CHAPTER VIII.

Fig. 56.—Rectocele and cystocele.

Rectocele.—A rectocele (Fig. 56) is the tumor formed by the protrusion of the lower part of the posterior vaginal wall into the vagina or through the ostium vaginæ. The condition is due to a prolapse of the posterior vaginal wall, and is caused by the loss of the support of the perineum, usually the result of laceration at childbirth. Sometimes the mucous membrane of the vagina alone prolapses, the anterior wall of the rectum remaining in place. Usually, however, the anterior rectal wall and the posterior vaginal wall protrude together. If the rectocele is not so extensive as to protrude through the ostium, the woman may be unaware of its existence. In many cases, however, the prolapsing vaginal wall protrudes at the vulvar cleft when the woman is erect, or when she strains at stool or performs work requiring heavy lifting. The woman often says that under such circumstances the “womb” protrudes. On account of the accompanying prolapse of the anterior rectal wall the passage of feces does not take place in the normal direction, but the fecal mass is forcedinto the pouch of the anterior wall of the rectum, and straining efforts push it forward into the vagina. The woman says she feels as though the passages were about to take place through the vagina. This discomfort is relieved by pressing the rectocele back with the finger during defecation. Accumulation of feces in the rectal pouch may result in inflammation or ulceration. The condition is readily recognized by introducing a finger into the rectum, when it will be found to enter the rectocele.

Fig. 57.—Median sagittal section of the pelvis of a woman in whom there has been a laceration of the perineum in the sulci, with rectocele and cystocele. The vagina is no longer a closed slit.

A rectocele is cured by Emmet’s operation, which restores the support of the perineum and the posterior wall of the vagina.

Cystocele.—A cystocele is a tumor formed by the protrusionof the lower part of the anterior vaginal wall into the vagina or through the ostium (Fig. 56). The prolapse of the vaginal wall is accompanied by prolapse of the posterior wall of the bladder. A sound introduced into the bladder through the urethra will be found to enter the cystocele. This test, and the soft, reducible character of the cystocele tumor, enable us to diagnosticate between cystocele and cyst of the anterior vaginal wall. The condition is caused by a loss of the support of the anterior vaginal wall that is furnished by the posterior wall and the perineum.

In a case of cystocele residual urine often remains in the pouch of the bladder-wall. In some cases the woman learns that, in order to empty the bladder, it is necessary for her to push the cystocele upward and forward at every act of micturition. The result of this inability to empty the bladder is decomposition of the urine and resulting cystitis.

Many cases of so-called irritable bladder and chronic cystitis are caused primarily by laceration of the perineum, which produces cystocele or prolapse of the posterior wall of the bladder; and such cases can be cured only by curing the cystocele.

A cystocele varies much in size. Every long-standing case of laceration of the perineum in the sulci presents a certain degree of prolapse of the anterior vaginal wall. The tumor may remain within the vagina and be rendered prominent only upon efforts at straining, or it may protrude through the vulva as a mass the size of a duck’s egg.

As a cystocele is caused by laceration of the perineum, it can be cured only by repair of this laceration. The most important part of the treatment, therefore, is perineorrhaphy, which should always be performed. Usually this operation is sufficient. If the anterior wall of the vagina is supported, the tissues will recover their tonicity and contract, and the tumor will disappear.

In some cases, however, where the mucous membraneof the anterior vaginal wall has become much stretched and redundant in the normal-sized vagina, it is advisable, in addition to the perineorrhaphy, to perform a plastic operation on the anterior wall in order to diminish the area of the vaginal mucous membrane. Such an operation is called anterior colporrhaphy. A variety of operations of this kind have been invented. The various forms are modified according to the requirements of the case and the whims of the operator. In one form of operation an oval area is denuded (Fig. 58), and the edges are brought together by interrupted sutures passed beneath the whole denuded surface.

Fig. 58.—Oval denudation for cystocele: sutures introduced.

Fig. 59.—Sims’ operation for cystocele.

