MALIGNANT.-1. Carcinomata. 2. Sar comata.
Herniae.
Diagnosis.—Hernia of the rectum, or rectocele, is determined by the finger or sound in the rectum, which readily de tects the pouch in the vagina formed by the prolapsed organ. Hernia of the bladder, or vesicocele, is similarly deter mined by a sound within the bladder.
Fig. 2.—The guiding threads have been drawn through the urethra, pulling the cir cular flap or frill into the bladder. The first nniting thread has been drawn tight and knotted, closing the upper extremity of the frill. This is shown also in enlarged detail. The two uniting threads are shown tied, and the frill thus closed above and below. (Stan wore Bishop.) Prolapse of the vagina is often associated with one or both of these forms of her nia, and the distinction between the two conditions is often overlooked even by gymccologists of skill and ability. Hernia at the top of the vagina is de termined by the presence of a soft, pain less, movable tumor, which, by combined palpation through the vagina and the abdominal wall, may be recognized as a process of the intestine.
within the vagina may be clue to descent of the bladder, rectum, or intestine. The first two are usually the result of parturition, and are especially common with those who have borne many children, who work hard, and bear heavy burdens. In the third form the intestine descends through the top of the after the uterus has been removed, or an incision has been made in the anterior or posterior fornix.
In rare cases a prolapsed intestine in Douglas's pouch has been forced through the vaginal fornix by a sudden impulse or by continued straining independently of any surgical procedure.
Treatment.—Relief to these conditions involves surgical measures. Those which were mentioned in the description of prolapse of the vagina may be used for the cure of rectocele and vesicocele, while for the hernia at the top of the vagina the patient may be placed in the left lateral posture with the hips elevated. The tumor can then be reduced, if pos sible, with the finger. A sufficiently large portion of the prolapsed vaginal mucous membrane is then dissected away; the sac of the hernia opened, cleared by careful manipulation of its contents, if it has any, and cut away; the edges of the peritoneal stump brought to the edges of the vaginal wound; and the tissues all closed with interrupted sutures, worm-gut being pre ferred for this purpose. Instead of this method, one may follow Thomas's recom mendation: open the abdomen, draw hack the prolapsed omentum or intestine out of the sac, draw back and excise the sac. and close the wound with silk or catgut. After this the prolapsed portion of the vagina may be excised and the wound sutured.