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always found. Chiari examined the gall-bladder of twenty-two
cases who had died of typhoid and found the bacillus nineteen
times. This statement has been made lately and not contra-
dicted — namely, that cholecystitis rarely if ever occurs in one
who has not had typhoid fever. Cushing experimented upon
the gall-bladder of dogs introducing the typhoid bacillus directly
into the bladder, but the bile had a destructive influence upon
the bacilli for, at the end of twenty-four hours, they could not be
found. Gilbert and Girode by their experiments found in 1890
that the typhoid bacillus had a suppurative action, that when the
pus obtained was examined it was found to contain the typhoid

Whenever the infection is of a virulent character and there is
some obstruction to the flow of bile, pus soon forms and unless
drainage is established a perforation will result, and an infection
of the peritoneum will rapidly follow. If a stone be so lodged or
so fixed that it forms an obstruction in the presence of a virulent
infection, and is not dislodged or removed, the gall-bladder will
become gangrenous. Again, if the gall-bladder be blocked say
in the cystic duct a hydrops will follow and may remain so for
some time, but if it be infected an empyema results.

If the case be an acute virulent suppurative inflammation,
the gall-bladder walls become enlarged and softened, some-
times markedly so and its color changes from a dark red to a
green. Naturally many adhesions will form to the surrounding
organs. The mucous membrane is destroyed and ulceration
occurs usually at or near the fundus with, in many cases, a
resultant peritonitis, or a perforation may take place into the

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Stomach or intestines. In the so-called gangrenous or phlegmon-
ous form, the destruction of the walls of the gall-bladder may be
very rapid. The following case of gangrenous gall-bladder
presents many interesting features.

Mrs. referred by Dr. Wm. Johnson. Age, fifty- three.

Looked like a woman of seventy. Was of the unintelligent class
and even the following incomplete short history was obtained
with diflRculty. Has had a number of attacks of fever with
violent pains in upper right side, but none so pronounced as the
present attack which has lasted about a month, hence her reason
for seeking aid. Mother of four children — married twenty-eight
years; has had the diseases of childhood, also typhoid at the age
of twenty-six, pneumonia at age of forty-two, and from the latter
disease claimed she had never fully recovered. Appearance like
that of a malignant cachexia. Slightly jaundiced, very thin, and
facial expression that of a chronic sufferer. Complained bitterly
of pain in gall-bladder region; constipated for years but now had
a septic diarrhea. Appetite very poor, in fact refused food for a
number of days as she claimed it passed through undigested.
Temperature ioi°, pulse 130. Some muscular rigidity but not
pronounced, and a small mass the size of an egg could be dis-
tinctly felt. Patient's condition would hardly allow an im-
mediate operation so she was removed to hospital, stimulated
for two days. There being little or no improvement it did not
seem wise to defer operation any longer.

Incision revealed a matted condition of the intestines, adhe-
sions numerous and all landmarks utterly destroyed. Upon
careful separation over gall-bladder region I came upon a
number of little pockets of pus and a black mass, which upon
gently liberating proved to be the gall-bladder. Upon traction its
walls gave way very readily and underneath was a large stone
now crumbled into many fragments, mixed with pus and bile.
The field was carefully mopped dry no more adhesions disturbed,
an extra large rubber drainage tube inserted and stitched into
that part of mass which I judged to be about the location for the
duct. No discharge appeared for twenty-four hours other than
a little bile-stained serum, which in another twenty-four hours be-
came mixed with pus; at the beginning of the fourth day bile
and pus was draining in large amounts through the tube. The
temperature and pulse became normal the fourth day. The
diarrhea ceased, appetite improved and the patient left hospital
in three weeks in fair condition except for a fistula which re-

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272 DICKINSON; retrodeviations of the uterus.

mained open. The jaundice gradually became lighter but never
entirely disappeared.

Two years afterward I heard the patient was up and around
doing household duties, but the fistulous tract remained open,
and at present time as far as I know her condition remains un-

19 West Seventh Street.




Jersey City, N. J.