As the transverse measurement of the vagina is greater in the upper than in the lower part, an operation by which a greater amount of the excess of tissue is taken in above than below is often desirable. Such an operation is represented inFig. 59. Two strips, about one-third to one-half inch in breadth, are denuded on each side of the anterior wall, extending from the position of the internal urinary meatus upward toward the lateral vaginal fornices. The length of these strips varies with the case, and depends upon the size of the upper portion of the vagina. It is often desirable to carry thedenudation to the level of the external os. The denuded surfaces are brought into apposition by interrupted sutures. By this operation the whole caliber of the vagina is narrowed from above downward. The degree of divergence of the denuded strips may be determined by seizing portions of tissue with tenacula upon each side and bringing them together, thus determining the amount of tension which will be put upon the sutures.

Fig. 60.—Dudley’s operation for cystocele (Ashton, modified from Dudley).

In Dudley’s operation the denudation is made and the sutures are introduced as shown inFig. 60. The advantage claimed for this operation is that by it the upper end of the vaginal wall is attached to the bases of the broad ligaments.

The operation of anterior colporrhaphy must always be accompanied by perineorrhaphy. The anterior operation should be performed first. The woman should be placed in the Sims or the dorsal position.

Enterocele.—Enterocele, or entero-vaginal hernia, is a rare condition. It consists of a hernia, or prolapse, ofthe intestine into the vaginal canal. Two forms of the disease have been described—the anterior and the posterior. The latter is the more common. In the posterior variety one or more loops of the intestine, or the omentum, reach the bottom of Douglas’s pouch and push the posterior vaginal wall forward, so that it encroaches upon the vaginal canal and in some cases protrudes from the ostium vaginæ.

The causes of this disease are not known. It is probably favored by loss of support of the perineum and the vaginal walls. An unusually deep pouch of Douglas would predispose a woman to this condition.

In the anterior form of the disease the hernia occurs at the bottom of the vesico-uterine pouch.

The posterior enterocele may be distinguished from rectocele by introducing a finger into the rectum and one into the vagina, when the prolapsed intestine or omentum may be felt between the anterior rectal wall and the posterior vaginal wall. The condition may be distinguished from vaginal cyst by percussion and palpation.

In the treatment of enterocele any existing injury to the perineum should be repaired, and the vagina should be narrowed by one of the plastic operations already described. Great care should be taken not to injure with the needle the intestine underlying the vaginal wall.

Subinvolution of the Vagina.—It should be remembered, in connection with the subject of prolapse of the vaginal walls as a result of loss of the perineal support, that there is always present, also, a condition of subinvolution of the vagina. During pregnancy all the elements of the vagina undergo a physiological hypertrophy analogous to that which occurs in the uterus. After labor the vagina normally undergoes certain changes by which it is again approximately restored to the dimensions, shape, etc. that existed before pregnancy. This change is called the involution of the vagina. Anything that arrests this process of involution produces a state ofsubinvolution of the vagina; this structure is then found much larger and more relaxed than normal, and a certain hypertrophy of all the elements of the vaginal walls persists. Such subinvolution of the vagina is caused by the various pelvic lacerations, which, by causing loss of support to the pelvic vessels, result in a state of passive congestion.

These redundant vaginal structures usually disappear and contraction takes place after the operation of perineorrhaphy. In some cases, however, when the vagina is very much larger and more relaxed than normal, it is advisable to remove some of the excess of tissue by a plastic operation on the anterior wall similar to that described for the relief of cystocele.

The uterus normally lies with its anterior surface in contact with the posterior aspect of the bladder, no intestines intervening. The absolute and relative positions of the uterus depend upon the degree of distention of the bladder and the position of the woman. The uterus is pushed backward and the fundus is turned upward by distention of the bladder. When the woman is erect the uterus lies at a slightly lower level than when the woman is on her back, and the intra-abdominal pressureacting upon the posterior surface of the fundus turns the uterus more forward, so that the fundus lies nearer the symphysis pubis.Fig. 61shows about the normal range of position.

Fig. 61.—Normal range of position of the uterus, depending upon the distention of the bladder.

It may be said that in the normal woman the long axis of the uterus is approximately perpendicular to the long axis of the vagina (Fig. 62).

