Search

In Reply.— Technically, Dr Utian has taken exception with our statement that there has been no physiological study of the effects of menopause on female sexual (vaginal) function. He further stated that the true physiological test of the vagina is its sexual function and refers to his articles, in which function is evaluated by reports of the study subject to the principal investigator and the impression of the principal investigator. In his reference 2, there is confirmation by vaginal smear. He suggests that cytologically, the parabasal cell is a more meaningful index to estrogen response than the intermediate or superficial cells after estrogen replacement. One of the major reasons for conducting a purely physiological study, one that related to the circulation of the vaginal wall, the electropotential of the cells to transudate electrolytes, and the effects of estrogen deprivation on the pH and quantity of vaginal secretions, was that with

There is no dispute as to the desirability of repairing the pelvic floor, posterior vaginal wall and perineum in the puerperium, although there is ample room for improvement in the manner of doing it in general practice. The old custom of immediate repair, even before the placenta is expressed, as one authority recommends, must be unlearned. The necessity for as careful a preliminary vaginal examination as any expert gynecic surgeon would make before attempting a secondary repair must be appreciated and the operation itself must be conducted like any other vaginal operation with a good table, proper implements and sufficient assistance if women are to be spared the secondary operations to which thousands of them are now subjected. It has been demonstrated by ample clinical experience that the cervix may be repaired with perfect success and with entire safety to the patient during puerperal convalescence, not only in well-appointed hospitals

At the Chicago Maternity Center we have been using a simple device, contrived by Dr. De Lee, to improve vaginal specular examinations, as shown in the illustration. A 2½ inch rubber sleeve, used in making cigaret drains, is slipped over the regular duckbill speculum. When the blades are opened a rubber side-wall is formed, which keeps the vagina from pouching into the field. This device is particularly useful in multiparas and pregnant women with relaxed and redundant vaginal walls. It also obtains good exposure for colposcopic examination and forms a protection to the tissues when the cervix is cauterized. 1336 Newberry Avenue.

During the past six years at the University of Cincinnati Medical Center, we have employed a modification of our standard procedure for vaginoplasty for correction of a congenital urogenital sinus. The technique permits suturing the vaginal mucosa to the skin without tension, creating an adequate vaginal orifice. A triangular skin flap is developed and rotated into a corresponding incision in the urogenital sinus and posterior vaginal wall. The skin flap thus becomes a part of the posterior wall of the vagina. The technique has been employed for 12 children. Nine had congenital adrenal hyperplasia. Three were type 2 female pseudohermaphrodites. A satisfactory vaginal orifice was created in each instance and there were no complications. Technique With the patient under general anesthesia and in the lithotomy position, the perineum is prepared with soap and water and painted wth aqueous benzalkonium chloride (Zephiran) (Fig 1). A curved hemostat is inserted into the

This operation consists of: An oval denudation of the most prominent part of the cystocele as in the old-time operation. Dissecting flaps from the vaginal wall on either side of the denuded area with which to cover it. Bringing the flaps together over the denuded area and suturing them to it and to each other. The result is: The cystocele is effaced. The site of the cystocele is strengthened by an additional layer of fascia; that taken from the sides. TECHNIC. The patient being anesthetized, placed in the exaggerated lithotomy position and the perineum retracted, the first step is to gather up the redundant tissues along the median line of the anterior vaginal wall and mark out the lines of dissection. In my first work I seized the crest of the cystocele with a tissue forceps and applied a light long-jawed forceps at the base of the fold, but later

The subject of this paper is limited to hernias involving the posterior vaginal wall, which we frequently encounter and recognize under the designation of rectocele, and to the much rarer hernia which is made up of the culdesac of Douglas, with its intestinal contents dissecting its way downward between the posterior vaginal wall and the rectum, known as vaginal enterocele or posterior vaginal hernia. The common condition of rectocele is the result of impairment of the function of the pelvic floor (the inability to properly close the vaginal mouth), due to injury in childbirth, thus allowing the vaginal wall to roll downward and outward with the attached rectum. This anatomic change in the relation of the parts alters the normal mechanism of defecation, the direction of the fecal current being changed so that the anterior rectal wall and the posterior vaginal wall receive the brunt of the strain and, consequently