An ancient Egyptian sage more than four thousand years
B. c. wrote:

"Would that I had words that are tmknown, utterances that are
strange, expressed in new language that has never occurred before,
void of repetitions: not the utterances of past speech, spoken by
the ancestors. I squeeze out of my body for that which is in it, in
the loosing of all that I say. For what has been said is repeated,
when what has been said has been said."

The sentiment expressed in the above quotation is an apology
for writing on that which has become commonplace, but
"principles require constant revision and consideration," and
perhaps the writer may be able to illuminate at least one point.

Retrodeviations of the uterus have been much studied and
much discussed by the profession and, although our information
as to the anatomy and physiology of the pelvic organs has been
thoroughly investigated and is well comprehended, nevertheless,
the true broad pathology of retrodeviations does not seem to
be entirely understood by the gynecologist of average mind.
The very fact that surgeons of eminence as yet disagree as to
the best method of giving relief from the distresses incident
to this condition, is full and complete evidence of some lack in
therapeutics. It has became almost an axiom that where many
drugs are recommended for the cure and relief of disease there
is no panacea. Perhaps the error has crept in, as is not un-
common with the modem physician, by his focusing attention
on an irregularity, forgetful of the known sympathy of tissues.

« Read at the Twenty-second Annual Meeting of the American Association
of Obstetricians and Gynecologists at Fort Wayne, September 21-23, 1909.

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We have three stages in diagnostics: clinical history, physical
examination, and laboratory determination. One or all of these
may be of service in every examination. The tendency of the
average mind is to do that which requires the least effort on its
part. When a woman presents herself to the physician complain-
ing of the uterine syndrome, examination is made, retroflexion
easily discovered, and further efforts in diagnosticating cease,
operation being ordered.

It is as important in retrodeviations as in, for instance, diseases
of the stomach, that all known anatomic and physiologic causes
for its existence and for associate symptoms should be considered.
The co-existence of several causative conditions should be taken
into account: the physiology of the uterus and its adnexa, and,
not the least important, the interdependence of complications
arising from or co-existing with the deviation, which affect
other important structures. Not until these have been consid-
ered and their importance in the production of discomfort
estimated in each individual case is it wise to proceed with thera-
peutic measures.

The uterus has a normal position, but not a normal direction.
It has become a matter of fiction to state a norm in our literature.
Such does not and cannot exist, but there is a normal relation to
surrounding parts. One must recollect that the position of
the uterus is one thing and its inclination another. Deviations
of the fundus have a different anatomic pathology from changes
in position of the uterus. The normal uterus is movable within
prescribed limits, and to functionate properly it should be mov-
able. It should have a proper possibility of excursion up and
down. The body of the uterus should be able to move with
changes in the size of the bladder and at times of impregnation.
Respiration and exercise also demand elasticity in its supports.

The uterus is held in position by no one structure, but by a
most delicate coordination in the action of several structures.
None of these are strongly fibrous and none are inelastic. Like
the other abdominal viscera, its most important support is its
meso, inappropriately termed the broad ligament. In addition
to the broad ligament, there are several bundles of muscular
tissue extending from the uterus and morphologically continuous
with it. A bundle of this tissue extends from the fundus of the
uterus to the inguinal rings which, by their tonus, aid in holding
the fundus toward the anterior abdominal wall, at the same
time being attached rather distal of the mesial line, keeping the

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274 DICKINSON: retrodeviations of the uterus.

fundus of the uterus free from lateral movement. In the base
of the broad ligament muscular tissues extend to the pubic bone.
These fibers are not abundant nor of great importance. Another
bundle runs posteriorly and laterally to the sacrum from the
cervix. This utero-sacral muscle, with its contiguous peritoneal
fold, is the first to feel the effect of any descensus of the uterus.
Such is its potential value that with many it is considered the
most important uterine ligament.