Fig. 62.—Median sagittal section of the normal female pelvis.

The uterus does not surmount the vagina with the axes of the two structures in the same line, as is shown in some anatomical plates.

The cervix looks backward toward the coccyx, from the tip of which it is situated 0.6 to 1.2 inches.

The uterus is maintained in position by a variety of factors. The ligaments, which have been described, are eight in number—broad ligaments, round ligaments, utero-sacral and utero-vesical ligaments.

With the exception of the round ligaments, which are muscular structures, the uterine ligaments are formed by peritoneal folds, including connective tissue, blood-vessels, lymphatics, and a small amount of unstriped muscle.

When the woman is erect the insertions and origins of the various uterine ligaments lie in the same horizontal plane. The insertion of no ligament is higher than its origin in the uterus; therefore these ligaments do not act as suspensory ligaments when the uterus is in its normal position. The truth of this fact is repeatedly demonstrated at operations. If the cervix be caught with a tenaculum when the woman is on her back, the uterus may, with but very little force, be drawn downward toward the ostium vaginæ to the extent of one or two inches; and similarly, by a slight digital pressure on the cervix, the uterus may be pushed upward from one to two inches above its normal position.

The ligaments of the uterus act as guys. They steady it, and prevent too great lateral and fore-and-aft movement; they do not, when the uterus is in its normal position or at its normal level, sustain it against the force of gravity. When, however, the uterus, for any reason, falls an inch or more below its normal level, the uterine ligaments become suspensory in character.

In the normal woman the vagina is always closed. As has already been said, it is a slit in the pelvic floor, valvular in character; consequently the abdominal and pelvic viscera may be considered to be contained in a closed vessel, in woman as well as in man. The uterus floats in this closed vessel at a level which is consistent with its own specific gravity. If, for any reason, the specific gravity of the uterus were increased, it would sink below the level at which it is normally situated.

Since, normally, there is no tendency in the uterus to change its position, the pressure upon it must be equal in all directions. The subject may perhaps be better understood by referring to a few simple facts in hydrostatics. If a fluid contained in a closed vessel be in a conditionof equilibrium so that its various particles are at rest, then the pressure upon any particle is equal and opposite in all directions (Fig. 63); otherwise the particles would not be in equilibrium, but would move. The bottom of such a vessel, however, is not, like the particles of the fluid, surrounded on all sides by the fluid, but above it is the fluid, and below it is the atmospheric air. Any point upon the bottom of the vessel is subjected to a downward pressure equal to the weight of the column of fluid above the point; this downward pressure is resisted by the strength of the material composing the vessel. If this material be yielding or elastic in character, the pressure above will make the bottom protrude to a certain extent. A particle within the fluid (like X immediately above the bottom of the vessel) will be subjected to a downward pressure equal to the weight of the column of fluid above it; but this pressure will be counterbalanced not by any strength in the particle, but by a counter-force acting from below equal and opposite to that acting from above.

Fig. 63.—Vessel containing fluid in equilibrium. The arrows indicate the direction of the pressure at various points.

A similar state of things exists in the female pelvis. The uterus floats at a certain level, and the intra-abdominal pressure acting from above is counterbalanced by anequal force acting from below, while the floor or bottom of this vessel (part of which is the perineum) is subjected to a force from above equal to the intra-abdominal pressure, and this force is opposed only by the strength of the perineum (seeFig. 64).

Fig. 64.—Diagram representing the directions of the intra-abdominal pressure upon the uterus in the uninjured woman.

If the vagina were an open tube admitting air, so that the uterus above was in contact with the contents of the pelvic vessel and below with atmospheric air, then the condition of things would be altered. In this case the uterus would in reality become part of the floor of the vessel, and would be subjected to a pressure from above equal to the intra-abdominal pressure, and to this pressure would be opposed only the strength of the uterus and its attachments. Such a state of things occurs when the perineum is torn and the vagina becomes a patulous open canal, and not a closed slit. Therefore when the opening of the vagina is torn and air constantly enters the vaginal canal, the normal hydrostatic equilibrium of the pelvic contents is destroyed, the resultant of the forces acting upon the uterus is downward, and the organ has a tendency to fall or to prolapse (Fig. 65).

