Results of Treatment of Injuries Occurring 
at Parturition. 
A PAPER 
READ BEFORE THE 
fit IX J. 
flame medical Issociattmt, 
PH*. 
JUNE 13, 1883, 
BY S. C. GORDON, M. D., 
OF PORTLAND. 
PORTLAND: 
STEPHEN BERRY, PRINTER. 
1883. Results of Treatment of Injuries Occurring 
at Parturition. 
A PAPER 
READ BEFORE THE 
0 
Jjithu jjjedical 
f&f 
(1/3 (. 
JUNE 13, 1883, 
BY S. C. GORDON, M. D., 
OF porTDCnd. 
PORTLAND: 
STEPHEN BERRY, PRINTER. 
1883. Results of Treatment of Injuries Occurring 
at Parturition. 
Since the publication of Marion Sims’ “ Uterine Surgery,” 
giving the results of his operations upon the various injuries caused 
by childbirth, the profession has been to a great degree familiar 
with what has been accomplished in repairing the lacerated per- 
ineum, in closing vesico-vaginal fistulae, and many other serious 
troubles that arose therefrom. Sims’ speculum and “ Sims’ posi- 
tion,” together with the general use of the silver wire suture, mark 
the beginning, in surgical diseases of women, of an era of the most 
brilliant character. The inventive genius of Emmet, the inde- 
fatigable zeal and industry of Thomas, the profound researches of 
that most eminent pathologist and skillful surgeon, Peaslee, 
together with a host of others, have given to gynecological surgery 
an impetus scarcely equalled in any department of our profession. 
Thomas, with his usual generosity, in his writings says: “If 
all that Sims has done for gynecology were suppressed, we should 
find that we had retrograded at least a quarter of a century.” 
So familiar, therefore, is every student of medicine with the results 
of most of the operations upon the female genital organs, that it would 
seem but a waste of time to add anything more, in a paper before this 
Association. Almost every practitioner who lays any claim to sur- 
gical skill thinks himself perfectly competent to perform the various 
operations of perineorraphy, elytrorraphy, and those for relief of 
vesico-vaginal and the other forms of fistula, lacerated cervix, etc., 
etc. The current literature of the profession is filled with reports 
of cases, and new methods of performing the operations, each man 
striving for some new “dodge.” A lacerated perineum or cervix 4 
seems a proper field for operation, whether there be any other de- 
mand for it than the mere fact that it exists. An operation is made, 
the case is numbered among the trophies of the gynecologist, and we 
hear no more. The patient may be relieved of the suffering, or she 
may be a patient or an impatient sufferer still. I believe the time 
has come to call a halt in this direction and sum up the results. Let 
us call in the reports from the army of operators, and find how the 
account of human suffering and relief stands. Let oui1 reports 
show, not how many cases we have operated upon, but how many 
we have operated upon for a specific purpose, and what percentage 
of cures we have effected; and, what is of as much or more con- 
sequence to the younger members of the profession, how many 
failures we have recorded, and, as far as we are able, what are the 
causes of those failures. Let us also inquire, as definitely as may 
be, what is the important purpose of many of these operations. 
Perhaps the most frequent and important of these variofts opera- 
tions is that of perineorraphy—certainly the most frequently made, 
and doubtless the most important, when made for certain purposes 
and properly performed. The accident of laceration of the peri- 
neum is the foundation of so many future troubles, immediate and 
remote, that we can well consider it the prime factor in a large 
majority of the results which the gynecologist is called upon to 
treat. First, it is the most important element in arrest of involu- 
tion of all the parts concerned in parturition, viz : vagina and 
uterus. Add to this a lacerated cervix, and you have sufficient 
cause for hyperplasia of uterus, a lax vagina; and as an almost 
necessary consequence, soon or late, there follows cystocele, recto- 
cele, prolapsus and retroversion of the uterus, urethral and cystic 
irritation, complicated, oftentimes, with vaginismus, hemorrhoids, 
fissure of the anus, to say nothing of passive congestion, with all 
its sequelae of vegetations of the uterus, metrorrahagia and leu- 
corrhcea. Years may elapse ere this entire train of symptoms ap- 
pear, and yet, in by far the larger proportion of cases, we can trace 
the sequel of symptoms from the parturition that caused the 
perineal laceration. A state of chronic invalidism marks the his- 
tory from that time until the patient comes to our hands. Often- 
times, too, we find that she has been treated in various ways, and 5 
by a variety of practitioners, for the several symptoms enumerated. 