The cervical portion of the uterus anteriorly is firmly attached
to the bladder. The posterior wall of the vagina being longer
than the anterior, the uterus enters it at an angle, thus inhibit-
ing prolapse tendencies. We can now see that the position
of the uterus will depend upon all of these several factors. A
defect in any one will affect its position. In fact, it is rare for
the uterus to be pathologically displaced without defect in more
than one of these important structures. The integrity of
the perineum, also of the pelvic diaphragm, size of the vagina,
and condition of the parametrial cellular tissue regulate the posi-
tion of the uterus. The tonus of the uterosacral muscle,
condition of the broad ligament, and, in a minor degree, the
condition of the other ligaments will influence the direction of
the uterus. Antenatal conditions lead to defects in development,
which largely predispose not only to malposition, but to dis-
tressing complications.

Extraneous causes for this condition are not uncommon.
Particularly potent is the ballooned cecum, which with an accu-
mulation of heavy fecal material may pound the uterus in spite
of a proper condition of its supports. Likewise, a pendant
overloaded transverse colon.

The relative value of these supporting agents to the uterus
can be estimated by a forcible dragging down of the cervix
into the vagina. The first tissue to resist will be the uterosacral
muscle, and when that is divided, the next resistance will be
produced by the broad ligament. Division of this throws the
support upon the parametrium in the neighborhood of the uterine
artery, the round ligament even then not being on tension.

Posterior displacements of the uterus have no symptomatology
per se, and not until they become associated with some lesion
of surplus tension, some disturbance of circulation, or exhaustion
of the sympathetic is distress felt. It is here that we see the
determining factor of "the way one is constituted." A woman
well-developed, with good nerve tone, whose cardiovascular

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apparatus is without defect, whose nature it is not to think of
her ills, will find little distress from the deviation. Others fairly
as well put together will only become conscious of it when tired
and exhausted by work or worry, but a woman of poor nerve
tone and hysterical temperament, whose vasomotor apparatus
is not sturdy, whose sympathetic easily plays to reflexes, with
perhaps some antenatal defect, will complain considerably.

The uterine syndrome, bearing down, backache, pains in the
thighs, quick tire on locomotion and psychic disturbances, is in-
duced by any of the noninflammatory lesions of the pelvis.
Some say that retroflexions produce disturbances in the circu-
lation of the uterus and congestions, but the uterus is never seen to
change in color as deviations are induced or relieved. Certainly
the circle of Robinson is so perfect and anastomoses so complete
and numerous that it would be difficult to induce any marked
congestion by a retroflexion.

In the parametrium is a certain amount of erectile tissue,
engorgement of which, if continuous, may be sufficient to induce
more or less persistent distress. A slight descensus of the uterus
can produce contractions of the uterosacral muscle and give
pain. Dragging on the uterine meso is another source of distress.
Pressure of the fundus against the rectum or against the sympa-
thetic ganglia in the pelvis may also be productive of disturbances.

Dysmenorrhea, sterility, and dyspareunia are more prone to
be due to some antenatal defect. The constipation associated
with retroflexion cannot be considered in the relation of cause and
effect, for women are notoriously careless in this matter, failing
to maintain a proper reflex irritability of the defecation center
through want of habit. Backache is entirely a neurasthenic
pain, and he is a bold surgeon who will guarantee relief by opera-
tive measures.

It is thus seen that distresses associated with uterine mal-
position are not local. We have no local tenderness. We have
no local changes. The pathology is simply that of its contiguous
nervous system, and in thinking out a treatment it must be recol-
lected that the uterus is more than a muscular apparatus. It
contains in its substance microscopic ganglia resembling those
found in the heart and intestines. Through the parametrium
it is in a large degree connected with the ganglia of the sym-
pathetic system in the pelvis, from which ganglia nerves pass
to the urinary and intestinal tracts. The pelvic sympathetic
sjTstem is the "executive apparatus" of the pelvic organs.

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276 DICKINSON: retrodeviations of the uterus.

More nerves depart from it than are received, suggesting that it
is an " originating center." It is connected with the first, second,
third, and fourth sacral nerves, and through the branches of the
pneumogastric it may send reflexes even to the respiratory center.