The normal perineum and vagina do not sustain theuterus by furnishing a mechanical support from below, any more than the bottom of a vessel sustains any single particle of fluid floating in it.

When the uterus tends to fall down or to prolapse, its progress is opposed at a certain level by its various attachments. The ligaments become suspensory in character as soon as their uterine attachments are below their pelvic attachments. The cellular tissue, fat, blood-vessels, etc. connected with the uterus restrain its downward motion. And, finally, this motion is restrained by what has been called the “retentive power of the abdomen,” which is merely the atmospheric pressure acting from below on the contents of a vessel the top and sides of which are closed.

Fig. 65.—Diagram representing the direction of the intra-abdominal pressure in the woman with a laceration of the perineum.

Refer again to a simple physical example: If a glass tube be filled with water, a finger placed over one end, and the tube inverted, the water will not run out: it is sustained by atmospheric pressure acting from below. If the finger be removed, atmospheric pressure also acts from above, and the water will fall. If a hole be made in the side of the tube, atmospheric pressure will act through it, and the water below the hole will fall.

In order that the column of water be sustained, the sides of the tube must be rigid or unyielding. If the sides of the tube yielded slightly to atmospheric pressure, they would sink in and a certain amount of water would escape.

The abdominal and pelvic cavities in the erect woman may be considered as a tube filled with fluid contents. The top of the tube is closed by the diaphragm; the sides are the more or less rigid abdominal walls and the back; the floor is the perineum. When the floor is destroyed a hole is made in the bottom of the tube: the contents tend to fall, but the fall is resisted by atmospheric pressure acting from below. If the diaphragm and the parietes were rigid as glass, there would be no prolapse, any more than there is prolapse of the water in the glass tube. If the parietes yield somewhat, the amount of fall or prolapse is proportional. Thus the retentive power of the abdomen is dependent upon the strength or rigidity of the abdominal walls.

Prolapse of the uterus means a falling of that organ below its normal level. The condition is popularly spoken of as “falling of the womb.” There are an infinite number of degrees of prolapse of the uterus, between the slightest descent on the one hand and complete protrusion of the organ from the body on the other hand. The term “complete prolapse” should properly be applied to the entire protrusion of the uterus outside of the vulva. This condition, however, is most unusual. The term is generally used to designate those cases in which the cervix alone, or the cervix and part of the body of the uterus, protrude from the vulva (Fig. 66). In any case of prolapse of the uterus it is best to describe in detail the extent of the prolapse and the other conditions present. Thus, some of the various kinds of prolapse may be described as follows: “Prolapse of the uterus, the cervix resting on the pelvic floor;” “prolapse of the uterus, the cervix presenting at the vulvar cleft;” “prolapse of the uterus, the cervix protruding about two inches from the ostium vaginæ, with elongation of the supra-vaginal cervix,” etc.

Injury to the pelvic floor that allows air to enter the vagina destroys the normal equilibrium of the pelvic contents and exposes the uterus to a direct abdominal pressure from above, which is not counterbalanced by an equal force from below, but is opposed by the strength of the uterus and its attachments and the retentive power of the abdomen. Most cases of prolapse occur in women in whom the perineum has been injured at childbirth.

Fig. 66.—Prolapse of the uterus, the cervix protruding from the vulva. There is a bilateral laceration of the cervix.

There are a number of predisposing causes of uterineprolapse that permit the descent to progress after the uterus has begun to fall—namely: Relaxation of the uterine ligaments that results from too frequent parturition, from old age, or from tissue-weakness which is part of a general condition, the uterine ligaments sharing the general feebleness of the other tissues and structures of the body; relaxation, loss of rigidity, or muscular weakness of the abdominal parietes, which diminishes the retentive power of the abdomen; diminution of the cellular tissue and the fat of the pelvis, such as occurs in wasting disease or in old age. Anything that suddenly increases the intra-abdominal pressure, such as lifting a heavy weight, may cause acute prolapse of the uterus. In some cases the uterus has suddenly protruded from the body as a result of heavy lifting. In cases of this characterit is probable that the muscular supports of the perineum have been weakened from some cause, or that the sudden increase of abdominal pressure drives the uterus downward before the perineal muscles have time to contract and close the vaginal outlet. In such cases there is also present rupture of the uterine ligaments. Constant violent coughing has produced uterine prolapse in a similar way.

