CLASSIFICATION OF GYNECOLOGICAL CASES AS

TO WHETHER MEDICAL OR SURGICAL.

HARRIS F. BROWNLEE, M.D.,

DANBURY.

After accepting the invitation of your committee to present a paper at this meeting, I took a long time trying to decide upon some subject which might prove of interest and perhaps be of a little help to you who do me the honor of listening to my remarks. While I see things of interest to me nearly every day, they are not always exceedingly rare or worderful, and the same class of cases probably occur in the daily work of every one of you, which would result in a failure to excite the amount of surprise and astonishment which I might anticipate; so instead of some anomaly, some special feat of surgery or some vague hypothesis, I am going to lead your thoughts to my office and back to your own and look over a class of cases which have often puzzled me and perhaps have done the same to you.

I am presuming that the great majority of the members of this Society are general practitioners, some of you may do surgical and gynecological work and all of you probably have occasion to send cases to other men for advice when your own work and words to the patient will come in for review to be either confirmed or corrected by the specialist.

I want to take a certain number of gynecological cases which come to my office, which we see in their homes, some old familiar subjects, hold them up to present day standards and while trying to remain in a conservative median line between too radical surgery and fatal delay avoid temporizing more than necessary.

I know a great many cases are operated upon which never should have been, and the results in those cases are disappointing as they are bound to be. Other cases should have been treated surgically and have often been prevented by too conservative advice.

Patients come to me who have received one kind of advice from one man and an opposite kind from another, and thus having little confidence and being altogether bewildered as to what they should or should not do. Now perhaps by going over a few of these old cases we can arrive at some normal line of conservative opinion whereby our advice to these patients can be more in accord and productive of good results.

It is not my intention to go into operative details or discuss the merits of this or that operation but simply try and classify those cases which demand operation and those which do not. The method of operation we will leave to the operator, after we have decided that it is an operative case.

PERINEUM.

We will first consider the perineum, it being the first to come to our notice, at the beginning of an examination. We encounter here four classes of old lacerations which have taken place at a previous confinement.

(1) Those which are wholly confined to the vaginal wall:

(2) Those which have torn through the perineal body and skin:

(3) Those which have torn both the vaginal wall and the perineal body.

(4) Those which are torn through the recto vaginal septum.

A certain number of the lacerations, excepting perhaps the last class which include the rectal wall, heal by granulation to such an extent that normal support has

been maintained and the resultant damage only a surface of rough scar tissue, while others have resulted in a relaxation of the whole vaginal outlet and regarding even the complete tears I have seen cases where the whole septum was torn through and still the pelvic support was maintained as well as fairly good control of the bowel.

I will at this point call attention to a fact not usually understood, though clearly demonstrated by Kelly and some other writers that the perineal body in itself has very little to do with maintaining pelvic support, but the tone and caliber of the vaginal outlet depends almost entirely upon the levator ani muscle which arises from the internal surface of the ramus of the pubic bones, extending downward and around the rectum meeting at the back with the muscle of the opposite side.

I have seen any number of prolapsed,uteri from relaxation of the outlet with good sound perineal bodies and on the other hand have seen a good firm pelvic floor with vaginal outlet of about normal caliber where the perineal body had been almost completely destroyed. It simply depends upon whether this muscle is affected or not. Now which of these old lacerations demand surgical treatment? In answer I would say that whenever the vaginal outlet is relaxed an operation is necessary to restore the normal caliber and support, and in complete tears when the bowel functions are interfered with, operation is necessary. As a rule most complete tears require operation. In saying that all cases of relaxed vaginal outlet should be restored I include a number of cases which have never been torn and perhaps have never borne children.

This relaxed condition is not to be determined by ap pearances or by the thickness of the perineal body but by placing two fingers in the vagina and pulling down into each sulcus thus testing its tone and resistance. You will often be surprised to find a normal appearing

outlet stretch out in this manner so as to easily admit three fingers or perhaps a whole hand and be equally surprised to see a scarred old perineum grip the fingers as firmly as if its integrity had never been attacked.

These latter cases do not require operation unless perhaps the scar tissue is sensitive and interfering with its normal functions. Therefore, excepting special cases which may present special features the question of operation depends largely upon the amount of relaxation.

LACERATIONS OF THE CERVIX.

Next we will consider lacerations of the cervix. I consider the treatment of the cervix as an important one as we so often find malignant disease originating at this point. Almost every woman who has borne children has some laceration. This may be hardly perceptible or extend deeply into the vaginal vault. These lacerations may divide the cervix in two, or only one side may be torn or we may find a stellated tear extending in many directions.

As a rule those cases which have healed smoothly and evenly and are not the seat of induration or any diseased appearance even though they may be deep tears do not require operation, although I have seen cases where small tears seemed the source of much irritation to the woman's nervous system and this irritation was benefitted by repairing the damage.

IMPROVEMENT.

Often this improvement is aided by the accompanying curettement, rest in bed and general hygienic surroundings during the period following operation and also by the general moral effect of having something done supposed to cure her, so we will admit that certain of these usually innocent tears require operation; this to be decided by the history of the case and the results of previous palliative treatment.

Those cases which are the seat of induration and in

filtration when the lips are pouting and the hypertrophied lining membrane of the canal everted and when the cervical glands are inflamed and occluded presenting a quantity of viscid secretion, should all be subjected to surgical measures of cure. Perhaps simple scarification and depleting applications will suffice, perhaps the tear will need to be closed and perhaps the cervix will require complete amputation.

One or all of these proceedings should be at once advised.

In these days we hear less of the ulcers of the cervix, though we do hear the term often among our patients.

These so called ulcers are either simple erosions about the external os due to acid discharges from the cervix or body of the uterus or the everted cervical lining due to chronic hypertrophic catarrh. These can be easily distinguished. The former can be relieved by appropriate treatment to correct the irritating discharges while the latter can only be cured by high amputation of the cervix. I have seen cases presenting an everted hypertrophied cervical lining for nearly an inch around the os which have been treated as an ulcer for months. Ten years treatment will not cure. Amputation is the only re

source.

DISPLACEMENTS.

The successful management of the various displacements of the uterine body requires some good sound judgment on the part of the physician. His opinion can sometimes be given at once after the first examination and in other cases a correct opinion can only be arrived at after observing a patient for some time and perhaps trying one or more ways of relief.

A normal uterus lies in an easy position of anteversion A displaced uterus may be anteflexed, retroverted or retroflexed.

Anteflexions are not as common as the retro-displace