The blood supply of the uterus and adnexa is controlled by
the vasomotor nerves originating from this sympathetic plexus.
The internal secretion of the ovaries has a special selective effect
upon the vasomotor system of the pelvic organs. Any antenatal
anatomic or physiologic defect in development will be shown
by irregular functioning of the nervous and muscular tissue.

According as a person is constituted so will there be reflex
disturbance from the conditions which may complicate retro-
flexion. Treatment demands that there be full recognition of
possible tension on the fibers of the broad ligament and its
contained nerves, of undue strain on the uterosacral muscle,
of disturbed vasomotor tone of the pelvic organs, and of the
numerous reflexes through the sympathetic — constipation,
nervous dyspepsia, asthma, hyperesthesia, destruction of blood
corpuscles, and stercoremia through retention of fecal matter.
This means that treatment shall not be entirely surgical. We
must treat the individual and not alone the womb; by improving
the nerve tone, particularly local nerve tone, by massage of the
lumbar region and the tonic effect of cold applications, control
of intestinal hemolysis by natural action of bowels, not through
laxatives, and increasing the hemoglobin. Cardiovascular
tonics are called for and have a decidedly beneficial action.

Operative interference is necessary in the majority of cases,
but not in all. The reason that all methods of operatio have
their failures is because they are all artificial. If any one liga-
ment or any one tissue were always at fault, then to treat it
would be reasonable and uniformly successful. If, after careful
examination, it be discovered that the position of the uterus is
abnormal, the perineum, pelvic floor, and vagina should be prop-
erly repaired. If the uterosacral muscles through prolonged
tension or disease have become atrophied, their shortening may
be indicated, although this operation is sometimes followed by
a tender cicatrix which will continue the symptom-complex
even though the position of the uterus be rectified.

Implantation of the bladder upon the anterior surface or
fimdus of the uterus will sustain the uterus in a more normal
direction. Shortening of the roimd ligaments for a too movable
uterus, not a descended one, has been advised by many surgeons

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reder: an operation for cystocele. 277

with the most happy results. According to the skill and bias of
the operator so will he select one or the other. By a posterior
colpotomy he may easily determine the presence of adhesions
and can separate the majority of them with safety. This will
allow of a shortening of the round ligaments at their weakest
part by an entrance into the inguinal canal through the fascia
of the external oblique.

The object of this paper is not to discuss the five-score methods
of surgical procedure. It is mainly to call attention to the
importance of treating the woman as well as the. uterus.

280 Montgomery Street.




St. Louis, Mo.

(With seven illtistrations.)

Some years ago, while a visitor at one of the gynecological
clinics in an eastern city, the surgeon remarked that the opera-
tion for cystocele has so often resulted in failure that it has been
abandoned by some operators and discouraged by others. I
failed to realize the gravity of his remark as I watched with great
admiration the operator's technical skill and looked upon the
completed work with a sense of satisfaction engendered by the
confidence that such work instills into an enthusiast.

When the occasion presented itself to approach the surgeon
with the question if he was satisfied with the operative measures
he had carried out for the cure of the cystocele, he remarked:
** Temporary relief is certain; as to the permanency of a cure there
remains an element of doubt." I was very much impressed
with this frank statement as I had expected a somewhat different
reply after such a splendid technic with a finished work that
reflected the greatest stability.

Ten years have since elapsed. My experience with the various
technics for the correction of a cystocele has been such that the
remarks of the eastern surgeon were brought back to me. It can
be said that recurrences in corrected cystoceles are quite frequent
and that no particular technic will promise a permanent cure.
I have operated on patients of my colleagues which they had

« Read at the Twenty-second Annual Meeting of the American Association of
Obstetricians and Gynecologists at Fort Wayne, September 21-23, ^9^'

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278 reder: an operation for cystocele.

pronounced cured, and I know that some of my "successful
cases " drifted into other hands and had to be looked after again.
It cannot be said of the failures that they were wholly due to
a faulty technic; instead I would rather say that an incomplete
technic was the cause. It can be readily appreciated how difl&-
cult it is to cure a cystocele when we consider the anatomy of
the vaginal tract, its relationship to the pelvic structures, and
the physiological causes to which the formation of a cystocele
can be attributed. I can assign my failures possibly to three