The list of general and local remedies has been endured, but no 
permanent relief comes, for the cause and its effects still remain, 
and only a temporary relief is given, or, what is worse, she is made 
very much more an invalid in consequence of treatment. In many 
of these cases, we find a condition of pelvic exudate, or passive 
congestion, as a result of former inflammations or interference with 
the circulation, by displacements, so that any manipulations upon 
the uterine canal, or stimulating applications to any part thus 
affected, is almost sure to light up a fresh attack of pelvic inflam- 
mation, from which the patient recovers only after a long period of 
rest and careful management. In all this class of cases, “ meddle- 
some medication” is always bad, and the last state is far worse 
than the first. 
Given, then, a case with hyperplasia of a uterus, retroverted, 
mobile to the full extent, with lax vagina, and an almost necessary 
accompaniment of cystocele or rectocele, what shall be the modus 
operandi of cure ? First, I would treat the uterus as I would an 
enlarged tonsil, by removing a portion of it, and thereby establish 
the process of fatty degeneration and absorption. If there be 
present lacerated cervix, operate for closure of that; if no lacera- 
tion exists, remove a V from each side of the cervix, as high up 
as the vaginal junction. Do not hesitate to make this operation 
upon a liberal scale. Most cases of hyperplasia admit of consider- 
able tissue being removed. Be sure that it is neatly done, by a 
single stroke of the scissors for the half of either side. With the 
utmost care, close the wound by as few sutures as will thoroughly 
graft the surfaces and absolutely control hcemorrliage. At the 
same time, put the uterus in position and adjust a well-fitting 
retroversion pessary, and wait a week, directing copious warm or 
hot water injections at least twice a day, to ensure cleanliness and 
stimulate the absorbent process. If everything goes well, at the 
end of this time the operation for cystocele may be made. I much 
prefer the oval denudation to any other, removing all that can be 
spared, and admit complete closure of the mucous membrane, 
without strain upon the tissues. Be sure that no haemorrhage 
occurs behind the flaps, or the operation will be a failure. At this 6 
operation, the sutures must be removed from the cervix. Another 
week, with similar treatment, and the case is ready for the final 
operation of perineorraphy, which is to restore the perineal body, 
cure the rectocele, and bring the posterior vaginal wall in contact 
with the anterior one,, thus shortening this wall and giving sup- 
port to the uterus, bladder and all the parts displaced. Before 
doing this, the sutures are to be removed from the cystocele and 
the pessary withdrawn. And just here let me suggest that this 
removal of the pessary must be done with the utmost care, so that 
the uterus shall not be disturbed and displaced. I deem this in- 
dispensable, for in many cases I find that, if no immediate dis- 
placement takes place, a complete cure of the retroversion follows ; 
it never becomes displaced afterwards. The shortening of the 
vaginal wall and the shutting of the vagina completely imprisons 
the uterus, so that there is no room for the change of its axis. 
Should this occur in spite of these precautions, advantage must be 
taken of the first opportunity, after the wound of the perineal opera- 
tion has sufficiently healed to bear manipulation, to replace the 
organ, and support by the pessary, until the process of involution of 
the uterus and vagina, now so well started, shall be complete. I be- 
lieve the accomplishment of this (involution) is by far the most 
important result to be aimed at in perineorraphy. Unless we can 
cure the retroversion, we have failed to obtain the benefit from the 
operation that the patient expects. Her symptoms are not relieved, 
except when the pessary is worn, and she fails to find sufficient 
reward for all the suffering and anxiety attendant upon what seems 
to her, a formidable operation. The general complaint among 
practitioners is, that pessaries do not cure displacements, especially 
in women who have borne children. In a majority of cases this is 
true, and much of the contempt for them (pessaries) has justly 
arisen from failure in this respect. Only so long as the instrument 
is worn does the patient experience any relief, and many become 
discouraged by the inconveniences, to say nothing of the sufferings 
caused by repeated attempts to properly adjust them to each par- 
ticular case, and the disagreeable irritation which often results 
from their long-continued use. My experience in these various 
operations justifies me in the assertion that the only certain cure 7 
for these long standing cases of retroversion is in this manner, 
and that for this purpose, if no other, we should advise the opera- 
tions. 
