For prolapse of the anterior wall a method of treatment by an operation which was devised by me several years ago is suggested (Annals of Gyn. and Ped., vol. iii, p. 516, '90). It is assumed that the prolapse of the vaginal wall is extensive, an elliptical strip of mucous membrane is removed from the long axis of the vagina, the vaginal wall being depressed with a sound (as in Hegar's operation on the posterior vaginal wall) to determine the extent to which the re dundant tissue is to be removed. Then another ellipse, sufficiently large, is re moved at right angles to the first, the plane of each ellipse cutting that of the other at its middle. With suitable pre cautions against hTmorrhage, the edges of each quadrant (or half-ellipse) in the denuded area are then united from end to centre with aseptic catgut. the ends being carefully tied to close with neat ness the central portion of the wound, which may show a tendency to gape. Iodine collodion is then applied to the wound and iodoform-gauze dressing in the vagina. After rest in bed for ten days and perfect cleanliness, it will usually be found that the wounds have healed by first intention.
Complete removal of the vagina and uterus for those extreme cases of pro lapse of the uterus and vagina which resist all other treatment, including colporrhaphy. The stages of the opera tion are as follow: I. A circular incision is carried through the vagina at the for mer site of the hymen, about centi metre behind the orifice of the urethra in front. 2. A vertical incision is made in the posterior vaginal wall up to the fold of peritoneum forming Douglas's pouch. After ascertaining the position of the rectum, six sutures are passed through the skin-margin of the circular incision, on the one hand, and through the peritoneum of Douglas's pouch, on the other, whereby the peritoneum is firmly joined to the external skin. 3. Anterior colpotomy is then performed, the bladder and urethra are separated from the vagina, and the plica peritonei anterior opened and sutured to the ante rior part of the incision, whereby the bladder is raised and pushed forward. 4. The lateral wall of the vagina is then raised from the underlying tissue as far as the cervix, the broad ligament is ligatured, and here also the peritoneum is sutured to the lateral part of the cir cular incision. After doing this on both sides, there is a funnel-shaped cavity where the uterus and vagina formerly were, which is completely covered in by peritoneum, and by the tension of the remains of the ligaments the margins of the vulva are drawn tightly inward and upward. The external opening of this
peritoneal funnel at the vulva is then closed by sutures, which draw the edges of the circular incision together, and the peritoneal surfaces in contact at the sides. This operation has been person ally performed in ten cases, and always with most satisfactory results. A neces sary condition for success is that the vagina be excised completely, right up to the hymen. A. Martin (Berl. kiln. \Voch., Oct. 3, 10, '9S).
Vaginismus.
This term was used by Sims, Thomas, and others to denote an excessive degree of hypetwsthesia, together with spasm of the muscles which form its outer wall and which render any contact with the vagina annoying or even positively pain ful. Hypercesthesia of the vulva or of the vagina is a better term, as this is the significant condition. The trouble may often be referred to the sensitive remains of the hymen, which may not bear the slightest pressure or even suggestion of pressure without exciting painful emo tion and spasm.
Treatment.—The induction of general anesthesia, dilatation of the introitus vagina; and excision of the ring of tissue which is the remnant of the hymen will usually cure the trouble. The hmmor rhage attending such an operation may be profuse, and it is always desirable to tie all bleeding vessels and preclude sub sequent hemorrhage by the pressure of a tampon filling the entrance of the vagina.
Fistulm and Tumors.
Fistulm communicating with the va gina may also communicate with the bladder, uterus, ureter, intestine, rectum, or pelvic connective tissue. They are most frequently the result of a prolonged and difficult labor, but they may also re sult from sepsis following surgical opera tions and from inflammatory disease of the pelvis in general. Eretero-vaginal and uretero-utero-vaginal fistulte arc rare; so also is uretero-vaginal fistula, the latter following rupture of the uterus. Entero-vaginal fistula may fol low hysterectomy, removal of the ap pendix, or any complicated operation within the pelvis in which the intestine, including the rectum, has been injured. This form of injury has become more frequent since the removal of diseased ructnres by way of the vagina became an approved method of procedure.
A vaginal fistula means the passage of urine, feces, or pus into the vagina by way of a canal connecting with the blad der, intestine, or an abscess within the pelvis. It is a very distressing condi tion, and the problem involved is to ob literate this canal. Such a problem is usually difficult and is subject to fre quent failures.