Vagino-uterine prolapse is a form of hernia through the vaginal outlet which may involve respectively the bladder and anterior vaginal wall, the anterior vaginal wall or the bladder and the cervix uteri; or the eversion may comprise cervix, or uterus, and the entire vaginal structure. The protrusion of the anterior pelvic segment is frequently a sliding of the bladder, pushing it before the anterior vaginal wall and dragging on the cervix where the uterus is firmly fixed as by firm ligaments and resistant peritoneum. The traction on the cervix causes a hypertrophic elongation of the supravaginal portion of the cervix. The anterior and posterior vaginal walls are attached to the cervix at different levels so that such an elongation may occur in the vesical portion of the cervix with complete eversion of the anterior vaginal wall and the cervix, while the posterior vaginal, remains intact and presents its normal length.

W HILE a certain degree of frequently asymptomatic vaginal prolapse follows probably every hysterectomy, not too infrequently a marked or even complete prolapse of the vagina is seen. The patient afflicted with this condition has often already undergone one or more previous surgical procedures by the vaginal route for the purpose of correcting a large cystocele associated with urinary-stress incontinence and a large rectocele. The prolapse may have developed gradually over a period of years, and while the patient originally was able to adjust to her symptoms, she eventually is brought to the physician by complaints of a constant bearing-down feeling, pelvic pressure, discomfort on walking and sitting, urinary stress incontinence, and inability to empty her rectum without replacing a large rectocele digitally. An enterocele can frequently be detected on vaginal examination above a protruding rectocele. Decubital ulcers may be present over the posterior vaginal wall causing discharge or even

Ahlfelt states that the only problem in plastic gynecology left unsolved by the gynecologist of the past century is that of permanent cure of cystocele. That these cases recur after operation is too well known. The late Paul Numde states that all of his cases ended in failure and he had given up operating for that condition. The reason for failure seems to be that the normal support of the bladder has not been sought for and restored, but instead an irrational removal of part of the anterior vaginal wall has been resorted to, which could result only in disappointment and failure. The support of the bladder may readily be determined in the cadaver by making a suprapubic incision and attempting to push the bladder out through the vulva. It will be found to rest on the anterior vaginal wall to which it is slightly adherent. If the bladder

The only sound basis for therapeutic treatment of menstrual disorders with hormones is a broad foundation of experimental evidence concerning the endocrine activity of the ovaries. I will summarize briefly in this paper the recent work on follicular and corpus luteum hormones and sketch in outline a conception of the factors responsible for the periodic changes in the genital organs during the menstrual cycle. ANIMAL REACTIONS TO FOLLICULAR HORMONE The hormone from the ovarian follicles ("theelin," "folliculin," "oestrin") is undoubtedly the principal ovarian hormone. The outstanding effect of this active substance is the production of rapid growth in the accessory genital organs. In the rat and the mouse, theelin is responsible for such rapid proliferation of epithelial cells as to replace completely the many layered vaginal wall in forty-eight hours. It exerts a similar growth stimulus on the uterus and mammary glands. It is probably responsible for maintenance of ciliation

On May 20, 1901, I presented for the consideration of the Johns Hopkins Medical Society a brief paper1entitled "A New and Better Method of Opening and of Draining the Bladder in Women." The method advocated consists in placing the patient in the knee-breast posture and then letting air into the bladder through a catheter or a speculum. If the posterior vaginal wall is now lifted up so as to expose the entire anterior vaginal wall from cervix to urethra, a suitably curved knife may be plunged through the vesico-vaginal septum into the air-distended bladder, and if the knife is sharpened on both edges the cut can easily be lengthened fore and aft from the cervix to the urethra, if it is desirable to make such a large incision. An artificial anemia of the bladder is induced by this posture and whatever blood escapes from the cut runs down