We all know, when once the process of fatty degeneration is set 
up in any of the hyperplastic parts, how rapidly it goes on. A 
simple illustration has already been given in removal of a portion 
of the tonsil, and the uterus and vagina are no exceptions to the rule ; 
therefore, I make this operation upon each of them for that reason 
alone, even if there he no lacerated cervix or very much destruction 
of the perineal body. In cases when it becomes necessary to apply 
the pessary, after the operations fail to produce immediate cure of 
the displacement, the patient should be instructed to follow the hot 
douche, while this should be supplemented by frequent glycerine 
packs, with the view to complete the process of involution as rapidly 
as possible, while the pessary should be removed at least every two 
weeks, and allowed to remain out for two days. As soon as 
possible, a smaller one should be substituted for the first one 
used, so that no undue distension be exerted upon the vagina. 
Astringent medication of the glycerine packs assists materially in 
the curative process. 
These minor details may seem trivial and commonplace, but 
they are by no means non-essentials. In my own experience, they 
are the potent factors in procuring the result aimed at and to be 
desired, viz: permanent cure of retroversion. Without attention 
to these several details, we find ourselves where we commenced, 
the result unattained, and the patient hopelessly discouraged. On 
the other hand, a patient, persevering, careful and intelligent 
management of these cases will satisfy any one that a majority of 
them can be entirely and permanently relieved, so that no longer 
shall retroversion be the “ bete noire” of gynecology. 
I believe that there is much yet to be learned as to the proper 
time and manner of making these various operations. Emmet has 
very properly laid great stress upon having the patient suitably 
prepared for any of these operations upon the female genitalia. 
Ilis important point of caution is with reference to the condition of 
the pelvic viscera and connective tissue. While I am fully in ac- 
cord with the sentiments inculcated in this respect, I feel sure that 8 
oftentimes much time is lost in vain attempts to get rid of all 
pelvic tenderness and passive congestion. I am sure that, do what 
we may, so long as the neuralgic ■point attendant upon a lacerated 
cervix exists, we are losing time until we operate for its removal. 
Once thoroughly removed, the pelvic congestion passes away, and 
the sufferer is relieved. I have seen cases treated for months, and 
no change occur until the thorn is removed. While I would not 
advise any operative interference with any active inflammatory 
process existing, I am satisfied that too many cases have been al- 
lowed to continue to suffer through fear of pelvic cellulitis. If 
very much care is exercised in handling the uterus (not putting 
too much strain upoft it), experience teaches me that the free haem- 
orrhage, caused by the proper performance of trachelorraphy, is 
the best remedy for the passive congestion of the pelvic tissues. 
Much more harm may be, and often is, done by the so-called 
“preparatory treatment,” in the hands of unskillful practitioners. 
All cysts of the cervix should be carefully destroyed as rapidly 
as possible, while the hot douche should be freely and systemat- 
ically used in the meantime, together with such general treatment 
as may seem indicated, but the delay need not be for any long 
period, for the inflammatory process is a short one, if acute, and 
the effects of inflammation will remain so long as the uterus con- 
tinues neuralgic; therefore remove the cause, and the effect ceases. 
The bugbear of pelvic inflammation has had too much control with 
experienced practitioners, in my opinion. To younger men, “ make 
haste slowly” is a most judicious rule of practice. 
I formerly postponed all operative interference so long as there 
seemed to be any special pain, referable to the pelvis or pelvic or- 
gans, but recently, I find that in many cases this is unnecessary, 
and, in some, I should never have operated at all had I waited for 
the indication. The greatest care, however, should be taken to 
distinguish pain of a neuralgic form from that due to inflammation 
or congestion of an active character. The operation frequently re- 
lieves the former, while it may develop an acute attack in the lat- 
ter condition. One thing is of paramount importance, viz: that 
all fungous growths, and causes that have contributed to produce, 
and may tend to keep up afterwards, menorrhagia or metrorrhagia, 9 
should be most thoroughly removed before operating for lacerated 
cervix. Catarrh of the cervix should also be entirely relieved. 
The uterus should be allowed a period of rest from local manipula- 
tions for a long period after such an operation. Plain and med- 
icated glycerine packs and the hot douche may be continued, but 
all harsher means are mentioned only to be deprecated. 
