excised as possibly malignant but returned as benign by the pathologists, says, " The patient is happy that he hadn't can- cer, and I am not unhappy that it wasi prevented. Instead of cha- Metfistatic crarciiiuiiia of a lymph gland. Characteristic nests of epithelial cells are present throughout the entire gland. This section of a normal-sized lymph gland, about an eighth of an inch in diameter, well illustrates the im- possibility of complete gland extirpation in cases of can- cer of the uterus. It confirms the present opinion that the extensive gland dissection with its high primary mortality is not justifiable. A carcinoma already beyond the cervix may have many such metastases. grin, when such reports are received from the laboratory, there is cause for exultation. The more of them the better. ' ' It is the belief of some surgeons that curettage or tissue removal done for examination purposes only hastens the spread of the disease. In no case must we disregard clinical findings for those of the laboratory, since it is impossible for any examination to be exhaustive, and the malignant structure may be overlooked by sur- geon or pathologist. It is better to do the radical work if the clin- PATIIOr.OGY OF THE CERVIX 51 ical syinptoins are suspicious, even if the pathological report is iu\t;ative. If i)()sitive evidence is obtained, no delay is justified, and the ([uestion of exten(lin,i!,' the infection, if an innnediate operation is done, can hai-dly enter into the discussion. Fibroids of the cervix are comparatively common. Sarcomas oc- cur, ))ut are rare. Neither condition conies within the scope of our ]) resent i)urpose. These are mentioned only to emphasize the possi- bilities. (Miorioepithelionia of the cervix or vaginal canal is a possibility, hut it always has as its forerunner a complete or an incomplete {jregnancy, a i)ervert- ed pregnancy, such as in hydatid mole, or a teratoma. When cliorioepithe- lionia occurs in the va- gina, it is most often situated on the dorsal wall a little beloAv the ])oint opposite the cer- vical OS. A recent case in my hands presented the appearance of an irregularly punched- out ulcer about one- half inch in diameter, the edges undermined, the base seemingly an attached blood-clot. Profuse bleeding had taken place from the ul- cerated area at the time of an abortion of a tAvo-month pregnancy, and had been controlled by the physician in charge only by suture and packing. Every chronic congestion of the cervix and cervical canal has a mechanical basis for its presence. It may be an injury from child- birth to the cervix itself or to the perineum, and this is the most frequent cause, but in the nulliparae we find other factors. The in- flammations of the mucous lining of the uterus have previously Section of segment removed for diagnosis. The squamous- cell carcinoma is replacing the normal epithelimn of the cervix. The findings are typical of epithelioma of the cervix, or the so-called ' ' chancroid der portio ' ' of the Germans. 52 THE GYNECOLOGY OF OBSTETRICS been considered as primary and various classifications of the sup- posed types of chronic endometritis and endocervicitis, and are still so described. According to various investigators, there are no changes in the lining membrane of the uterus in the supposed chronic inflammations which are not duplicated in the normal men- strual cycle. Hitschmann and Adler, in describing the normal changes in the menstrual cycle, divide them into four stages, and their findings are so far borne out by other observers. " 1. The premenstrual stage, corresponding to the chronic glan- dular endometritis, begins six to seven days before menstruation. The mucous membrane is thickened and develops a deeper, spongy portion in comparison to the superfi- cial compact layer. There is increased glandular ac-, tivity, as evidenced by the swelling of the cells with encroachment on the lu- men, the glands as a whole being more numerous, large, and tortuous, the stroma consisting of large cells of the decidual type. "2. As the time of men- struation approaches, the vascular engorgement be- comes more marked. With the onset of menstruation red blood cells appear, first in the superficial layers of the endome- trium, then in the cavity of the uterus. The hemorrhage produces a rapid detumescence and emptying of the glands. " 3. The post-menstrual stage, corresponding to the description of chronic interstitial endometritis, is a short period of comparative inactivity and rest. The mucosa appears thin and pale. The glands are straight, oval in contour, simple, and are lined with low, colum- nar eiDithelium. The stroma is composed of spindle cells. Secretion is entirel}^ absent. "4. The final stage is characterized by renewed activity, mitotic cell diydsion abounding. The glands increase in size, are at first A portion of the preceding specimen more Mglily magnified in order to show the type of cells and their arrangement in finger-shaped masses — findings that are typical of an epithelioma. PATllOlJXiV OK TIIK C'KKVIX 53 corkscrew in shape, and later approach tlie ii re^uhir iMeineustrual tyi)e. The epitheliuiii likewise develoi)s increasing- activity, wdth increasing- intracellular secretion, and the stroma cells IxM-ome more succulent and translucent." Many patients having- all the symptoms formerly supi)osed to be ]iatlioti-nonionic of glan'dular endometritis, the increased bleeding and leucorrhea, have been shown by several observers to have no r Invasion of the cervical tissue beneath the intact epithelium by the cancer cells is shown in this section removed for diagnosis. The ill-defined line of invasion, the character of the invading cell, and the line of round-cell infiltration are characteristic. demonstrable microscopical signs of inflammation; and many others without the supposed classical symptoms do present what is acknowledged by all who have studied this problem to be the only true test of inflammation — the romid-cell infiltration from the blood plasma. Clinically, it is evident that there are many conditions remote from the uterus that give the symptoms generally credited to 54 THE GYNECOLOGY OF OBSTETRICS endometritis or endocervicitis ; this is emphasized by the ahnost invariable failure of a curettage alone in curing the patient. Aside from a curettage done to complete the emptying of the uterus or to obtain material for diagnosis, I feel that the place for a simple cu- rettage does not exist. From clinical experience, I feel justified in attributing all inflammations of the cervix, aside from infections, to some condition in the pelvis of mechanical production. There is Sec'tioii uf segment removed for diagnosis. The diagnosis of adenocarcinoma of cervix is made be- cause of tlie characteristic cells invading the tissue beneath the epithelium. There is no distinct line of demarcation between the cancer cells and the cervi- cal tissue, but the surrounding line of the round- cell infiltration is marked and typical. no doubt that ovarian, or possibly other ductless-gland pathology, may stimulate glandular hypertrophy or msij give rise to the symp- toms of leucorrhea and hemorrhage without pathological changes in the uterus, although severe glandular overgrowth often gives no such symptoms. In most cases, however, these S3anptoms are an attempt of nature to relieve the pelvic congestion, and as such are a benefit to the patient as long as the cause remains, but it is abso- PATHOL()(JV OF TIIK CP:RVIX 55 liitely essential to look far afield in order not to overlook the causa- tion. In this coiineetion a detailed eoiisideratioii of the pathological possibilities of endometrial changes resulting from causes away f I'om the pelvis is not in place. Conditions that produce circulatory disturbances, especially those increasing blood pressure, are the pathological possibilities of greatest importance. Some men claim that a displacement of the uterus does not pro- This section shows a typically malignant nodule situated in the deeper structure of the cervix. It emphasizes the possibility of overlooking a begin- ning tumor if small or deeply situated. The sur- rounding inflammatory infiltration is well shown. duce congestion of that organ, and argue that because a uterus does not change in color when replaced it is not congested. It does not require much clinical experience to show that a uterus rapidly decreases in size when replaced or even held higher in the pelvis by tampon treatment. A knowledge of the course of the circulatory supply of the uterus with its tortuous vessels shows how a very little rotation may produce marked venous stasis. With the circu- lation interfered with, and often aggravated by improper clothing forcing down the abdominal organs and interfering with the ve- 56 THE GYNECOLOGY OF OBSTETRICS nous flow, it does not need any infection to produce changes in the mucous membrane. However, all the conditions are present for the rapid growth of germs if implanted. The mucous membrane, being the softest and most vascular tis- sue, shows the effect first, and the more readily so on account of its The fibrosarcoma of the cervix is comparatively rare. In this section the masses of embryonic connective-tissue cells are em- bedded in the fibrous tissue with no distinct arrangement. The free blood supply is fairly well shown, the vessels exhibiting the characteristic thin walls of the sarcoma. The larger vessels have in places practically no walls, and these are known as ' ' blood channels. " It is this construction that accounts for the transmission of these growths by the blood stream. physiological function. As the uterine cavity does not readily in- crease in caliber, the swollen membrane tends to seek the course of least resistance and is crowded outward, so that even in the un- injured cervix we get an everted mucous membrane. The continued internal pressure from the increased congestion gives in time a dilatation of the canal. In all these cases of long standing the canal is abnormally patulous. The mucous membrane, designed to occupy PATII()L()(iV OK MMIK CKKXIX .IT a |)i-()t('ctt'(l position, wlicii I'oi-ccd outward toward the vagina, wIkm-c tlic prcssuic of the adjacent oi-.gaiis has more effect, loses its siiiule hiyer-cell covei-ini;' and an ei-osion results. Within tlie eanal the sweHin,^■ and coiig'estion tend to altei- the secretion of the glands, wiiich heconies thicker and more tenacious in character. The gland tlucts become obstructed, and with the collection of the contents within the gland itself we lind i)resent what has been called a cvstic endocervicitis, and later, as some glands crowd outward This higher magnification of the preceding section of a sarcoma of the cervix shows the embryonic connective- tissue cells more in detail. The irregular arrangement of the cells, typical of malignancy, also more clearly shown. toward the vaginal lining of the cervix, the development of the cystic cervix. This condition may have taken place with the me- chanical interference to the cervical branches of the nterine arter- ies found in anteflexion as well as with the retrodisplacements and l)r()lapse. Such pathology occurs more rapidly and markedly in a case of lacerated cervix where the wound has healed by granulation process ending in scar-tissue formation. The contraction of this scar tissue seriously interferes with the blood and nerve supply. The old-time ''ulcerated cervix" of the woman who has had 58 THE GYNECOLOGY OF OBSTETRICS children is, as was first emphasized by Emmet, the end result of the ' ' ectropion, ' ' or turning outward of the normal mucous mem- brane of the canal. The read- ily bleeding area around the OS, which is looked upon as an ulceration, is the mucous membrane of the cervical ca- nal eroded through exposure A chorioepitheliiiiiiH of the cervix. In this ease the growth is situated be- neath the intact epithelial covering. The irregular arrangement of the embryonic structures surrounding and penetrat- ing the blood sinuses is typical of this type of malignancy. A chorioepitheli- oma must of necessity be associated with a pregnancy of some type or a teratoma, on account of the villi base. Pick has demonstrated the occurrence of practically all the body elements in teratomata, or so-called ' ' dermoids, ' ' except the villi, but the occurrence of chorioepithelioma in non-pregnant wom- en, and occasionally in men where ' ' dermoids ' ' existed, would seem to pro\e the presence of villi in such cases. A section from a case of metastatic chorio- epithelioma with the primary growth in the cervix. At abdominal section a diagno- sis of tuberculous peritonitis was made from the gross appearance of the lesions. The tumor presents the characteristic ap- pearance of this growth as well as some fatty tissue of the omentum from which the nodule was taken. The section is from the laboratory of Prof. Ludwig Pick. A higher magnification of the metastatic cho- rioepithelioma on the omentum. It shows the typical elements of the growth and their re- lation to the blood cavities. rATIIOIJXiV OF TIIK CKKN'IX 59 to friction, and rnrtiicr congested and swollen by nature's efforts to Ileal by lynipli infiltration. Tliis healing- process imposed upon the incchanical congestion I'aN'ors tlic overgrowth of tlie deeper structures and a hypertrophy of the ventral and dorsal lips re- suits, wliicli tends to further exi)ose the canal lining. It has al- ready lieeii shown how the relaxed vaginal outlet, by its mechanical ^. Chorioepithelioma of the cervix. The characteristic findings in this type of growth are the presence of villi elements, irregular overgrowth associated with large blood spaces. Pick says, * ' Villi hunt blood as a magnet hunts steel," and so, naturally, in the malignant development of tliese embry- onic elements the same close association with blood cavities is present. Tn this specimen the villi are still intact, and there is marked irregular ]iroliferation of the syncytial cells Avith invasion of the stroma. effect, can produce the same general condition. Outside of these pathologies of the cervix, we can discard all the old-time varieties of cervical inflammations designated mider the head of endocer- vicitis, for the round-cell infiltration alone can be considered diag- nostic of chronic inflammation, and the presence of pus and germs of the acute. Tn considering the question of cervical erosion I am limiting the discussion to those cases Avhich are the result of passive congestion 60 THE GYNECOLOGY OF OBSTETRICS or injury. These are the two types which naturally fall into the limits of this monograph. I do not wish to be understood as including in this question of etiology the type of erosion and eversion found in infants, the con- genital form ; or that found in pregnant women, which is probably the result of overgroAvth of glandular structure ; or the type asso- This higher niagnification of the preceding section shows in detail the large, deeply staining Langhan 's cells with their well-defined membrane and the smaller syncytial cells with indistinct cell membrane. These two elements are typical of the villi structure, but normally occur associated in single layers. In the malignant overgrowth these elements form in masses with no regular arrangement. Here the blood spaces are well shown, but with no blood elements present. ciated with the presence of the gonococcus, diphtheroid bacillus, or other germs which cause irritating discharges. Eliminating these forms naturally takes out of the discussion the various theories ad- vanced by Huge, Veit, Fischel, Gottschalk, and others, which deal with the* glandular perforation from below the epithelium, the sub- epithelial hemorrhage in inflammations, and the other processes which can produce erosions in loco. The erosion under consideration is essentially an inflammatory l\\TII()IJ)(iV OK TIIK CKin'IX 61 ])i-()('("ss nssociatcMl with roiiiKl-ccll iiililti-atioii and scai--tissu(' for- mation. That the i-oiiii(l-<'('ll iiililtratioii pi'cccdcs the ci'osioii in isonic case is appai-cnt, more cspcciallN- so in i-ccui-rciiccs. The most connnon picture in the pi-occss of hcalin.i-- is the raw A section of an eroded cervix. The stratified sqnamous epithelium ' has disappeared from a considerable area. The mucous membrane lining the cavity is also wanting. The eroded surface is covered by a blood-clot. Some of the glands are slightly cystic, and the tissue near the eroded area shows marked round-cell infiltration. area covered by granulatioii tissue and that by pavement epitlieli- iim, to be replaced again later by the stratified squamons form. It is probable that in some cases the epithelial covering- comes from the colmnnar cells of the cervix or from islands of epithelium in the raw area. In time this squamous epithelium is replaced by the more resistant, slower-growing stratified cells. 62 THE GYNECOLOGY OF OBSTETRICS It is the round-cell infiltration, with its scar-tissue formation, interfering with the circulation and the gland secretion, that causes a recurrence and demands operative treatment for permanent cor- rection. In the chapter on the etiology of pelvic injuries the effect of the tight binder has been spoken of as a possible factor in preventing primary union of an injured cervix, and thus giving rise to the chronic pathological conditions just discussed. If, at the same time, A section from an eroded cystic cervix. The glands are increased in size and number. One has become definitely cystic. The stratified squamous epithelium has been destroyed, and near the raw surface the inflammation, as evidenced by the plasma-cell infiltration, is marked. In this section there is some evidence of a beginning heal- ing process. on this granulating area any degree of infection is imposed, the greater degree of infiltration and the slower healing exaggerate the mechanical defect. It will not be amiss here, while considering cervical pathology, to mention a factor which is not always recognized as of injury to the cervix, and that is the pessary. The pessary holds the uterus forward by a stretching of the upper portion of the vaginal canal, especially the dorsal fornix, also by a relative shortening of the sacrouterine ligaments through giving them a new point of attach- PATHOLOGY OF THE CERMX 63 meiit at the pessary's transverse bar. Both these actions, while maintainino- the position of the litems, i)nt tension on the dorsal attachments of tlie cervix, thns tending- to separate the lips and ex- aggerate any defect. If a cystocele is present, it is partially relieved l)y the liolding- u\) of the vaginal vanlt and cei'vix and the stretch- ing of the vagina laterally, ))nt this gives no direct snpport to the body of the cystocele. Thns the weight of the nrine is exerted be- tween the bars of the pessary npon the rectum, and this is rather A more highly niii^iiifiiMl section of a nuirkcd i-asc nf erosion. The gland epithelial covering is intact as far as the eroded surface. The extreme round-cell infil- tration, with the ragged raw surface from which the epithelial covering has disappeared, indicates the acuteness of the pathology. exaggerated, if anything, by the position of the fnndns above. Natu- rally, the greater portion of this strain comes then upon the cervix, especially the ventral lip, and thus the pathology is rapidly exag- gerated. In fact, so great is this pull on the cervix that in cases where a pessary has been necessary after a trachelorrhaphy, it has often been found that the new-formed line of union has stretched out markedly, and a recurrence of the ectropion has occurred, necessitating a second repair when the abdominal work is done. In cases in which a relaxed vaginal outlet was not repaired at 64 THE GYNECOLOGY OF OBSTETRICS the same time as the cervix (which is' by no means uncommon, through lack of recognition or lack of appreciation of the signifi- cance of a poor diaphragm support), the effect on the cervix is one of hypertrophy and elongation as a result of the pull from below, instead of the separation of the cervical lips. In time, with the fall- ing of the uterus, the ectropion will occur. Section from a cystic cervix that shows the loss of the stratified epitlielial covering and the char- acter of the cystic development of the glands. The cervical structure beneath the raw area shows intense round-cell infiltration. The cells lining the cyst cavities are uniform in struc- ture, with an intact basement membrane. The cavities contain some round cells in the remains of the mucous secretion. PATllOLOdV OK ^rilE CKRVIX r 1 65 Au eroded cervix that is beginning to heal. The infiltration is marked, but the glandular elements are not nearly so prominent in this case. The healing is taking place by the covering of the raw area with a single layer of squamous cells. These are replaced later by the stratified epithelium. A more higlily magnifie- i)raeticaUy the same proccMhnc. l)i-. Baii^lniiau »>iv('S credit to liis colleas^'ue, Dr. (Miai-lcs R. Rohiiis, i'ov the sug- i!,'esti()ii. I shall (|U()te froiii the papei" I then read to emphasize the iiii- l)<)i-taiiee of a pi-oeediii-e that will attain more satisfactory results than now prevail. In |)'art my paper was as follows : "A proiiiiiient general ])ractitioner in discussing perineal re- pairs at a society meeting made the statement that he never allowed any degree of tear to go unrepaired, for he did not intend that any woman whom he confined could he told that she needed a perineor- rhaphy. That is the feeling and practice of all conscientious ob- stetricians, and yet when a patient who has a relaxed vaginal out- let is told that she has to have a repair, she invariably tells you that her doctor sewed her up when the baby came and also how many stitches were taken. But this only goes to show that a large percentage of repairs in recent tears result in failure, and unless the attendant can recognize early the cases of failure, the patient gets out of his hands with a false sense of security as to her good condition. ' ' Lately, due to the rather large proportion of unsatisfactory results with the use of the interrupted suture, I have been applying the continuous mattress suture of silkw^orm gut advocated by Dr. Geo. B.Somers of San Francisco for secondarj^ perineorrhaphies." M}^ technique is as follows: Using a small curved needle while the edges of the tear are being retracted with vulsellum forceps, the lirst suture is applied from side to side in the depth of the wound, the tissue being finall}^ pushed back along the untied stitch. The second suture is applied in the same w^ay^ above. In this Avay one can approximate the divided perineal body and prevent the re- traction of the torn musculature. While this type of suture is much harder to use in these immediate repairs than the interrupted, on account of the rapid swelling of the parts and the quantity of ob- scuring blood, the advantages gained and the much more satisfac- tory results make the extra care well worth while. The continuous suture does not constrict the circulation as does the interrupted. It approximates the perineal body throughout its entire depth, and after the edema and SAvelling have subsided there is no slack on the sutures; oi-, if there is, it can be taken up by 80 THE GYNECOLOGY OF OBSTETRICS pressing the tissue back along the stitch. If interrupted sutures are used, we shall find after the swelling has subsided that the swollen tissue in the grasp of the suture has been partially cut through and that the stitch is too loose to give a perfect approximation, and so the fluids can percolate and prevent perfect primary union. If by any chance infection of the perineum has occurred, the insoluble continuous suture acts as a drain, and whatever swelling takes place can be accommodated on the untied sutures without any cut- ting through of the tissues, so that the results are good. This would be impossible if the repair had been done with either absorbable or non-absorbable interrupted stitches. Sometimes the rectal sphincter is injured and overlooked, on ac- count of the difficult}^ of thorough inspection. It is not of such vital importance if we succeed in getting a good perineal bod}^ by pri- mary union. It is not the severance of the sphincter-muscle fiber that is of such moment, for that is often done intentionally in fistu- la operations without bad effect ; but it is the poor perineal results with the retraction of the muscle layers, and the consequent lack of ventral anchorage, that allow the retraction and atrophy of the rectal sphincter. If, despite our failure to unite the torn sphincter, we have succeeded in getting an otherwise normal perineum, then the muscle will not lose its function. If we consider the injured sphincter ani from the standpoint of the fistula operation, we find that practically all authorities agree that it is the multiple or the oblique incisions of the muscle that are likely to be followed hj incontinence. In discussing the operation for rectal fistula, Earle states : " In- continence of feces may follow an}^ of the operations for fistula, but it generally results from an oblique incision of the sphincter muscle, which should always be avoided. ' ' Fortunately, in complete tears of the perineum the sphincter-ani muscle is torn through in the median line on account of its anatom- ical relations to the central tendon and coccyx. An oblique tear is hardly likely to occur, for the force required to accomplish this would more naturally expend itself in separating the whole sphinc- ter along the cleavage line between it and the rectal sling of the pelvic diaphragm, so that the rectal orifice with its sjDhincter mus- nrMEDTATE REPAIRS 81 cles would be drawn to one or tlie otlier side and left uninjured. It is this anatomical relation which accounts for the possibility of ol)- taining good fecal conti'ol under the conditions described. Naturally, the ends of the torn sphincter ani have a more ragged character than tlu' cut nuiscle of the fistula operation, and perfect continence may not conw until the scar tissue has contracted per- manently. For the purposes of repair, every perineal injury must be stud- ied individually. In extensive " Y "-shaped injuries, the continu- ous mattress suture used alone is difficult to apply. In the majority of cases, it is easier, and perhaps wiser, to approximate the upper limits of the injury with interrupted sutures, starting the continu- ous suture at the point just above the levator-ani muscle. It is from here outward that the important structures lie, the approximation of which is essential to good results. There is no reason, however, wdiy the w^hole repair cannot be done with the continuous suture. It usually needs four sutures to properly unite an extensive injury so that the sutures can be used alternately in the lateral tears, which are naturally less than half the depth of the external por- tion. The only disadvantage is the difficulty of insertion and the length of suture to be removed. The tissues, however, remain soft for some time after confinement, so that, as a rule, the sutures are easily withdrawn. It is not necessary, in fact I think it is sometimes unwise, to ap- proximate with any buried absorbable suture the sphincter ani, if injured, for the continuous suture can easily be made to accom- plish the same result. After three more years' experience in using this method of re- pair, I feel that it is the only reliable procedure in such w^ork. As a proof of the results, I had a counterclaim in a suit for fees against a patient who, at the instigation of a general practitioner, was threatening suit for having given her too good a perineum. This physician examined the patient for the first time eight months after confinement, and on the witness-stand testified to finding an ulceration of the vulva and being unable to make a digital exam- ination. Yet he was positive that his inability to make an examina- tion was due to a too perfect perineorrhaphy rather than to the local 82 THE GYNECOLOGY OF OBSTETRICS conditions and the vaginismus he testified were present. My own records show an examination of the patient two months after con- finement, when the perineum was found in perfect condition, and examination Avith the ordinary speculum offered no difficulty, though even two months previous to labor the vaginal canal had been extremely small, only admitting a virgin speculum. I do not believe that it is possible in a perineorrhaphy at the time of labor, especially in a case in which there is no denudation done and no loss of tissue, to get any smaller vaginal canal than formerly. Anatomically, it is out of the question to build up a perineal body beneath the mucous membrane better than nature originally provided. With sloughing of mucous membrane and later scar-tissue contraction, it is possible to get a too narrow vaginal canal, but such a condition did not exist in the case mentioned. In this chapter I do not consider in detail the