The occurrence of a tumor beneath the base of the bladder causing an anterior colpocele is very rare, judging by an extensive review of the literature. When such tumors do occur, they are usually fibromas or myomas. In the following case a fibromyoma produced an anterior colpocele, and a mistaken diagnosis of cystocele was made as it was noticed soon after labor. A white woman, aged 23, with a negative past history, entered the hospital, May 23, 1931. The patient had her first labor, June 10, 1928. The delivery was normal and a slight perineal tear was sutured. About two months after the labor she first began to notice a bulging of the anterior vaginal wall when straining or when on her feet. The swelling could easily be pushed back, but it slowly became larger and inconvenienced her when on her feet. There were no urinary symptoms except for slight

My purpose in this note on the treatment of gonorrheal vaginitis in immature girls is to corroborate the work and observations of Lewis. 1 Gonorrhea in young girls has always been the bugbear of the medical practitioner and seldom is cured short of months of intensive treatment. Because of the delicacy of the structures involved and the lack of cooperation on the part of the young patients, local treatment is difficult. At best, even in older girls, when cooperation is more readily obtained, treatment is long and tedious and highly unsatisfactory. Perhaps the reason for this is to be found in the peculiar microscopic changes in the generative tract of the immature girl, so splendidly shown by Schauffler and Kuhn. 2 It has long been known that gonorrhea in the mature female seldom attacks the vaginal wall per se or, if it does, it is of short duration. Allen 3

While the complete descent of the uterus is common enough in multiparae, it is very rare in those who have never borne children, and few systematic writers have cases of their own to report. The subject has received scant attention, but five years ago Beyea and C. C. Norris were able to collect sixty-four reported cases, in all but two of which the prolapse was complete. Beyea reported one case. While little definite information as to its cause is furnished by these reports, it is most probable that in nearly all a congenital condition would be found to be contributory, as in all hernias not distinctly traumatic. Any procidentia should be viewed as a hernia through the pelvic outlet, frequently including in the mass, bowel, bladder and urethra the vaginal walls as well as uterus, tubes and ovaries. In other hernias relaxation of all tissues and congenital defects in the

Urethral diverticulum in the female is being diagnosed more frequently today. We have observed 18 cases in persons ranging in age from 18 to 60 years. Common symptoms are burning on urination, dyspareunia, frequency, and dribbling after urination. Vaginal examination usually reveals a tender mass in the anterior vaginal wall. Pressure on the mass may bring pus to the urethal meatus. Cystoscopy and urethroscopy are necessary to determine the size and number of openings of the diverticulum on the floor of the urethra. It may be difficult in some instances to find the urethral opening of the diverticulum. Urethrograms usually show the size and may show the ramifications of the pockets. Treatment is surgical removal of the sac and repair of the floor of urethra. History of Surgical Patient A woman, aged 52, was first seen by us for urinary infection. Cystoscopy then revealed a stricture of urethra with a

At the meeting of the American Gynecological Society in 1902,1and the following month before this Section,2I presented this subject, reporting 8 cases operated on by the vaginal and 3 by the abdominal route. At this time I desire to report 17 cases operated on by each of the two routes, together with some points noted from this experience. There has been no fatality or even notable morbidity in the 41 cases. In every instance of shortening the round ligaments the plan suggested by Webster and Baldy has been practiced. Curettage was done in every one of the 17 vaginal operations. In 3 of them trachelorrhaphy was done in addition, and in 8 perineorrhaphy and trachelorrhaphy. In one of these anterior and posterior colporrhaphy was added; in another posterior colporrhaphy up to the vaginal roof was done. In one the anterior vaginal wall was