Fig. I. — Cystocele as usually met with.

factors, namely: (a) not properly attending to the urethrocele, a
hypertrophied tract of vaginal tissue immediately behind the
external urethral orifice, very prominent in all my cases when
recurrence has taken place. A urethrocele, no matter how small,
can be the starting-point of a cystocele and its principle can be
readily compared to the principle of any beginning hernia. Fur-
thermore, if such a protrusion of vaginal tissue is not properly
obliterated during a cystocele operation, it may, through its
wedge-like impact upon the repaired perineum, gradually weaken
this important structure and eventually cause a recurrence of

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reder: an operation for cystocele. 279

the former trouble, (b) Neglect to loosen the bladder sufficiently
from its anterior uterine attachment, (c) Failure to construct
a pelvic floor adequate to give the proper support to the anterior
vaginal wall.

An essential factor to a successful operation is the denudation
necessary on the anterior wall. No fixed rules can be laid down
as to the amount of tissue to be removed for the reduction of the
hernia, nor can any definite principle be adhered to whereby the

Fig. 2. — Separation of bladder trom vaginal wall.

limits of the denudation for the proper approximation of the
flaps, without encroaching on the proposed field of operation
upon the posterior wall, can be determined. The good judg-
ment of the operator and his experience will aid him in meeting
the requirements of the particular case. The steps of the opera-
tion are as follows: the patient is placed in the lithotomy posi-
tion at the edge of the table. With a tenaculum forceps the
anterior lip of the uterus is seized and drawn downward toward
the vulva. Another tenaculum forceps seizes the urethral

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280 reder: an operation for cystocele.

extremity of the cystocele about a quarter of an inch below
the external urethral orifice. Sufficient traction in opposite
directions is made upon the forceps to cause the tissues over the
cystocele to be put on a gentle stretch, thus facilitating the plac-
ing of the incision which is carried from the urethral to the cervi-
cal extremities.

The incision is made through the vaginal mucous membrane
to the depth of the bladder wall. The dissection of freeing the
bladder from the vaginal wall is a skillful procedure. Its satis-

Fio. 3. — Showing resected flaps of vaginal mucosa.

factory execution and the ease with which it may be accom-
plished rests wholly with the operator's fancy and expertness in
such work.

I have met with dissections that have proven quite difficult
on account of the thin vesicovaginal septum and the scarcity of
cellular tissue. Fortunately, there is usually a moderate degree
of hypertrophy of the vaginal mucosa, as well as a sufficient
amount of cellular tissue in a well-developed cystocele, that will
enable the dissection of the flaps to be accomplished more easily
and more rapidly. I have found that I could facilitate my work

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reder: an operation for cystocele. 281

by using a cuticle knife, such as is used by the manicure. The
knife has no point and the shape of the blade is such that it
can be made to cut in any direction with great convenience
(Fig. 7).

The beginning of the dissection is usually attended with some
little difficulty till the cellular space can be demonstrated satis-
factorily. After that much of the work can be carried on by

Fio. 4. — Operation complete. Showing application of interrupted sutures.

gauze dissection. As the dissection progresses, it remains
optional with the operator whether he continues the use of
forceps or his fingers to hold and manipulate the flap. Whenever
I can do so I prefer the use of the fingers covered with gauze.

In making the dissection it is advisable to hug the vaginal
wall closely, particularly at the base of the bladder and at the
location of the ureters. After the vesical wall has been suffi-
ciently exposed, the bladder is detached by blunt dissection

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282 reder: an operation for cystocele.

from the anterior surface of the uterus. The vesico-uterine fold
of peritoneum is not opened.

It is not an easy matter, where the laxity of the tissues is so

Fig. 5. — ^Showing area of denudation for construction of new perineum.

pronounced as is found in a well-developed cystocele, to determine

Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 28 of 109)