continuous mat- tress suture advised, for it will be spoken of under operations for secondary repair. CURETTAGE A S AN accoiiipaiiiiiu'iit of pchic plastic work, a curettage of /^ the uterus is of value, unless there is a latent infection in r — m tlie uteins oi- tul)es. By the removal of the mucous mem- -^ -^- ])ran(\ we deplete tlie circulation of the uterus somewhat, and give that organ also a chance to reproduce a new membrane under the favorable condition of rest in bed. in cases of sus])ected malignancy we have in a careful curettage, This iJlustratioii is from a frozen section of endome- trium removed by curette. Decidual wandering cells are present in large numbers in the tissue. There is marked round-cell infiltration. The possibility of mis- taking such a section for chorioepithelioma is great. These cells normally persist in the uterine mucosa for some time following pregnancy. The tissue lacks the elements of villi formation with the blood cavity association that is indicative of chorioepithelioma. done to obtain tissue for microscopial examination, a valuable aid to diagnosis, and in polyp formations of the mucous membrane it is an essential treatment. But outside of these indications, un- less done for the purpose of emptying a uterus of abnormal struc- tures, such as a hydatid mole, or retained products of conception, 84 THE GYNECOLOGY OF OBSTETRICS the curettement as a treatment by itself is practically seldom in- dicated. The more skilled the physician is in diagnosis, the less frequent- An enlargement of the preceding section that shows more in detail the decidual wandering cells. The comparison with the higher magnification of the vaginal chorioepithelioma section is of interest. The wandering cells and villi elements are always found in the mother 's structures, on account of the close re- lation of the fetal elements to the blood stream. Under normal conditions, these elements, being fetal, are destroyed by the mother. They have no tendency to reproduction, and, even if in excess and increasing, will disappear with the improved resis- tance of the mother. Ludwig Pick believes that the villi ele- ments (the Langhan's cells and syncytium) may produce wan- dering cells, or vice versa, though one probably predominates at the start. If continued scrapings of the mucous membrane show the persistence of these wandering cells for a consider- able time, he advises the removal of the uterus. In the majority of cases, however, the fetal elements disappear in a few months following a termination of conception. ly does he resort to curettage, for he learns hy experience that the group of symptoms supposed to indicate an endometritis, so- called, is nothing more than an indication of pelvic congestion that CURETTA(JE 85 lias as its orii^iii sonic patliolo.i^ical coiKlilioii ol'tcii situated outside of the uteiiiic cavity. Curettage doue at the time of llie eoirection of i)eivie jjatlioiogy is in nou-iufec'tious cases a wise niocedui-e, for the depletion of the utei'us acconiplislied is of heiielit. In cases associate(l with acute iiilVctioiis it is an unwise treatment, as we open up new lymi)hatic si)aces and l)reak down nature's protections. In cases of miscar- riage many writers i-econuuend non-interference, even though the A polyp of the cervix. The forceps grasps the cervix above the tiimor. possi])ility of hemorrhage or sapremic infectioii is always a factor to ])e considered. The serrated curette of Kelly is by far the most useful type of instrument to employ, for with it the mucous memhrane can he re- moved in larger segments, and this is an advantage if microscopi- cal examination is indicated. The removal of the membrane also can be done more thoroughly witliout as much danger of pene- trating the uterine walls. The main purpose to accomplish in the operation is to make sure of a thorough curetting of the cavity so as to leave no shreds of membrane incompletely separated. Other- wise, we have the factors present favorable for a sapremic infec- tion. The possibilities for harm from the curette in tlie unskilled 86 THE GYNECOLOGY OF OBSTETRICS A section from a beginning cervical polyp, removed for diagnosis. The condition present is one of chronic inflammation accom- panied by marked increase of the squamous cells. The unbroken line of demarcation between the epithelial covering and the cervix beneath is characteristic of non-malignancy. Such proliferation of the epithelial layer is often found in benign polyps. This specimen shoAVS a non-malignant polyp of the cervix in which many of the glands are cystic. The typical strati- fied squamous epithelial covering, and the normal struc- ture of the glands as shown in detail in the higher magni- fication, are evidence of a non-malignant growth. CURETTAGE J 87 A section of a cervical polyp that shows glaud prolifer- ation with cystic development. The round-cell infiltration indicates an inflammatory origin. There are none of the marks of malignancy. This section shows in detail the gland structure foun( a cervical polyp. The glands are somewhat cystic. Tlie cylindrical cells lining the cavities are uniform, with no abnormal heaping and with intact basement membrane. The apparent piling of the cells in one cavity is due to the fact that connection with the larger cyst is at an acute angle, so that the cells have been sectionerocess. we bear in mind the ease with which any solution under pressure may be forced through the tubes into the abdomen, and provided our asepsis is perfect. The more usual procedure of applying tinc- ture of iodine, carbolic and alcohol, or other antiseptic or caustic, may be wise if we suspect an infection, but can hardly be advocated as essential, or even of value, in clean cases, in the light of our present knowledge of endometritis and our methods of asepsis. CURETTAGE 89 Tf we arc certain that the cavity is clean and smooth, that tlio drain- age will not be disturbed by our other opei-ative ])r()cediires, and that our asepsis is good, there is not much to be accomplished by one internal application to the uterine cavity. This Mgher magnification of the preceding section shows that the epithelium lining the gland Imnen is regular, with the basement membrane intact — findings which speak against a malignant growth. CERVIX OPERATIONS OF THE j)lastic operations in the pelvis, none have reached a greater degree of simplicit}^ in the number of procedures than those upon the cervix. Since the paper of Emmet, in 1874, first emphasized the fact that so many supposed ul- cerations were but the exposure of the mucous membrane as a re- sult of injur}^, and suggested the method he practiced for correc- tion, practically no change has taken place in the operation for repair. Tait said of the Emmet trachelorrhaphy that "we can't modify the operation; we can't change it, for it is perfect — perfect in its method, and perfect in its results. ' ' In this monograph, which deals mainly with the injuries of par- turition and the resulting inflammations, I shall consider in detail only the so-called low amputation and the Emmet repair. The high ami^utation, Avhich means the cervix removal at or above the vaginal junction, and which depends upon the vaginal mucosa for the covering of the uterine stump, has no place in minor surgery. The consensus of opinion is that this operation is often attended by more shock than even a hysterectomy. It is not the op- eration of choice in a malignant condition of the cervix, unless we are absolutely certain that the growth is only superficial. Any question of a more than superficial involvement demands a hys- terectomy as a necessary precaution. If for any reason a hysterec- tomy is refused or is impossible, the growth destruction by the actual cauter}^ is more desirable than cutting into a malignant cer- vix and thus opening up fresh channels for the cancer-cell reinocu- lation. I am inclined to think that in the very early stages of epi- thelioma, and possibly in some other cervical conditions, the use of the carbon-dioxide freezing may offer just as satisfactory re- sults as it does in epithelioma and other growth formations of the skin. Outside of conditions of malignancy, there is practically no pa- thology necessitating the high amputation. The low amputation, on CP]RVIX OPEFiATlOXS 91 account of the i-ciuoval of a ccftaiii aiiioiiut of tissue as well as by the I'avorahlc retrooradc process stai'ted, takes eare of even an cxc('ssi\'('ly lai-i;'e cervix, so that little is o'aiiied by the lii^li opera- tion. If there is any occasion I'oi' <'lioice, the consideration should lie between a hysterectomy and the hi,i;li amputation ratlier than between the hii2,-h and'tlie low amputations. 'riiere has been much discussion, especially in tiie Uei-man liter- ature, of the effect of the hi^h cervical amputation on prej^-nancy, and the opinions have been faii'ly evenly divided as to the possi- An irregularly lacerated cervix. Both lips are markedly hypertrophied. hility of a fibrous ring resulting that would interfere seriously with lal)or. Some contend that their experience has showm a rapid ending of the first stage in the majority of cases. On the other hand, the tabulated results of cases reported seem to show a much greater increase in the tendency to abortion as well as a marked reduction in fertility — after-effects not found in trachelorrhaphy or the low amputation. Again, at operation severe secondary hem- orrhage occurs in over five per cent of the cases. The simple repair of the cervix was designed by Emmet when he had his attention drawn to the true pathology back of the so-called "ulceration of the cervix." He showed that this supposed uleera- 92 THE GYNECOLOGY OF OBSTETRICS tion was in reality the turning out of the normal lining of the cer- vical canal, as a result of lateral tears at childbirth. The healing, taking place by the formation of granulations, deposited scar tissue in the angles. Superimposed on that came the erosions and result- ing inflammation, as the consequence of circulatory disturbance and friction. In order to correct this condition, he removed a wedge-shaped segment of tissue from each angle that marked the site of the original injury, but left the canal untouched. He then approximated the raw areas. Thus, practically, he reproduced the original injury and turned back into the canal what was the nor- mal lining. The best way to judge the extent of the denudation required is to grasp each lip of the cervix with a single hook or a vulsellum for- ceps and hold them together. One will then readily see the amount of tissue requiring removal from the angles. The area is outlined by an incision, and at the same time the width of the cervical canal is marked off. The denudation within these lines is, as a rule, more readily done by making first a lateral incision on each side in the angle deep enough to reach below the scar tissue. The sides of both lips are then denuded with knife or scissors, as is most convenient, keeping well beneath the scar formation, since it is important that all the scar tissue should be removed, as that is largely the basis for the pathology. Each angle is united by three or more interrupted sutures. The first suture is inserted at a point about an eighth of an inch outside the denuded area in the vaginal portion of the ventral lip on the patient's right side. It passes under the raw area at right angles to the canal, exiting at the edge of the undenuded cervical strip. It is then reinserted at a corresponding point on the undenuded portion of the dorsal lip, passing beneath the raw area again at right angles to the canal to exit at a point corresponding to the starting- point on the vaginal mucous membrane. This suture must be placed well in the depth of the angle, in order to prevent a gap and control the bleeding. About a quarter of an inch externally, the second suture is placed in the same manner, and so the third, and, if neces- sary, a fourth. The procedure is repeated on the patient's left side, the sutures being inserted from right to left on the dorsal lip and CERVIX OPERATIONS 93 from left to Ti,i;-lit on the vciitfal ; siu-li placiii.i;- of the sutures l)i-mgs tlic kuots ou tlic vas>,inal surface. Usually, the six or eijj;-lit sutures are inserted before any ai'e tied, thoiig'li if bleeding- is profuse the phieiu.L;- and t>in,i;- ol' the first ou each side will conti-ol that and pei-iiiit hettcM- vision while the other sutures are being- placed. Before tying- any sutures it is inii)ortant to make sure that there are no blood-clots left in the angles to pre- vent primary union. When the sutures are all placed and tied, the cervix should jn-e- sent a normal contour with a single line of approximation extend- ing out on either side of the os, running over the summit to the base in the median line. Some operators prefer to remove the strip of tissue in each angle in one wedge-shaped piece Avithout making any transverse incision. Left-handed operators, or even some right-handed opera- tors, may prefer to apply the sutures in the reverse order by start- ing the stitch on the right side on the ventral lip, on the left side on the dorsal. The main factors to be borne in mind are the necessity for the complete removal of scar tissue, and the application of the sutures so as to place the knots on the vaginal side of the cervix. This operation on the cervix, wdien thoroughly understood, is not one which can be considered difftcult, and yet, to get good results, it is essential that it should be done with care. The number of cases that one sees in Avhich broad or irregular scars are found follow- ing trachelorrhaphy is surprising. Sinus formations between the sutured points are also frecpient. Both these defects, on account of the remaining irritation, continue the development of the cyst formation, and therefore necessitate a secondary plastic operation. The difference in the value between trachelorrhaphy and the low amputation is one wholly of the amount of tissue removed. Of the low amputation there are several types, all, however, having as their purpose the removal of a certain amount of tissue from the ventral or dorsal lip, or both, as well as the scar tissue in the an- gles, and at the same time the preserving of a patulous canal. It is much easier to obtain a good-looking result from the flap type of operation devised by Schroeder than from the "cone and mantle " operation of Simon. It is by no means easy to judge the 94 THE GYNECOLOGY OF OBSTETRICS size of the canal flap, or so-called cone, in relation to the portion of the cervix removed. If the cone is too large, it will later protrude and give a margin of everted mucous membrane surrounding the OS when the remainder of the cervix has undergone its normal in- volution. The Simon operation is also advisable only when the cer- vical canal mucous membrane is healthy and the cervix itself is thick and hard. The simplest operation, and the one giving the best cosmetic results, and best adapted where only a moderate amount of tissue removal is required, consists first of two lateral incisions carried well below the scar tissue in the angles. Then, with a knife, or often better with the scissors, as much as seems desirable of the upper portion of the ventral and dorsal lips is removed, but at least enough to get below the everted mucous membrane and the cyst formation. If this section of the cervical lip is extensive, it is well to make either the incision somewhat wedge-shaped or to under- mine slightly the vaginal mucosa, in order to approximate more easily the cervical and vaginal mucous membranes. This approxi- mation is done with two interrupted sutures about the width of the canal apart, care being taken when passing the needle through the cervical mucosa to go deep enough to include some muscle tissue and thus avoid the tearing out of the suture when tying. In all cer- vical work the general surgical principle of working from below up, so that the blood will not unnecessarily obscure the field, should be observed. Having obliterated b}^ the sutures both the denuded areas on the lips, it is then possible to determine the amount of tissue that it is necessary to remove from the angles of the cervix in order to get rid of the scar tissue and obtain an even and accurate approx- imation. This removal is done just as in the ordinary repair. Three or four sutures on each side, placed in the same wa}^ as in trachelorrhaphy, complete the operation. The bleeding may be rather profuse at first, especially if the tissue removal is extensive. As a rule, this bleeding is readily controlled by the first sutures applied. If, how^ever, it comes from a vessel in the exposed lateral areas, a hemostat can be applied until it is time to place the first sutures in the angles. AYith these properly placed and tied, there CET^VTX OlM^RATTOXS 95 is no fni-tlicr ti'<)iil)l(' .'iiid no necessity of li,i;atiii,t;' any iiidiN'idiial \'essel. It is well ill all operations on the cefX'ix to nse clironiic ,!^iit, for even as late as the tenth day secondai'X' hleedini;' has heen ri-ecjuent- ly reported, pi-ol)al)ly as a result of the too eai'lv disappearance of the suture material. 'As most of tliese eases are associated with perineal repair, it is wiser to use a])sorbable sutures, and thus avoid the early stretching' of the i)eriiieum necessary for the re- moval of non-absorbahle niatei'ial. It is wise, also, to ])lace a loose wick of gauze within the cervical canal in all cases of amputation, in order to i^revent the gluing together of the lips and the inter- ference Avith drainage. If this gauze is left sufficiently long to pro- trude from the vagina, or a ligature is tied to it for the same j)ur- pose, the gauze can be readiW removed by the nurse at the end of thirty-six or forty-eight hours. In the Simon operation an attempt is made to remove in one section a wedge-shaped piece extending across the whole width of the cervical lip, usually after the primary lateral incisions have been made. It is then necessary to form on the inner surface of the wedge a flap of mucous membrane for the cervical canal. Here it is that the difficulty is presented of judging the amount of tissue to l)e removed and the shape of the wedge, so as to obtain a nice ad- justment without a redundancy of the canal mucous membrane. Schroeder's single-flap method modifies the operation by making an incision at right angles to the cervical canal across both lips, separated by the first incisions, to a depth sufficient to get below the cystic portion, and then removing a section of tissue at that depth across the whole cervix parallel to the cervical canal. This procedure makes a somewhat thinner flap of the lips, so that they can be folded upon themselves in approximating the nmcous edges. In both modifications the suturing is identical. In all cervical operations the first essential is to leave a cervical canal as normal as possible. In order to do this and prevent a com- plete closure, it is necessary to leave on at least one lip a sufficient amount of undenuded mucous niemln-ane. It is important to make sure that the canal is sufficiently patulous at the os, so that the caliber is the same, or at least not greater, within the cervix. If the 96 THE GYNECOLOGY OF OBSTETRICS reverse is true, normal drainage is interfered with and future pos- sibilities for trouble offered. Every text-book of gynecology contains detailed descriptions, with illustrations, of the cervical operations, at least those advo- cated by the individual writers, and it is not the purpose of this chapter to repeat what is already in every doctor's library, but rather to emphasize the procedures which are most applicable, es- pecially from the standpoint of the details that experience has made pertinent. SYMPTOMS AND DIAGNOSIS OF THE RELAXED VAGINAL OUTLET Tl 1 1^] diagnosis of a relaxation of tlie vaginal outlet ought to ]) resent no difficulty. The reason that so many of these con- ditions are neglected is probably due not so much to the lack of recognition of the injury as it is to a poor apprecia- tion of the importance of correct support to the woman's health. A history of the character of the labors with a review of the pres- ent symptoms will almost always direct attention to the possibili- ties, and a careful examination will readily confirm what we suspect. In making this examination, however, it is important to use an examining-table instead of a lounge or bed, for the posture of the patient may obscure the gravity of some of the pathology. By noting the changes from the normal in the vulva, such as the increase of distance between the vestibule and anus, the flattened appearance of all the parts in contrast to the contour of an unin- jured outlet, with the thinning out of the perineal bod}^ itself, the diagnosis is possible. If, with these, the cystocele and rectocele pro- trude, there can be no doubt of the condition. However, one of the simplest and best methods of judging the degree of relaxation is to ask the patient to bear down. This forcing down of the pelvic contents in cases with no diaphragm support causes a rolling-out of the vaginal septa and a reproduction in a more marked degree of the condition that is present when the patient is standing. Es- pecially is this procedure valuable in cases where the diaphragm is injured but the central tendon remains fairly intact, for in such cases the outward signs are often not marked. It is surprising sometimes to find to what a degree the cystocele and rectocele will protrude, when on simple inspection their existence may have been doubted. Again, with the finger, or better both index fingers, inserted in the vagina and pressure exerted downward, in the lateral aspects of the canal, Ave can readily judge of the degree of relaxation, 98 THE GYNECOLOGY OF OBSTETRICS and with more gentle pressure can palpate the location of the injury. The third method of judging the degree of laxity is to request the patient to contract the pelvic diaphragm; with the finger in the vagina against the perineum, we can readily determine the amount of muscle tissue still functionating. In a marked relaxa- tion, what the patient ac- complishes by this procedure is the contraction of the fibers behind the rectum. This brings the structures ventral to the levator ani forward as a whole, instead of contracting the perineum directly beneath the fingers. In a normal individual this demonstration will readily show the distribution of the levator-ani muscle. These three methods are not only useful in making a diagnosis of the degree of relaxation, but will give us an idea of the value of our repair work when the patient returns later for examina- tion. When the operation is completed, and before the patient leaves the table, it is easy by palpation to demon- strate the correctness of the work done. If by chance the patient happens to vomit or cough, we are given an interesting demonstra- tion of the value of our diaphragm repair. If perfect, then the con- traction of the muscle pulls up the dorsal vaginal wall snugly against the ventral and prevents the rolling-out of the structures that took place before. Of course, there is always a transmission of the pressure impulse from above, which causes a protrusion of the This patient submitted to a trachelorrhaphy and perineorrhaphy two years ago. From external appearance, the results are good, but careful examination shows that the diaphragm offers no support. The illustrations that follow show the degree of relaxation and the methods used in determining the value of the support. TIIK KKLAXKI) VAGINAL OUTLKT !)9 soft parts as a whole, hut the rcphiccd muscle ('h)ses the vagina and prevents auv protrusion of the septa hevoud the hody line. Tf any does take place, it s|)eaks I'oi- a poor repair, which, hy just such inipuLses, is i;radually sti'etched out later on. W'hih' exaniinini;' a patient with a I'elaxed va.ninal outlet, it is wise to grasj) tiie cervix with a vulselluin and make traction down- ward, for thus we are enabled to judge more readily of the level at which the cei'vix lies and can better determine the amount of sui)p()rt necessary in the venf ral and dorsal va- ginal walls. This procedure also enables us to estimate the shape and size of the uterus and its exact position, thus doing away with the use of a uterine sound. As an instru- ment for diagnosing the posi- tion or the size of the uterus, the intrauterine sound should have no place in any physi- cian's hands, and the more the instrument is used the poorer gynecologists we can acknowd- edge ourselves to be. 1 \ ^B ^'^^I' ( 1 /"' A separation of the labia shows the prominence of the ventral vaginal wall with a portion of the rectocele. In this case the greatest injury to the diaj^hragm is in the left sulcus. Evident- ly no attempt was made to approximate the diaphragm at time of the perineorrhaphy, as judged by the degree of levator-ani retraction. There is probably no phys- ical defect that gives such variety in its symptomatology as does the relaxed vaginal outlet with its resulting pathology. It not only produces local symptoms depending directly upon the character of the pathology present, but, by its undermining of the equilibrium of the nervous system, can account for almost any type of nervous phenomena. In fact, there are few abnormal conditions of the body that have greater disturbing influences on the nervous system, especially when we consider that the abnormality is of the type of pathology 100 THE GYNECOLOGY OF OBSTETRICS that is not dangerous to life. Moreover, these general symptoms are often associated with only mild, or even overlooked, local dis- comfort. For example, in the case of Mrs. S., aged forty-five years, the following history is characteristic. She is the mother of two chil- dren, the younger being eighteen years of age, both born under normal conditions, with no injuries reported. For three years following the birth of the last child the patient complained of symptoms, the result of pelvic congestion — backache and leucorrhea, with increased menstrual flow — but these ills disap- peared under local treat- ment hj the family physi- cian. Some months later she l^egan to have distressing- headaches, referred to as " sick headaches," which, on account of the severe nau- sea and vomiting, produced marked prostration. Being- incapacitated for two to three days each week, she had despaired of obtaining permanent relief. Thorough physical examination dis- closed no abnormal condi- tion outside of the pelvis, and there a moderate degree of perineal relaxation and cervical congestion. The pelvic condition was asso- ciated with such slight local symptoms that only careful question- ing brought to light the existence of some bladder irritation. The degree of relaxation, though easily demonstrable, had been previ- ously overlooked. In this case the correction of the pelvic pathol- ogy Avas followed by the prompt disappearance of the headaches, and the last seven years has proven the permanency of the cure. This illustrates one method of determining the degree of relaxation of the outlet. The finger de- monstrates by palpation the location and the degree of injury to the pelvic diaphragm. In this i^atient an Emmet perineorrhaphy was performed, judging by the character of the scar. THP] RELAX Kl) \'A(I1XA1. OUTLET 101 Aj»'ain, Mrs. B., a^-ed thirty-live years, has iiad one child, Ijorn \vith iiistniineiital delivery. Some months after the birth of this child, the patient's eyes be»-aii to give trouble. Frequent change of glasses hrouglit oiils- tcinpoi-ary relief. 'J'he jx'lvis gave no symp- toms, and visits to two piiysicians in the hope of discovering a rea- son for the relative stei-ility resulted in the assurance that every- thing was normal. This i)atient was referred by an oculist, who reported the eyes without defect except for nuiscular irritability, and susi)ected a pelvic abnormality. The pa- tient comjilained of no ])elvic symptoms, and felt confident the trouble was not there. An examination, however, re- vealed a marked degree of perineal relaxation, with a })rominent cystocele, of which the patient acknowledged be- ing conscious w^hen standing, but considered it a normal sequence of her pregnancy. The correction of this pathol- ogy resulted in the complete restoration of the eyes. In these two cases we have a good example of the remote symptoms of jielvic pathol- ogy ; but in the vast majority of cases these remote symptoms are associated with very definite local conditions that should at once attract the physician's atten- tion. In some naturally neurotic women the nervous manifestations may take even a more severe form than eye-strain from muscle- weariness or the various types of headache, so that mental states such as melancholia or hysteria are by no means uncommon. It is not safe, however, to let one's enthusiasm, which is a natural se- ((uence of results from correct perineal work, prevent one from The patient bcijiy uskuil to bear down, a marked rolling out of the vaginal walls takes place. This method of demonstrating the relax- ation also conveys an idea as to the condition of the sagging when the woman is standing. 