_b._ v.a.g.i.n.al wall.

_c._ Suture.

_e, e_{1}._ Liberating incisions.

_k, k_{1}._ Flap-splitting incisions.

In A the flap-splitting is seen in section (_k, k_{1}_); in B the flaps have been everted towards the bladder and v.a.g.i.n.a respectively and the suture pa.s.sed. In C this suture has been tied; liberating incisions, _e, e_{1}_, have been made on the v.a.g.i.n.al surface to prevent tension in the wound.

The patient is placed in the lithotomy position, and the fistula is exposed: the cervix is drawn downwards and backwards by means of a wire loop or tenaculum, and the urethral prominence held with a pair of hooked forceps. An incision is then made in the median line extending across the fistula and through the v.a.g.i.n.al walls down to the bladder, in this way exposing the entire base of the bladder. The edges of the fistula are then split so that the bladder and the v.a.g.i.n.al walls are separated. The two vesical flaps are now carefully and separately sutured by catgut and the edges of the v.a.g.i.n.al wound are brought together as much as possible: if necessary, the fundus of the uterus may be used to a.s.sist in closing the opening.

=For vesico-utero-v.a.g.i.n.al or juxta-cervical fistula.= In this affection the cervix is involved, and it must therefore be carefully differentiated from the vesico-v.a.g.i.n.al variety, in which the cervix is intact.

[Ill.u.s.tration: FIG. 44. REPAIR OF A VESICO-v.a.g.i.n.aL FISTULA. _Sims's Operation._ The edge of the fistula has been denuded and the sutures have been pa.s.sed.

_a.v.w._ Anterior v.a.g.i.n.al wall.

_cl._ c.l.i.toris.

_s_{1}, s_{11}._ Retractors.

_sp._ Posterior speculum.

_t._ Tenaculum.

_u._ Orifice of urethra.

_v.v.f._ Vesico-v.a.g.i.n.al fistula.

In operating upon such cases the chief difficulty will be found in denuding the surfaces necessary for the introduction of the sutures, owing to the density of the cicatricial tissues, which are always present. This is best overcome by drawing the cervix forcibly downwards and backwards and incising the anterior cul-de-sac; the bladder wall with its fistulous opening is then dissected off the anterior surface of the cervix and carefully sutured independently of the cervical laceration; the latter is treated by suture in the usual way (see p.

128). In the deeper forms of juxta-cervical fistula, the above technique is impossible, and suprapubic incision and suture of the bladder must be subst.i.tuted.

RECTO-v.a.g.i.n.aL FISTULA

This condition may be defined as an opening between the r.e.c.t.u.m and v.a.g.i.n.a through which flatus, or faeces, or both, may pa.s.s from the former into the latter; it is chiefly the result of an imperfect union subsequent to an operation for complete perineum laceration. It may also be caused by the rupture of a pelvic abscess or by the spread of primary malignant disease of the rectal wall.

=Operation.= If the sphincter ani is incompletely united, it will be found much the most satisfactory proceeding to divide the healed portions of the perineum and make a complete perineal laceration; this may then be treated as described above (see p. 128).

If, however, the sphincter is intact and serviceable the fistula should be pared and the edges brought together by silk sutures. It is not infrequently necessary to perform a temporary colostomy (see Vol. II) in order to divert the faecal contents of the bowel during the process of healing.

OPERATIONS FOR CYSTOCELE

In cystocele there is prolapse of the anterior v.a.g.i.n.al wall and the corresponding area of the posterior bladder wall. Cystocele often complicates rectocele and prolapsus uteri, and operation upon it is often carried out in combination with colpo-perineorrhaphy.

=Operation.= The operation for the cure of this affection is very simple, and may be performed:--

(1) By denuding an oval s.p.a.ce over the swelling and bringing the raw edges together.

(2) By Stoltz's operation, which is really purse-string suture.

The instruments necessary are a bladder sound, two tenacula, sharp-pointed angular scissors, a needle-holder and fine silk.

(1) The parts are exposed with a Sims's or Auvard's speculum and a volsella, or silver wire is pa.s.sed through the cervix, by means of which traction downwards and backwards may be exerted. The cystocele itself is fixed by tenacula, and, with the sound in the bladder, an oval incision is carried completely round the base of the cystocele. The whole area contained in this incision is denuded by knife or scissors, care being taken to avoid wounding the bladder mucous membrane.

Any bleeding having been controlled, a spiral buried suture, as in the operation for perineorrhaphy (see p. 128), is pa.s.sed antero-posteriorly, thus reducing the size of the raw area and making a solid support in the median line. The raw edges are then brought together by sutures. The catheter should be pa.s.sed every eight hours for three days, and then the patient should be allowed to micturate on her hands and knees.

(2) _Stoltz's operation._ The instruments necessary are: a No. 8 male bladder sound; two tenacula; hooked forceps; sharp-pointed angular scissors, and a needle-holder (Schauta's for preference).