In procidentia associated with an unusual degree of vaginal relaxation and perineal damage, this pessary will remain in place much more surely than the ordinary ball device. Direct advantage is deliberately taken of the vaginal relaxation, the collapsed walls serving to retain the pessary. I first used the outer device, without the ball, but in cases characterized by an undue transmission of intra-abdominal pressure it was found that the relaxed vaginal walls would become impacted between the hard rubber coils. The inclusion of the ball was a later thought, obviating the impaction while at the same time taking sufficient advantage of the relaxed walls. This pessary weighs about 1½2 ounces. The symmetrically disposed convolutions constituting the outer section are made from a hard rubber ring which, when heated, is bent into the shape of a three-leaf clover, each leaf or lobe being then curled over a small ball pessary. Its

The primary repair of the perineum is one of the important features of the obstetric work of every general practitioner, and often one of the most difficult and unsatisfactory to perform, owing to lack of the skilled assistants and inability to obtain a satisfactory view of the operative field. To overcome these difficulties, I have devised a small instrument which is simple, light and self-retaining. It is quickly applied, giving a full view of both the anterior and posterior vaginal walls, and the operator now has full use of both hands. The vagina can be packed with sterile gauze carried in a large test-tube and an immediate repair made in an easy, bloodless and satisfactory manner. The instrument is conveniently carried in an ordinary obstetric bag and its mechanism is not complicated. It is convenient for examination of the vagina after delivery as it can be painlessly inserted and can

Pressure necrosis of the anterior vaginal wall, due to prolonged and difficult instrumental labor, is not a very frequent complication, especially to the extent in which it occurred in the case reported below, in which the urethra had completely disappeared and the bladder was entirely detached from the symphysis, suspended only by the ureters and the peritoneum covering its posterior surface. The literature on the subject of the traumatic separation of the bladder from the symphysis is somewhat meager, and this case seems to be the first reported as occurring from labor. Ludolf Sussenguth 1 reports a case observed about the same time as mine. He states that he found only three other cases in the literature, those of Bartels, Grossich and Stierlin. These cases were all produced by a sudden trauma. Whether the condition in my case was brought about by sloughing, following a prolonged and excessive pressure on

We were taught: "Keep the cervix of the uterus in the hollow of the sacrum and the rest of the organ will take care of itself." This teaching is just as applicable now for prolapse of the uterus in the modern treatment of that condition as it was found for all kinds of displacements of the uterus, when these conditions were treated by pessaries and multitudes of "methods" of surgery. The most modern and satisfactory operation for extreme descent of the uterus is undoubtedly the Duhrssen-Watkins-Wertheim anterior transposition operation. This involves the placing of the fundus beneath the bladder and making a high restoration of the rectovaginal septum. This throws the uterus into extreme anteversion and places its fundus below the bladder—between it and the anterior vaginal wall. This, of necessity, turns the cervix backward and with a fulcrum of the highly restored levator ani muscles to act beneath it

In reviewing the records of St. Mary's Hospital from Sept. 30, 1889, to Sept. 1, 1912, I find that 629 women have been operated on for prolapse of the uterus. The patients coming to this hospital are largely from agricultural communities. The majority of these cases were of the more serious forms of this condition brought about by changes in the tissues, the result of repeated pregnancies aided by physical exertion due to the occupation of the patients. In all of these patients the cervix presented itself at the vulvar orifice or protruded from the vagina with more or less of the vaginal wall. In many of the senile cases the entire uterus and a large portion of the bladder and rectum composed the constituents of the prolapse. It is a curious fact that, while erosion and ulceration of the cervix are comparatively common, there were but two cases of malignancy

The propriety of repairing the posterior vaginal wall and the pelvic floor after labor by an immediate or intermediate operation is universally conceded. It is curious, therefore, that the other injuries of the genital canal in labor are ignored by the majority of general practitioners and specialists, although they are almost as common and have consequences quite as serious as the so-called "lacerations of the perineum." Indeed, when one considers the indubitable relationship of lacerated cervix to cancer of that region and the discomfort of a cystocele, it is questionable if injuries of the pelvic floor are not of subordinate importance among the three varieties of traumatism to which the genital canal is subjected in labor. It must appear illogical to the unprejudiced observer to admit that injuries of the pelvic floor should be repaired without fail in the puerperium, but that the other injuries of childbirth, equally disadvantageous to