102 THE GYNECOLOGY OF OBSTETRICS rememhermg that, even though a relaxed vaginal outlet is present, there may l^e other causes for some of the s^anptoms. It is natural for one to be very sanguine of the results from correct pelvic plas- tic work, for there is no other field in surgery involving only external structures that gives as good and as uniform results in health improvement. The local s^miptoms are either the result of the accompan3dng congestion or are due to the interference of the function of the ad- jacent organs, on account of the break in the pelvic diaphragm. Probably the most frequent complaint, especially in the severer types of injury, is the feeling of lack of support, or, as the patient puts it, a feeling that "things are going to drop." This is, of course, more noticeable when standing or walking, and when seated these patients usually get more comfort with the knees crossed, on account of the support given by the thighs. Backache, though a very frequent S3aiiptom, is by no means al- ways present, and I believe it is more common in cases associated with the early grades of uterine and ovarian displacement. As the organs drop lower in the pelvis, it is not unusual to find no mention of backache, even in some severe degrees of procidentia. The backache that is due to a loose sacroiliac joint, while differing in location and character, is so often found in women who have borne children that it is very often confounded with the reflex ache of pelvic pathology. Only lack of thoroughness in examination, how- ever, can account for the conflict. Postural backache and the sideache and backache of kidney ptosis are frequently present in women, but usually respond to cor- rect corset support and heel adjustment. The too. popular tendency to lay stress on the pelvic congestion as a cause of reflex backache should always be combated and care taken to eliminate all other possibilities before assigning the pelvic injuries as the cause, or we may find ourselves and the patient disappointed by the per- sistence of the ache after the operative work. The s^miptoms that are the result of the pelvic congestion are directly traceable to the associated pathology in the cervix, and these (the leucorrhea, with the increased or irregular menstrual flow) have been considered under that head. THE RKI.AXKI) \\\(JIXAL Ol TLH/P 103 The iiia,j()i-ity of women witli relaxed va|i,iiial outlets sufTci- i'l-om various distui-hauccs of the hladdei' f'luictioii. Krccjiieiitly it is tlie iiud)ilityto eouti'ol the s))hiu('t(M- uniscle when the bladder heconies somewhat distended, necessitating;' an imuKMliate evaeuation. This condition is |)i'esent, as a I'ule, only in the da\time oi- as soon as the woman arises in the morning, and the ability to retain moi'e readily the urine at night speaks against bladder inflannnation, though in time that is often associated. These patients will usually tell you how they always have to plan to iind a toilet convenient after a drive or street-car ride, and must find opportunity for rather frequent evacuation. This is often associated with an in- ability to control urine leakage on excretion or when coughing or sneezing. Such are the bladder symptoms complained of in the early stages of relaxation. AMien a cystocele has develojjed, the inability to empty the blad- der completely on account of the sagging adds a new type of symp- tom. Often it is the consciousness that the bladder is not empty, and the resulting mental distress added to a usually irritable sphincter increases the frequency of micturition, especially when arising in the morning or after physical and mental overexertion. When infection is sui^erimposed, the frequency is increased ; burn- ing during urination and pain after are then present. The rectal symptoms, as a rule, occur earlier than those of the bladder, but, as the bladder is called to the attention more through its frequent function, the rectal symptoms are more often overlooked. The ear- liest indication, as a rule, is constipation, a constipation that is due to a lack of perfect control of the lower rectum rather than to any change in the peristaltic waves higher up. This lack of expul- sive power is, of course, the result of the stretching out of the ven- tral rectal wall and the retraction of the sphincter ani, due to the destruction of the perineal anchorage. While the desire for evacu- ation is present, the expulsive powder, is wanting, and in some cases it is necessary to support the rectocele in order to accomplish the emptying of the bowels. Interference with the bowel action low dowai soon has a direct reflex effect higher up, and a chronic per- sistent constipation results. On account of the sagging interfering with the return circula- 104 THE GYNECOLOGY OF OBSTETRICS tion from the rectum, associated with a more or less spasmodic sx^hincter mnscle, the formation of hemorrhoids, especially of the external tjj)e, is very frequent. The lack of tone in the stretched- out rectal wall, the pressure above from the enlarged cervix and the often low uterine body, with the pressure of the bowel contents, produce the congestion. In fact, the presence of hemorrhoids in women who have had children is exceedingly suggestive of a re- laxed vaginal outlet as a cause. A large pelvic tumor is often asso- ciated with hemorrhoids, but the simple retroversions uncompli- cated b^^ an injured perineum are not nearly as frequently the cause of hemorrhoids as supposed. A woman with a marked degree of relaxation will sometimes complain of the audible expulsion of air from the vaginal canal, though often imagining that it comes from the lower bowel, due to poor control of the sphincter. The permanent patulous condition of the vaginal canal permits the ready ingress of air when the patient gets into a position ap- proaching the knee-chest or Sims's lateral posture. The value of these two positions for examination purposes depends on the air distention of the vagina. Through the gravitation of the abdominal and pelvic organs toward the thoracic diaphragm by the patient's posture, the ballooning out of the canal occurs, thus permitting un- obstructed inspection. In order that this may be accomplished in an uninjured outlet, it is necessary to retract the perineum so as to permit the air to enter. In fact, the knee-chest posture as a thera- peutic procedure is of little value unless the patient is directed to permit the entrance of air by retracting the perineum. With a re- laxed outlet a far less exaggerated position than the typical knee- chest or Sims's allows the air to enter, and a change of posture as readily causes its expulsion. Plate IX DISSECTION OF A RELAXED VAGINAL OUTLET TO SHOW THE RETRACTION OF THE LEVATOR- ANI ^lUSCLE This subject had a relaxed vaginal outlet. The central tendon has been cut through and pulled aside, thus distorting the superficial structures, in order to show the absence of the levator-ani muscle between the vagina and rectum, the only tissue intervening be- tween these canals being a layer of fascia. The levator-ani fibers are shown retracted to the attachment of that muscle to the va- gina. Beneath this portion of the muscle a strip of white cloth has been placed, in order to show the size and relation of the middle segment of the levator ani. PKKINEORRHAPHY F( )li a cori-cct I'c'paii- of the i-claxcfl N'a.i'-iiial outlet a tliorou^h kiio\vl(Mli;(' of the normal |)('riii(Miiii is essentia!, and with such kno\vh'(lt;(' any of the acK'ocatefl repairs can he ina(h' successt'uh no niattei' wiiat the Form of (ienu(hition or the luetliod of suture. Gynecological literature is continually suggest- ing new varieties of perineal operations; and yet, when everything is c()nsi(hM-e(l, jiractically the only advance of recent years woi-th nuirked notice is that of the differentiation and direct nnion of the separate structures to l)e unite(L With this statement we record the only vital difference between the flap-splitting operation, the outgrowth of the original Tait, which was exceedingly su|)eriicial, and the j)o])ular operation of today, credited under the names of various oj)erators. All other variations are siinph' methods of suture ai)j)lication or structure separation. The vaiiety of suture or the method of its application will always be a matter of the op- eiator's personal i)reference. Again, the extensive dissection, with the sepai-ation of tissue, no matter how accomplished, is contrary to the normal anatomical relation, and favors some complications. To produce a correctly functionating perineum, it is essential to accomplish not onh^ a union of the pelvic floor, but of the pelvic diaphragm as well. Wells in a recent paper gives the following steps as necessary 'to get jierfect results in au}^ perineal repair, and advises the fla])- splitting method as the best to accomplish the result : "First, the miion of the fibers of the levator-ani nrascle with their proper perineal attachment ; second, the restoration of the fascial covering of this muscle ; third, the union of the two layers of fascia, the pelvic and perineal, at their points of nmtual attach- ment, namely, in the center of the perineum; fourth, the restora- tion of the action of the transversus-perinei muscles, which have hitherto drawn upon the severed fil)ers of the levator-ani nmscle in a lateral direction, flattening the caliber of the vagina and causing it to gape." 106 THE GYNECOLOGY OF OBSTETKICS Theoretically, this advice is excellent. Practically, even in the hands of the expert, its accomplishment in every case is exceeding- ly problematic. In many cases of dissection in the anatomical lab- oratory it is impossible to separate to one's satisfaction the layers of fascia entering into the construction of the pelvic diaphragm from the muscle itself, on account of the close blending. What can- not be done under conditions entirely favorable to its accomplish- ment can hardly be possible in the operating-room. Moreover, in the injured perineum the distortion, on account of the muscle re- traction and the scar-tissue formation, further complicates the separation. No matter what the distortion or how great the muscle separation, it is always possible even without dissection in all forms of denudation to pick up the edges of the levator ani later- ally at its middle segment for direct suture to the corresponding portion on the other side. The function of the vaginal sphincters is of just as much importance as the transversus perinei, but probably the first step, consisting of "the union of the levator-ani muscles with their proper perineal attachment," is intended to care for them. Since the early days of gynecology there have been three types of operation, and upon these practically all our multitudinous mod- ern operations are built, though too often the worthy pioneer loses the credit of the procedure by the addition of unessential varia- tions. These three classical operations which w^e should still do well to bear in mind are the Tait, the Emmet, and the Hegar. First, we have Tait's method for the incomplete tear. The Tait, however, that is here described is the result of a gradual develop- ment of the originally described operation, which was exceedingly superficial. This consists of a linear incision carried along the mucocutaneous border from a point a half inch or less dorsal to the orifice of one gland of Bartholin to a corresponding point in relation to the other. This incision was carried beneath the mu- cous membrane or the scar tissue, and by a dissection separating the vaginal mucosa a flap was formed which was continued well out in the lateral aspects, exposing a broad area of perineal tissue beneath the imperforated mucous membrane. This flap-splitting PERINEOHRTIAPHY 107 was c'arri('(| up to n point aboNc the pelvic diap]ii-a,i;iii. 'I'lic area of perineal structui'e exposed when tlie flap was elevated was then a|)|)i-oxiniat('(l from side to side. 'IMie sutures, if iiisei'te(l deeply eiiou,i;li ill the lateral tissues aud made to exit in the median line before reinsertion on the opposite side, produced a flat approxi- mation of tissue instead of a puckering-string effect. The first su- ture was i)laced dorsally in the denudation, the remaining sutures inserted at short distances apart from below upward, the last su- tui'e passing tln-ougli the under surface of the flap in the depth of the wound so as to eliminate any dead space and anchor the mu- cous membrane. The portion of the flap which did not naturally recede within the vagina upon tying the sutures in the order in- serted was stitched over with a superficial suture, to close any raw spaces. Practically, the difference between this operation and our pres- ent-day flap-splitting is the difference between the older ' ' through and through " closure of the abdominal wall and the more careful layer approximation of the present. But no one can deny the fact that the majority of closures by the old method were successful, even though we realize that the present method is more uniformly satisfactory. For the complete tear of the perineum no scheme of incision and denudation, whether the flaps are left intact or removed, serves the purpose as ingeniously as the Tait. It differs from the opera- tion for the incomplete injury, in that a line of incision is carried dorsally on either side of the rectovaginal cleft, starting at points that would be about the limits of the middle third of the original incision for incomplete repair. These dorsal incisions are carried far enough down to make the findings of the ends of the external sphincter ani easily accomplished. If we bear in mind that nearly always we have a superficial dimple formed where the ends of the torn muscle have become attached to the superficial structures, and that these landmarks are usually well defined, we shall have no dif- ficulty in deciding the extent of the incisions. Tait, writing in 1879, describes his operation for the complete injury as follows, though later descriptions by other men give somewhat different versions: 108 THE GYNECOLOGY OF OBSTETRICS " In case of complete tear of the perineum, my method of oper- ating is this : I make two incisions abont one inch and a half long, just at the margin of the skin and mncons membrane, and marking the edges of the torn perineum. These will be more or less apart, according to the depth of the tear. They should be nearly parallel, but somewhat converging toward the coccyx. The knife is carried right through the skin down to the subjacent tissues, and the rest of the operation is done by strong, sharp-pointed scissors. These are introduced just under the skin at the upper end of each w^ound and run under the mucous membrane (cutting nothing else) about half an inch from each side inwards, meeting in the middle line, and forming a curve parallel with the margin of the torn septum. The lower lip of this wound is then seized by dissecting forceps and the mucous membrane carefully raised from the adjacent tis- sues as far as the edge of the rent, but not separated at that edge, so as to form a flap. This flap is turned downwards and backwards into the rectum. A stout curved needle armed with strong Chinese silk is then to be introduced about a quarter of an inch from the center of the skin wound on one side, and carefulh^ carried through the tissues of the septum till its point is within a quarter of an inch of the middle line. The point is then to be brought out in front of the flap and passed into the septum again at about another quarter of an inch on the other side of the middle line, and is then to be con- tinued till it comes out at a point corresponding to its original insertion. The whole success depends upon this stitch, so that the utmost care must be taken with it. Two other stitches are similarly introduced, one in front of, and the other behind, the first stitch, and all three must be in front of the flap. ' ' In case this original Tait method will not apply, a modification may be readily devised, which will give a dorsal flap that may be turned into the rectum as its ventral wall, thus protecting the peri- neum from contamination. In an extensive injury, where the defect in the ventral rectal wall is high, there is no mucocutaneous line as a guide for the first in- cision, and the location of that incision is a matter of judgment for each individual case. The flap, which is dissected upward and turned into the vagina as described, having to cover a much greater area in length, must consequently be of larger proportional size, though in the majority of cases the vaginal flap may be eliminated entirely, as in the Tlegar denudation. The dorsal flap need be made PERINEORRIIAIMIV 109 only of suHicicnt l('ii,i;tli to reach just Ix'yoiid tlic point iliat will be- coiiic the \-eiiti-al e(l,i;(' of the anus when the sphiiieter niusele is sutured o\'er the downwardly retraete(l ineiu])i-ane. This dorsal ilap, as a rule, nee(ls hut sli,i;lit dissection al'ter the scar tissue has heeii cut tlirou,i;h, tor it will easil>- retfact (lowiiwai-d. With the rec- tal Hap i)ulle(l dowu and the va,<;inal i-eti-acted u|)wai-d, the resiilt- iui;- denuded area is ck)se(l from side to side in the same manner as in the incomplete operation, the sphinctei- ani having- been first repaired by direct sutnre. Such an approximation adds to the length of the vaginal canal a distance equal to one-half the width of the denuded area, and the portions of the two flaps that are not used in forming the covering of this increased length of ca- nal may he removed and the edges sutured. But, general- ly, the redundancy is slight, and the normal shrinkage will take care of the excess. The dorsal incision of both the Hegar and Ennnet in- complete operations follows the lines of the Tait along- the mucocutaneous border. P\)r the complete injury, lat- eral incisions toward the anus are added as the method of ohtain- ing tissue for the ventral rectal wall and reaching the retracted sphincter ends. Thus in the dorsal aspect of the denuded area they do not differ either in the resulting line of union or suture appli- cation. The completed Tait operation is represented by a linear line of This patient serves as another illustration of poor diaphragm support following an imperfect perineorrhaphy. To casual observation the re- sults seem good, though there is a small point of the rectocele visible. The distance from the posterior commissure to the anus is about nor- mal, the contour of the parts being good. This is a result of a good approximation of the pelvic- floor structures. no THE GYNECOLOGY OF OBSTETRICS union from the anus to the vaginal " posterior commissure " in the complete tear, Avith about the ventral half of that length in the incomplete tear, each line being approximated by transverse inter- rupted sutures. The other operations differ only in the internal vaginal aspect. In the Hegar operation a point is selected on either side of the vaginal orifice sufficiently below the openings of the glands of Bar- tholin and in the line of tlu^ ' ' carunculae myrtif ornies ' ' so that when the points are approximated a vaginal ca- nal entrance of normal di- mensions is formed; for, on suture, these points come to- gether in the new "poste- rior commissure." A third point is chosen on the dorsal vaginal wall in the median line, the height of this point depending on the amount of redundant vaginal mucous membrane and the extent of the rectocele, but it should be high enough to allow easy access to the pelvic dia- phragm. These three points caught in forceps and re- tracted give a triangular area which is then outlined by incisions and the enclosed mucous membrane denuded. If the lateral lines of this triangle are made to diverge some- what at the depths of the sulci which mark the line of cleavage in the injured pelvic diaphragm, it will be found easier to pick up the retracted muscle. Better support will be given to the ventral va- ginal wall by the slightly greater area of denudation, but this slight modification simply helps in the approximation of individual The labia separated while the patient bears down shows the marked relaxation above the floor. The character of the scar would indicate either an Emmet or Hegar denudation. The tubercle of the vagina is somewhat prominent, but there is no evidence of cystocele upon fur- ther examination. PERIXKOIMMIAIMIV 111 striH'tui'cs, ;iii(l <'aii liardix' he ('()iisi(l('rtMl as cliaii^iiiu- llic cliaracter of the opcralioii. The original I l(',t;ar ope rat ion a|)|)i-()\iiiiat(Ml this area of dciiiKla- tioii I'loiii side to side with (h'cply iiiscrtccl iiit('ri-ii|)t(Ml sutui-('S. The more iiii|)oftaiit sutiifcs al\va_\s ('xit('(l in the median line Ix'- The points uf forceps api>lieatiou indicate the angles of the Hegar denndation of the degree that is neces- sary in this case. The orifices of the glands of Bartholin are plainly evident. fore reinsertion on the o^iposite side, in order to obtain a fiat ap- proximation, and also to prevent injury to the rectum. The main advantages advocated for the Tait operation over the Hegar were, first, that in the Tait no injury existed within the vagina — a point of importance in the early-day surgery, but hardly of consequence with our modern asepsis; second, that the Tait sacrificed no tissue, and thus was more applicable to cases of ex- tensive injury in which scar-tissue contractions had formed. 112 THE GYNECOLOGY OF OBSTETRICS Emmet plamied his operation to take better care of the lateral tear within the vagina which naturally involved the pelvic dia- phragm. He probably figured that the highest point of the rectocele had primarily its normal attachment at the external orifice of the vagina, but on account of the injury had retracted upward, and his operation was devised so as to bring this point into apposition with the two lateral external angles of the denudation. The area of denudation has been likened to an inverted " W," though also called the "butterfly" denudation. The outlines are best defined by taking five points of location : one on each side ex- ternally, corresponding to the lateral points in both the other types of operation ; one on the crest of the rectocele in the median line, low enough to permit of retraction downward to the first XDoints; and one on either side of the rectocele in the sulci, high enough to be above the injur}^ of the diaphragm. These five points caught up with forceps and put on tension, and the lines of in- cision carried from one to the other, give a "W '-shaped area with the angles inside the vagina and the mucocutaneous line join- ing the main arms. Emmet advised the removal of the mucous membrane in narrow strips by means of scissors, thereby conserving the fascia layer. This raw area is united by closing each angle as far as the recto- cele tip with interrupted sutures, the remaining lozenge-shaped area being united from side to side in the same manner as in the other operations, Avith the exception of what Avas called the " crown" suture. The latter Avas inserted so as to give as broad an approximation as possible of the structures beneath the recto- cele tip. In reality, upon the right application of this suture de- pended the correctness of the operation, and probably many critics failed in their results on account of misunderstanding this step. The suture should be introduced at the point of the lateral forceps, inserted parallel to the direction of the A^aginal canal, exiting at the end of the lateral line of sutures already inserted, then brought across under the puUed-up rectocele tip, and from there applied to the opposite side in the same manner. This suture, Avhen tied, pulls in not only all the structures blending into the central tendon, but also, if properly applied, the retracted levator-ani segment. Thus Plate X THE MAIN MUSCLE STRUCTURES OF THE PELVIC FLOOR Here an attempt is made to emphasize the main muscle structures of the pelvic floor. The sepa- ration of the superficial and deep muscles was not attempted, and probably some of the super- ficial fibers have been removed with the inter- vening fascia layers. The surgical interest being the purpose in mind, I have attempted to define and emphasize the main muscle structures in their relation to the central tendon and to one another. PERINEORRHAPI I V 113 is ToriiKMl the " postci-ior coiiimissui-c,'" and the rcinaiiiini;' area united hy dccj) sutures becomes the luediandine skin apixjsition. The rcsultiu.L;- line of* union eoi'i-espouds to the line of the " Y "- sluijx'd injury |)r('\i()usly (h'scrilx'd. The operations of the present lit niodihcation to suit tlie individual surg-eon or accommodate the character of the ])articular injury. The difference, as lias been said, between the old and the new is that the sur,<;'eon now attempts to separate and de- line tlu' vai-ious structures and unite them individually, and this he does by some ])ref erred method of suture, each method of suture or slig-ht modification of denudation going by a different name. A detailed consideration of these multitudinous methods is of no value, for if the principles involved are understood each operator will consider the individual case and apply thereto the methods best suited. A surgeon adopting one type of operation, and be- coming expert therewith, can readily modify that type to fit the individual variations. While a detailed consideration of the various modern operations will not be imdertaken, there are phases of some methods which are worthy of consideration and study. The operation Avhich seems to find most favor at the present time is one probably first advocated, at least in some of its aspects, by Hall, of Cleveland, though Watkins, of Chicago, published a meth- od almost identical about the same time. Their incision follows the nuicocutaneous border around the dorsal edge of the vaginal canal. The dorsal vaginal nmcous membrane is then dissected up, which often can most easily be done by means of scissors inserted under the membrane, then opened and withdraAvn. When enough room is ol^tained, separation laterally is continued by the gauze-covered finger until a sufficient area for reaching the levator ani has been exposed. So far this differs in no way from the Tait incomplete perineorrhaphy. At this stage Morris, of New York, inserts the closed scissors in the plane of the pelvic diaphragm in an outward and ventral direction for a distance of about one inch ; the blades then opened and withdrawn leave a space through which the leva- tor ani can easily l)e reached. Hall picks up the levator without so 114 THE GYNECOLOGY OF OBSTETRICS mucli tissue separation and dissects out carefully the muscle edges. The edges of the muscle are then picked up and united beneath the flap hj several interrupted absorbable sutures. The first suture placed and tied is pulled downward, thus permitting a higher one to be readily applied. This draws in the tissues of the diaphragm toward the median line, and thus lifts up the dorsal vaginal wall so that it tends to close the vaginal canal. The pelvic-floor struc- tures are then approximated beneath the diaphragm, and the skin incision is closed by some operators in the same direction as the incision was made. This method repairs the injuries to both the floor and the diaphragm, but does away with none of the mucous membrane, so that, for cases with much scar tissue and no redun- dancy of mucous membrane, it is ideal. It is claimed by some of the advocates of this operation that the stab of the scissors goes under the fascia layer covering the levator ani, and thus permits the picking up of the muscle, but in the ma- jorit}^ of cases the anal fascia is intimately interwoven with the muscle, and the separation is impossible. On this account the theo- retical union of the muscle, followed by the reinforcement by the anal-fascia approximation, as suggested by Wells, is practically impossible of accomplishment. In reality, the scissors simply sepa- rates the normal attachment of the levator ani with its enclosing fasciae from the structures of the pelvic floor ; it enters the lateral structures between the deep layer of the triangular ligament and the anal fascia. Whether such separation is of value is question- able, for it is not essential. By such separation we disturb not only the normal relations, but we interfere with the blood supply, es- pecially the venous flow, which here, on account of the relaxed va- ginal outlet, is often varicose, so that bleeding of a character hard to control and dangerous to the success of the operation may be encountered. The portions of the levator ani thus united are called by most writers the pubococcygeus fibers. Anatomically, this designation refers to that portion of the muscle running from the bony attach- ment on the pubes to the tip and sides of the coccyx. If it is true that these are the fibers united, it naturally justifies the conclusion that they are pulled out of their normal course and made to ap- Plate XI BLENDING OF THE LEVATOR-ANI MUSCLE AVITLI TLIE MUSCLES OF THE FLOOR AT THE CENTRAL TENDON AMft The purpose of this iUustration is to show how the levator-ani muscle blends with the super- ficial muscles. No attempt was made to sepa- rate the superficial muscles of the floor from the deep muscles, but the fascia layers Avere removed between the individual muscle groups. These muscle groups, indicated by initials, are pulled aside, so as to emphasize the close blending of the attachments at the central- tendon area and the side of the vagina. This blending I wish to emphasize, since it shows that the scissors puncture in perineorrhaphy is not a necessary procedure in picking up the levator ani if the tear has extended through the central tendon. In this subject the muscles are well developed. I'KinXKOIiiniAIMIV 115 pi'oxiiiiatc xciitral to llic rcctiiiii as a support to the \'a,L:,iiia. Such l)eiiii;' so, it semis i-casouablc to su))])os(' that the iioi-inal working- of tlu' iiuiscle as an elevator of the rectum would he interfered witli and tlie tendenc>- to separation where unite(l wouhl he ^Teat. If we were (h'alin.i;' with the uiah' peK'ic diaphra.uin, such an oj)er- ation wouhl in reality unite the lihers noruudlx' passini;- to tlie outei* A itlaxatioii of the vaginal outlet of moderate de- gree. In this case also the central tendon is only slightly injured. Abdominal Tvork had been done in this patient, but the external plastic work had not been recognized as essential. side of the rectum, for, if we can accept the anatomical descrip- tions as correct, there are no fibers rimning in front of the rectum. Pierson describes the male levator ani thus : "From this long line of origin the fillers converge downward and medially to be inserted into the sides and tip of the coccyx, into a tendinous raphe extending in the median line between the tip of the coccyx and the anus and into the sides of tlie lower part 116 THE GYNECOLOGY OF OBSTETRICS of the rectum. The fibers from the most anterior portion of the origin pass ahnost directly backward and downward to reach the sides of the rectmn. " Consequent!