Extreme uterine prolapse sometimes occurs in a nulliparous woman in whom the perineal supports are naturally weak. In such women there exists a condition of relaxation identical in results with subcutaneous laceration of the perineum.

Anything that increases the specific gravity of the uterus will make it sink somewhat lower in the pelvis. Subinvolution, congestion from inflammation, or retroflexion may do this. In such cases, however, the prolapse never becomes extreme, rarely extending beyond a slight sinking of the uterus.

In most cases uterine prolapse takes place slowly. Sometimes many years are necessary for the development of complete prolapse. The equilibrium of the pelvic contents is destroyed by one of the causes already mentioned. The uterus falls through a certain distance before the uterine ligaments become suspensory. Then, however, its further descent is impeded.

If the original cause continues to act, the uterine ligaments become stretched and the descent of the uterus gradually progresses, impeded to a varying degree also by the retentive power of the abdomen and the cellular tissue and other pelvic attachments.

As the uterus descends, the vaginal walls attached at the cervix are dragged down with it, so that when the prolapse becomes complete the vagina is turned inside out (Fig. 67).

When the perineum has been injured so that the lower portion of the vagina loses its support and the equilibrium of the pelvic contents is destroyed, two distinctphenomena occur: The uterus falls as already described, and at the same time the lower part of the vagina begins to fall, so that there appear a prolapse of the anterior vaginal wall, or a cystocele, and a prolapse of the posterior wall, or a rectocele. The condition finally produced will depend upon which prolapse takes place the more rapidly—that of the vagina or that of the uterus.

Fig. 67.—Complete prolapse of the uterus.

If the prolapse of the lower vagina progresses faster than that of the uterus, then the vagina will begin to drag upon the cervix, to which it is attached, and under these circumstances the uterus will be subjected to two downward forces—intra-abdominal pressure from above, and traction of the vaginal walls acting from below.

Fig. 68.—Prolapse of the vagina and the vaginal cervix, with great elongation of the supra-vaginal cervix.

As the traction is exerted upon the lower part of the cervix, and the body of the uterus is sustained by the uterine ligaments, which resist the downward traction, the isthmus, or point of junction of the body and cervix, is dragged out or stretched, so that in some cases a verymarked elongation of the supra-vaginal cervix, or the part of the cervix above the vaginal junction, appears. This elongation is sometimes so great that the length of the uterine cavity from external os to fundus measures six or eight inches. Such elongation of the cervix is usually found to a greater or less degree in every case of marked prolapse of the uterus caused by injury to the perineum. Such a condition should be described as prolapse of the uterus with elongation of the supra-vaginal cervix (Fig. 68). In many cases the prolapse of the vagina and the elongation of the cervix are the most marked features, the body of the uterus falling but slightly below its normal level. The cervix will be found protruding some distance from the vulva; the vagina will be foundturned inside out; while the fundus may be felt approximately at its normal level in the pelvis, and the presenting cervix and the body of the uterus are connected by a round, cord-like structure about the size of the little finger, which is the stretched, attenuated supra-vaginal cervix.

Fig. 69.—Prolapse of the vagina and cervix, with elongation of the supra-vaginal cervix.

As a result of the traction upon the cervix the blood-flow from the infra-vaginal cervix is impeded, and passive congestion results in hypertrophy. This hypertrophy is increased by irritation of the infra-vaginal cervix from friction against the clothing and from urine, etc. In such cases the presenting cervix becomes much larger than normal, sometimes measuring two or two and a half inches in diameter.