The patient is placed in the lithotomy position and the parts are exposed by means of an Auvard's speculum. A silver wire or tenaculum is pa.s.sed through the posterior lip of the cervix, by means of which downward and backward traction may be exerted. Four points must be selected: two lateral (Fig. 45, 1, 1'), fixing the external boundaries of the surface to be denuded; one immediately behind the orifice of the urethra (2); and a fourth in front of the cervix (3). These four points should be capable of close approximation. They are carefully joined by curved incisions so that the area to be denuded is almost oval in shape.

The bladder sound is now pa.s.sed, and the mucous membrane of the v.a.g.i.n.a kept on the stretch by pressure on its point. The process of denudation should be carried out with a scalpel or pointed curved scissors. It will be found that bleeding rarely gives any trouble. The point of the needle threaded with silk is inserted on the operator's right side of the urethral orifice and a little below it; it pierces the mucous membrane on the left side of the median line, and again appears upon the surface.

By an in-and-out st.i.tch all the way round the circle which has been pared, the point finally issues on the operator's left side of the urethra and below it: by traction on these two ends the edges of the denuded surface are drawn together and the prolapsed bladder is sutured in its normal situation. A puckered cicatrix results. This method is valuable for prolapsus uteri when combined with the operation of posterior colporrhaphy.

[Ill.u.s.tration: FIG. 45. STOLTZ'S OPERATION FOR CYSTOCELE. The oval surface has been denuded and the circ.u.mferential suture pa.s.sed but not tied.

1,1',2,3. The four points first selected as boundaries for denudation.

_s._ Suture, the arrows denoting the direction in which it is pa.s.sed.

_sp._ Retractor.

_t._ Tenaculum.

_u._ Urethral orifice.

CHAPTER XIV

OPERATIONS UPON THE v.u.l.v.a AND v.a.g.i.n.a

OPERATIONS UPON BARTHOLIN'S GLANDS

The glands of Bartholin, or the vulvo-v.a.g.i.n.al glands, are two racemose structures about the size of a pea, lodged between the layers of the triangular ligament, one on each side of the orifice of the v.a.g.i.n.a.

Their ducts open a little in front of the fossa navicularis, on each side of the v.a.g.i.n.al orifice, in the groove between the attached border of the hymen and the labium minus.

=Removal of a cyst of Bartholin's gland.= These cysts really arise in the ducts rather than in the gland itself. The orifice of the main duct is very liable to become blocked from inflammation of the v.u.l.v.a, and leads to the formation of a single cyst varying in size from a cherry to an orange. Less common is the blocking of the secondary ducts, wherefrom a collection of small cysts results. The cyst forms a characteristic tense ovoid or pyriform swelling in the posterior third of the labium majus. The chief symptoms the patient complains of are discomfort in walking and pain on coitus.

=Operation.= The best procedure is complete excision of the cyst. A longitudinal incision is made over its cutaneous surface, and the cyst carefully dissected out, together with the gland itself: care must be taken not to perforate the v.a.g.i.n.al mucous membrane stretched over the inner surface of the cyst. Brisk bleeding from vessels at the base of the cyst, usually follows from the cavity which contained the cyst and this must be carefully arrested, otherwise a large haematoma may result.

The cavity is closed by five or six interrupted catgut sutures, pa.s.sing deeply through its sides and floor, so as to ensure complete closure. A gauze drain may be inserted and retained for twenty-four hours.

The method of incising the cyst, swabbing its interior with undiluted carbolic acid, and packing it with gauze is not to be recommended, for cure is neither so rapid nor so certain as in excision.

=Incision of an abscess of Bartholin's gland.= Abscesses arise by infection pa.s.sing into the gland along the ducts, and are a very frequent accompaniment of gonorrha. The orifice of the duct can usually be seen red and prominent, and may exude pus if pressure be made over the abscess-sac. Sometimes the abscess bursts and spontaneous recovery may follow, but it is very liable to recur, for infection lurks among the smaller ducts and is carried to a fresh part of the gland, and the process may continue until the whole gland has been thus destroyed.

=Operation.= The abscess must be freely incised and all pockets and septa broken down. It is stuffed with iodoform gauze, which is changed daily, and the cavity is allowed to granulate up from the bottom. If the abscess recurs, or if it consists only of a small collection of pus surrounded by brawny dema, the whole gland should be excised.

OPERATIONS FOR ATRESIA OF THE HYMEN AND THE v.a.g.i.n.a

Occlusion of the hymen is the commonest form observed. The v.a.g.i.n.a becomes slowly distended with blood, forming an elastic pelvic swelling (haemato-colpos) upon which the uterus is, so to speak, perched. Later in the course of the disease, this organ itself (haemato-metra) and the Fallopian tubes (haemato-salpinx) may become affected similarly.

=Indications.= In atresia of the hymen symptoms only commence after p.u.b.erty; there is then congenital amenorrha with periodic pelvic pain and gradual formation of a pelvic swelling. On inspection the hymen is distended and the blood-tumour above it gives a bluish tint to its surface.

=Operation.= After administration of an anaesthetic, careful palpation of the tubes should be made _per r.e.c.t.u.m_: if they are distended it is better to open the abdomen, ligature and remove them; if not, the hymen should be incised by means of a crucial opening and the characteristic tarry fluid allowed to escape: no hypogastric pressure should be used.