}^, in the male perineum the muscle edges exposed in such a method of dissection as that used in the repair of the female outlet would naturally be the pubococcj^geus fibers, since the muscle is seldom in separate segments. In the female, however, as we have shown, there is a more or less distinct separation of the levator-ani muscle into segments. The segment running behind the rectum has no fibers from the pubic bone, as all these fibers have their origin in the dorsal portion of the " white line." The fibers arising from the pubic bone and the ventral segment of the ' ' white line ' ' run to the sides of the vagina and urethra, and between the vagina and rectum in usually two distinctly separated segments. Thus, it is the middle segments, or what corresponds to the middle segments if there is no distinct division, that are picked up and united beneath the vagina. In no way, then, is the rectal sling interfered with, as can readily be demonstrated by vaginal and rectal palpation. The scissors puncture is not only unnecessary, but, as I have stated, may be injurious, for when the muscle is simply picked up with a vulsellum it comes readily into the median line and its rela- tions to the pelvic floor and central tendon are not disturbed. This gives, I believe, a better and more normal support. For a relaxed vaginal outlet in a case with only a moderate re- dundancy of the vaginal mucous membrane, the flap operations are without doubt the methods of choice. There is always a consider- able gain in tone of the vaginal w^alls following a correct perineal operation, and where the relaxation is not extensive this improve- ment takes care of the excess. However, the majority of patients with an injured perineum, especially where the condition has been of long standing, have not only excessive relaxation of the dorsal vaginal walls, but also of the ventral, and this involves as well the fascia layers beneath the muscle tissue. There is no way of correct- ing either the mucous membrane or the fascia relaxation without eliminating some of the mucous membrane and building up the fascia layers beneath. This can be best accomplished by a denuda- tion of the Hegar type, which is not limited in its area, as is the Platk XII PORTION OF THE LP]VATOR-AXI .Ml'SCLE BP7rWEP]N THE VAdlXA AND THE RECTUM The central tendon is cut through and sewed to the side, in order to expose the levator ani and its fascia layer. The fascia layer has been partially separated and shows (uncolored) between the sling of the levator ani and the central tendon structures. A piece of cloth is placed beneath the portion of the levator ani that runs between the vagina and rec- tum. The blending of the deep ventral muscles of the floor with this segment of the levator ani is evident in this dissection. Plate XI I L snows TIIK INDIVIDUAL :\III)I)LK SK(i.MHXT OF THE LEVATOR-AXl .MI'SCLK The structures superficial to the levator-ani mus- cle are severed at their attachments to the pubic arch on the subject 's right and pulled over to the left. This shows the middle segment of the levator-ani muscle as it passes cephalad to the right crus from its ' ' white line ' ' origin to its insertion into the side of the vagina and between the vagina and rectum. A piece of white cloth lies under its dorsal edge, in order to show that it is not only distinct, but that it overlaps the ventral portion of the dorsal segment. The struc- tures running into the central tendon are pulled aside over the cloth, so that the blending of the dorsal segment of the levator-ani muscle with the central perineal tendon is shown at the line of demarcation between the muscle and tendon struc- tures (colored red) and the uncolored levator ani. ]n^:RIXK()KRIIAIMIV 117 Fjiiiiict, !)>• tlic tip of the rcctocclc. W'liilctlic Pjiiiiict i-cpfoduccstlK' injury as it pi^iiiiarilx- cxistc*! and eliminates the scar-tissue foi-nia- tion wliieli formed (jver the torn areas, it <;ives no oppoi'tunity to coi'iect the exeessive stretcliini;- of tlie vaginal fasciae that lias taken place with the i-ectocele ronnation. It is important, I believe, to take cognizance of the fascia layers between the vagina and rec- tum above the pelvic diaphragm, even to the cervix if necessary, for by doing so we aid the function of the rectum through the re- turn to usefulness of its nmscle, which has often Ix'come more or less atropliic tlirough sti-etching. The reefing, as it were, of this fascia gives tlie stretched-out nmscle fibers of the rectum new points of attachment, and thus an opportunity to gain renewed activity. Not only is the support of value to the rectum, but also, by taking off some of the strain from the ventral colporrhaphy, is of direct value to the cystocele repair. In some cases of excessive re- dundancy, even where an excellent perineal support has been built l)y a flap operation, one finds the vaginal Avails crowding downw^ard and favoring a pouching of the rectum and bladder between the cervix and the pelvic diaphragm. The main objection of many operators to the triangular denuda- tion is the belief that the dorsal wall of the vaginal canal is con- siderably shortened, and a tendency to pull down the cervix and favor retroversion results. In reality, the length of the dorsal wall is increased to a marked degree. As the tissues are brought in from side to side, the apex of the denuded area recedes farther within the canal, and careful measurement will show half an inch or more of lengthening with improved lateral support along the whole vagina. It is essential, however, to pick up the fascia layers laterally well underneath the edge of the denudation, and not simply to unite the nmcous membrane alone, if we expect to get proper support of the rectal canal. The claim for great advantage through having no incision line within the vagina, on account of its supposed aid to the better heal- ing and the greater freedom from infection, has no basis. As the vaginal region is relatively resistant to infection, the ordinary aseptic care should eliminate the danger of outside contamination. In no case should a repair be undertaken if there is any danger of 118 THE GYNECOLOGY OF OBSTETRICS infection by discharges from above. Outside of the conservation of tissue, the flap operation has no advantage over those in which the mucous membrane is removed. The manner of suturing these various types of operation will alwaA'S largely depend upon the operator's preference. No matter whether an absorb- able buried suture is used to approximate the various ele- ments, or a non-absorbable one applied from the surface as a simple stitch or a figure- of-eight, the results will be satisfactory in the hands of the surgeon who understands the principles involved. The general preference is for the buried interrupted absorbable sutures to approximate the pelvic diaphragm and then the floor, and the whole re- inforced externally by a few silkworm-gut sutures for lat- eral support. For the average repair, my preference is for the Hegar denudation, the upper angle above the diaphragm being- closed by interrupted catgut sutures uniting both mucous membrane and fascia. When the upper level of the levator ani is reached, continuous mattress sutures of silkworm gut are used to approximate first the levator-ani fibers and fascia, which structures are pulled well up in the field by vulsellum forceps ; then the su- tures are continued on through the central tendon. The first suture is placed in the depth of the denudation; it is carried from side to side at about the distance of a quarter of an inch from the median The completed operation after a modified meth- od of Somers. The four silkworm-gut sutures used in the approximation are clamped together with a shot. The ends distal to the shot will be removed. Note especially the absence of any constriction of tissue. PKIMNKOinniAlMIV 119 line. ;iii(l as it proceeds the tissues are caferiill)- |»i('ke(l ii|) so as to lea\-e IK) relraele-. The foui-tli suture, \\holl\- suluuucous and sulx'uticular, closes the supei-ficial fascia with the mucous lueinhrane of the vat^'iiia as well as tlie superficial portion of the central tendon and the skin. These sutures are not tied, for they remain in place l)y the friction of the tissues. The h)n,U' ends within the vagina are gathered togetlier in a ])erf orated shot and the shot clamped some distance away from the nmcous membrane. The same is done with the external ends, and the su- tures are cut close to prevent irritation of the tissues by the suture ends. Both shot are left sutficiently far from the tissue line so as not to be buried if swelling occurs. The number of sutures will, of course, depend on the size of the denuded area. The main advantage of the continuous suture is that in case swelling of the perineum takes place there is no tendency for the stitch to cut into the softened sw^ollen tissue, for the long untied, smooth silkworm gut will accommodate the increased bulk. AVhen the swelling subsides, the tissues retract along the sutures or can readily be pushed back. If, again, by any possibility infec- tion occurs, as it occasionally will, the sutures act as excellent drains, and do not have to be removed until the process subsides. In fact, the continuous silkworm-gut suture may l)e the factor that will mean a good result, where with absorbable, or even non-absorb- able, interrujited sutures a failure is inevitable. The presence of the shot and the length of the suture aid as well toward an easy removal. The silkworm-gut sutures are left in place ten days; the inner ends are then cut close to the nmcous membrane and drawn through one h\ one, tlie ujiper and the lower ones usually coming easily, but the two running through the muscle structure are often ludd by the voluntary contraction of the patient when tension is exerted. There is no need, however, of their innnediate removal, for 120 THE GYNECOLOGY OF OBSTETRICS as the patient is permitted to sit up the gut works loose and can be readily withdrawn in a few days. If by any chance the suture has been locked upon itself during the insertion, the removal becomes impossible until the tissue grasped is cut through, which usually occurs after a little longer time than the ten-day period. Care, however, when the repair work is done, will readily prevent such an accident, for by pulling on the suture it is eas}^ to see just how much tissue has been picked up in the preceding stitch on that side, thus avoiding the suture material in the next bite of tissue and the locking of the stitch. The credit for this method of continuous mattress suture of non- absorbable material is due to Dr. George B. Somers, of San Fran- cisco, who began its use prior to 1901. Since then several other op- erators have advocated a continuous mattress suture not differing very widely from Somers 's method. CYSTOCELE THE rcctocclc is always cai'ccl foi- in tlic i-cpair of tlio ])eri- iieuiii, and does not liavo to l)e considered as an entity. The same is j)ra('tically true of that complication sometimes found with tlie injured perineum, the rectovaginal fistula. Occasionally, a fistula of this kind conies from a ])us-for)iiiii.i;' ])i-oc- ess openiiii;' into the vai>,ina, but this is not connnon. Tlic majority of sncli oi)enings exist as the result of an im))roj)er healing of a complete injury at childbirth. A rectovaginal fistula has a greater power to heal spontaneously than has the vesicovaginal, on ac- comit of the character of the rectal contents ; but, on the other hand, if extensive, it does not so well respond to operative repair. The majority of rectal fistulae are situated low down and usually just above the sphincter, so that the ordinary perineorrhaphy denuda- tion covers the tract. A careful dissection of the sinus to the rectal wall, with its ligation or possible inversion, and a careful perineal a])i)roxiniation surmounting take care of the condition, and no further special operative plan is necessary. When a fistula is situated high in the vagina, but too high for the carrying up of the perineorrhaphy incision, it is necessary to dissect out the tract from the vaginal wall, separating freely tlie vagina from the rectum, and then treating the sinus as a hernia sac, by ligation, avoiding the inclusion of the rectal mucosa. One ingenious operator suggests closing the edges of the dissected-out fistulous tract by a purse-string suture, the ends of which are then passed out through the s]^hincter by attaching to a curved forceps inserted from below, thus inverting the opening into the rectum. The reinforcing of the rectal muscularis and fascia, and above that the vaginal structure, practically assures a successful outcome. The consideration of cystocele, both its causation and correction, is not a simple matter. As has been already shown in preceding chapters, a cystocele is only a small part of a general abnormality, and consequently can oidy l)e considered primarily from that view- 122 THE GYNECOLOGY OF OBSTETRICS point. Yet there are some factors that place the anterior relaxa- tions in a class more individual, and these factors depend upon the anatomical relations. The ventral vaginal-wall relaxation, or so-called cystocele, is fonnd in a variety of forms, and frequently much confusion arises in discussions which do not recognize these variations and the rea- sons therefor. Sooner or later all forms of relaxation develop into a condition of similar character, and most methods of repair deal with this final state. It is often unrecognized that one may find all the symptoms which can be credited to a cystocele occurring in an individual in whom there is no external protrusion, yet back of the vulva closure may be a marked bladder-sag, evidenced by cysto- scopic examination and the finding of residual urine. A cystocele may be of five types. The most conspicous form, and one always separable into an individual classification, is the form that occurs with a uterine prolapse. Naturall}^, on account of the attachment of the bladder to the true cervix, a sagging of the uter- us must alwa3^s be accompanied by a descent of the bladder. Whether this protrusion will involve the whole urethra as well, depends on the degree of prolapse of the uterus and the extent of the levator-ani injury. If the segment of the levator ani running from the pubic bone to the sides of the vagina around the urethra and the fascia attachments of the urethra to the pubic arch are intact, the lower end of the urethra is held up under the arch and a sharp flexion is present in the canal. In such a case it is possible to demonstrate the muscle fibers throughout their course. If the fibrous attachment of the urethra to the arch has given way, the whole urethra will be prolapsed and the levator fibers will also be everted. Cystocele with procidentia must be dealt with by methods best adapted to the correction of the procidentia, and consequently is beyond the scope of this article. The main causative factor here is not necessarily the condition found in other forms of cystocele, though they are likely to be associated, but it depends on the in- jury that has occurred to the uterine and vaginal supports at the cervical level. Some men claim that cystocele is the cause of procidentia, and tliat II is llic wciiAiii ol' tli<' hK-uldcr that pulls (If)Wii tlic iitci-us. Tlio i-casoii the cxsldcclc foniis, tlic>- ar,i;ii(', is that, as a result of the st rclchiii.i;' of the \-(Milral \'a,i;iiial wall and iii.jiii->- to the pcriiicuiii, the liladdcr with its incoiiiprcssihlc li(|uid coiitciits prodiu-cs a her- nia of that xisciis. Were a cystocele always the cause of pi-ocideu- tia, it would he icasoiuihle to expect every extensive cy.stocele to ))(' associated with prolapse of the uterus. Kroni the clinical aspect, it is evident that the nuniher of cysto- cele cases are out of proportion to the j)rocidentiae, and that many ventral-wall i)rotrusions of long' standing and excessive size are unassociated with any sag of the uterus. On the other liand, many cases with the uterus prolapsed to the vulva present no marked degree of cystocele. Looking at the subject from the anatomical basis, it is easy to lind a rational argument to explain the occurrence of a cystocele unassociated Avith ])rolapse. From both stand})oints, the clinical and the anatomical, it seems reasonable to account for uterine prolapse as a result of injury to structures at the cervical level. This has alread}^ been discussed. A]iart from the cystocele ahvays associated wuth procidentia, there are four other forms of cystocele when classified according to their mechanical etiology. Naturally, these arbitrary varieties may be more or less associated either with one another or with procidentia. Tlie most connnon form is the one which results as the outcome of a general stretching of the fascia layers beneath the vaginal wall. It has been showm that these fasciae have their origin, or rather attachment, at the " wdiite line," and that in normal indi- viduals the layers are as firm as any abdominal layer and have, as well, considerable elastic tissue in their composition. The nearer to the "white line" our dissection is carried, tlie greater the rein- forcement that takes place. This general stretching will usually result from a too forcible forceps delivery or over-rapid distention after the child's head has left the uterine cavity. The second variety, and one usually associated with the first, depends u])on the injury of the levator-ani anterior segment, which 124 THE GYNECOLOGY OF OBSTETRICS results in a protrusion of the lower portion of the ventral vaginal wall, and possibly is better designated as a nrethroeele. A urethro- cele, especially if associated with a relaxed vaginal outlet, soon permits the sagging of the upper ventral portion of the vaginal canal. If the outlet is not much relaxed, the protrusion acts as a wedge to widen that outlet. This wedge action is given by some men as the cause of a recurrence of the cystocele. The recurrence is not on account of the wedge itself, but is the result of the lack of attention to the levator fibers at the time of operation that permit- ted the persistence of the wedge. The other two forms of cystocele are comparatively rare. In one class of cases a split in the fascia layers j)ermits a true her- nia of the bladder or the urethra, or of both, as can be evidenced by palpation of a hernia ring. In the other class the lateral vaginal supports have given way at their attachment along the ' ' white line. ' ' George R. White, of Savannah, in an article on cystocele has classified under three heads the generally accepted theories of bladder support and cystocele causation, though he believes that of these theories none are correct : "1. Cystocele is due to overstretching and thinning out of the ventral vaginal wall and other supports of the bladder, which al- low the bladder to descend in the form of a hernia. The condition is caused, or at least increased, by the relaxed perineum, which leaves the ventral vaginal wall unsupported. ' ' 2. The bladder is supported in part at least by its firm attach- ment to the uterus, and when this attachment is overstretched or broken during labor, or otherwise, the bladder descends as a cysto- cele. "3. The bladder, like the stomach and other abdominal organs, is suspended by ligaments, which are attached below to a relatively inelastic portion of the bladder, and above along the obliterated hypogastric arteries and the uterus." This classification expresses fairly well the varying opinions re- garding the causation of cystocele. With none of these, however, does White agree, and his reason for believing that the cause of the ventral-wall relaxation is due to an injury along the ' ' white line ' ' is that in a repair done according to his method the vaginal wall Plaik XIV THE VENTRAL SEGMENT OF THE LEVATOR-ANI MUSCLE AND A section through the pelvis at the symphysis pubis. The urethra, vagina, and rectum have been drawn downward; the layers of fascia covering the levator ani have been cut away to near their line of attachment at the ' ' white line. ' ' The ventral segment of the levator ani, having its origin mainly from the pubic bone, is shown blending into the muscle structures of the pelvic floor and the sides of the urethra and vagina. The blue area represents the attachment at the " white' line " of the middle and dorsal segments of the levator ani. iufi^ J--?ji cvs^rocKi.K i2r) fits into tlic space ()i'i,i;iiiall>' occup'kmI witlioiit i-(Mliiii(laiK'\' and witliout the necessity Tof any resection. To snppoit this tlieoi-)-, lie claims that thickeiiinij,- ol' the pfotnid- in,U' structufes takes place instead of thinning', as shonld occui- with stretchinii,', and fui'thej', that the pei'ineal siii)])oi't as a pi-o|) to the venti'al wall is disproved, because in complete rupture of the peri- neum cystocele is rare. We have shown that tlie ui'ethra is attached undei- the puhic arch liy lirm fascia hands; that between the vaginal nuicous membrane and tlie urethra is a firm layer of fascia stretching' across the pelvis from side to side. This fascia layer has its origin on each side at the i)nl)ic lione, along the "white line" and at the spine of the ischium, these attachments corresponding to the origin of the leva- tor ani. The fascia layer beneath the dorsal vaginal wall has its origin along the same line, and thus reinforces the portion of this shelf at the sides of the vagina. The first segment of the levator-ani nmscle, which runs from the pubic bone to the sides of the urethra and vagina, is reinforced by the layers of the triangular ligament, and thus supports the lowT^r portion of the ventral vaginal wall. These structures, with the attachment of the urethra to the under surface of the pubic arch, carry the Aveight ventral to the perineal body. The attach- ment of the bladder to the uterus aids in the support of the upper portion of the vaginal ventral w^all. Between these two reinforced segments there is, in a normal individual, no other direct muscle support needed, for the middle and dorsal segments of the levator ani, running dorsal to the vagina, keep its tw^o w^alls in close touch, and thus act as a support to this unreinf orced section. The oblique direction of the vagina in the pelvis in relation to the center of gravit}^ is what permits the levator ani to functionate in this w^ay. Normally, the muscle structure of the vagina itself nmst also enter largely into the support of the fascia layers on account of its close blending to the fasciae and the presence of much elastic tissue. In a cystocele that is not associated with a uterine displacement, and in which the lower portion of the urethra is in place, it is evi- dent that the factor at fault is a stretched ventral w^all, wdiich, un- supjiorted by the perineum, does not properly recuperate. In a 126 THE GYNECOLOGY OF OBSTETRICS complete tear of the perineum the reason we do not always find a cystocele associated is that the force exerted during labor has expended itself in splitting the pelvic diaphragm dorsally, and the head consequently has not crowded down the upper vagina or ex- cessively distended the canal. These cases, if left unrepaired a suf- ficient length of time, must result in a sag of the ventral wall sooner or later. Nor do they offer any proof against the value of the peri- neal supj)ort of the ventral vaginal wall. The hypertrophy of the mucous membrane that always occurs in the first stage of cystocele and rectocele gives us no grounds for arguing against an^^ stretching of the fasciae, for the thickening that results from the congestion, due to friction and exposure, is that of the mucous membrane alone. As the age of the patient ad- vances, the normal atrophy of the mucous membrane supervenes, and the wall between the bladder and vaginal cavities becomes ex- cessively thinned. In such a thin-walled cystocele, were Ave to fol- low a method of attaching the sides of the vagina to the "white line," as advocated by White and others, we should be depending on the weakest portion of our cystocele wall for the holding up of the bladder, and would be open to the same criticism that has been offered to the Emmet perineorrhaph}^ If we grant that a cystocele formation is due to a tearing at the "white line," we should expect to find in all cases a vagina in which the anterior column and the rugae of the mucous membrane are not obliterated or even smoothed out, or at least not until the weight of the bladder has produced an extensive protrusion, and then the attachment at the " white line " must necessarily be com- bined with a denudation method. CORRECTION OF CYSTOCEFJ] I 'I' IS «;('ii(M-nlly i-(H'(ji;iiiz(Ml, and, I think, with Justice, tliat a iiiihl (Icuicc of cystoccle will be taken caic of by a i)i-opei" perineon-haphy that builds up a lii-ni perineal body, especially provided that the uterus is in position, or is so placed and kept. llo^vever, the presence of an enlari>,ed sa<2,'^in^' cervix, if left im- con-ected, tends to bear down on the dorsal vaginal wall and dis- turb the perineal su])port of the ventral wall. This distui-bance of the support, together with the tendency of the bladder to sag, on account of its close attachment to the cervix, favors the develop- ment of the cystocele, no matter how thoroughly the perineal re- pair is done. If a separation of the attachment of the urethra to the pubes and the stretching of the ventral segment of the levator ani have occurred, and are not corrected, it is only to be expected that the urethrocele will grow and be followed by a cystocele, even with a perfect perineorrhaphy, since it is evident that the perineum offers no su])i)ort to the vestibule, and the urethrocele acts as a wedge in dilating the vaginal outlet. The patient who, in bearing down or straining, forces out the ventral vaginal wall requires some degree of correction of the re- dundancv^ The greater the protrusion, the more extensive nmst be our bladder separation and support. It is questionable whether at any time during labor a marked separation takes place at the attachment of the uterus to the blad- der. For while this attachment is always loose and easily separated, no matter how severe the degree of cystocele or prolapse, the nor- mal area of union is not lessened, nor are the ureters or their ori- fices distorted, as should occur with such an injury. Again, the cavity of the cystocele does not detract from the capacity of the bladder, but adds to its capacity that additional area. It is evident, then, when we consider these two facts, that the area which has i>'one into the formation of the cvstocele cavitv nmst have come as 128 THE GYNECOLOGY OF OBSTETRICS a stretcMng of the vaginal and bladder walls. The stretching of the bladder wall has occurred at the expense of the sides of the bladder rather than the fundus, or base. An operation, then, which will separate the bladder from the vagina and so allow its contraction, and thus its better support, is most reasonable ; but only in exces- sive relaxation does a complete separation from the uterus seem to be warranted. The circular reefing stitch in the bladder itself after denudation, if used in a moderate degree, does not form an inverted cone within the bladder cavit}^ as so often stated by many men as their objec- tion to that type of operation, but simply helps to give the circular muscle fibers of the bladder their normal points of attachment, with the proper limits of action, which thus develops their func- tion. It is essential, however, to support this bladder-reefing by the fascia and vaginal-wall muscle reinforcement, and below that by the perineum. A large cystocele denuded but unseparated laterally and inverted hj a purse-string suture of broad area could readily raise the neck of the bladder relatively higher than the lateral sulci and shorten the ventral vaginal wall to an excessive degree. A correct support of the fascia layer below would eliminate these sulci, though a free- ing of the bladder lateral to the cystocele area permits a more uni- form collapse. The types of operation advocated for the correction of cystocele are numerous, and each t^^^pe has for its basis the purpose of cor- recting the etiological factor considered by the various advocates responsible for the occurrence of the protrusion. The methods of operation are classifiable into seven varieties : 1. Those which are done through the abdomen, such as the sepa- ration of the bladder from the uterus, so as to approximate the base of the broad ligaments in front of the cervix as a support for the bladder. This same operation is done by Alexandroff and Tweedy through the vaginal route. 