It will be seen that very pronounced structural changes are present in old cases of prolapse of the uterus. The uterine ligaments and the pelvic attachments become so stretched and atrophied that they can never become functionally useful again. The normal shape and size of theuterus become very much changed from elongation of the supra-vaginal cervix and hypertrophy of the infra-vaginal cervix. The vaginal canal becomes patulous and stretched several times beyond its normal dimensions, and the delicate mucous membrane, from exposure, becomes tough and cutaneous in character. The large protruding mass of uterus and inverted vagina stretches the genital outlet far beyond its normal dimensions, and the muscular supports that may have remained after the original perineal injury undergo atrophy from pressure.

Fig. 70.—Prolapse of the vagina and the vaginal cervix, with elongation of the supravaginal cervix. Extensive ulceration.

Accompanying the prolapse of the uterus is usually prolapse of the bladder and of the anterior wall of the rectum, producing a condition already described under Cystocele and Rectocele.

Women who do hard manual labor are those who suffer with the most marked forms of uterine prolapse. The form of prolapse accompanied by elongation of the supra-vaginal cervix is usually characteristic of the hard-workingwoman. Such prolapse of the uterus is common among the Western Indian women, who return immediately after delivery to hard labor and horseback-riding.

Fig. 70,A.—Elongation of supra-vaginal cervix (St. Bartholomew’s Hospital Museum).

Many cases of prolapse would be avoided, even though there might be serious perineal injury, if women remained in bed a sufficient time after delivery. By rising too early prolapse is favored, for a variety of reasons. The uterus is large and heavy; the uterine ligaments are elongated, and the abdominal walls are weak; consequently the retentive power of the abdomen is poor; the vagina is flabby and much larger than normal; the genital outlet has not contracted, and the muscular and fascial supports which may not have been torn are stretched and relaxed.

The subjectivesymptomsof prolapse vary greatly and are not characteristic. A woman in whom the uterus hasdescended but slightly below the normal level may suffer so much with backache, weakness of the legs, and a feeling of pelvic weight, or “bearing down,” that her life will be rendered useless; while, on the other hand, a woman with complete prolapse of the uterus may suffer no inconvenience except from the presence of the protruding mass. In fact, the lesser degrees of prolapse seem to cause more suffering than the extreme degrees.

The first subjective symptoms of injury to the supports of the pelvic floor that appear when the woman leaves her bed are those referable to beginning prolapse of the uterus. Backache is the most common symptom, and occurs here as in almost every other disease of the uterus. The pain, a dull ache, is situated in the upper part of the sacrum. It is increased by standing, by walking, or by manual labor. It often disappears entirely when the woman lies down and the intra-abdominal pressure is removed from the uterus. Headache situated in the occipital region or the vertex is also usually present, and varies in severity with the severity of the backache.

Pain extending down the posterior aspect of the thighs, and a dragging feeling of loss of support in the pelvis, may also be present. The rectal and bladder symptoms occur later, when rectocele and cystocele appear.

There is often very marked general physical weakness, much of which may be referred directly to the loss of the muscular support of the perineum. Almost every effort that the woman makes is accompanied by increase of intra-abdominal pressure, and she feels keenly the loss of the accustomed perineal support which normally resists any increased abdominal pressure. In the sound woman the perineal muscles contract and the vagina is more tightly closed to meet the increased pressure incident to a muscular effort. In the injured woman the vagina is open and the pressure is resisted by weak vaginal walls and uterine supports. She feels that her point of resistance is gone. The best proof of the profound effect of injury to the perineum upon the general strength of a woman is given by the operation of perineorrhaphy.The repair of this apparently slight lesion restores the woman to her former strength.

Thediagnosisof prolapse of the uterus is readily made by examination. In the extreme cases the cervix and the greater part of the body of the uterus are found outside the vulva. In less marked cases the cervix is seen presenting at the vaginal orifice as soon as the labia are separated. In other cases the cervix is felt by the vaginal finger resting on the pelvic floor. It should be remembered that every case of prolapse is greater when the woman is standing than when she is being examined upon her back. Sometimes the cervix will present at the vulva, where it may be felt when the woman is erect; but when she lies down and intra-abdominal pressure is removed, it retreats beyond inspection except through the speculum. In order to determine the full extent of prolapse, therefore, when the woman is examined on her back she should be directed to strain or bear down, when much more marked descent of the uterus and vaginal walls will become apparent.

