follow with the point of Hanks' rubber dilator. The dilator may be made to cause quite an opening, but this may be enlarged by the finger or other instrument. There will be no hemorrhage if the operation is done without cutting.

In the case of the indolent abscess all that will generally be found necessary is to draw off the pus by the aspirator. In this variety the lining-membrane (or wall) of the cavity has ceased to produce pus, and consequently when the sac is emptied the fluid does not reaccumulate. I have seen several cases thus happily terminated.

CHAPTER XXVIII.

DISPLACEMENTS OF THE VAGINA, BLADDER, AND RECTUM.

In every displacement of the uterus the direction of the axis and the calibre of different parts, or the whole of the vaginal canal, are changed from their normal conditions. In procidentia the vagina is in part or wholly inverted. In such cases, however, the changes are complications of the displacements of the uterus, and are described and treated as such.

The more common and yet not entirely independent displacements of the vagina are known as cystocele and rectocele.

Urethrocele, Cystocele.

Cystocele is a prolapse of the anterior wall of the vagina, the latter being borne down by a prolapsed bladder, or drawing down that organ with it. The prolapses of the anterior vaginal wall and bladder may also make sufficient traction upon the uterus to cause prolapse of that viscus, and thus be complicated by it without the posterior wall of the vagina being much disturbed. Sometimes the mucous membrane of the anterior or posterior wall of the vagina may prolapse through the vulva without displacing the fibrous sheath, the bladder, or the rectum. At other times the urethra alone will descend with the vaginal wall.

Rectocele.

When the posterior wall of the vagina protrudes externally it is generally, in nullipars, attended with displacement of the anterior wall of the rectum, and sometimes the uterus is drawn down and displaced by traction of the wall of the vagina. In nullipars the rectum is usually but slightly displaced.

Symptoms.

The symptoms of cystocele are dragging sensation or weight in the vagina, with leucorrhoea and burning pain, occasioned by the inflammation from the exposure or friction of the mucous membrane of the vagina, and vesical suffering. In recent cases there is simply frequent desire to micturate and unsatisfactory discharge of the urine.

As the case becomes chronic the incomplete discharge of urine leads to its decomposition, the precipitation of the salts contained in it, and the evolution of ammonia.

The ammonia and salts irritate the mucous membrane of the bladder to a greater or less degree, and in aggravated cases severe inflammation and ulceration occur, attended with discharge of mucus, blood, and fetid gases.

These local results are attended by constitutional disturbances commensurate with their gravity.

The sufferings in rectocele are usually less severe. There is weight, leucorrhoea, and unsatisfactory defecation. The muscular coat of the rectum loses its tone and permits the fæces to collect in a large mass in it, which intrudes into and fills up the vagina.

When an effort is made to expel the excrement it is apt to collect in larger quantities and remains in this passive pouch until the patient presses or scoops it out with her fingers.

Diagnosis.

Upon examining the vagina the anterior or posterior prolapse will be readily discovered, and may be isolated by passing the finger into the vagina. If the anterior wall is prolapsed the finger will pass behind the tumor, and in front of the tumor if the posterior wall is the portion affected.

We may demonstrate a cystocele by introducing the catheter. The instrument, instead of passing backward and upward, will go downward and backward, and the point may be felt occupying the tumor. In rectocele, if we introduce the finger into the rectum, it may be turned forward toward the vagina and made to enter the tumor. If the prolapse consists of the mucous membrane alone, the finger or catheter will not pass into the tumor. (See Palpation of the Pubovesico-uterine Lig., p. 86, also Palpation of Vagina, p. 88, Chapter II.)

Causes.

Loss of substance or tone in the perineum is one of the most im portant conditions necessary to prolapse of the vagina. (See Chapter VII.) There may be loss of substance in the anterior border of that body from rupture, or loss of firmness from subinvolution, lack of general muscular vigor,-debility,-or senile atrophy.