2. The numerous methods of operation advocated for the cor- rection of procidentia, Avhich condition naturally is always accom- panied by cystocele and which places the cure of the cystocele wholly secondary to the procidentia. These methods come naturally coiMJKcriox OK ('^'s'r()('^:LK i^d Tor clisciissioii iiiidcr the head of procidentia, tlioii,L;li, as a rule, tlie opci'atioii must include some of the t_\ pes of cori'ection to be con- si(le|-e(l Tor the cure of cystoceh'. .'1. The " interposilion," oi' \a,uinal fixation opei'ati()H,wliich witli slii;lit m()(hlication is cr(Mlite(l to Alackenrodt, Wertheim, Scliauta, l)iilii-ssen. W'atkins. and otheis. 'Idiis metlio()SM^-()l'Klx\\'n\l^: TRF.ATMF.XT 135 to li('l|) (X'casioiiall.N- in conti-olliii^' nausea, hut there is uotliiu^- that is uiiit'oniily successrul. 'IMie use of j>,as and ()xy<>,'eii as an anesthetic nives souiewliat h'ss post-operative v()initiii<;'. Durini;- the first few iates during the ten-day period, which has not infi'equently been the cause of severe autointoxication. In all cases in my practice I have used the continuous suture method of rejiair, so that the silkworm gut reinforced the catgut approximation of the sphincter muscle, a thorough stretching of the nniscle being done previous to the denudation. I have in no way treated the patients otherwise than in an ordinary perineorrhaphy, . except by exerting greater care to feed a diet with small waste and to ])rocure soft bowel movements, and have always had satisfactory results. Kelly and Noble report a percentage of failure of one in twenty in com]:)lete perineorrhaphies, on account of infection. I believe that with the continuous non-absorbable suture the percentage of good results should be much higher. So far, in both recent and secondary cases, my results have been good where this type of su- ture was used. Two of these had a mild degree of infection, yet with successful results. In all cases of perineorrhaphy the best drug for the bowels is castor oil, ])oth as a preparation and as the first laxative after op- eration. The second morning following operation a dose is given, and then if other laxatives are needed the patient's preference or custom is consulted. In complete perineorrhaphies the use of sul- phur and cream of tartar aid in keeping the passages soft. Occasionally, if much catheterization is necessary, or if there has been complaint of bladder irritation before operation, urinary anti- septics, such as salol, arbutin, or hexamethylamine, with demulcent drinks, are of service. I am glad to say that the old method of tying the patient's knees 138 THE GYNECOLOGY OF OBSTETRICS together after a perineal operation has been rather generally dis- carded, though some surgeons still cling to the custom. If we con- sider the position the patient occupied on the operating-table when the work was being done, it is easy to see that the patient can hardly injure the operative results by the separation of the thighs. The strain from vomiting, coughing, or hiccoughing puts just as much, if not more, tension upon the pelvic diaphragm than can be applied by voluntary exertion, so that the attempt to restrain the patient by tying the knees accomplishes nothing but the discom- fort of the individual. As a rule, the patient is only too glad on ac- count of the soreness of the parts to restrain her own movements. In immediate repairs it is well to avoid for the first week au}^ sud- den or straining movements, for such might, especially in an inter- rupted-suture repair, lout unnecessary strain upon the united struc- tures and tend to make the sutures cut through the relatively soft tissues. It is best not to permit a patient to sit up before the end of the tenth day. After that time the parts are pretty thoroughly united and will stand some tension. The sutures, as a rule, are left that length of time. The patient should be cautioned against any actions which will put too much strain on the pelvic diaphragm for at least several weeks following the return home, for while it may have no bad effect on a well-repaired perineum, it is just as well to be on the safe side, and it will aid in the general recuperation to encourage rest and avoid overexertion. It is interesting to watch a well-repaired perineum increase in strength as time passes, through the development of the muscles which had undergone considerable atrophy by the limitation of function. Without proper muscle support no amount of care or rest will prevent the gradual recurrence of the relaxation. So far nothing has been said regarding the local preparation of the patient for the vaginal plastic work. The careful shaving and preliminary cleansing of the vulva with soap and water, followed by two or more copious vaginal douches, are always essential. In these douches some operators use a liquid soap and require the scrubbing of the vagina with a mounted gauze sponge while the IM)S'r-()l*KIJATI\'K TRKATMKXT 139 solution is ruiiiiiiii;-. l)iit en re must be taken to avoid usinji,- sul'licient foi-ee to injure the mucous meinbi-aiies. This is followed by some antiseptic solution, and then possibly l)y stefile water, the douches beini;' rejx'ated in the morning- before operation. Here, as well as iji all other operative work, the use of iodine lias become almost mdversal, and applications of every strength liave been recommended. Undoubtedly, iodine is a most excellent ])rei)aration for emergency cases of all sorts, and especially dirty ones. But the ])endulum is beginning to swing the other way, as we are realizing that iodine has some disadvantages. It has been shown recently in experimental abdominal surgery that the unpro- tected iodine-covered skin may carry enough drug to the peritone- lun to cause firm adhesions wherever contact has occurred. Again, cases of iodine dermititis are coming to light continually. Unless in very weak solutions, iodine as a routine in vaginal work is not wise, since the vaginal canal has much greater absorptive powers than the skin, and in a susceptible patient sufficient quantity of the drug may readily be absorbed to produce a systemic effect. Even a small quantity will occasionally produce a severe dermititis of extensive area not at all eas}^ to relieve and often more uncom- fortable to the patient than the operative procedures. Iodine, too, l)y the discoloration of the tissues rather interferes with the differ- entiation of skin and mucous membrane and hinders accurate ap- proximations. If used at all, it should be applied only in weak solutions. The vaginal tract is resistant to the germs which normally are present there, so that careful cleanliness with the exclusion of out- side sources of contamination through careful aseptic technique is sufficient to prevent infection, and too strong antiseptic solutions are to be avoided. By the use of irritating solutions we may set up conditions which will favor germ development. If an infection of pus-forming character is already present in the pelvic tract, no variety or quantity of antiseptic or germicide will prevent a light- ing up of the condition with the probable failure of our operative work. So in all suspected acute or subacute processes our policy should be one of non-interference unless special indications arise. Here, as in other surgical work, the knowledge of when to avoid 140 THE GYNECOLOaY OF OBSTETRICS intervention or when to postpone it is just as niuch a criterion of the surgeon's skill as the correct doing of the operation itself and the correct carrying out of the after-treatment. PROGNOSIS AND POST-OPERATIVE COMPLICATIONS NiVr only for tlic pliysical 1)ut also i'oi- the iiicutal wcU- ht'ing of the patient the i-esiilts of eflieieiit plastic work are always good. The coiiiplications that may arise at the time of operation or later are not man}^ and can usually he avoided, so that, when all factors are considered, there are few branches of surgery that yield such uniformly satisfactory results. The full measure of improvement, however, is not felt before six months or more. While the immediate gain from the support is noticeable as soon as the patient is upon her feet, through the re- moval of the bearing-down feeling, the better control of the rec- tum, and the clearing up of the bladder symptoms, yet time is es- sential for the building up of the undermined nervous system. It is no unusual happening to have a patient return at the end of four or five months disappointed that she still feels nervous, irritable, and is readily tired ; but if our diagnosis has been complete and our work well done, we are safe in giving assurance of the improve- ment that is bound to come, and come the more rapidly the greater the physical care employed. Generally, a few months later such pa- tients are only too glad to report that they never felt better in their lives, for the gain both physically and mentally is well marked. One patient, and one who exhibited not more than the average im- provement, expressed her feelings thus : ' " In the face of the great change it would seem a simple thing to say that the pain and weariness have stopped — though, in truth, they were no simple things w^hile they lasted. But it is not only what has gone, but also what has come. " That miserable phrase 'female trouble' is such an old one — ■ so old, so accepted that to rebel against its inevitableness is almost to question the eternal verities ! So many days of sunshine and wind, jo}" of life and work, flash of vision and strong pull of en- deavor, lost each month ! So many hours of agony, creeping, strain- ing, crashing to the roots of one's mind — breaking into all the 142 THE GYNECOLOGY OF OBSTETRICS wholeness of life and peace ! — then the drugged quiet and the light going out. " Nor is this all. Every month a little less strength to go on with, a little less control, a little less hope. And always gathering in the background tense hysteria. But one was supposed to bear that. It was almost a womanly virtue to be frail. And certainly womanly traits to be hysterical and unreliable ! " One can bear the pain. But it is not right to see the days pass — empty. ' ' But now life seems a new chance. The pain and the shadows and the weariness have gone. The memory that was failing, failing every time the light went out, is quick and true again. My body is my own again. It does not desert me when I need it. It does not weigh me down when I would forget it, I fight no more devils in the dark. I could tell you all the pathological symptoms, but it is a bigger, truer test to tell that life is good, and that the work has wings. ' ' This sentiment, though expressed a little more graphically than usual, conveys an idea of the general post-operative satisfaction of the patient. There are a few factors whose presence may interfere somewhat with the customary good results and lead to disappointment — fac- tors which we cannot consider as operative complications. For instance, sometimes in cases of tertiary or latent syphilis we find to our great disappointment that, while the results immediately after the patient's convalescence are excellent, a gradual stretching out of the scar takes place, so that, without any apparent reason, a considerable relaxation has occurred with a recurrence of many of the nervous symptoms. Usually in these cases the general evi- dences of specific infection are not marked; otherwise, operative procedures would probably have been postponed; and, consequent- ly, specific measures are not instituted in order to prevent the bad results. It may even be that the failure to obtain a permanent re- sult is the first thing that leads us to investigate the possibility of specific infection. The same systemic infection may lead to a failure in cervical work, but here it is expressed through a recurrence of the inflamed, hypertrophic condition for which the operation was undertaken. However, in specific infections involving the cervix we are not IM)S^r-()PKRATI\'K ('OMn J CATION'S 143 jiistilMMl ill cxciisiiii;- our lack of realization of the true pathology, as we perhaps may he in perineal conditions, for it should always be l)()riie in mind that cervical j)athology result in,<;- fi-oni injury may be aggravat(Ml in syphilis. In the luetin skin reaction and the Noguchi and \Vass(,'rman ))lood tests we have aids to a j)ositive diagnosis. While, of course, o|)eratiou sooner or later is essential, it is wisei- to first ()l)tain control of the general condition, if we are to ex])ect good results. Another factor that has ah'eady been mentioned is found in a small class of cases of relaxed vaginal (nitlet in which there is excessive redundancy of the vaginal walls — not those cases associ- ated with ])]()lai)se of the uterus, but a condition in which the cer- vix remains at the normal level. This redundancy seems to be a relaxation of the tissues generally, rather than the result of disten- tion from cleavage injury alone, and the question of its correction is not an easy matter. The building up of the ventral vaginal wall and of the pelvic diaphragm and floor does not, as a rule, take up sufficient slack to give the vaginal walls the support required to accomplish the desired gain in tone, especially in cases where a flap repair has been done. With the ordinary amount of plastic work, the imi)rovement is very marked, but still there is sufficient re- dundant tissue left, so that when using a speculum the walls crowd in and make an examination of the cervix difficult. If the patient bears down, there is more or less tendency to bulging of the walls, even though well supported by the perineum. This tendency of protrusion of the walls has in time an unfavorable influence on the perineum, and a relaxation of that may occur. But previous to this condition, on account of the poor dorsal support of the upper por- tion of the ventral vaginal wall, the bladder is not sustained as it should l)e, and the cystocele tends to recur, though within the vagina. When this condition is due to a general lack of tone in the pa- tient, efforts directed to building up the physical condition, with the avoidance of overexertion, will do a great deal toward con- tinuing the improvement started by the operative work. The local use of depleting tampons, to be followed by astringent douches, which should be of only moderate temperature, will aid much. It 144 THE GYNECOLOGY OF OBSTETRICS is not generally recognized that in some women hot douches will favor a relaxation instead of producing the blood-vessel contrac- tion that the prolonged use of heat is intended to accomplish. Neither do we always appreciate the excessive amount of xoressure that may be exerted from above by an improper corset, especially in these cases of relaxation. This pressure not only interferes with the venous circulation, causing congestion, but it produces the same character of sagging and relaxation just considered. In these cases, however, a better surgical support of the vagina is almost a necessity, and should be planned for primarily. If the woman is beyond the child-bearing age, we are, of course, at liberty to do a much greater resection of tissue, and thus obtain better support throughout the whole vaginal canal. In the child-bearing- age, however, it is often difficult to judge the degree of denudation and how much building up of the fascia layers beneath the mucous membrane may be done so as to correct the relaxation but 3^et al- low room for a subsequent labor without the danger of splitting the vaginal canal. Fortunately, most of these patients have their condition as a result of successive labors and are usually near the menopause. If not, we simply have to do the correction as exten- sively as is compatible with possible subsequent labors, even if later it may necessitate more operative work. A woman who is anxious to have children readily agrees to possibility of reoper- ation. In the correction of this type of relaxation practically the only perineal repair to be considered is the Hegar type of denuda- tion, which allows for the reconstruction of the fasciae and the support of the rectmn. There is a milder degree of relaxation which might be spoken of as a recurrent type. The patient is immensely improved by the operation, but from time to time has a recurrence of the irritable bladder or the bearing-down feeling. These cases are essentially due to a lack of tone, not always confined alone to the pelvic tract. Following periods of overexertion, either mental or physical, the symptoms usually return. It is in women who "live on their nerves," as the saying is, and w^ho are continually going beyond the limit of their strength, that we find such a delayed period of full improvement; and it is not to be wondered at, for it takes I'os'roi'KUATix'K ('()Mnj(\\^ri().\s 145 time foi' aii\' hod)- stnictiirc in wliicli an ovci-supply of blood lias l)e(Mi incscnl for a coiisidcrahlc period to ceaso to rospoiul througli its still dilated xcsscls to any al)noi-inal stiniulns. As time ))asses, if rccniicnt congestion is avoided, the tissues undei-go a perma- nent contraction and con.gestion occurs less easily. These patients usually respond to the simple depletion jiiethods after a few treat- ments, but require general supervision for some time, in order to ])i'evciit, if i)ossil)le, any abnormal conditions in life tending to i-e- duce the general resistance. The innnediate dangers at the time of operation are not many and can always be avoided with care. There is some danger of in- jury to the adjacent organs — the bladder in ventral colporrhaphy, and the rectum in dorsal. Hemorrhage may occur in any part of the work, but more especially in the trachelorrhaphy and perineor- rhaphy. An entrance into the bladder and rectum need not, as a rule, occur if care is used. Where it does occur, it is generally the re- sult of too hasty handling of excessively thinned septa or struc- tures distorted by scar tissue. I have, however, seen a few cases Avhere the friability of the mucous membranes was so marked that the greatest care did not prevent injury to the rectum, and some of these occurred in the hands of the most skillful operators. When hemorrhage takes place, it is usually in the perineor- rhaphies, and is of venous character, due to injury of the rectal plexus. The properly placed suture will readily control this type. There is a chance of more severe hemorrhage, and a hemorrhage more difficult to control, in the type of operation which does exces- sive dissection, such as has been discussed under perineal repair. In the practice of the best men I have seen bleeding start up from a location difficult to reach after the completion of the operation, but never have I seen it occur where the simple denudation was done and the muscle picked up without further dissection. The secondary bleedings from the cervix occurring shortly after the recovery from the anesthetic are due to poorly placed or in- sufficiently tied sutures in the angles, so that care in placing these deeper sutures will avoid that awkward sequela. A pack in the va- gina, in case the complication arises, may be sufficient if the bleed- 146 THE GYNECOLOGY OF OBSTETRICS iiig is not severe, though it will endanger the perineal repair unless very carefully placed. If the flow comes from a larger vessel, it will necessitate the application of a suture well out in the angle of the denudation. This is such an annoyance to surgeon and patient, on account of the necessity for more anesthesia and the danger of in- jury to the repaired perineum, that it is always well to inspect carefully every cervical repair before leaving it, and if there is any suspicion of bleeding, to apply a reinforcing suture at that time. We must remember that the bleeding point is at the deepest por- tion of our denudation and from a branch of the circular artery, and the suture may need to be applied even above the denuded angle. Care in these seemingly minor points of plastic work will tend very largely to freedom from anxiety on the surgeon's part and better results by the avoidance of interference at unfavorable times. Secondary hemorrhage from the cervix occurring as late as the tenth day has been mentioned. The probability is that the majority of such cases are the result of infection, though I once saw it hap- pen in a case in which the surgeon removed the stitches before the tenth day. Mild grades of infection in the uterus and tubes will often interfere seriously with the repair process. The absorbable sutures dissolve much more rapidly in the presence of infection, and when they have disappeared we find a granulation process covering the denuded areas with only slight or no attempt at union. A little increased motion or slight mechanical interference, or even the inflammatory process alone, may be sufficient to start a bleed- ing from the circular artery. To control such bleeding suturing is necessary, but from this second suturing there is little prospect of a perfect cervix. The use of absorbable sutures of sufficient resistance to last over ten days is best in cases accompanied by perineorrhaphy, if there is no possibility of infection, as it is better to avoid interference with the perineum in the first three weeks. In case no perineor- rhaphy is done, or if infection is feared, non-absorbable sutures may be used, but their removal should not be undertaken inside of fourteen days. The cervix always looks more or less irregular after the removal of stitches on account of the depressions left by the IM)SM^-()I'KRAT1\ K COM i*IJ CATION'S 147 sutiiics, i)iit, as a rule, in a few weeks the irrei^ulaiitics disappear and the sui-faee assumes a normal aspect. Occasionally, in amputation of the cei'vix, the di-ainaii,(' suPfers interference tiirouiAli a temporary adhesion of tlie incision edges, and the fluids are r^^ained within tlie utei-ine cavity. Tlie same lack of drainage may occur in a sim])le re])air, if, by chance, the uterus in ))eiiig pulled down lias been displaced and left in the i-etroverted position. A small clot lodge(l in the canal may also have the same effect. This retention of some curettage remnants or menstrual blood shows itself in a few days after operation with a chill and a sharp rise of temperature, usually followed by profuse ])eisj)i ration. Previoush'^ to the chill there is a slight elevation of temperature present, but, as a rule, it has been considered naturally as the ordinary operative reaction. Such a condition is readily remedied by a vaginal douche with a few doses of ergot or other oxytocic. It is to prevent such obstruction that the use of a loose gauze wick within the cervix in amputation was advised in the op- erative procedure. The removal of this gauze at the end of thirty- six or forty-eight hours leaves the canal patulous. Also, it is impor- tant before the patient leaves the table to make sure of a correctly placed uterus in cases in which there is no abdominal work to be done. If the uterus is found out of position later, the knee-chest or Sims's position will usually correct the condition without instru- mental interference, though the necessity for air entering the va- ginal canal must be borne in mind. However, the less we have to interfere with our patients after perineorrhaphies the better the results will be. After the menopause, when the nmcous membranes normally be- come more or less atrophic, it is not uncommon to find that adhe- sion has taken place lietween the ventral and dorsal vaginal walls, or between them and the cervix at points on the suture lines. These unions are often fairly firm, but, as a rule, can be readily separated with the finger when the sutures are removed. If no vaginal ex- amination is made at the time the perineal stitches are removed, and the condition is overlooked, later on it may be impossible to separate the approximation without dissection. It is not always necessary to have two incision areas in apposition to have such a 148 THE GYNECOLOGY OF OBSTETRICS complication arise, for the senile membrane itself, if injured by friction, will readily unite with the line of incision on the opposite wall. In fact, in senile vaginitis very frequently opposing areas will become adherent, even without any mechanical interference of DAV OF MONTH Mar. 17th 18th 19th 20th 21st 22nd DAY OF ILLNESS A.M. P.M. A.M. P.JI. A.M. P.M. A.M. I'M. A.M. PJI. A.M. P..M. Hour 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 S 12 4 S 12 4 S 12 4 8 12 4 8 12 4 8 12 S 12 4 8 12 ^ 101° PULSE yS 7^ u fo fo rz So Z 'OS ^£ f6 9y 96 f¥ g6 St> Operation- Trachelorrhaphy - Perineorrhaphy Uterus retroverted- No operative correction. A case of retroverted uterus with relaxed vaginal outlet and a lacerated hypertrophied cervix. The patient refused abdominal operation or other method for correcting the retrodisplacement. The uterus becoming displaced after operation, the drainage was interfered with, and a sapremic condition resulted. The replacement of the uterus through the knee-chest position re-established the drainage. In these cases the pulse rate is out of proportion to the temperature, and the leucocyte count is not increased, factors that are against a diagnosis of infection. oi^eration, when the lining membrane has become excessively thin and friction has resulted in erosion. I have seen the adherence of the vaginal walls occur in two cases where there had been con- POS^roPKIJATlVE COMPJ.ICATIOXS U!) si(l(M-al)le swelliii.i;- ol' the structuros following- o])erati<)ii, and in one case wliei-e union of an aini)utat('(l cervix and a veiiti'al coli)or- rhaphy occurred — these tliree cases in wonien well under the meno- pause and with normal vaginal walls. While such a complication Juri" iO'.h il-.h 12t.i 13th 14'vh Ibth \M !■ M A.M. P.M. A.M. P.M. A.M. I'.J! A.M. PM. A.M. P.M. 4 S IJ 4 8 rj 4 S li; 4 S 12 4 .S 12 4 S 1-' 4 S 12 I 6 12 4 S 12 4 8 12 4 8 12 1 S 12 c e a so M ? lor PULSC ?o fa fo ff fo f6 JO Si to «3 Oparation — - Plsstic Work on Cervix and Perinaum. 1^ % ^^ So ^0 In this patient tlie plastic work upon the cervix produced a temporary gluing together of the surfaces, thus interfering with the drainage. The uterine cavity had been curet- ted, but the debris had been removed by gauze without irrigation. A vaginal douche with a dose of ergot produced sufficient uterine contraction to re-establish drainage. is not common, it is well to bear the possibility in mind, and never permit a patient to leave the hospital without a digital vaginal examination, even if the use of absorbable sutures has eliminated the necessity for removal. If such an adhesion becomes firm and is of any great extent, it may give rise to unpleasant complications. 