When the tension exercised by a hypertrophied prolapsed vaginal fold causes increasing displacement, the ablation of the mass will occasionally suffice. I once cured a case by the extirpation of an oval protrusion of the posterior vaginal wall, which was 2.4 inches long and as thick as a finger.
It has been attempted to effect vaginal constriction for the cure of vagi nal and uterine prolapsus by operation, and by bloodless methods. For the latter purpose cauterization and the ligature have been employed.
Various cauterizing agents have been recommended; but no one of them, not even the red-hot iron, has turned out to be trustworthy. Meding used nitrate of silver; Philipps nitric acid; ' Dtgranger chloride of zinc;' Langier,' Evory Kennedy,' Dieffenbach,' ferrum candens. Longitudinal or ring-shaped cauterization cannot be applied thoroughly enough to form deep eschars, from the danger of injining peritoneum, bladder, or rectum. The resulting cicatricial contraction is therefore in sufficient, and the method has been abandoned in spite of Dieffenbacb's encouraging remarks.
The tying of the prolapsus tumor or the hypertrophied portion of the vaginal wall was recommended by Richter,' and first successfully done by Iledrich ° in a patient forty-four years old with an irreducible pro lapse, the size of a child's head. The masa of the prolapse weighed one pound, and v.-as removed in eighty-two hours without much bleeding or pain. Bellini ° has described a modification of this process under the name of kolpodesmorrhapia. It consists of a submucous application of the ligating threads. Naturally it has found few adherents. The same may be said of the method employed by Blasius,'° who gradually tightened a number of ligatures passed circularly through the vagina, so as t,o ob tain a ring-shaped, constricting scar. Most recently Carl v. Bmun " and C. von Rokitansky jr.," have again employed the elastic ligature. But Braun noticed that the time of treatment even for small hypertrophies was longer than that required by excikm, and that fever occurred once in twelve cases.
The combination of c,auterization with mechanical procedures, the pincement du vagin of Degranges with a toothed forceps armed with chloride of zinc,' and the extensive cauterization with lapis, with subse quent suture of the wounded surfaces recommended by Joubert,' are only of historical interest.
Mende ' was the first to theoretically recommend, and Fricke, ' inde pendently of him, the first to execute an operation for the retention of these prolapses. Since their time this method of treatment has constantly grown in popularity.
Fricke's episiorraphy consists of a freshening and union of a part of the labia majors and a strip of mucous membrane between these points at the posterior commissure, thus constricting the vulva. But the pressure of
the tumor was found to be too great for the weakened and thinned-out perineum, and the operation itself was not much more valuable than Dommes' plan of uniting the labia majora by means of a gold ring. Yet it has formed the groundwork for all subsequent improvements. Mal gaigne soon gave greater breadth to the median band which united the denuded labial surfaces; and Crede,' Kehler,' Baker Brown,' Mohler," and Linhart have worked in the same direction. But as Hegar rightly says, all these modific,ations are only to be looked upon as improved episiorrhapies having for their chief aim the constriction of the vulva.
On the other hand attempts were made to freshen and unite the vaginal walls themselves, so as to narrow the vagina and at the same time to form a high column which would leave no room for a prolapse above it and would oppose any further descent of the uterus and the upper part of the vagina. B. Gerardin'° seems to have been the first to do kolporraphy or elytrorraphy. Occasional excisions of the prolapsed tumor had been done before by Stalpart van der Wiel, Medren, and others; but only the hyper trophied mucous membrane was operated upon, and the operation was not methodically developed. The successful operations of Heming," and of Ireland ' first brought kolporraphy into general notice. The former freshened ;tip the anterior wall of the prolapsus tumor; and the latter cut out a strip 1+ inches wide from the entire length of the vagina, and united it with sutures. Dieffenbach excised from each side of the pro lapsed vagina oval flaps the size of a hen's egg, and united the wounded surfaces with sutures.' Later he advised the excision of elliptical and pointed areas 3 inches long by 2 inches wide; and when there was great laxity of the vagina a small segment of the anterior wall was to be remov ed also. He also recommended another method: the mucous membrane was to be denuded to the breadth of half an inch or more, and the strip to extend from the vaginal entrance to the colltun uteri. No sutures were to be used, but the vagina was to be tamponed. These operations are for large vaginal inversions complicated with uterine pro lapse. If the vagina alone is involved, D. recommends that the tumor be seized with a toothed forceps, a strong ligature applied in front of it, and then the tissues divided between the two. As many sutures as may be needed are applied to the surface of the wound. Though we would pre fer to excise longitudinal areas, Dieffenbach says we will more commonly have to excise transverse folds.