The operation consists of the excision of an oval piece of the anterior vaginal wall, and is known as colporrhaphia anterior. The origin of the operation and its slow perfecting may be read in Marion Sims's clinic, p. 228. Sims claims that until his time nothing had been done in an opera tive way for cystocele, and that its success is due to the use of the silver suture; a view which is not correct. The length and breadth of the ex cised piece depends upon the grade of the inversion and the cystocele. The more extensive this is, the longer and broader must the piece be, ex tending in the worst cases from the tuberculam vaginEe to the anterior lip of the uterus, and measuring 2i to 3 inches across.
The woman is prepared by injections and by emptying the bladder, is placed in the dorsal position, and is anmsthetised. The anterior lip of the uterus is then strongly drawn downwards with hook or a thread, so that it approaches the posterior commissure. The assistants hold the legs, draw the nymphze apart with sharp hooks, so as to expose the entire field of operation. The anterior vaginal wall is then thoroughly washed with a 3 to 5 per cent. carbolic acid solution, and an irrigator trickles some of the same fluid over the wound during the entire operation.
The incision is begun below. The outlines of the piece to be excised, are lightly marked with the scalpel, then the deep incision is made, be ginning at the left and going through the entire thickness of the vaginal wall. As soon as the loose connective tissue between vagina and bladder is reached, the handle of the scalpel only must be used to separate them. In the middle of the piece to be excised, are one or two larger vaginal arteries, arising from the uterine, as well as some veins. The arteries must be seized with the catch-forceps. The excision of the entire oval piece takes 5 to 6 minutes. The surface of the wound is then smooth; any islets of vaginal tissue that have been left are removed, the surface then freely washed again with the carbolic solution, and then the stitches ap plied. Tho points of entrance and exit should be inch from the edges of the wound. If the surface freshened is very large, the sutures, if passed behind the entire surface, would cause it to lay in folds; they should therefore be brought out at the middle of the wound, and the needle reintroduced half an inch further on and brought out at the op posite side. In smaller excisions all the threads may go behind the entire denuded surface.
Ligature of the divided arteries is unnecessary. The sutures pass be• hind them, and they are enclosed in the threads when they are tied. To overcome the greatest tension gradually, the sutures must be tied alter nately above and below towards the middle. I hardly ever apply super
ficial sutures, while K. Schroder, on the contrary, uses a few deep sutures and many superficial ones; a procedure which Werth has rightfully char acterized as improper. As soon as all the sutures are closed, the neigh borhood of the wound is carefully washed, and the whole wiped dry. When not a drop of blood longer exudes, the vagina can be replaced. It is not necessary to use protective or a cotton tampon.
As a rule it is unnecessary to use the so-called sunken sutures which Dr. Werth (Kiel),' has proposed; and they may hinder union. I prefer fil de lelorence for the sutures. The whole time of operation is 20 to 25 minutes.
If the patient after the operation can pass her water voluntarily, as is most commonly the case, there is no need of catheterization. Ischuria, however, does occur, since the stitches are carried through the bladder vrall. If vesical pain or catarrh follows the use of the catheter, the blad der must be washed out with a 1 to 1000 solution of salycilic acid, or a 3 per cent. solution of boracic acid.
The stitches must remain in at least eight days; iffi/ de Florence is used they may remain in for weeks. Silk sutures must be removed in six to seven days.
Defecation must be seen to after the fourth day, and on the twelfth to fourteenth the patient can get up. By this time the cicatrix is stout enough to withstand considerable pressure. If the patient belongs to the poorer classes she must for a time avoid heavy work.
In very marked cases of inversion with cystocele, which usually occur in combination with descensus and prolapsus uteri, colporrhaphia anterior alone is insufficient, and must be combined with the similar posterior opemtion.
It may be necessary to remark that on account of their uncertainty and the liability to cause trouble in neighboring organs, we have entirely abandoned the use of strong caustics, as fuming sulphuric acid, chloride of zinc, or the actual cautery, for the purpose of diminishing the amount of tissue present Supplement.—In Fig. 25 I have reproduced a drawing from Schatz, which may be described as showing retrofiexio vesicce urinarim The pos terior vesical displacement is caused by the fall of the womb. I have lately seen the same thing at the post-mortem examination of a non-preg nant woman. The uterus lay horizontally in the true pelvis, and its fundus was adherent to the rectum. 'The portion of the bladder that was drawn backwards formed a diverticulum which contained a calculus, and the vesical neck was securely fastened to the rectum by adhesions which ran over the uterus.