150 THE GYNECOLOGY OF OBSTETRICS After plastic work it is not at all unusual to find a recurrence of the menstrual flow, even though the patient has just completed the normal period. This return seems to be largely due to the reflex congestion of the ovaries, as a result of the irritation of the cervix by the presence of the sutures. It is not found, as a rule, if the uterus and cervix are not interfered with. On the other hand, it is often present after pelvic abdominal operations where no plastic work has been done. The question as to what time of the month in relation to the X)eriods is best for operative work has usually been decided as immediately following a period. It is true, and especially in the abdomen, that then there is less trouble in controlling the capillary bleedings, but this is probably the only reason for choosing this time. In plastic work the bleeding is freer during, or especially just before, the period, yet it is never too great to interfere with the work or prevent ready control. It is very questionable whether the bleeding from the curettage and trachelorrhaphy, if done just prior to a period, will head off the normal flow. In some cases it will, but, as a rule, the menstruation is only delayed a few days, and then occurs probably on account of the stitch irritation of the cervix. It is in acute or latent salpingitis that operative interference even for simple plastic work must be avoided, for then the traction on the cervix necessary in repair work is sufficient to light up the inflammation and produce pain and temperature with often a fail- ure to heal. If such a condition is suspected, the omission of a cu- rettage is wise; but it is always better to postpone any operative work of this non-emergency kind until we are sure of the sub- sidence of the infection. The presence of the gonococcus, as a rule, does not seem to in- terfere with the healing, yet it is not safe to recommend operative interference in its presence. Cases of suspected latent infection in the glands of Bartholin, unconfirmed by microscopical examina- tion, may sometimes be submitted to operation on account of the great improvement to be attained by operative work. In a few such cases I have seen good results, though considerable local reaction and swelling occurred immediately following operation. In each I>()ST-()I*KRAT[VK (*( )M PLK 'A^riOXS IT)! case tlic coiitiiiiious suture was used in the |>('riu(M)i-rl)a[)iiy, and \ <|U('sti()ii wlictlicr int(Miu|)t(Ml sutures would liav he just tlie iiiitation siifhcieut to light up a tubal in- volvement and result in the development of a pelvic abscess. One cannot too strongly condenm the tendency to interference in acute tubal conditions before a complete subsidence of the infection. It is not only dan.nci'ous to the life of the woman, l)ut, if she survives, is the forerunnei- of many pathological pelvic conditions. Few women have ever lost their lives l)y the conservative treatment of tubal infections. It has ])een jjroven conclusively that after a period of time has elapsed, placed by German anthorities at two years, the pus within the tul)es becomes sterile, thus permitting of safe intervention. The only acute condition where operation is permissible is the pel- vic abscess formation, and that, by vaginal drainages only. The rare pyosalpinx rupture probably is best treated in the same way. hi a ]n'osalpinx complicating an acute appendicitis, drainage through the abdomen and cul-de-sac combined may be necessary, in simple acute tubal infections I believe that operative interfer- ence is absolutelv unwarranted. MISCARRIAGE AND STERILITY IT IS generally recognized at the present time that a simple flexion of the uterns is not sufficient in itself to offer a barrier to the spermatozoa, and thus prevent pregnancy. Either the inflammation of the cervical mucous membrane (which is so often associated with the anteflexion) or the infantile character of the pelvic organs (which in varying degrees is at the base of the etiology of the condition) is the factor that prevents conception. There are cases unassociated with inflammation where sterility exists, and where it can be overcome by a thorough dilatation with the wearing of a stem pessary. This treatment, however, is effec- tive more because the presence of the foreign body within the uter- ine canal stimulates the development of the undeveloped organs than because of the correction of the stenosis. Yet, on the other hand, Pozzi's operation, done to enlarge the os, has to its credit a sufficiently large proportion of sterility cures to show that in some cases the smallness of the external opening bears considerable relation to the absence of conception. This may be due directly to the enlarged opening permitting the spermatozoa to enter more readily. Indirectly it may be of value by affording freer drainage of the cervical canal, and thus preventing its ob- struction by mucous plugs. The operation advised by Pozzi to correct sterility consists of two lateral incisions separating the ventral and dorsal cervical lips and the closure of each raw area laterally by interrupted su- tures so as to prevent reunion. Pozzi insists on silver wire with a cone-shaped lead shot for this purpose. He recently reported a large percentage of resulting pregnan- cies, with no bad effects in those cases not successful No cases of miscarriage are reported. However, other operators have had cases where the after-effects were not good, on account of the irritation of the exposed mucous membrane. Cases of miscarriage following incision of the cervix AllSC'AliKIA(;K AND STP^RIIJTV 153 (lone t'of iiiciisti-iinl pain ai'c not niicomtiioii, and ai-c in pi'actically the same catc.tAoi'N'. By tliis operation we arc actnallx' ii,ottini2,' the conditions wliicli result I'loni a toi-n cervix, tliou,i;li, of course, without the scar tissue at the angles. The ])os>sil)ilities are ])reseut for irritatiou of the mu- cous nieuihrane through exposure, thus giving rise to the train of patlioh)gical processes already considered. The scar tissue in the angle und()ul)tedly j)lays a very inii)ortant ])ai-t in the i)atliology and symptomatology resulting from cervical injury. In order to get a]i]iroximation of the mucous membranes without scar tissue, Pozzi carefully removes a wedge-shaped portion from each side so as to ])ermit of accurate approximation. His reports of good re- sults serve to em^Dhasize the importance of the scar-tissue angles in cervical inflammations. Possibly those operators reporting in- Hannnatory sequelae failed to get perfect primary union, which naturally resulted in scar tissue. VieM'ed as a whole, the indications for an operation of this kind are narrow. It is never indicated in the presence of any inflamma- tory i^rocesses or in any pathology of the uterus or appendages that might account for the sterility. When done, it should be done with great care, to avoid scar-tissue formation. The same indications apply, though in a somewhat narrower sense, to the Dudley-Reynolds operation as a cure for sterility in anteflexion. These operations may be done even though a chronic inflammation of the cervix is present, w^hich condition ought to ex- clude Pozzi 's method. ■ The Dudley operation, which is a modification of Sims's discis- sion of the dorsal cervical lip, advised for dysmenorrhea and ste- rility in cases of uterine anteflexion, consists of a median vertical incision in the lip, extending through the internal os and down to the uterovaginal junction; a wedge-shaped segment is then re- moved from each side, so as to permit the folding over and closure by suture of each raw area. The purpose of this procedure is to change the direction of the external os and make straight and wide the cervical canal. Dudley's modification was devised to prevent the exposure of any cervical mucous membrane to vaginal irrita- tion, such as often occurred with the original Sims operation. 154 THE GYNECOLOGY OF OBSTETRICS This Dudley operation is frequently combined with the Reyn- olds, the latter being a modification of Skene's anterior incision, advocated for the same indications. An incision an inch and a half long is made transversely at the vesicovaginal junction down to the uterine tissue. By blunt dissection, the bladder and uterus are separated to a point above the uterine flexion. Then the raw area is united vertically without including the uterine tissue. This opera- tion lengthens the ventral vaginal wall and straightens out the uterus, so that the external os points backward in a more normal direction. . These two operations were devised for the purpose of correcting the mechanical abnormality of the uterus ; the supposition being that the pain would disappear because of the more direct and patu- lous canal, and that the sterility would be cured through the same factors, and the more normal position of the os. Recently Holden, of Brooklyn, reported the results of forty of the combined operations done in a period of over nineteen months. His percentage of cures of the dysmenorrhea was eighty-five; of the sterility, twenty-five. Previously Breckner had reported seven- ty-three cases in over six years' time, with sixty-five per cent of dysmenorrheas cured and twenty-seven per cent of sterilities re- lieved. All cases evidently included as a primary procedure the dilatation of the cervical canal. These reports are interesting from the standpoint of the cor- rection of the sterilit}^ as well as the relief of the pain. It is a ques- tion, however, whether or not the dilatation alone would have been sufficient, for we know that a thorough dilatation will relieve these symptoms, though not alwaj^s permanently. These Dudley- Reynolds operations would be of more value from the scientific point of view if they had been preceded by an attempt to accom- plish the same result by simple dilatation. Of course, there is no doubt that the patulous os and canal are obtained more certainly and permanentl}^ by the Dudley-Reynolds method, but, on the other hand, it is a more exact surgical procedure, requiring great care for good end results ; poor results are probably factors that favor miscarriage. Practically, I believe that all that the Dudley-Reynolds method :\IIS('ARRIA(iK AXI) STKIMLrrV 155 ac'C()ini)lisli('s is tlic Ix'tlcr (li-aiiia<;(' of the canal. Tlie resulting drainage })erniits a greater eliance for the clearing up of the in- flanunation that in the great majority of cases of anteflexion is hack of holli the dNsniciiori-hca and the st<'rilit\'. We have spoken of the class of nnd('\<'h)ped uteri unassociated with inflannnation. Naturally, these are in a somewhat different class, and are the cases that may he aide(l hy a stem i)essary. The relief of pain is prohahly largely the result of obtaining a lai'ger and less rigid internal os through a perfect operation. With a i)atul()us internal os there is less chance of the menstrual blood collecting and causing clots within the uterine cavity, and thus pro- ducing the colicky pains of expulsion. Yet in Breckner's cases 33.3 per cent of the dysmenorrheas were not relieved. It is probably true that the congestion present in these pathological cases of ante- flexion alters the normal proportion of blood, lymph, and mucus, and thus favors clotting. In Breckner's cases 33.3 per cent of the dysmenorrheas were not relieved, though they were all patients supposed to be free from tubal or ovarian pathology. To be of greater value, these case re- ports should consider more in detail the character and degree of inflannnation in the cervix previous to operation. From the pregnancy standpoint alone, we know that the direc- tion of the OS has little to do Avith the prevention of conception. Eetroversion is not, as a rule, recognized as a cause of sterility, and yet the os is always out of its normal direction. There are many women also in whom pregnancy readily occurs in spite of the fact that the uterus is in such extreme anteflexion that in many of them it returns to its flexed position after each pregnancy. AVe are surely justified in the conclusion that in the far greater number of cases the symptoms in anteflexion and the sterility are secondary to the inflannnation, and that the cause of success in curing these conditions by the Dudley-Reynolds operation is the subsidence of the inflannnation by drainage. We shall find that some patients will l)y ordinary local treatments get over their inflammations and become pregnant. In cases that have had a chronic endocervicitis over a long pe- riod, which has resulted in a cystic degeneration of the cervix, with 156 THE GYNECOLOGY OF OBSTETRICS a hypertrophy of all the cervical elements, the mistake is not infre- quently made of expecting a stem pessary to cure sterility. An operation that in reality often amounts to an amputation or an Emmet repair, even though the cervix has never been injured, is the only method in such cases for obtaining relief. This has already been discussed under cervical inflammations. In these cases it is the increased amount, the tenacious character, or the change in re- action of the cervical-gland secretion that accounts for the sterility. A stem pessary used where the mucous membrane is diseased is usually productive of more congestion and an aggravation of the inflammation. The pathology of the cervix has a very vital bearing on the ques- tion of what might be called a relative sterility — that is, the in- ability of a woman to go to term, or the non-occurrence of preg- nancy after the first child. We must ever bear in mind the frequen- cy of the abortion tendenc}^ in syphilitic individuals and recognize that disease. Though in most of these cases the termination of pregnancy is the result of syphilitic changes in the placenta, I be- lieve it is sometimes due to the syphilitic cervix, and not neces- sarily dependent upon the placental pathology. Another cause of sterility in which, of course, the cervix plays no part is the tubal obstruction or distortion due to pelvic inflam- mation. Eliminating these two classes, I believe, we have a very great number of relative sterilities due to cervical injuries. Personally, I consider that a most frequent etiological factor in both the non-occurrence of pregnancy and the occurrence of mis- carriages is the lacerated cervix, especially if associated with the resulting inflammation. In many cases this is further aggravated by the relaxation of the vaginal outlet. Very frequently, indeed, a woman with a lacerated cervix or a relaxed vaginal outlet, or both, is advised to wait until the child- bearing period is over before having the injuries repaired. The physician who advises waiting argues that, despite the repair, there will be a recurrence of the injuries at the next pregnancy, and that little wisdom is shown in doing something that, in his opinion, would probably be undone. Even some of our supposedly best authorities still recommend such a procedure and overlook MISCAKKJAGE xVXl) STERILITY 157 tile possible I'litin'c conijjlicatioiis. Fs it not better to do a minor o|)ei-atioii, and fepeat it later slionld tlie tears recur, if by so doin<^" we are enabled to avoid j)ossible miscarriages and an abnost cer- tain majoi' opei'atiou, to say iiotbing' of liaviiii;' tlie woman in i^ood liealtli pelvically ''. The likeliJiood of as severe injuries with su))se(iuent labors is never so great as with tlie first cluld, whether a good innnediate re- ])air or a secondary ])erine()rrhaphy has l)een done. The profession has been well drilled in the theory that an epithelioma of the cei-vix has always as a forerunner the lacerated cervix, and as a result most severe cervical injuries are repaired when discovered. But lately even that stimulus to putting the woman into at least a par- tial state of good health is being assailed by many waiters, who scout such a theory, claiming that cancer of the cervix never begins in the tear. Statistics show^ that cervical cancer has always been preceded by dilatation of the cervix, either by labor or from an op- eration. Some authorities believe that it is recurrent injuries that favor malignant developments of the cervix. Instead of belittling the injured cervix as an etiological factor in cancer formation, it is wiser to bear in mind the clinical evidence. Perhaps it is unfortu- nate that there is not some similar possibility to stimulate perineal repair. Severe cervical injury with its resulting inflammation usually prevents pregnancy, but its symptoms are sufficiently marked to attract attention and result in repair. The moderate degree of in- jury Avhich may give few symptoms, and which more often than not is passed over by the examiner as of little significance, is the one which is frequently unrecognized as a cause of sterility or miscar- riage, and this is the type I wish to emphasize. Herman, of London, in his book on gynecology advises the Em- met operation as a preventive of abortion, since sometimes patients with deep lacerations of the cervix repeatedly miscarry. His ex- planation is that during pregnancy the body of the uterus con- tracts intermittently, and if the cervix is weakened by deep lacer- ations its normal power of opposing the contractions is destroyed and abortion results. I believe that more stress should be laid upon the inflammatory 158 THE GYNECOLOGY OF OBSTETRICS sequence and the stretching out of the scar tissue. Every injured cervix in which the cleft persists has the formation of scar tissue in the angle, and as the uterus enlarges this scar tissue stretches out, weakening the supporting power of the cervix. If only the deep clefts were associated with the abortion cases, Herman's explanation might be sufficient, but many cases are not associated with pathology of gross character and the deep cleft is wanting. In some of these cases the inflammation that is secondary to the scar-tissue formation, causing endocervicitis and later cervical hypertrophy, may not involve the uterine body as a whole, but may extend high enough to interfere with the placental development, as the fetus grows, and favor placental separation, and, consequently, the termination of pregnancy. In these cases of border-line pa- thology probably all three factors are at the base of the frequent abortions. Practicall}^, no emphasis has been placed on the influence that the relaxed vaginal outlet exerts in exaggerating cervical defects, and thus its consequent relation to this type of miscarriage, but in many of these patients the cervical repair would not alone be suffi- cient, for the pathology of the cervix recurs with fair rapidity, due to the drag of the vaginal walls from below and the pressure from above, with the resulting congestion. This same relaxation which favors the descent of the uterus naturally tends to exaggerate a pathology in the cervix. Under a normal condition of the perineum this degree of pathology might not be sufficient to result in abortion. The relaxed outlet is seldom alone primarily the cause of miscarriage, for it is only in the first few months that it has any direct bearing on the position of the nterus, as that organ grows rapidly out of the pelvis, and then is l^ractically self-supporting. But it bears weight by its indirect ac- tion on the cervix, through the greater chance for increased irrita- tion by friction and dragging that results in inflammation. Thus occurs the exaggeration of what might, under other circumstances, be minor pathology. Consequently, it is just as important to rem- edy the relaxation of the outlet as it is to repair the cervix in these cases that are subject to a too early termination of pregnancy or to sterilitv. .MISCAIJRIAdK AXI) STERTTJTV l.")!) Sterility is in practically cvcin' case the direct result of the iii- flaiiimatioii within the c('i-\i.\. This iiiflainniatioii fi-equently alters the chciiiical icaclioii of the ccrNical secretion, hy which sperma- tozoa are desti-oycd, oi- produces such an incfease in the (puintity of secfction as to form a tenacious mucous plu.ii,' of the canal. In these cases especially is it important to re|)air any defect of the ])elvic diai)hrai!,-m and floor, since these defects are often the cause of the ceivical inflammation. A history of the following rathei- exaggerated case will serve to illustrate more forcibly how small a degree of i)athology may be the direct cause of the abortions: ** Airs. A. R., aged thirty-eight, was exceedingly desirous of hav- ing children, and was referred for an opinion as to whether or not a mild degree of cervical pathology was sufficient to account for the too early termination of the pregnancies. The menstrual history previous to the first conception was witliout marked abnormality, and there w^as nothing in the general history that could influence the pregnancies, with the exception of a rather marked recurrent anemia of transient duration. The first pregnancy had resulted in an abortion at three months, and the physician wdio had attended at the time spoke of the inflamed and everted cervical mucous mem- brane. A second pregnancy, a year later, had also terminated at three months, there being in neither case any discovered cause. Conception occurred again a year later, the fetus being carried for six months, wdien labor again intervened without warning. The last pregnancy, which, like the first two, ended at three months, oc- curred tAvo years ago. ' ' Pelvic examination showed a normally placed uterus, slightly enlarged, a cervix somewdiat hypertrophied, with an erosion on the ventral lip and a few Xabothian cysts. The pelvic outlet was some- what relaxed, though without any marked cleavage defect. "The suggestion of performing a cervical amputation with a perineorrha])liy was gladly accepted. Within two months after leaving the hosjutal the patient was again pregnant; went through a normal term in excellent condition and with less discomfort than during the former pregnancies, and delivered herself with only a moderate degree of injury to the perineum. Throughout the preg- nancy a careful watch was kept on the blood, and an iron tonic used occasionally, as had been done in the previous pregnancy. This patient expressed herself as being very conscious of the increased sup]iort from the ])erineum and the comfort obtained therefrom." 160 THE GYNECOLOGY OF OBSTETRICS This case is an extreme one of frequent miscarriage without any systemic cause, and depends Avithout doubt on the cervical pa- thology. The following history is t^^pical of a considerable number of cases of what has been referred to as relative sterility, or sterility occurring after the first pregnancy : '' Mrs. B., aged thirty-two, had five years ago an abortion at six months, following a fall, and no conception since. The physicians consulted recognized nothing abnormal and had no suggestions to make. The general health of the patient was good, and the only complaint was of some increase in the menstrual flow foUow^ed by leucorrhea. Examination showed a normal pelvis except for a mod- erate degree of cervical injury, a slight eversion of the mucous membrane, with an eroded area on the dorsal lip, and increased cervical discharge. The correction of the cervical pathology by operation was followed some months later by conception and in due time by a normal delivery. ' ' Gross cervical pathology is generally recognized as a possible cause of sterility or of the too early termination of pregnancy, but the minor degrees of injury or inflammation are too often passed over, and seldom do we hear of the relaxed outlet as of importance. It is true that many women, in spite of marked defects in the pel- vis, bear children with small inconvenience, but this does not alter the fact that there are women with only slight defects who are un- able to do so. It depends, I believe, in a large degree on the sen- sibilities of the individual to irritation, which is a factor that must always be borne in mind, especially in pelvic pathology. A condi- tion that will make an invalid of one woman wdll seemingly cause no inconvenience to another. The modern woman, however, with her wide interests, her intense life, responds readily to the exter- nal, mental, and physical stimuli surrounding her at all times, but does so at the expense of her nervous stability, and this naturally favors a greater reaction to any pathological process. These things are factors that should be taken into consideration in deciding upon the advisability of operative interference in border-line pathology. With so many strains upon the nervous system, it is well to con- sider carefully the effect of even a mild degree of pelvic inflam- mation as a cause of irritation to the already overstrained nerves. MISCARRIAGE AND STERILITY 161 The occ'iirrcMH'c ol' |)i-(\uiiaiH'_\- and its uoi'iiial coiiiijlction is at best a coin])lieat(Ml process of iiatun". and it is not snr|)risini;' tliat iii- flaiiiiiiation from even a mild de.iAree ol' patliology iHa\-, through the alteration of tlie secretions or in some more indirect way, interfere with the processes either before or after conce])tion. BLADDER INFECTIONS XE phase of cystocele to which scant attention has been given is the residual urine and its relation to urinary- tract infections. The bacteriological findings of the uri- nary tract in relation to the various pathological condi- tions is a subject still open to investigation. So far, even the question as to the normal sterility of urine seems to be debatable. In isolated instances considerable work has been accomplished by the bacteriologist, but generally without the collaboration of the physician. Our writers of authority are content with meager statements. In the International Clinics of recent date Burnett, of Edin- burgh, writes : "Workers in this field at present are but pioneers and our knowledge but scant}^ In fact, I am more and more convinced that we have still a wide field before us, in the bacteriological study of the urine in disease, and I feel that the time is not far distant when a bacteriological examination of the urine will be regarded as of even greater importance than ordinary chemical investiga- tion." A¥ood, of St. Luke's in New York, told the writer he would con- sider any bacteria in the urine pathological. In his book he states that the bacteria that may be found in the urine are very numerous, and the important species are the colon, typhoid, streptococcus, staphylococcus, gonococcus, and tubercle. He emphasizes the im- portance of differentiating the tubercle from the smegma bacillus, " as the smegma are common in urine, and may be even in a cath- eterized specimen. . . . The gonococcus and the tubercle bacillus are the only species in which a morphological examination is of much value." And later: "The only morphological diagnosis w^hich is allowable is unfortunately confined to two species, the tubercle bacillus and the gonococcus." And again: " The casts give positive evidence of a kidney lesion." BLADDER INFECTIONS 163 Hiss and Zinsser luu'c nothiii,!;' to say on the liactcriolo^v of tlic vii-inai-y ti-act except to state the necessity for a catlieteri/e(l speci- men. ()sler's new work i;ives hut one shoi't j)ara,i;raph to hactei'iuria, and hiter states as his conclusion that vaccines have been used a great deal, but with little beiieiit. (luitei'as in his new work says: "Althoui^ii i^'ernis iiave been found in tlie urine of liealthy per- sons, the majority of investii2,-ators state tliat tlie ui-ine in health is sterih', pr()vide(l it he obtained by sterile instruments and under ])r()i)ei- precauti(nis. l)urint>' and after infectious diseases, j>,-ernis are often found in the urine. " Exi)erinients have proven that the urine possesses bactericidal proi)erties in health and have shown that the absence of bacteria from normal persons may mean that the germs have been de- stroyed by virtue of this property. The acid potassium phosphate supi)osedly being- the protector, the neutralization by alkali de- strovs its bactericidal property. Possibly, the chloride may also act.'' One of the most elaborate articles on bacteriuria is by Thomas R. I^rown, in Osier's " Modern Medicine." He states: "It is important to remember that the epithelium of this tract is extremely resistant to infection and that in the vast majority of cases certain predisposing factors must be met with before inflam- mation is set up. The weight of evidence, however, certainly points to the belief that the urine of healthy individuals if obtained under careful precautions contains no bacteria. That the organs and urine of absolutely normal individuals are free from bacteria has the weight of authority, and thus at the present time, at least, it is not fair to assume that we may have autogenous infections of the kidney." Judging from the results obtained in bacteriological examina- tions of practicall}^ normal urine in a relatively large series of cases in women, I think that we are justified in concluding that a urine which contains a few germs to the cubic centimeter can prac- tically be considered sterile. In only a few examinations have we found the urine absolutely free of all germs, though what would be considered a normal urine will show only a very few to each culnc 164 THE