The lesser degrees of prolapse, in which the cervix has not yet fallen enough to rest on the pelvic floor, are more difficult to recognize by bimanual examination. It will be found that the upward range of motion of the uterus is greater than normal, and vaginal examination when the woman is erect will make the condition more apparent.

Extreme prolapse of the uterus, in which we find protruding from the vulva a pear-shaped tumor at the apex of which is the opening of the cervical canal, should not be mistaken for any other condition. Inversion of the uterus and a uterine polyp resemble it only in shape, and in no other particular. If there is any doubt, it may be dispelled by placing the woman in the knee-chest position, when the prolapse may readily be reduced and the normal anatomical relations restored.

Treatment.—As prolapse of the uterus is usually caused by injury to the pelvic floor, treatment should be directed in the first place to the restoration of the perineum.

In slight cases of prolapse that are seen early, restoration of the perineum by Emmet’s operation is sufficient for cure.

In cases of long duration, however, we have to deal with a variety of secondary conditions. These are as follows: Hypertrophy of the uterus from subinvolution or congestion; elongation of the cervix; hypertrophy of the cervix; elongation of the uterine ligaments; stretching of the vagina; stretching of the genital outlet; and atrophy of all the structures of the perineum from pressure. The atrophic changes give the most difficulty. The prognosis, therefore, depends upon the duration of the case.

In cases of prolapse in which the cervix has reached or has passed the ostium vaginæ, rest in bed in the recumbent position should always be prescribed for two to four weeks before any operative procedure. The woman should be placed in the knee-chest position and the prolapse of the uterus and vagina should be reduced. Reduction of this kind should be practised as often as the prolapse returns—as, for instance, after straining at stool. It may be performed by the woman herself or by the nurse. It is well for the woman to assume the knee-chest position three or four times a day, for five to fifteen minutes at a time. One or two hot vaginal douches of a gallon of 1:4000 bichloride solution should be administered daily. The intestinal contents should be kept soft by laxatives. As a result of such preparatory treatment the uterus will diminish very much in size, and the vagina and the vaginal outlet will contract, so that at the time of operating the amount of tissue to be removed may be more accurately determined. The diminution in the length of an elongated cervix as a result of rest is most striking, and demonstrates the truth of the explanation of the etiology of this condition that has already been given. A uterine canal that measures five or six inches in length may be reduced to three or four inches after traction on the cervix has been removed by rest in bed.

Ulceration of the cervix, which is often present as a result of friction from exposure, readily yields to this treatment of rest and douches.

From the considerations already referred to it will be seen that the operative treatment of any case of uterine prolapse varies according to the special conditions present.

Perineorrhaphy is always necessary. Emmet’s operation is usually the best one. The denudation in the lateral vaginal sulci should be extended well up the posterior vaginal wall, in order to diminish the caliber of the overstretched vagina. One of the operations already described should also be performed for the cure of the cystocele and to diminish the area of the anterior vaginal wall. The best of these operations are Sims’ and Dudley’s (Figs. 59 and 60). After all plastic operations for the cure of prolapse the woman should be kept in bed for three or four weeks—the longer the better—so that the perineal and vaginal structures and the ligaments of the uterus may contract and regain strength.

In some cases of long standing it is impossible, by operation, to restore the integrity of the pelvic floor, and to restore the shape, size, and direction of the vaginal canal so that the normal equilibrium of the pelvic contents will be re-established. In such cases operators have attempted to build a direct mechanical support for the uterus.

Le Fort’s operation is an ingenious method of attaining this object. The uterus should be replaced, and a longitudinal strip of tissue, about one-half to one inch in breadth and two to two and a half inches in length, should be denuded on the anterior vaginal wall, extending from a point near the vulva, where the two vaginal walls are in contact when the uterus is in place, up toward the cervix. A similar strip should be denuded on the posterior wall. These two denuded areas should be brought into apposition by interrupted sutures passed transversely. Perineorrhaphy should also be performed.

