New Form of Posterior Colporrhaphy. 
BY J. H. KELLOGG, M. D., 
of Battle Creek. Mich. 
The necessity for some relief from the distressing incon- 
veniences attending complete procidentia and extreme cases 
of prolapse of the vaginal walls, has led to the origination 
of a great variety of operations for the purpose of diminish- 
ing the size of the vagina, a procedure commonly known as 
colporrhaphy. As each new method has been brought for- 
ward by its originator, it has been advocated as obviating 
the defects of methods previously employed. But, one by 
one, the various methods thus far introduced have proved 
wanting. The difficulty experienced with all methods alike 
has been that, however much the vaginal canal might be 
narrowed by the operation, the wedge-shaped uterus, stead- 
ily acting in a downward direction, has in time succeeded 
in reproducing the original condition. The one exception 
to this history of failure has been the median colporrhaphy 
of Lefort. But this procedure, admirable as it is in the cases 
to which it is adapted, is evidently justifiable only in the 
cases of women who have passed the menopause, since the 
strong median raphe produced by the operation necessarily 
presents an insurmountable barrier to parturition. There are 
also cases in which this operation might be considered ob- 
jectionable upon other grounds. After making thorough 
trial of the various approved forms of colporrhaphy for the 
relief of subinvolution, cystocele, and procidentia, some five 
or six years ago I adopted a method of operation which, so 
far as I know, is novel, and which it is the purpose of this 
paper to describe. 
This operation is especially adapted to the posterior wall 
of the vagina. The operation consists in the removal of a 
longitudinal strip of mucous membrane from the posterior 2 
New Form of Posterior Colporrhaphy. 
vaginal walls, the form of which is indicated m the accom- 
panying cuts. The peculiarity of this part of the operation 
consists in the bifurcation of the denuded surface at its in- 
ner extremity, the cornua being made to converge and ex- 
tend upwards on either side of the cervix so as to include 
about two-thirds of the circumference of the vaginal canal. 
The purpose of this form of denudation is to create, by 
uniting the edges of the wound, a pouch to receive the cer- 
vix uteri, the advantages of which will be presently ex- 
plained. The surfaces of the wound are united in such a 
manner as to produce, not simply a superficial line of union, 
but in addition to this, an artificial thickening of the pos- 
terior vaginal wall subjacent to the superficial line of union, 
for the purpose of strengthening the relaxed and weakened 
structures. The following is a brief description of the op- 
peration:— 
The operation consists of four steps — 
(i) Mapping out the area to be denuded.—The patient 
being placed upon her back in the lithotomy position, the 
vaginal orifice is enlarged by 
means of retractors so as to 
bring the cervix uteri into view, 
and enable the operator to de- 
termine the amount of narrow- 
ing required. I mark out the 
area to be denuded by mean* 
of traction sutures ten or twelve 
inches in length, which arc in- 
troduced thus: Seizing th< 
mucous membrane in the me- 
ridian line about one inch in 
front of the cervix A (this 
suture is not shown in the cut), 
a needle armed with a piece of suture silk about two leet 
in length is passed through the fold of membrane held by 
the forceps, and the two ends tied. The hold of these 
seizing forceps being now released, the mucous membrane is 
seized at another point to the right or left, one-third of thc 
Fig. i. /. H. Kellogg, M. D. 
3 
circumference of the vagina. A traction suture is introduced 
as before, and another upon the opposite side in like manner, 
B and C, Fig. i. Other traction sutures are introduced at 
points marked D, E, F, G, H, and I. Finally the external 
points J and K are fixed, and indicated by a slight incision, 
or a snip with the point of the scissors. 
(2) Denudation.—Starting at K, remove a strip of mucous 
membrane along line of union between the skin and the 
mucous membrane reaching to J. A similar strip is removed 
along the line K I, and another along the line J F. The 
space included between the points K I and J F may now 
be rapidly denuded by dissecting off narrow strips from 
right to left. Now drawing down the traction sutures attached 
to the points I and H, a fold of membrane is raised up 
along the crest of which a strip of membrane may be dis- 
sected up, reaching from I to FI. In a similar manner dis- 
sect up a strip on the opposite side. Now denude the sur- 
face up to the points E H in the same manner as before. 
Then make taut the traction sutures H and 
G so as to raise a fold, and proceed as be- 
fore. In like manner the sutures G C, 
D B, A C, and A B are successively drawn 
down, and the spaces inclosed between 
the points GCA and DBA are denuded. 
Haemorrhage during the process of denud- 
ation is usually controlled by a stream of 
hot water sterilized by corrosive sublimate 
in proportion of one to four thousand, 
which is kept constantly flowing. Any 
troublesome bleeding points are secured by 
means of small snap forceps, which are al- 
lowed to remain in position until the edges 
are brought together in closing the wound. Ligatures are 
seldom required. 