GYNECOLOGY OF OBSTETRICS centimeter. When the method of collecting, the fact that the find- ings are uniform in S3^stematic checking of individuals, and the re- sults of ureter catheterization are considered, I think I am justified in assuming that these are not due to contamination from the urethra. We know that in man}^ infectious diseases the germs present in the body are eliminated through the urine, but give rise to no symp- toms directly traceable to their presence. This is also true of many infections of moderate severity that usually attract no attention to the urine. In case urine examina- tions are made, no chemical alteration of marked character is evi- dent, even though the germs are present. In order to be able to have a basis for comparing the degree of infections of the urine, we decided to determine the number and variety of the bacteria present by plate cultures. Through the num- ber of bacteria found in each cubic centimeter of urine we believed the variations in progress might be recorded. However, there are many factors that make such determinations only relative. Some germs resist plate culture, thus making a tube grow^th essential to check the results. The quantity of urine secreted is bound to influ- ence the proportional number of bacteria. The length of time be- tween the obtaining of the specimen and the making of the culture is perhaps of greatest significance. This is on account of the loss of the normal bactericidal property in urine when left standing. In pathological urine the germicidal function is already destroyed, and the increase in the number of bacteria is consequently rapid. Normal urine has a marked germicidal action, which may be due, as some think, to the various chemical substances present, or, as others argue, to the presence of a substance of the nature of a fer- ment. The fact that the urine loses its germicidal action a few hours after voiding, and also after the application of moderate de- grees of temperature, gives possibly more weight to the ferment theory. It is relatively easy to give rise to an inflammation of the blad- der by careless catheterization, and it is not unusual to find acute cystitis in various forms of infectious diseases. Such cases are self- evident and respond readily to the ordinary methods of bladder P>LAI)I)KR INFECTIONS 165 treatniciit, in'oxidcd they ai-c not ass()('iat<'(l with aii\- ])la(lder or kidney ptosis. It* aii>' mine stasis exists, tiu^ iiii'ection is inofc tliaii likely to become clironic. The cystocele of marked de'-ree is seldom overlooked, and, con- sequently, is promptly treated; but there is a type of case on the l)()i(ler line which has so far been too often neglected. Such moder- ate conditions will often be diagnosed as cystitis and ti'eated as such, but with the etiology unrecognized and uncorrected. I believe that in women by far the larger proportion of chronic inflannnations of the bladder are secondary to a bladder ptosis, caused by a relaxed vaginal outlet \vitli resulting or associated sagging of the ventral vaginal wall. This bladder-sagging may not be enough to give any marked evidence of cystocele ; but if it is suf- ficient to cause the retention of an}' urine, it can be accounted of sufficient importance. Poor bladder drainage may in some cases be due also to a relative ptosis from a displaced uterus. In women be- yond the menopause the bladder symptoms may be the only ones present, though the misplaced uterus was the original pathology. It is the condition producing residual urine that is the direct etio- logical factor in the production of most cases of chronic cystitis in women. In cystitis, if the residual urine is present, it is the factor of greatest importance, since it accounts for the return of many sup- posedly cured bladder conditions. Urine retained in the bladder for any length of time undergoes annnoniacal fermentation, and, as a consequence, its chemical char- acter is altered. The germicidal action due either to the inorganic contents or a ferment ingredient is then destroyed. It needs only the presence of some pathological germ coming from above in the urine, or introduced from below by mechanical interference, to cause the inflammation. In a bladder wdiose function is interfered with any type of medi- cation for cystitis can be of value only as long as it is continued, since, as a rule, such medication only inhibits the development of the germ. If by chance the germ is removed by treatment, the bene- ficial result endures only until a reinfection has an opportunity to come througli tlie l)lood stream or from mechanical interference. 166 THE GYNECOLOGY OF OBSTETRICS The following histories illustrate the effect of a moderate degree of bladder ptosis : Mrs. B., aged 55. One child; menstruation ceased two 3^ears ago. Present ill-health dates from fall astride a bath-tub five months ago. Had cystitis twenty years before. The coccyx has been removed and the tissue around the perineum incised by a surgeon to whom she had been referred because of pain upon sitting down and frequent urination. The operation exaggerated rather than improved these symptoms. She complains of frequent desire to urinate, especially when seated; when lying on back urination frequency is increased, but can lie face downward with comparative comfort ; feels well, but is extremely nervous and depressed. Pelvic examination shows mu- cous membrane pale and atrophic ; perineum shows scar of repair, but muscular support is poor ; considerable irritation around ure- thral orifice and vestibule ; small cystocele ; uterus rather low, atro- phic; bladder tender. Cystoscope shows bladder congested, other- wise negative, except for pouching of dorsal wall. Urine cloudy, alkaline ; sp. gr, 1.010 ; trace albumin ; culture shows colon and pro- teus. Treatment consisted of vaccine and urinary antiseptics. A small pessary was placed to raise the bladder. In three weeks the urine was perfectly normal and bacteriological examination negative. The pessary corrected all other symptoms, but three weeks later had to be removed on account of irritation to the senile mucous membrane. The discomfort in sitting returned immediately, though there was less frequency of urination than before the infection of the urinary tract had been corrected. Two months later the patient came, desiring operation, real- izing that the majority of her symptoms were due to the bladder ptosis. The operation consisted of a ventral colporrhaphy with perineorrhaphy and abdominal suspension of the uterus. This ac- complished permanently what the pessary had temporarily, and now, three years later, the patient sends word that she is in good health. Mrs. A. B., aged 51. Has had one child; ceased menstruation at thirty-five years. Had just come from college hospital where gyne- cologist removed a urethral caruncle without an}^ relief of symp- toms. Complains of frequent urination, burning and pain on void- ing, backache, and a sense of prolapse. Examination shows considerable irritation around urethra from where caruncle had been removed. Vulva and inside of buttocks P>I.A1)I)KI^ INFECTIONS 167 sliow pi'iiritus, prohably I'l-oiii siii^ar in ui'iiic; small cystocele ; uter- us atfopliic, altlioii^h in normal ])()sition. Patient had attcmjjtcd to empty bladder four times in forty minutes, but upon catheteriza- tion six ounces of residual urine was obtained, the bladder wall sliuttiuii,' down on catheter just as if a stone were present. Chemical examination shows albumin; no sugar; culture, an acid- forming streptobacillus. Cystoscope shows a marked trabeculation and congestion of the bladder, a few bleeding spots, no foreign body, but considerable pouching of the dorsal wall. A further report from medical clinic where patient had been under treatment confirmed diagnosis of diabetes mellitus. Treatment consisted of urinary antiseptics and vaccine, vaginal canal being too contracted to use a pessary as a test of condition. A^accine finally cured the infection, and thus lessened the frequency of urination, the patient being able to retain urine two hours. On account of the diabetes, an operation was discouraged, but the i^atient's discomfort caused me finally to do a ventral colpor- rhaphy and perineorrliaph}^ The incisions healed by first intention and resulted in a great improvement in the local s3anptoms. The general physical condition was improved. This patient claims that she is well unless she indulges in sugar. Mrs. C, aged 58. Two children. Ceased menstruation at fifty. Had no pathological menstrual history. Up to four years ago was fairly Avell, but since then has had gradually increasing trouble with the bladder. Complains of considerable pain just before void- ing and frequently persisting for some time after. Also complains of a bearing-down feeling and general distress in the pelvis. Two hours is the longest interval between urinations, and at times, when worried or tired, the intervals are as short as ten minutes. AVent to the Atlantic coast two years ago for medical advice, and while there a surgeon removed a urethral caruncle. Since her re- turn her symptoms have been Avorse, though she has undergone the most careful, conscientious treatment for cystitis at the hands of a competent physician, who referred the case. Examination showed a slight degree of vaginal relaxation ; the mucous membranes senile; the tubercle of the vagina more ex- posed than normal, but only a slight bulging of vaginal walls when bearing down. The uterus was atrophic, retroverted, fixed. There was some thickening at base of bladder and left broad ligament. Cystoscope showed a congested bladder ^yith pouching of dorsal Avail. The catheter gaA^e tAvo ounces of residual urine. The urine had a sp. gravity 1.015, A\ith a trace of albumin, some pus cells and 168 THE GYNECOLOGY OF OBSTETRICS colon bacillus infection. The kidneys were not palpable, though there was some tenderness over the ureters. The fixation of the uterus with the small vaginal canal prevented the use of a pessary. The operation consisted of a ventral colporrhaphy and a peri- neorrhaphy with a suspension of the uterus to correct the sag. The result has been that the patient has gained in weight, is free from bladder irritation, and, unless excessively tired, the frequency of voiding is normal. The confirmation of the diagnosis of a case of this character must depend mainly on the bacteriological examination and the finding of residual urine. The cystoscope shows a bladder con- gested and sagging. The chemical and microscopical examinations of the urine are of only relative importance, for the elements of pus and albumin upon which the usual dependence is placed in the diagnosis of bladder inflammations are very variable constituents — sometimes in marked abundance, sometimes very scant. For the bacteriological examination it is necessary to have a catheterized specimen. This is preferably obtained by means of a glass catheter with a rubber cuff protecting the end, taken directly from the lysol solution in which it was placed after boiling and in- troduced without other lubrication into the urethra after the orifice has been thoroughly washed off with a sterile antiseptic solution. The first portion of the urine is discarded, and then the flow is directed into a sterile bottle. The bladder is not completely emp- tied, for thus, I believe, we obtain a more uniform sample. Though Kelly, of Baltimore, advises the removal of the rubber cuff before collecting the specimen, this is not necessary. If left attached and the end untouched, it is useful for directing flow into the sterile bottle. It is important that the patient take no urinary antiseptics for twelve hours preceding the catheterization. Lately the current literature has been belittling the value of the hexamethylenamine preparations as antiseptics, and even such au- thorities as those from the Rochester clinics have decided that the antiseptic value was nil. It is true that individuals do not break up the drug in the body in the same degree, so the quantity of formal- dehyde liberated varies. Thus, in some cases, large doses are neces- sary, in order to obtain free formaldehyde. Individuals naturally vary in susceptibility, and kidney irritation is not uncommon even IJLADDKIJ INFECTIONS 169 witli small doses. These two ohjectioiis, liowevef, ai-e not siitticient to justify discarding' tlie dni^'. Our experience in a large number of l)act(Miol()<>ical examinations of the urine has been that, unless tlie infection was a very severe one, the taking by the ])atient of any of the hexamethylenamine preparations previous to the ex- aminatioii interfered witii tlie findings. It does not seem necessary even to have free formaldehyde present in order to ])i()duce some inhibition of the culture. The determination of tlie resi(hial urine is accojnj)lished ])y hav- ing the ])atient urinate and then passing a catheter. In some cases the ([uantity obtained may be only a few drachms, but any consid- ('ral)k^ quantity obtainable after urination in the normal manner indicates the degree of sagging, and it is upon this ptosis that the infection depends. The fact that a nervous individual under ex- citement may secrete excessive quantities of urine must be remem- l)ered, for thus the findings will be modified. The finding of residual urine is of value only when taken in conjunction with the pelvic examination. As has been mentioned indirectly in the histories quoted, we have in the ordinary hard-rubber pessary, where its insertion is j)ossil)le, a valuable aid in determining the prognosis of operative interference. In fact, it is so good that a number of our patients will accept the pessary as a substitute for the operation. Without operative procedures to overcome the residual urine, the prospect for a permanent cure is not good. The type of opera- tion must depend upon the condition and aim to correct the incom- l)lete emptying of tlie l)ladder. In urinary-tract involvement in women it is impossible by symp- toms alone to draw the line between the pathological conditions in the l)ladder and those in the kidney and ureters. When by chemical and bacteriological examination of the urine we have proven that an infection exists in the urinary tract, it is then necessary to de- cide as to the location of that infection. The presence of bacteria in the urine is not alone sufficient evidence of infection. If it is pos- sil)le to exclude a systemic source as the cause of the bacterial contamination of the urine, it is fair to assume that the germs have their origin in the urinary tract. The bacteriuria of urinary-tract 170 THE GYNECOLOGY OF OBSTETRICS origin is not necessarily associated with symptoms, though, as a rule, their presence is indicative of some pathology which gives its own symptom complex. Bladder contamination, with sterile kidney urine, and no pelvic infection to account for the presence of bac- teria by direct extension, is suggestive of improper drainage. The bladder ptosis may have none of the signs and symptoms of cystitis apart from the irritable bladder. In the absence of kidney infection symptoms, when the kidney urine shows contamination, this con- tamination is most frequently the result of stasis above the blad- der. The most common cause for such stasis is the floating, or mov- able, kidney. Severe kidney conditions which give bladder irritation are natu- rally outside the scope of this work, though many such pathologies have as their beginning the conditions under consideration. Many symptoms and findings of bladder-urine stasis are also found with urine stasis above the bladder, but the movable kidney at the pres- ent time is given ybtj scant pathological consideration. As late as September, 1912, Hedges, in a paper read before the American Gynecological Society, wrote as follows, and to his state- ments no exception was taken by those present : "Reverting to the subject of neurasthenia, just a word about floating kidney. We frequently find these two conditions in the same patient and used to jump to the conclusion that the movable kidney was the cause of nervousness, but fixing the kidney did not cure the nerves. If in one of these cases there are severe paroxysms of pain due to kinking of the ureter or pelvis of the kidney, and during these attacks of pain or just afterward marked urinary changes occur, then we are warranted in fastening the kidney. Morris has recently called attention to the splint-belly rigidity of the muscles overlying the organ on the same principle that the rec- tus protects an inflamed appendix. It seems only reasonable that a moderate amount of nephroptosis should be harmless, just as a moderate sagging of other viscera gives rise to no unpleasant symptoms. ' ' Quoting from a personal communication from Dr. Guy L. Huri- ner, of Johns Hopkins : '^ I suppose you refer in your question to the cases mentioned of stricture of the ureter. Of course, many of my hydronephrosis I J LADDER INFECTIONS 171 cases j-vrc due to ptosis of the kidney, tlie hydronephrosis develop- ing: hecause of an al)en'aiit vessel, as suo-(!,ested by Mayo, or be- cause of the i)t()sis of tlie ki(hiey wliile tlie ureter is being hehl in its original position by the periureteral bands of the peritoneum. As to tlie bacteriological findings, it is rather significant that in my cases of stricture of the ureter which 1 credited to tonsil infection or toxemia the infection has been by the staphylococcus, unless the urine was sterile. As you know, most hydronephrosis kidney infec- tions from all causes are l)y the colon bacillus." Osier says far too nuich attention is given to the condition wliich is often associated with neurasthenia. Says Lepine : "It is incontestable that a displaced kidney is predisposed to the development of nephritis. Kinking of the ureter may cause changes in the excretion of the urine, but also stasis in the canalic- uli, which is very favorable to the infection of the kidneys." Stiumpell says : " In a great majority of cases of floating kidney, we have to deal with those familiar and frequent conditions of a nervous character which are termed h^^steria or neurasthenia. It is not always advis- able to apprise the patient of the fact, for with a person of this sort the mere idea of possessing a ' floating kidney ' is enough to stir up a host of subjective symptoms — unless you wish to use it for suggestive therapeutics." He advises elimination of every possible pathology before credit- ing the floating kidney with importance. I quote the following statements from Dieulafoy's latest work on medicine : "Edebohls, Box, and Newman have claimed to cure a one-sided nephritis by fixing a movable kidney — cases where the kidney was enlarged, painful, and the albumin abundant. The movable kidney was supposed to be exempt from lesions for a long time. Although the cases reported by Edebohls do not give all the medical details of the question, it is none the less true that people with movable kidneys have albuminuria. The albumin is present in fourteen per cent, according to Schilling. The term Bright 's disease implies the idea of bilateral nephritis. The presence of albumin and casts in the nrine is not sufficient to prompt the diagnosis of Bright 's dis- 172 THE GYNECOLOGY OF OBSTETRICS ease. This confusion is made by surgeons. It may falsify our ideas. I am of the opinion that in some of the published cases, neverthe- less, it does seem that tuberculosis was not present and that they were really cases of chronic unilateral nephritis Avithout pain and hematuria. It is certain that results of surgical intervention are often excellent in unilateral acute or chronic nephritis, but it is in- dispensable to state clearly the indications and contraindications and select cases amenable to operation. For the time being, we are unable to ansAver this question because many of the published ac- comits are incomplete from a medical point of view. I am con- Adnced, however, that this gap will soon be filled. " The consensus of opinion seems to be that the movable kidney is very common, and ma}^ occasionally be associated with diverse morbid conditions without causing original symptoms. But a diag- nosis of movable kidney is very questionable unless the kidney is definitely giving trouble by pain, hematuria, and abdominal tumor, with possibly gastralgia, nausea, and vomiting, and occasionally an intermittent hydronephrosis. All writers acknowledge the coincident occurrence of mental and nervous disorders and movable kidney, but none see any signifi- cance in the fact or offer any explanation. Alienist writers have frequently demonstrated the variations in blood pressure that are so often coincident mth the aggravations of mental disorders, and are inclined to look upon toxemia as a cause, and that probably of intestinal origin. A clinical study of the urine in cases with mov- able kidney in connection with this blood-pressure investigation should be of interest. By the presentation of some clinical cases I can best summarize the results of my study of the bacteriology of the urine with spe- cial reference to movable kidney. Miss C, aged 24, complains of severe pain at menstruation, re- lieved when flow commences. Has some pain after urination, and occasionally has to void frequently. A^Hien seated vulva is sensitive. Has been treated in the East, Examination shows introitus normal excexDt for eroded area external to f ourchette. Uterus slightly retro- verted, mth cervix flexed on body so that os and fundus are in line ; OS very small. Appendages on left side thickened. Right kidney low, tender, enlarged; tenderness along course of both ureters. Ex- amination of urine gives trace of albumin. Specific gravity 1.020 BLADDER INFECTIONS 173 witli sonic cell detritus, and on culture the stap?iylocoecus alba. Cystoscopc shows bladder normal except for some congestion at orifice of riTiip- toms by Long-year's operation on the nephrocolic ligament com- bined with fixation of the capsule. Concurrently with the improved symptoms, the bacterial count in the urine rapidly diminished, un- til now a practically sterile urine exists A\ith only twenty-eight bac- teria to the cubic centimeter, compared Avith the uncountable num- ber preoperatively. Miss B., aged 25, has been in many physicians' hands with vary- ing diagnoses, with conformity by only two on a tuberculosis of the right kidney. She is better now than for some years, but suffers from severe backache. About once in six months she has an attack of pain in abdomen and diarrhea with much fresh blood. She had 174 THE GYNECOLOGY OF OBSTETRICS a hip trouble fifteen years ago. She states that in 1908 tubercle bacilli were found in the urine, and improvement followed tuber- culin. Examination shows an enlarged, tender movable kidney low down; no ptosis of the left. The cystoscope shows no bladder ab- normality. The quantity of urine from each kidney is practically the same, but the right shows more normal character of flow. The phenol sulphophthalein shows up in four minutes from right side and in four and a half from the left. The proportional elimination is the same with a total return of sixty per cent in two hours. The urine from the left kidney gives twice as much urea ; both show a trace of albumin and some blood cells, but no casts. Bacteriological examination of bladder urine gives an uncountable number of a streptococcus and a staphylococcus. With guinea-pig inoculation the urine of both right and left kidne3^s shows a negative finding. This patient improved with urinary antiseptics and a corset, and six months later submitted to operation. Four months after oper- ation all the symptoms had subsided, and there were less than a hundred staphylococci to the cubic centimeter of urine, the strepto- cocci having disappeared. Two months later, with still no medicinal treatment, the urine contains only twenty-eight staphylococci to each cubic centimeter. In these three cases I infer that we have the " unilateral nephri- tis " of Dieulafoy. He believes that many are due to tuberculosis. I would go a step further and add that all of them are germ condi- tions. They are in no sense a '' Bright 's disease," but are second- ary to a displaced kidney interfered with in function. And I believe that in the bacteriological examination we have our data for the exact medical classification he desired. In neither case was the urine from the normal kidney free from growth, but this growth was always less pathogenic, and with its germs so few in number that for all practical purposes the urine was considered sterile. The unimpaired function showed that a Bright 's disease did not exist. I have shown, I think, that we cannot cure these cases without support, and I believe operation is indicated. These cases are the type of movable kidney that one can not overlook, on account of the local symptoms ; but the following cases I have selected to show that before that stage is reached the movable kidney is giving trouble and is gradually developing into the gross type : in. ADDER 1NFF.CTI0NS 175 j\l |-s. D., ai;(Ml ,')(), has had one chihl, hoi'ii in a (liriiciilt la])()r. Three years a^'o she had a <>()()(l surr('e eliminated from tlic Ixxly by tlio kierms in a miliary tract with iioniial (lrainajj,e have little ciiaiice to |»i()(hi('(' abnormal s)!ii|)tonis, since tiie noriiial rapid elimination and the germicidal action of the urine prevent develop- ment. To all intents, they can be looked upon as of no pathological significance, unless through the great virulence of the infection and the patient's poor resistance they form i)art of a general septi- cemia. If, however, in the course of tlie uriiiai'y tract there is an interference to the normal escape (so that an actual or relative re- tention occurs), the urine itself so changes its chemical character as to afford a favorable culture medium. Whether this is due to the destruction of the ferment or to the presence of altered chemical salts is problematic at present. AVe know, however, that urine heat- ed a few degrees over bod}^ temperature or let stand for a few^ hours outside the body serves as a good culture medium, and as such was used by Pasteur in the early days of bacteriology. In typhoid fever and in other diseases in which the germs are present in the blood stream we find them recoverable from the urine, and yet without attendant symptoms of urinary tract infec- tion. Experimental intravenous injections of cultures have shown that germs can be demonstrated in the urine within fifteen min- utes. These facts justify us in assigning a germ-excreting function to the kidney and show the necessity of some associated pathology for the production of a urosepsis. Xot only in bladder ptosis, but also in that of the kidney, we can prove by temporary support that the urosepsis is dependent there- on, and operative correction properly done emphasizes the fact. The very fact that seldom in our examinations of urine do we find onl3^ one germ present makes more probable the autogenous theory of infection. Consequently, this prevents any conclusions of value being deduced from the character of germ present outside of the self-evident fact that the severity of the symptoms will de- pend on the characteristics of the germ. Yet even active strepto- cocci are frequently present without producing symptoms when no stasis complicates the urine discharge. Like many other observers, I have found that in cases of uro- 180 THE GYNECOLOGY OF OBSTETRICS sepsis in which the bacillus coli communis is present it is almost impossible to eradicate the germ completely, though the patient to all intents has been cured. Some bacteriologists believe this continuance of the colon bac- teriuria is due to the low type of the organism and the character of the mucous membranes of the bladder, rather than to the fact that the colon is naturally a habitant of the body and proof against its defenses. . KIDNEY PTOSIS AS'1'^1)^' of sixty-five eases of movable kidney (made with special reference to tlie l)acterioloj>;ical aspect) has pro- duced data of considerable interest. In these cases I do - not include those ])atients with general enteroptosis; nor are those with acute infection, the pus kidney, or the tuberculous infection considered. The acute kidney infections are mostly associated with general systemic involvements. If the virulence is great or the patient's re- sistance poor, the breaking down of the parenchyma occurs and tlie "pus" kidney develops. Otherwise, the process subsides, re- sponding more or less promptly to therapeutic measures unless a urine stasis exists. If there is any interference with the urine es- cape, the inclination to chronicity is present, and the pathology becomes resistant to medication. Patients with general enteroptosis are excluded from this study because there are in their pathology so many other factors that must be considered as likely to complicate the findings. As has been seen, the simple presence of bacteria in the urine is not diagnostic of urogenital-tract infection. For, though the con- sensus of opinion is that urine in normal individuals is free from germs, some observers report a considerable percentage of pre- sumably healthy individuals whose urine contained bacteria. Many individuals with no urinary symptoms may have the urine loaded with germs. Any germ free in tlie blood stream makes its appear- ance in the urine after a short interval of time. Thus germs intro- duced through intravenous injections of cultures are recoverable from the urine, and in systemic diseases such as typhoid the bac- teria are also found. The urine has germicidal power, as shown by the decrease in the number of bacteria during the first few hours after voiding, but this action is not marked, and is readily destroyed by slight modi- fication, such as comes from exposure to air or moderate degrees 182 THE GYNECOLOGY OF OBSTETRICS of heat. The urine from an infected bladder and kidney has al- ready lost its germicidal power through chemical changes previous to voiding, so that after expulsion the increase of the number of germs is rapid. In order to avoid too great a variation from such a cause, the quantitative determinations have been made as early as possible after catheterization. However, for clinical purposes the variation in twelve hours is not of great consequence. The frequency of the occurrence of bacterial contaminated urine must justif}^ the conclusion that associated with bacteriuria there is present a predisposing factor that determines the production of kidney infection. With this factor in mind, a study of the bacteri- ology of the urine in movable kidneys was undertaken. A necessity for a classification of the varieties of kidney ptosis early became evident; and to meet that need the cases were divided into four groups, using the clinical and bacteriological symptoms as a basis. The first group consists of the cases of so-called "unilateral nephritis." Here a usually right-sided involvement is found. The kidney is low, easily palpable, tender to the touch, and somewhat enlarged. There is bladder irritability, though inspection reveals nothing but possibly a congested mucous membrane with a redden- ing of the right ureter orifice. The urine shows some albumin and pus, a few casts, and numerous bacteria, but these vary from time to time. The patient complains of a dragging feeling with dull pain in the right lumbar and hypochondriac regions. These cases sel- dom exhibit Dietl's crises, but are often associated with periodical uremic attacks evidenced by headache, fever, puffiness of the face, and lessening of the urine output. As has been stated, the classification of this pathology as a "uni- lateral nephritis " is not technically correct, for the term "nephri- tis " is too intimately associated with Bright 's disease to convey any other impression. Such cases are invariably germ involve- ments of the kidney pelvis, and what changes take place in the kid- ney parenchyma are wholly secondary to the infection. The patients exhibiting definite Dietl's crises come into the sec- ond division. The attack of pain known as a crisis most frequently comes if the patient suddenly assumes the standing posture. The pain is accompanied by faintness and occasionally a variation in KIDNKV I^TOSIS 183 urine secretion, not only as to (juantity, hnt also in clieinical and iniei-oscopical Undiniis. The symptoms are relieved l)y the recuni- Ix'iit posture, and the attack may he followed hy a tenderness of the kidney, i)ersistin,<;' foi- a few houis. Diiriiii;' the interval hetween attacks the mine nia\' e.