always follows the anterior wall of the vagina more or less in its descent.

Causes. By far the most common cause of this displacement is childbirth. During pregnancy all the constituent parts of the vagina and the surrounding connective tissue grow and become infiltrated with serum. During childbirth these parts are bruised and torn. During the lying-in period, and when the patient gets up, the weight of the accumulated urine presses on the yet soft and yielding anterior vaginal wall. If the perineum has been ruptured or the vaginal ring is broken or over-distended, there is a still greater lack of support from below. The increased weight of the vagina itself, due to subinvolution, contributes also to the prolapse.

Cystocele may occur apart from childbirth, in consequence of excess in venery, or even in virgins who work hard and are underfed; but such cases are exceedingly rare.

Symptoms.-The condition gives rise to frequent and often imperfect micturition. The bladder is not entirely emptied, and the retained urine undergoes alkaline decomposition and produces catarrh. When the patient lies on her back with flexed and separated knees, the anterior vaginal wall is seen forming a round swelling protruding through the vaginal entrance. By means of a catheter we can easily satisfy ourselves that this swelling contains the base of the bladder. If the condition is complicated with procidentia uteri (see below), the bladder forms in front of the uterus, which hangs between the thighs, a large soft swelling.

Treatment.-Minor degrees of cystocele may be successfully treated with astringent suppositories or injections, by galvanism, by repairing a torn perineum and a posterior vaginal wall, and by a general tonic regimen. More pronounced cases call for direct surgical interference. These operations are called anterior colporrhaphy. It may be median, lateral, or bilateral. The median operation may be performed according to Sims's or Stolz's method.

Sims's Method (Fig. 208). The patient is in the dorsal position, the knees drawn up and separated by means of Clover's crutch or Robb's leg-holder (p. 193). The posterior wall is pulled down with a single Sims speculum, a tenaculum-forceps is fastened in the median line just below the point corresponding to the inner end of the urethra, which is marked by a transverse ridge (Fig. 137, p. 162), and another at the lowest point near the cervix. The operator seizes the mucous membrane of the anterior wall of the vagina somewhere near the lateral sulci with two tenacula, and draws them together. Thus he ascertains how much tissue is redundant, and makes a snip with a pair of scissors on each side, in order to mark the greatest width of the surface to be denuded. Just outside of these points he inserts a tenaculum-forceps, so that the whole surface to be pared may

be put on the stretch. With a pair of scissors curved on the flat a strip of mucous membrane about inch wide, and extending from the lower forceps to the upper, is cut off. Similar strips are cut off parallel to the first on the right side until the landmark is reached. Then the same procedure is repeated on the left. In this way an elliptical surface, with the long axis in the direction of that of the vagina, is denuded. Next silk or silkworm-gut sutures are inserted from side to side, alternatively deep, under the whole surface, and superficial, only through the edges. It is very convenient to use irrigation instead of sponges (pp. 177, 195, and 215). The sutures are removed from nine days to four weeks after

Diagram of Sims's Cystocele Operation: A, denudation by cutting off longitudinal strips of mucous membrane with scissors; B, insertion of sutures, alternatively deep (1, 3, 5, 7) and superficial (2, 4, 6).

the operation, according to their accessibility, which again depends on whether other operations are performed simultaneously on the perineum and on the posterior wall of the vagina or not. This method leaves a linear cicatrix in the median line. Some prefer a continuous catgut suture inserted in superposed tiers (p. 213).

Stolz's Method (Fig. 209) differs from Sims's by the circular shape of the denuded surface and the insertion of a purse-string suture along the circumference. The denudation is made in exactly the same way. For the suture is used a strong silk thread (No. 4 or 5 braided), armed at both ends with a medium-sized curved needle without cutting edges except quite near the point. One of the needles is given to an assistant; the other is seized with a needle-holder, introduced in the median line (a) inch behind the denuded surface, carried inch to the left under the mucous membrane, then made to emerge inch outside of the denuded surface (b), reintroduced inch nearer 4

to the meatus, and carried in the same way alternately below and above the mucous membrane at a short distance from the denuded surface. Arriving a little beyond the middle line (c), under the meatus (m), the operator hands this first needle to an assistant, and introduces the other exactly in the same way on the other side, until the whole denuded surface is surrounded with the thread. The two ends are now pulled together, while the assistant pushes the denuded surface back with a uterine sound. The suture is tied, and the two ends fastened with adhesive plaster to the abdominal wall. Thus the pared surface is brought together and closed like a tobacco-pouch.

FIG. 209.

m

a

Diagram of Stolz's Cystocele Operation: 1, first needle; 2, second needle; a, first point of entrance; b, first point of exit; c, last point of exit with first needle; m, meatus urinarius.

There is formed a small puckered cicatrice, which gives excellent support to the bladder.

The suture is removed after nine or ten days if of easy access; otherwise it may stay for weeks.

