tongue is removed upward along the dorsum of the vagina. The small triangular area thus made in the vaginal mucous membrane is first approximated by sutures, after which the remaining bat wings are brought together and sutured by their approximated mucous margins. The rectal mucous surfaces are then sutured together by means of interrupted sutures, the free ends of which are left in the rectum. A third row of sutures is finally applied to the cutaneous surface. The operations of Freund, Hildebrand, Heppner, A. Martin, and Le Fort, all contemplate denudation by cutting away the tissue, and closure by the use of interrupted, nonabsorbable, sutures. It is not apparent that any of them are more philosophical in conception, more easily done, or followed by better results, than is the flap-splitting operation of Tait. In conclusion, the practitioner may accept as a safe working method, the operation of Lawson Tait for complete laceration of the perineum, just as he may accept, as already ad- [fUilOr'f !\':; vised, the operation of Emmet for incomplete laceration.

The repair of deep injuries of the pelvic floor has engaged the serious consideration of various operators. One of the principles most emphatically enunciated by Emmet was the necessity of reapproximating the separated median fibres of the levator-ani muscle. It would seem, however, that in the case of extensive injuries to this muscle the technique of the Emmet operation will not reach or control it, and the same may be said of those operations to which are attached the names of Freund and A. Martin. Goldspohn was the first to devise and carry into execution an

operation calculated to restore the integrity of the deep muscles of the pelvic floor (Medicine, July, 1897). In connection with this operation he laid it down as an axiom that " direct union of the two lateral halves of the muscle and edges of the pelvic fascia beneath the vagina and anterior to the rectum, should be the minimum requirement, no matter where the rupture showed itself superficially in the vagina." His operation consists of an adaptation of the advanced views of Schatz and the flap-splitting principle of Tait. It is done by dissecting up the lateral walls of the vagina, exposing the injured muscles, and restoring them, and the associated fasciae, by buried animal sutures.

[graphic]

Fio. 109.—" The operation is concluded by means of an intcrcutaueous suture which may be fortified . . . with a buried serpentine suture."—Reed (page 270).

Harris's Operation.—Harris has perfected the technique of this operation which he describes (Journal of the American Medical

Association) as follows: "When laceration of the perineum is present the denudation of this part is made in the usual manner. If this body be intact, the denudation is omitted. An incision is then carried up each lateral wall of the vagina from 3 to 5 centimetres. The edge of the muscle can now usually be felt and an incision parallel therewith is made through the perivaginal connective tissue, exposing the muscle (Fig. 110), which may easily be dissected out with the handle of a scalpel, blunt dissector, or the finger, ventrally as far as the symphysis, and dorsally until it curves round posterior to the rectum. Should the muscle

have been so ruptured and its ends so retracted that its edge can not be distinctly felt, the incision is made along the line which the muscle should occupy, and careful dissection is made for separated ends. The ends of the muscle will be found connected by cicatricial tissue. I have yet failed to find the remains of the muscle even when badly torn and the ends widely separated.

[graphic]

110.—"The edge of the muscle can now usually be felt and an incision parallel therewith is made."—Rekd.

"The muscle may vary considerably in thickness, and, when very thin and ribbonlike, it may be torn by a careless dissection. When multiple small lacerations are present, the muscle will not be entirely separated at any point, but will be lengthened, loose, and relaxed. In width or distance laterally, the muscle may be dissected from 3 to 5 centimetres. When it has been well freed, forceps should be placed on either side of the portion to be resected, so that the ends when cut shall not retract out of reach. The portion resected should correspond to the point of laceration if found, or when no distinct separation is found, to about the centre of the muscle. The extent of the piece resected will depend upon the amount of separation or the degree of lengthening and relaxation. It should be sufficient so that when the ends are drawn together the floor of the pelvis will be restored to its normal position and degree of tension. The ends of the muscle are then sutured together with an interrupted or continuous catgut stitch, which, of course, remains buried. The opposite side is treated in a similar manner when the incision of the lateral walls of the vagina is closed by a catgut suture. This latter suturing should be thoroughly done so that no openings will remain through which fluids or infection may reach the deeper parts. When the perineum has been torn this is closed in the usual way."

Hemorrhage in the course of this operation is sometimes free, never excessive and always controllable. It is, however, of extreme importance that all bleeding points be secured before the operation wound is closed, as a hematoma will prevent union by first intention, and, by a favouring infection, may defeat the objects of the operation.