(3) Introducing- the sutures.—We are now ready for the 
introduction of the sutures, Fig. 2, one of the most impor- 
tant parts of the operation. Two lines of sutures are intro- 
duced in the vaginal portion of the wound : (rt) a continuous 
Fig. 2. 4 
New Form of Posterior Colporrhaphy. 
deep suture ; (b) a continuous superficial suture. Beginning 
at the apex of one of the cornure, a medium-sized catgut 
suture about fifteen inches in length is secured, and the sides of 
the denuded surface are carefully brought together by a buried 
suture from B to A. The needle s-hould be slightly curved, 
being made to dip as deeply as possible without involving 
danger of wounding important structures. By this means 
the line B D is made to approximate closely to the line 
B A. By means of another suture, which should be about 
eighteen inches in length, the edges of the mucous mem- 
brane defined by the lines B D and B A are now united by 
superficial sutures. When the closure of the edges of the 
triangle is complete, the suture should not be cut off, but 
should be saved to complete the closure of the superficial 
portion of the remainder of the vaginal wound. The cornua 
A G C is now treated in like manner, only that the deep 
suture is left long to serve as a deep suture for uniting the 
sides of the vaginal wound. The cornua being closed, the 
portion of the wound having parallel sides is next closed in 
like manner. I find it advantageous to carry the two lines 
of sutures down together, making the deep suture superficial 
at intervals of an inch, so as to closely unite the mucous 
membrane with the underlying tissues. The perineal portion 
of the wound is closed in the usual manner, only I do not 
use silver wire. If the sphincter has been torn, I employ a 
form of suture pin having an eye near the point, (Fig. 3) 
which J. described in a paper published in the proceedings 
of the American Medical Association for 1887. I have con- 
Fio. 3. 
tinued the use of these pins, and consider them a great ad- 
vantage over wire or any other form of suture for perineal 
operations, at least in most cases. 
(4) The dressing.—This is the final step in the operation, 
which I endeavor to make as antiseptic as possible. The 
vagina should be thoroughly cleansed from any remnants of J. II. Kellogg, M. D. 
5 
clots. Pure iodoform is applied by means of a powder-blower, 
afterwards a quantity of antiseptic powder, consisting of 
equal parts of subnitrate of bismuth, iodoform, and tannin, is 
thrown in. A quantity of iodoform wool or charpie is placed 
against the perineum. Pads of sublimated cheese-cloth are 
applied, and secured by proper bandage, and the patient is 
put to bed. The urine must be passed through a catheter. 
I have performed this operation, or some modification of 
it, twelve times in all, and have always secured immediate 
union, and, with only two exceptions, without rise of tem- 
perature of more than one degree. In each of these cases 
the temperature reached ioi° the second day after the op- 
eration, but came down to normal the next day, and re- 
mained thus. 
What I suppose to be the novel and original features of 
this operation are : (i) the bifurcated form of the denuded 
surface at its inner end ; and (2) the use of the buried sut- 
ure for approximating the deep surfaces of the wound. The 
buried suture I have employed only during the last year, 
but the bifurcate form of denudation I adopted several years 
ago. 
As to the results of this operation, I find that it ac- 
complishes what it is designed to do. The cervix being 
caught in the pouch formed between the cornua, is held 
high up, so that the fundus is tilted forward. By this means 
the two chief causes to which failure in other forms of col- 
porrhaphy is due are eliminated ; namely, the wedge action 
of the uterus in dilating the vaginal canal, and the forcing 
outward of the vaginal wall from the weight of the pelvic 
organs, the last-named difficulty being obviated by the for- 
ward position of the uterus. I find, also, that the disposition 
to prolapse of the vaginal walls is greatly lessened by the 
peculiar result obtained through the use of the buried suture. 
As will be readily seen, the approximation of the sides of 
the wound by the buried suture has the effect to produce a 
thick fold of tissue in the recto-vaginal septum. This 
fold projects into the rectal space, and forms a thick and 
strong pillar of tissue, forked at its upper extremity. In this 6 
New Form of Posterior Colporrhafhy. 
fork the cervix uteri rests, and is held backward, thus tilt- 
ing the fundus forward. I can hardly see what more could 
be desired in an operation of this sort. 
The value of this operation in cases requiring it can 
hardly be overestimated. In the cases in which it is the 
most essential, the condition of the vagina is usually such 
that pessaries, with the exception of those having an exter- 
nal support, are of no avail, unless, indeed, we except the 
inflated ball-pessary, which gives only temporary relief at 
the expense of ultimately creating a condition still more de- 
plorable. Indeed, the patients upon whom I have performed 
this operation have, almost without exception, been those 
who had abandoned pessaries of every description after hav- 
ing tried everything in this line that their medical advisers 
could suggest, and their uniform testimony is that their 
condition was in the end aggravated by pessaries, instead 
of being helped. 
I do not wish to be understood as claiming that every 
case of procidentia, rectocele, or subinvolution of the vagina, 
can be radically and permanently cured by this operation 
alone, but I consider this operation as a fundamental pro- 
cedure for the proper treatment of these cases. Cases of 
retroversion and procidentia require Alexander’s operation. 
Cases of extreme anteversion connected with protrusion of 
the vaginal walls, may be relieved by the same means. In 
the treatment of sixty cases of Alexander’s operation, I 
frequently found this procedure of exceedingly great service 
as supplementary to the operation for shortening the round 
ligaments, and consider it a necessary procedure to insure 
success in this operation in cases where there is great laxity 
of the vaginal walls.