\lii!)it ahsolutely no ahnoi-mal chang'es. Occasionally one sees cases that nmst come under this head even thouii,!) no i)ain is conii)lained of, where a sudden faintin*>' is the piimary symptom. It may be that these patients are extremely sns- ceptihle to pain, and that the complete nnconseionsness is the re- sult of tile pain stinudus, Init that symptom is fori^otten. The sug- gestion of Dr. R. A. Archibald that anaphylaxis may enter largely into this type of attack is of interest. Anaphylaxis (or allergy, as \^on Pirquet terms it) depends on periodic proteid splitting. The absorption of these split products gives rise to definite clinical symptoms peculiar to the type of proteid present, Init necessarily these t)eriods of abnormality must be separated by a considerable interval of normal metabolism. It is reasonable to suppose that, in a patient with free urine drainage that suddenly becomes dis- turl)ed, the chemical changes taking place can readily cause marked disturbance. The two patients that I have seen with this type of attack have had more marked urine changes and more prolonged uremic symptoms than those patients with classical crises. Since the ptosis was corrected, these patients have had no recurrence of their fainting spells. These two groups are well-recognized pathological entities. Un- der the third group should come the cases that might be said to be of questionable etiological importance. It is to this class of cases that the already quoted criticism of Strumpell and Osier apply. In these cases the kidney is readily palpable, the left almost as fre- ([uently as the right. The organ may not necessarily be tender, and usually is only slightly enlarged. The patient complains of side- ache and some backache with occasional irritability of the bladder. The nervous symptoms are often marked and of almost any type. If the right kidney is the one at fault, digestive disturbances are present, due to the close relation of the cecum and kidney. Upon examination the bladder is usually found healthy, and the nrine may show absolutely no changes except from the bacteriological 184 THE GYNECOLOGY OF OBSTETRICS side. If, however, the germ present is in excess, a trace of albumin and a few casts are present. It is in these patients that the results of the bacteriological examination of the urine are of most signifi- cance as an aid to diagnosis. Under the fourth head are classified the patients with kidney ptosis in whom no symptoms can be found traceable to the con- dition and who show on examination a relatively sterile urine. I say ' ' relatively sterile, ' ' because only a small per cent of speci- mens are absolutely free of germs. Out of one hundred and twenty- five examinations made in the type of case under consideration there were only three specimens absolutely sterile. In the one hundred and twenty-two examinations in which growths were obtained, twenty-six patients, who could not at the time be considered as suffering from the effects of the kidney dis- placement, gave twenty or less colonies per cubic centimeter in thirt^^-two examinations. Of the sixty-five cases of kidney ptosis investigated, five patients suffered with definite crises, two of whom had marked uremic symp- toms associated. In two of these same five cases, including one of those with uremic symptoms, the urine had never more than twenty germs to the cubic centimeter, even following a marked attack, and the urine was without variation in the two kidneys. Two others of these five cases had more definite local kidney symptoms, and the urine upon culture gave counts varying from two hundred and ninety-four germs per cubic centimeter upward to an uncountable number. After operation on these tAVO iDatients to correct the kid- ney displacement, the count dropped to below twenty per cubic centimeter, and has remained so consistently^ for over six months, associated with general good health. Four cases of unilateral nephritis of the right kidney have been carefully investigated. Two have been cured by operation, and two have been improved by corsets and treatment. Cystoscopic exami- nation in each case showed negative bladder findings, except for some congestion of the orifice of the right ureter. The kidney func- tion was not impaired, though the quantity secreted by the sepa- rate kidneys was not equal. In three cases the larger quantity came from the abnormal side, but of decreased specific gravity. KIDNEY PTOSIS 185 On tliis side also tlici'c was no rliytlnn to tlic discharge. The hac- t('riolo,i;ical coniit (lirfcicd in cacli kidney, the number on the right side being nncountahle. On the left not over four hundred ap- peared in any examination. Jn all cases there was a mixed infec- tion. Careful guinea-pig inoculations gave no evidence of tuber- culosis. The character of any kidney infection will depend on the pri- mary location, the type and virulence of the germ, and the pa- tient's resistance. A severe involvement in the parenchyma will lead to abscess formation and kidney destruction. Rosenow's find- ings that the selective tendency of germs depends on the type of virulence may ])ossibly account for either a parenchyma or a kid- ney-pelvis involvement. My conclusion is that the unilateral nephritis is essentially a kidney-pelvis condition with a certain amount of parenchyma con- gestion as a sequela, for it is devoid of the systemic and blood signs of an acute septic condition. It is invariably imposed upon a displaced kidney, and the condition promptly responds to oper- ative replacement of the organ that permits improved drainage. When treated by corset support and therapeutic measures, im- provement takes place, but there is a tendency to recurrence of the more acute symptoms. The corset support promptly decreases the bacterial count to a marked degree, but during its omission the increase is again rapid. A woman of sixty-five, whose pathology occurred following the grippe, had on the diseased right side an uncountable number of germs, and on the left side four hundred and thirty-two to the cubic centimeter. The corset correction reduced the count on both sides to less than half the number. In two other non-operated cases the results were more marked. In the two cases operated upon, the bacteria practically disap- peared from the urine within a few months, the decrease being uni- form and rapid. The symptoms were relieved immediately; the patient promptly gained in weight, and had no recurrence of the uremic signs. An interesting feature in these patients with unilateral nephritis is the presence of a considerable number of bacteria in the urine 186 THE GYNECOLOGY OF OBSTETRICS from the supposedl}^ normal side. But the urine of this side shows a more rapid decrease in the number of bacteria following surgical correction of the abnormal kidney. The findings in the class of cases listed as of cpestionable eti- ology were also w^ell marked. The number of bacteria in the urine never reach the amount found in the '^ unilateral " type, but corset correction always produced a marked decrease — with a prompt in- crease if omitted. With the lessening of the germ the symptoms disappeared to reoccur when the count again increased. The factor at fault is without doubt poor drainage, since the urine through chemical changes becomes a suitable culture medium for germ increase. The number of bacteria is relatively an indica- tion of the degree of stasis. If we can eliminate the cases that have a bacterial count de- pending upon a bladder involvement that is the result of bladder ptosis, or upon jielvic inflammation, we have an index in a measure of the disturbance the kidney ptosis produces. The type of germ found seems to be of little importance. The va- rieties will vary in the same individual from time to time, and, as a rule, a pure culture is seldom present. The results obtained so far from the bacteriological examina- tions in these cases seem to justif}^ the conclusion that urine con- taining a relatively small number of germs may be considered nor- mal. In seemingly normal individuals a perfectly sterile urine is rare, and this must emphasize the fact that bacteria are being con- stantly eliminated by the kidneys. Taken in conjunction with the ex- perimental inoculations and the occurrence of germs in the urine in systemic infections, it is essential to acknowledge a germ-secreting function to the kidney. This factor necessarily increases the im- portance of the presence of a kidney ptosis that may interfere with drainage. With the kidney ptosis of no matter what degree, the question of its bearing on the patient's health is one of individual determi- nation. The amount of trouble from the ptosis depends more upon the interference with the urine flow and the amount of stasis pro- duced than upon the particular location of the organ. The stasis alone may result in symptoms of a uremic character, but on the KIDNEY PTOSIS 187 kind of iiilVctioii iiii|)()S(Ml will (Icpciid the (l('ive rise to symptoms essentially pathologic de- jX'iid very lai-gel\' npoii the patient's sensitiveness to defective ])hysioh)gy. If tile peristaltic action of the kila(l(l('r — conl inucd intlamnuition of. 1()4. Kio (see Ctjslitis) irritable. 67. 144 ptosis of. 165. 168. 169 (see Ffosis of bladder) Boroglyceride. 71 Bulbs of the vestibule structure of. 18 location of. 18 Cancer of cervix Bossi's theory of. 46 carbon-dioxide freezing for. 48. 90 carcinoma. 45 early manifestations. 48 effect of scar tissue in occur- rence of, 47 epithelioma, 45 involvement of Ivmphatics in. 49 methods of diagnosis. 49 operations for. 48. 90 radiotherapy in. 47, 48 relation of to lacerations. 45. 50 symptoms of. 48 Carbon-dioxide freezing. 48. 90 Carunculae myrtiformes as land- marks. 110 Case history- of abortion from cervical pathol- ogy. 159 bladder ptosis. 166. 167 kidney ptosis. 175 relaxed vauinal outlet. 100. 101. 141 sterility from cervical pathol- ogy." 160 unilateral nephritis. 172, 178, 174 192 THE GYNECOLOGY OF OBSTETRICS Cervix amputation of, 90, 93 (see Am- putation of cervix) ''arbor vitae" in, 6 blood supply of, 8, 9 canal of, 4 cystic endocervicitis, 57, 155 definition of, 3 ectropion of, 57, 58, 70 elongation of, 26 gland secretion of, 5, 57, 66 healing of injuries to, 38, 57, 59 hypertrophy of, 26 imanediate care of injuries of, 38 inflammation of, 53, 59 (see Endocervicitis) injury to adjoining structures in operation on, 9 injuries to, 37 lips of, 3 lymphatics of, 10 '"'Naboth ovules" in, 5, 48 nerves of, 7 placing of pessary in lacerations of, 8 prevention of injury to, 31 relation of to uterus and vagina, 4 relation of to bladder and rectum, 9 repair of lacerations of, 70, 90 (see Trachelorrhaphy) sensation of, 7, 8 structure and size of, 3, 6 ' ' ulcerated cervix, ' ' 57 Chorioepithelioma character of growth of, 51 location of, 51 of cervix, 51 of vagina, 51 Correct body posture, 30 Corsets in kidney ptosis, 178, 185 in relation to posture, 30 pelvic congestion from, 55 "Crown" suture, 112, 130 Crura, 21 Curettage contraindications to, 151 dangers of, 85, 88 diagnosis through, 49, 50, 83 indications for, 83, 85 in malignancy, 50 instruments for, 85 Cystitis acute, 164 chronic, 165 production of, 164 residual urine a factor in, 165, 178 value of treatment in, 165 Cystocele as hernia, 23 correction of, 127, 128, 130 (see Repair of cystocele) denudations for correction of, 129 fasciae in, 10, 24 in relation to relaxed outlet, 97, 117 mucous membrane hypertrophy with, 126 pessary as support for, 63 production of, 23, 24, 103, 121, 123, 125 residual urine in, 162 theories of cause of, 124, 126 types of, 122, 123, 128, 165 unassociated with protrusion, 165 with procidentia, 122, 123, 128 Diaphragm (see Pelvic diaphragm) Dietl's crisis, 176, 182, 183 Diptheroid infections, 41, 42 treatment of, 42 Douches medication in, 72, 73, 135 method of giving, 73 relaxation from, 73, 144 temperature of, 72, 73, 135, 143 Drainage of uterus interference with, 147, 148, 149 Drugs in gynecology, 70, 71, 72, 73, 139 INDEX 193 Diidlcv (»|)('i';i1 ion for stc'i'ilit\' mid (hsiuciiorrhea, 15:3, ]r)4" Dysinciioi-rlH'a dilatation ol' ccfx'ix i'or. l.l-i Dndley-Re\n(ilds (ipcration for, 153," 154 relief of, 153 statistics of cure of. 154, 155 Ectropion. 58, 70 Ennn(4 perineorrhaphy • l)u1t('rti\' denudation. 112 crown suture, 112 incision and denudation, 106, 10!). 112 Ennnct trachelorrhaphy prevention of miscarriage, 157 steps of operation, 90, 91, 92 (see Trachelorrhaphy) Endoeervicitis contraindication of stem pes- sary, 156 cystic. 57. 155 due to remote pathology, 55 round-cell infiltration in, 53 symptoms, 54 treatment of, 70 Endometrium congestion of. 56 glandular hypertrophy of, 54 intiannnation of, 54. 84 Episiotomy Berkeley and Bonne.y on, 32 bilateral incisions. 32 Hartmann on, 32 location of incisions, 33 median incision, 34, 35 Peterson on, 33 results on vaginal outlet, 33 Erosion of cervix effect of scar tissue on. 62 healing of. 61. 70. infiannnatory. 60. 61 types of, 59! 60, 92 Floating kidney anaphylaxis in. 183 case histi- (lon. 35 I'clvic Hoor ( 'olios 's fascia, 17, 18 function of, 22 muscles in relation to fascia. 16 repair of, 10-4 result of injury to, 23 structure of, 15, 16, 22 triangular ligament, 18 Perineal tears character of, 36 diagnosis of, 36 direction of, 35, 36 how produced, 37 repair of, 74 (see Perineor- rliaphij) Perineorrhaphy ( immediate ) best time for, 75, 76 cause of poor results from, 79 delayed, 75 difficulties of, 74 methods for, 77. 78 sphincter-ani repair, 78, 80, 81 tearing out of sutures, 75 use of continuous suture, 77, 78, 79, 80, 81 Perineorrha phy ( secondary ) demonstration of correct, 99 Emmet, 106, 109, 112, 113, 117, 126 essentials for perfect, 117 flap method of, 116. 117 Hall's, 113 Hegar's. 106, 108, 109, 110, 111, 116. 118 hemorrhage following, 145 landmarks for. 106. 108 ^Morris's mediflcation. 113 objections to triangular denuda- tion. 117 I 'criiicorrliii |)liy ( scc(»n(l;ii-y ) — -i-oiil . pool' lllliiill ol' IMIICOIIS lllclll- hi'anr. l;').") preparation for. 138, 139 prognosis in, 141 rectal flstula in relation to. 121 scissors puncture in. 114, 116 Somers's sutiu'c, 119, 120 stretching out of scars after. 1 -12 sutures used in. 104, 118 Tait's, 104, 107. 108 Perineum episiotoniy on. 32 function of intact. 25 Ilartnuuni on injury of, 35 posture of mother in preventing injury to, 31 prevention of injury to. 31 results of injury to, 25 vaginal redundancv, effect up- on, 143 Varnier's method for prevent- ing injury to, 31 Positions for examination, 104 "Posterior commissure," 113 Post-operative treatment, 134, 136, 138 catheterization, 137 getting up, 138 laxatives, 137 of complete perineorrhaphy, 137 removal of sutures, 138 tying of knees, 138 Pozzi's operation for sterility indications for, 153 poor results following, 152 scar-tissue resulting from, 153 Procidentia, 25, 26, 27, 122 Ptosis of bladder case histories, 166, 167 cause of chronic cystitis, 165 diagnosis of, 168, 169 pessary treatment for, 169 prognosis in. 169 Quantitative determination of germs in urine. 177 Rectal fistula. 80. 121 196 THE GYNECOLOGY OF OBSTETRICS Rectocele as hernia, 23 fasciae in, 10, 21 in relation to relaxed outlet, 97, 103, 117 not severe with procidentia, 27 production of, 23 Rectovesical fascia, 12 Rectum direction of, 20 introduction of speculum, 20 relations of, 20 Relative sterility, 156, 157 Relaxed vaginal outlet air in vagina with, 104 backache in relation to, 102 case histories of, 100, 101 cause of eye-strain, 101 cause of miscarriage, 156, 157, 158 cause of sick headache, 100 cystocele as diagnostic of, 97 demonstration of, 97, 98 demonstration of correct repair, 98, 99 development progressive, 32 diagnosis of, 97, 99 effect of gravity in, 27 effect on nervous system, 99, 100 episiotomy in relation to, 34 excessive vaginal redundancy, 143 external appearance of, 97 gravity a factor in, 27 ideals of correct repair, 105 intra-abdominal pressure in, 29, 30 rectocele as diagnostic of, 97 recurrence of symptoms of, 144 symptoms of, 99, 102, 103 Repair of cervix (see Traclielor- rhaphy) Repair of cystocele Graves's, 129, 130 methods of denudation, 131 methods of operation, 127, 128, 129, 130 Sanger's, 130 White's, 124, 131 Reynolds operation for sterility and dysmenorrhea, 153, 154 Residual urine, 169 Retentive power of abdomen, 27 Rodman on cancer of cervix, 45, 50 Rosenow's germ theory, 42 Separation of recti muscles, 39 Silver nitrate, 71 Sims 's discission operation, 153 Sims 's position, value of, 104 Skene's anterior incision operation, 154 Sphincter ani repair immediate operation, 78, 80, 81 secondary operations, 109 after treatment of, 137 Stem-pessary contraindications, 156 Sterile urine, 162, 163, 169, 170, 179, 180, 184 (see Bacteriological examination of urine) Sterility of infected tubes, 151 Sterility case history of, 160 causes of, 152, 158 Dudley-Reynolds operation for, 153' due to cervical tear, 38, 160 due to tubal pathology, 156 Emmet operation for, 157 Pozzi's operation for, 152 relation to cervical amputation, 91 relative sterility, 156, 157 statistics of cure, 154, 155 Sutures, effect of absorbable, 69 Syphilis of cervix appearance of cervix in, 142, 143 chancre, 43 cause of failure of operation. 142 cause of miscarriage, 156 diagnosis of, 143 secondaries, 43 tertiaries, 43 treatment of. 70 INDEX 197 Tait \s pcriiicdfrlijipliy advaii1;i.u('s oW 1 1 1 conipli'tc, lOS iiu'omph'te, 104, 107 Tanii)()ii tivatineiit, (i!). 70. 71. 148 (•oniposition of tampon, 72 vlriigs used in, 71, 72 prtjprietary tampons, 72 removal of tampon. 72 Trac'liclori'liaphy adhesion oT lips in. 147. 148, 149 after-treatment of patient. 134. 136, 138 determination of denudation, 92 tiiscliarge following, 136 etfect of pessary upon, 63 Emmet, 90, 91,' 92 hemorrhaoe following, 145, 146 immediate repair, 74 interference with drainage after, 147 method, 74 preparation of patient, 138, 139 prognosis in. 141 sutures in, 74 suture insertion in, 93 Treatment in gynecology (see Tam- pon) applications to cervical canal, 70 dangers from applications to cervical canal, 71 Triangular ligament, 18, 125 Tuberculosis of cervix, 42, 43 diagnosis of, 43 Unilateral nephritis, 171, 173, 174, 182. 184 ease histories of, 172, 173, 174 cystoscopic findings in, 184 pathology of, 174, 182 results of operation in, 185 symptoms and findings in, 182 ureter catheterization, 177 Ureters course of, 9 palpation of. 10 relations. 9, 24 Urethra attach iiienls of, 20, 125 catheterization of, 20, 135, 137 cleansing for catheterization, 135 gonorrhea of, 41 landmarks for finding orifice of, 19 Littre's follicles, 41 location of, 19 severance of attachments, 127 Urethrocele, 127 Urine casts, diagnostic value of, 162 collecting specimens, 168 culture of, 164 determination of residual, 169 fermentation of, 165 germicidal power of, 164, 181 quantitative determination of germs in, 164, 179 residual, 165, 169 sterility of, 162, 163, 179, 180 (see Bacteriological examina- tion) value of bacteriological exami- nation of, 181 Uterus anteflexion of, 3 applications to, 88 circulation of, 55 congestion of. 55 effect of relaxed outlet upon position of, 25 endometritis in, 53, 84 irrigation of, 88 ligaments of, 24 mucous membrane of. 56 OS (external) of, 3 OS. direction of. 3 OS (internal) of. 3 pessarv for abnormal position of. 62 position of. 25 prolapse of. 26. 27 retroversion of. 25 retroversion not a cause of procidentia of, 25 support of, 128 198 THE GYNECOLOGY OF OBSTETRICS Vagina blood supply to, 11 direction of, 10 fasciae of, 10 injuries of, 2 lymphatics of, 11 mucous membrane of, 10, 11 nerves of, 11 relation to other organs, 10 resistance to infection of, 189 structure of, 2, 10, 11 Vaginal-wall denudation, 143 Vaginitis, senile, 148, 149 Vomiting post-operative, 134 treatment of, 134, 135 " White line," 12, 123, 125, 126, 132 ' ' White line ' ' in relation to cvsto- cele, 123, 126, 129 White's cystocele operation, 124, 131 White's theory of cystocele causa- tion, 124, 131 THE FOLLOWING PAGES CONTAIN ADVERTISEMENTS OF A FEW OF THE MACMILLAN BOOKS ON KINDRED SUBJECTS GYNECOLOGICAL DIAGNOSIS AND PATHOLOGY Bv A. II. F. BARBOUR, M. D., LL.D., F. R. C. P., Ed., Lretuicr nf (lyiiecology in the University of Edinburgh, Gynecologist to the lOilinburgh Royal Infirmary; and B. P, WATSON, M. D., F. R. C. S., Ed., Professor of Ohstt'trics in the University of Toronto, Canada 8vo, 2S0 pp., li'Hh S colored plates and 202 illustrations in the text. $3.00 net The scope of* this work is uiiusiuil, and it therefore tills a place thus far not undertaken by any other work. It is not the object of the work to give a complete account of Gyneeolooieal Pathology, but rather to furnish the stu- dent with a method of study. Gynecological teaching has suffered in the past from the fact that the student has not been led to the study of actual speci- mens and the results of microscopic examination, on which alone Gyneco- logical Diagnosis can be founded. Pathology in relation to physical signs forms the basis. The authors have described and figured such specimens as have been examined by them during the last five years and the colored plates are excellent and interesting, demonstrating well what they are intended to shoAv. Dr. Barbour is well known in the United States by his previous "works on Gynecology, while Dr. Watson is the prominent Professor of Obstetrics and Gynecology in the University of Toronto. This book will therefore be invaluable in the courses of medical colleges in this country. A TEXT-BOOK OF MIDWIFERY FOR STUDENTS AND PRACTITIONERS By R. W. JOHNSTONE, M. A., M. D., F. R. C. S., M. R. C. P. E., Assistant to the Professor of Midwifery and to the Lecturer on Gynecology in the Univer- sity of Edinburgh ; Extern Assistant Physician Royal Maternity Hospital, etc. With S64 illustrations. Cloth, 485 pp., index, 8vo, $3.25 net This book is published in the ' ' Edinburgh Medical Series, ' ' under the general editorship of Dr. John D. Comrie. It is designed to fill the need for an authoritative work containing only the matter essential to give the stu- dent or practitioner a thorough grasp of the entire subject. It is also adapted to the use of students in Nurses' Training Schools. Special attention is given to practical points and the discussion of nornuil and abnormal labor cases. THE MACMILLAN COMPANY Publishers 64-66 Fifth Avenue New York INFECTION AND RESISTANCE AX EXPOSITION OF THE BIOLOGICAL PHENOMENA UNDERLY- IXG THE OCCURREXCE OF INFECTIOX AND THE RECOVERY OF THE ANIMAL BODY FROM INFECTIOUS DISEASE By HANS ZINSSER, M. D., Professor of Bacteriology at the College of Physicians and Surgeons, Columbia University, New York AVith a Chapter on Colloids and Colloidal Reactions By professor STEWART W. YOUNG, Department of Chemistry, Stanford University Crown 8vo, ill., hihliography, index, 546 pp. $3.50 net Students and physicians will find this book an authoritative work which presents, with clearness and simplicity, the subjects of immunity and the forces of resistance to infectious diseases in the body. Recent developments have shown the great practical importance of these subjects to the student and general practitioner, as well as to the laboratory specialist. The material dealt with is fundamental to the comprehension of the processes involved in the occurrence and cure of infectious diseases, and a thorough study of it is essential as a j^reparation for the study of infectious diseases in the clinic. THE CANCER PROBLEM By WILLIAM SEAMAN BAINBRIDGE, A. M., Sc. D.. M. D.. Professor of Surgery, New York Polyclinic Medical School and Hospital ; Surgeon and Secretary of Committee of Scientific Eesearch, New York Skin and Cancer Hospital; Consulting Surgeon, Manhattan State Hospital, Ward's Island; Honorary President, First International Congress for the Study of Tumors and Cancers, Heidelberg, 1906. Cloth, 8vo, illustrated with 38 microscopic plates and 14 text cuts 534 pp., iibliography, index. $4.00 net "Is cancer contagious?" "Is it infectious?" "May it be inherited?" ' ' Can it be prevented ? " " Can it be cured ? " " Is it on the increase ? " - These pointed questions are being asked on all sides today. Dr. Bainbridge's experience in the diagnosis and treatment of malignant diseases, and his familiarity with the experimental investigation of the dis- ease, have enabled him to exercise rare discrimination in the selection of the subject-matter for his book. 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THE MACMILLAN COMPANY Publishers 64-66 Fifth Avenue New York THE INTERPRETATION OF DREAMS By PROPESSOK SIGMUND FREUD, M. D., LL. D.. Formerly Professor of Nervous and Mental Diseases in the University of Vienna Translated by A. A. BRILL, Ph. B., M. D. Chief of the Neurological Department Bronx Hospital and Dispensary; Clinical Assistant in Psychiatry and Neurology, College of Physicians and Surgeons, New York Cloth, 510 PI)., index, literary index, 8vo. $4.00 net The general advance in the study of abnormal mental processes has called particular attention to the dream, whose riddle has been solved by Professor Freud, the noted neurologist at the University of Vienna, in connection with his study of nervous and mental diseases. Professor Freud asserts that dreamis are perfect psychological mechanisms and are neither foolish nor useless. 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