Watkins's Method1 is lateral or bilateral. According to its author, laceration of the anterior vaginal wall is unilateral or bilateral. It is usually submucous, and occurs at or near the insertion of the fascia into the bony pelvis. The location and extent of the tear are detected by touch and by inspection of the change in the shape that occurs in the anterior vaginal wall, which normally presents a convexity corresponding to the urethral curve, a marked concavity corresponding to the trigone of the bladder, and a straight line or slight convexity from this point to the uterus.

T. J. Watkins of Chicago, Ill., Jour. of Gynecology, Toledo, O., Aug., 1891, vol. i. No. 5, p. 305.

For Watkins's operation the patient is placed in Sims's position, and the anterior vaginal wall exposed with his speculum. A point of the mucous membrane to the side of the urethra, near its meatus, is caught with a tenaculum. The denudation is carried from this point, along the antero-lateral wall of the vagina, to a point beyond the prolapse. This point may be opposite the neck of the bladder, or the denudation may extend even as far back as the lateral aspect of the cervix uteri. The breadth of the denuded surface is dependent upon the extent of the urethrocele and cystocele, all the redundant tissue of which it should take in. The denudation is made on one or both sides according as the laceration is unilateral or bilateral. Silkworm-gut sutures are passed, beginning at the uterine end of the denudation, from side to side in a curved line which has its convexity outward and forward. Each suture as inserted is tied, and traction is being exerted toward the cervix while the next suture is being introduced and tied. The sutures should include as much connective tissue as possible, care being taken not to injure the bladder, the ureters, or the urethra. After passing the trigone of the bladder the sutures should be passed deeply into the lateral wall near its insertion into the pubes, and as deeply into the anterior vaginal wall as the increased thickness of the vesico-vaginal septum from this point outward will permit. The stitches may be removed after a week or be allowed to remain for two or three weeks. It is claimed that this operation cures the incontinence of urine that sometimes is a distressing feature of cystocele and urethrocele. (Compare Pawlick's operation for incontinence, under Urinary Fistula.)

In any of these operations the bladder should be emptied every four hours. If the patient can urinate, she may be allowed to do so. If not, the urine is drawn, preferably with a soft-rubber catheter. The patient should stay in bed three weeks.

Cystopexy-A new French operation for cystocele, by which the anterior wall of the bladder is fastened to the abdominal wall, has been performed several times with success. The bladder is injected with five ounces of solution of boracic acid. A transverse incision 23 inches long is made through the abdominal wall in the hypogastric region. Two catgut sutures are carried through the lower edge of the wound except the skin, then through the outer layers of the anterior wall of the bladder, and through the upper edge of the wound. After tying these sutures the skin is stitched together. During the first six days the catheter is used twice a day only.

CHAPTER IV.

PROLAPSE OF THE POSTERIOR VAGINAL WALL; RECTOCELE.

NEXT to the prolapse of the anterior wall, that of the posterior is the most common form of prolapse of the vagina. It is commonly called "rectocele," but this name is only used correctly if the prolapse contains the rectum, which, as a rule, is not the case. The connective tissue between the rectum and the vagina being much longer and looser than that between the bladder and the vagina, the latter slides away from the rectum, doubles up, and forms a round swelling bulging out through the vaginal entrance. By pinching this fold and by introducing a finger into the rectum we can easily satisfy ourselves that this is so. But in the course of time the anterior rectal wall, lacking its normal support in front, may become distended and form a pouch descending inside of that formed by the vagina.

Etiology. The causes are similar to those enumerated for cystocele, except the weight of the bladder, for which here is substituted constipation.

Symptoms.-The symptoms are a similar dragging sensation. Constipation, besides being a cause of rectocele, is a sequence of it, and may lead to proctitis with ulceration of the mucous membrane. When the patient lies on her back with separated knees, a globular swelling, formed by the posterior wall of the vagina, is seen protruding through the vaginal entrance-a swelling that increases in size when she bears down or stands on her feet.

Treatment.-Posterior colporrhaphy consists in the denudation on the posterior wall of an elliptic surface similar to that described in treating of Cystocele, but is seldom resorted to. As a rule, the perineum and the vaginal entrance have been injured, and the operation called for is Hegar's or Emmet's colpoperineorrhaphy. (See pp. 303 and 308.)

Vaginal Prolapse and Inversion.-When the whole vagina sinks down all around, the condition is particularly called prolapse of the vagina, and if this goes so far that the whole tube is turned inside out and forms a sausage-shaped mass hanging between the thighs and surrounding the prolapsed uterus and bladder, and sometimes the rectum, it is called inversion.

The mucous membrane, exposed to the air, becomes dry and scaly, and, on the other hand, the thrown-off epithelial cells, if the parts are not kept clean, form a white, malodorous smegma in the pouch between the prolapse and the perineum, which irritates the mucous membrane and gives rise to vaginitis. This condition is connected with prolapse of the uterus, and will be considered in treating of that disease.