Accident.— On July 4, Mrs. A. R., aged 39, quintipara, Pregnant at term, while milking, was knocked down by a cow, and struck the vulva on a corner of a box. Immediately a vulvar tumor appeared, with lancinating pain, faintness and shock; the swelling increased until she was carried to the house and placed prone. Patient was seen in half an hour; pulse was 110, respiration 30, temperature 98. Examination.— There was found a tense globular tumor at vulva, as large as the head of a 9-pound child, elastic in consistency, purple in color, painful to the touch, and located in the right labium major. The vulvar orifice was displaced to the left, barely admitting a finger, which outlined the tumor for 3½ inches, along the bulging right vaginal wall. No varices were apparent. Treatment.— Under chloroform anesthesia, administered by Dr. George S. Tweedie, and with aseptic precautions, the tumor

This instrument is designed to facilitate the inspection of the vulva, vagina and cervix. It is especially serviceable in stout patients, or in patients with relaxed vaginal walls, which close in between the expanded blades of a speculum and obstruct the field of vision. It should be constructed of the most durable quality of steel wire. It is easily rendered aseptic, is self-retaining, and is readily introduced and withdrawn without pinching the tissues. The adjustment is such that the distension of the vaginal vault by the expanded blades draws the cervix well forward within the speculum and toward the vulvar outlet. The spring lop or vulvar extremities of both sections are intended to be permanently expanded and not compressed for introduction. The location of the cervix is ascertained with the index finger, the anteroposterior blades (Fig. 1) are introduced by placing the thumb through the loop on the

The methods of perineorrhaphy that have been chiefly employed for the past twenty-five years suggest more of a mathematical than an anatomic basis for their existence. For the most part, they have consisted of excisions of mucous membrane from the posterior vaginal wall having geometrical patterns that vary as do the fancies of different surgeons. In support of the various operations much has been written about the laceration in the muscular and facial planes and of the effectiveness of particular operations, yet one who studies the work of various gynecologists will be impressed by the thought that usually the precise anatomic restoration of the perineum occurs only in the theory of the operator, for the operation, as a rule, consists of little more than the removal of an area of mucous membrane and the union of the wound edges. If at times the operator's needle is made to sweep in

The newest addition to our operative treatment of the backward displacements of the uterus is vaginal fixation. It is the result of a gradual evolution of Schucking's method, and its modifications by Zweifel and Sanger, and has been developed to its present form by Duhrssen and Mackenrodt, each of whom claim priority, and is known by their respective names, their methods varying very little from each other. The technique of Duhrssen's operation, which is the simpler of the two is as follows: the cervix, having been seized by a volsellum forceps, is drawn down toward the vulva; a transverse incision is made through the anterior vaginal wall close to its attachment to the cervix, care being taken to avoid the bladder. The latter is then dissected away from the uterus just the same as in vaginal hysterectomy. It is important to push the vesico-uterine fold as far up toward the

To the Editor:— The idea that the vagina needs regular cleansing douches seems to rest on psychological rather than physiological grounds. From our knowledge of the anatomic and physiological facts it is clear that the vagina is well adapted to take care of itself. In fact, douching, especially with highly medicated solutions, may upset the balance. Over the years, there has evolved the notion that feminine hygiene can be achieved only by artificial means. The purpose of this paper is to challenge that concept and indicate when the vaginal douche can be of value. The vaginal walls are lined by squamous epithelium. At the menarche, under the influence of estrogen, the epithelium becomes many layers thick and remains so until after the menopause, when there is a reduction in the number of layers. In adult women prior to the menopause, the vaginal walls are arranged in longitudinal columns and transverse