In perineorraphy, there is one caution to be observed, the lack of 
which has caused many a patient to regret having had it performed. 
I allude to the use of too many sutures. In my own practice, I have 
found several cases where the vaginal passage was too small, and 
coitus necessarily painful. This is no unimportant matter, but 
one that we are bound to regard. If the last suture is carried up 
through the undenuded mucous membrane, thereby drawing the 
posterior wall down and covering the wound, and by so much 
shortening the vagina, we obtain a perineal body sufficiently strong 
and thick, without closing the vulva so high as to interfere with 
the proper sexual relation. After no one of these operations do 
I allow the catheter to be used, unless the patient is unable to 
evacute the bladder. The use is almost sure to produce more or 
less cystitis, which continues, in many instances, for months. 
Neither do I allow the bowels to become constipated, much less 
take measures to check them. They should be kept soluble, so 
that no fecal impaction shall occur. 
An additional word in regard to the operatiom for lacerated 
cervix. The operation is not made simply for the laceration. 
The fact alone that such a condition exists may not be sufficient to 
urge an operation, although, where any ectropion occurs, I believe 
all are justified in operating to prevent epithelioma. By far the 
most important point aimed at is to relieve the actual neuralgic 
pain through the pelvis and back, as well as to cure the nervous 
symptoms that follow from the long-continued irritation. Now, 
barely closing this laceration, so that the parts unite, is by no 
means a sure relief to these troubles ; unless it be done thoroughly 
and properly, the last state of that woman is far worse than the first. 
I stated, at the beginning of this paper, that we must have a 
definite object in view whenever we attempt any of these opera- 
tions. I have made this operation, and have seen it made many 10 
times more, when not only was the patient not relieved, hut 
actually made worse—all the symptoms were aggravated. Emmet 
has placed great stress upon the removal of the cicatricial tissue 
from the angle. Of equal importance, in my opinion, is the 
removal of all the cicatricial tissue the entire length of the lacera- 
tion. Merely eroding the surfaces, as is so often done, while it 
may permit the surfaces to adhere, only unites two neuralgic sur- 
faces, and the pain is increased. A clean, deep cut, symmetrical 
throughout, is an imperative necessity. A rough, uneven, ragged 
surface, is worse than letting the patient alone. 
I could cite cases illustrative of these various operations, but I 
deemed it best to present the matter to you in this way, believing 
that the general principles involved in the whole question would 
be of more interest. 
In conclusion, I can only say that in all the various operations 
for accidents occurring at childbirth, I have never had a fatal re- 
sult ; and whenever I have failed to accomplish all I desired, I 
could almost always trace it to a violation of some one of the prin- 
ciples or minor details herein described. 
DISCUSSION 
Dr. Bricketv asked how a case of pure retroversion was to be cured. 
Dr. Gordon said never by pessaries alone, but, when there is hyperplasia, 
by lateral section of the cervix. 
Dr. Gordon stated, in answer to a question, that when he made trache- 
lorrhaphy and perineorrhaphy at the same time, he used for the cervix 
sutures of catgut, and for the perineum, wire; when only one operation is 
made, always uses wire; when catgut is used for the cervix, his practice is 
to make an extra knot. 
He guarded against impaction by keeping the bowels loose throughout. 
He would not provoke cystic irritation by invariable use of the catheter, 
but would use it if necessary. Preferred a celluloid catheter for use in these 
cases to any other. 
Dr. Wedgwood asked what advantage the oval method of operation for 
cystocele had over the triangular method. 11 
Dr. Weeks said that he frequently met with cases in women nulliparous, 
married and unmarried, which go to demonstrate that the uterus never im- 
pregnated does become hypertrophied, notwithstanding Emmet’s denial. 
He would favor Emmet’s modification of Simons’ operation, not only to 
close the wound, but to increase interstitial absorption as well. 
Dr. Gordon believed that the time had arrived to collect statistics of the 
results of labor upon these cases after operation. He replied to Dr. Wedg- 
wood that he favored the oval-shaped incision, because he believed the 
presence of the triangular flap left by the Y-shaped incision to be the cause 
of failure in many cases, and the triangular incision was unsymmetrical, and 
the edges would not come together so smoothly. 
Dr. IIorr asked if, in very severe and obstinate cases, we could count on 
complete success. 
Dr. Gordon believed we could with certainty.