In those cases in which the vagina and the vaginaloutlet have become very much stretched by the protruding mass of prolapsed structures, Emmet’s operation seems to be insufficient. In such cases the following operation is useful. This consists in denuding a triangular area on the posterior vaginal wall (Fig. 77), the apex of the denudation being immediately below the cervix, and the base at the ostium vaginæ. The denudation should extend well on to the lateral vaginal walls. The denuded area is then closed by sutures passed transversely.

Fig. 71.—Prolapse of the vagina and of the infra-vaginal cervix. The sound showed the internal uterine length to be 5½ inches. An erosion appears on the posterior margin of the os uteri.

Judgment, derived from experience, is necessary in choosing and performing the various plastic operations for prolapse of the uterus.

In every case of prolapse a certain degree of retroversion of the uterus is present. In fact, the uterus could not escape from the vagina unless the fundus were turned somewhat backward. The operation of ventro-fixation of the uterus is therefore a useful adjunct in some casesof uterine prolapse. The operation is not intended to furnish a mechanical support to the uterus, but only to keep it in a position of anteversion, so that it will less readily escape through the vaginal canal. The plastic operations and the ventro-suspension may all be done at the same sitting.

Fig. 72.—Amputation of the hypertrophied cervix:A.The cervix has been split laterally.B.The posterior lip is being amputated.

Fig. 73.—The posterior lip has been amputated.

Fig. 74.—A.Both lips have been amputated and the sutures have been introduced.B.The sutures have been secured by the perforated shot.

Fig. 75.—A.The anterior vaginal wall is pushed backward by the staff, while on each side of the median line portions of mucous membrane are grasped by tenacula and brought together in order to determine the position of the strips to be denuded.B.Denudation on the anterior vaginal wall (Sims’ operation).

Fig. 76.—A.The sutures have been introduced. The prolapsed vagina and cervix have been reduced. The cystocele is pushed upward by the staff, so that the denuded strips may be brought into apposition.B.The sutures are secured. The cystocele has disappeared. The area of the anterior vaginal wall and the caliber of the vagina have been much diminished.

Fig. 77.—A.A point on the median line of the posterior vaginal wall, about an inch below the cervix, has been seized by the tenaculum. This marks the apex of a triangle the base of which is at the ostium vaginæ and the sides of which are on the lateral vaginal walls.B.The triangle has been denuded. The sutures have been introduced.

Whenever there is hypertrophy of the infra-vaginal cervix, this structure should be amputated in addition to the other operations.

Fig. 78.—The sutures in the posterior vaginal wall have been secured. The caliber of the vagina has been very much diminished. A strong sling or band of tissue has been formed immediately above the ostium vaginæ, which supports the lower portion of the posterior vaginal wall. The operation is completed.

In those very rare cases of incurable prolapse that have resisted all conservative treatment the operation for the removal of the uterus may be considered. The writer has never resorted to it. The operation consists in supra-vaginal hysterectomy followed by fixation of the cervical stump by sutures to the abdominal wall.

This operation, however, should not be proposed hastily.The surgeon should not become discouraged by one or even two failures of the more conservative methods of treatment. Though the first plastic operation may fail to retain the uterus inside the body, yet something is always accomplished by it, and when supplemented by a second or a third operation, cure will often result.

The operative procedures required in a case of prolapse of the vagina and of the infra-vaginal cervix, with hypertrophy of the infra-vaginal cervix and elongation of the supra-vaginal cervix, are illustrated inFigs. 71-78.

The condition represented inFig. 71is that which is commonly spoken of as “prolapse of the uterus.” It is the usual form of prolapse. It may be cured in the very great majority of cases by the operations which are here depicted.

A great number of mechanical devices have been introduced for the relief of prolapse of the uterus. Every vaginal pessary has been used for this condition. None of these implements cure the disease. All of them, if used continuously, produce ulceration of the vagina and of the cervix from pressure, and must be abandoned until such lesions heal. In those cases of prolapse in which pessaries remain in the vagina and support the uterus, without producing ulceration, operation would effect a cure.

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