The operation in the hands of Harris has proved entirely satisfactory. By its means he restores the normal floor of the pelvis in regard to both tone and integrity, carries the vaginal opening ventrad to its normal position, and restores its perineal flexure, while the muscles regain and retain their contractility and resume their elevating and sphincteric action at the vaginal orifice.

CHAPTER XXIII

MALFORMATIONS OF THE UTERUS

Classification: Embryonic, foetal, postnatal—Absence—Uterus unicornis—Foetal, infantile or pubescent—Uterus septus—Uterus bicornis— Uterus duplex—Minor malformations: atresia—Treatment; stomatoplasty.

The malformations of the uterus are very numerous and they are among the best known of all the structural anomalies to which the organs of the body are liable. Further, their mode of origin is in most instances fairly well understood, a fact largely explicable by our considerable knowledge of the embryology of the utero-vaginal canal. They have also a marked and practical bearing upon the phenomena of the reproductive life of the woman, gynecological no less than obstetrical.

Classification.—The most recent and most approved classification of the malformations of the uterus is founded directly upon the development of the organ (F. von Winckel, Eintheilung der Bihlungshemmungen der weiblichen Sexualorgane, 1899). Uterine development may be divided into two periods, an antenatal and a postnatal; the former may again be subdivided into an embryonic and a fwtal period. The embryonic development of the organ takes place, roughly speaking, in the first three months of intrauterine life: it passes through three stages, in the first of which there exist the two Miillerian ducts as solid cords in the neighbourhood of the Wolffian ducts (first month); in the second, the ducts obtain their lumen and unite externally into one utero-vaginal tube (second month); and in the third, the ducts fuse internally into one hollow tube, the utero-vaginal canal, their upper parts, however, remaining distinct as the Fallopian tubes (third and fourth months). The foetal development of the uterus occurs during the remaining five or six months of intrauterine life, ami chiefly consists in the formation of the fundus of the organ, the transition from the uterus planifundalis into the uterus foras arcuatus, or foatal uterus. Postnatal development takes place in two stages: in the first, corresponding to the first ten years of extra-uterine life, through the greater growth of the body as compared with that of the cervix, the uterus fcetalis becomes the uterus infantilis; and in the second, which may be said to extend from the tenth to the sixteenth year, the infantile uterus takes on the characters of the adult but virgin organ. Now, the majority of uterine malformations are simply stages of development normally temporary but which have become permanent, and they may be divided into groups corresponding to the developmental stages which have been enumerated. These groups may be put in the form of a table.

PeriodB of life.

Groups.

I. (a) Absence of uterus, complete, together with absence of
tubes and vagina (very rare).
(b) One-horned uterus, with no trace of the other horn
(uterus unicornis sine ullo rudimento cornu alterius).
II. (a) Externally double uterus (uterus duplex sine didelphys;
uterus bicornis).
(b) Solid or partly excavated uterus (uterus solidus, uterus

rudimentarius, uterus partim excavatus).
(e) Combination of (a) and (b) (uterus duplex solidus, uterus

bicornis rudimentarius), (d) One-horned uterus, with other horn solid or partly excavated (uterus unicornis cum rudimento eornu alterius). III. Uterus divided internally more or less completely, without or with external signs of duplicity (uterus septus, subseptus, uterus bicornis septus). (" IV. Uterus with flat fundus, with or without complete or partial internal duplicity (uterus planifundalis septus, subseptus, simplex). V. Uterus with foetal characters (small body, large cervix). VI. Uterus with infantile characters (uterus infantilis).

There are some malformations which do not find a place in this scheme of classification. One of them, the trifid uterus or uterus accessorius, is specially difficult of embryonic explanation. To account for it we have to suppose the existence of a double Miillerian duct on one side; possibly it arises in the prc-embryonic or germinal period. Congenital prolapsus uteri also, which may be grouped with the malformations, does not represent a stage in the development of the organ so far as is known; since, however, it has always been found associated with spina bifida, it may be really rather a concomitant anomaly of spinal arrested development than an arrest in the evolution of the uterus. As to the cause of these arrests in uterine development there is still much darkness: inflammatory processes, e. g., foetal peritonitis; defective formation of the abdominal walls, e. g., umbilical hernia; the presence of tumour germs preventing union of the Miillerian ducts, and traction upon these ducts exercised by neighbouring structures, have all been adduced as possible teratogenic factors; but they are all insufficient to explain the anomalies which have arisen in the embryonic period of intrauterine life. It will probably be found that uterine malformations, like malformations and monstrosities of other parts of the body, are due to the action of germs, toxines, and poisons, upon the tissues in the course of evolution (Pathology of the

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