In old women we not infrequently find all the genital organs in a state of abnormal relaxation from loss of fibrous tissue.

Instead of normal atrophy, in which the parts are condensed, as the fibrous tissue disappears, there is no contraction, and the uterus, vagina, and perineum are reduced to their membranous structures, incapable of resisting force in any form. Subinvolution of the vagina. bladder, and rectum, en account of the vascularity and laxity attendant upon that condition, permit displacements, which are favored by the weight of these and other pelvic organs.

Retention of the urine and fæces are also important factors in the displacements. They distend and weaken the walls of the viscera until they become incapable of resisting the pressure.

Treatment.

The same general principles govern the treatment of these two conditions.

If the perineum be deficient, its integrity should be restored by perineorrhaphy, and this will often be sufficient to effect a cure of either or both.

When there is no loss of perineum, or the deficiency is slight, we may often cure cystocele by returning and retaining the prolapsed portion in position until the redundancy of tissue is reduced by the contraction and condensation which take place when the distending forces are removed or counteracted.

The instrument which I have found most serviceable in cystocele is Zwank's pessary. (Fig. 242). The points upon which it rests are the rami of the ischium, and it presents the flat surface of its expanded wings upward, affording an admirable lodging-place for the redundant tissue. The application of this instrument is not difficult, and when of the right size it very generally relieves the symptoms at once, especially the irritableness of the bladder. It will be necessary for the patient to wear the pessary for many months until the condensation or involution is complete. Like every other pessary, this one should be removed and examined often enough to insure cleanliness and prevent damage to the vagina.

If it causes ulceration it must be removed at once. Sometimes a ring, kept in position by external support, may be made to retain the procident wall quite securely. The practitioner should rely upon the pessary in most instances of this kind as far preferable to other surgical means, except the restoration of the perineum when deficient. When a surgical operation is required, the object to be attained by it is to remove a portion of the redundant mucous membrane over the central part and draw the edges together, and thus lessen the calibre of the vagina.

To the inexperienced this operation seems a formidable one, but it is not so, and when attempted the difficulties will rapidly vanish. In the natural condition, the mucous membrane of the vagina is attached to the fibrous sheath by very loose connective tissue. In cystocele the space is much greater, hence, with a tenaculum we can lift the membrane freely away from the vaginal sheath and with the scissors remove it to any extent we desire.

As before remarked, the protrusion in many instances is made up of the mucous membrane alone, when the operation is easy and a complete success.

When the fibrous wall of the vesico-vaginal space yields, and is prolapsed with the mucous membrane, the operation is much more likely to fail, and we will at last be obliged to resort to a support.

Marshall Hall was the first to remove pieces of the anterior vaginal wall, but he limited his amputations to the protruding folds. J. Marion Sims denuded an oval surface extending back nearly to the os uteri and closed by transverse superficial sutures. Stoltz removes a circular piece of mucous membrane and draws it together by a silk thread passed completely around the circle in and out of the mucous membrane, about an eighth of an inch from the edge.

When the urethral fossæ and anterior vaginal sulci are loosened from their facial attachments behind the pubes, and sag down along with

FIG. 220.
U

C

Stoltz's Denudation for Cystocele (Mundé).

the central ridge, I prefer to remove two small oval strips in the urethral fossæ extending back along the sulci (Fig. 234). The tissue in the fossæ should be removed deep enough to get to the firmer fascia so that the edges of the denudation will be held up by it. The denudation may, in case the whole vaginal septum be relaxed, be made to extend backward along the sulci and be joined under the neck of the bladder by a transverse strip, as in Fig. 235.

In this way the anterior vaginal walls are drawn up into the sulci, or to the vesico-vaginal septum, and as nearly as possible reattached behind the pubes by deep stitches. Care must be taken that the strips be not too wide or the traction upon the stitches will be too great. (For particulars as to these operations, see Operations upon the anterior vaginal wall for Prolapse and Procidentia, p. 501).