Irrigation and packing with gauze may be resorted to as after-treatment, but are considered unnecessary by a large number of operators.

Atresia of the v.a.g.i.n.a may be congenital or acquired. In the latter case the condition results from contraction of adhesions developed from damage done during labour; or it may follow acute septic vaginitis, the introduction of acids or irritating materials to produce abortion, or as a sequel to typhoid fever.

Treatment is by slow dilatation with Hegar's bougies over an extended period of time; relapse is common.

DILATATION OF THE v.u.l.v.aL ORIFICE

=Indications.= This is done for vaginismus due to a pathological spasm of the levator ani and resulting in more or less complete obstruction to coitus.

=Operation.= Under an anaesthetic the v.u.l.v.al orifice should be thoroughly dilated by means of the thumbs, and for some days subsequently graduated Sims's 'v.a.g.i.n.al rests' (Fig. 46) should be inserted twice daily and worn for twenty minutes at a time. This treatment may be necessary for a fortnight or longer. In many cases of dyspareunia the cause will be found to be due to a thick, fleshy, and unruptured hymen or to tenderness about the remnants of that organ. Under these circ.u.mstances, exsection is the better plan to pursue. The hymen is seized with a pair of toothed forceps and removed with curved scissors along its entire base of attachment. Free bleeding often occurs from the raw surface, which must be controlled by ligatures. The two almost parallel cut edges must then be carefully brought together either by continuous or interrupted suture.

[Ill.u.s.tration: FIG. 46. SIMS'S v.a.g.i.n.aL REST.]

COLPOTOMY OR v.a.g.i.n.aL CLIOTOMY

By colpotomy is meant making an opening into the peritoneal cavity through the v.a.g.i.n.a; the operation is known as anterior or posterior colpotomy, according to whether the opening is made through the anterior or posterior fornix.

Colpotomy has certain _advantages_ over abdominal section. There is less interference with the peritoneum and intestines, and therefore less shock; if pus is present, there is less risk of infecting the general peritoneal cavity, and better drainage; there is no abdominal scar, and therefore no risk of hernia; lastly, there are certain pathological products which can be more easily reached by this route. The operation is difficult in a nullipara, where the v.a.g.i.n.a is narrow, and easier in a multipara, where the v.a.g.i.n.a is more capacious, and it is still easier if the cervix can be drawn down as far as the v.a.g.i.n.al orifice.

A serious _disadvantage_ is that, during the course of the operation, it may be found impossible to deal adequately with the conditions for which the operation is being performed; in the case of a tumour, for instance, its size, position, or the presence of adhesions may render it necessary to complete the operation by the abdominal route. Further, in more than one instance, the abdomen has had to be opened after the completion of the operation on account of bleeding, the source of which could not be dealt with by the v.a.g.i.n.a.

Therefore, before deciding upon the removal of a tumour by colpotomy, all the above points must be taken into consideration.

=Indications.= When the above conditions are fulfilled, colpotomy is suitable for:--

(i) The evacuation of collections of pus or blood in Douglas's pouch.

(ii) The removal of fibro-myomata, ovarian tumours of small size, and early tubal pregnancies.

(iii) The drainage of collections of pus or the removal of the appendages in cases of acute inflammation where immediate operation is necessary.

(iv) Conservative operations upon the Fallopian tubes or ovaries.

(v) A preliminary to the performance of v.a.g.i.n.al hysteropexy.

(vi) Those cases in which the patient's general condition is unfavourable to the performance of exploration by the abdominal route.

Anterior colpotomy is more suitable for removing small tumours growing from the anterior wall of the uterus, or for conservative operations on the ovaries. Posterior colpotomy is more suitable for removing inflamed appendages, and for evacuating collections of pus or blood from Douglas's pouch.

[Ill.u.s.tration: FIG. 47. POZZI'S RETRACTORS.]

Posterior colpotomy has been used for many years for the opening of abscesses and haematoceles in Douglas's pouch. The anterior operation is of more recent date, and its relative advantages and disadvantages and the indications for its use have not yet been definitely agreed upon by the majority of gynaecologists. Taking all things into consideration, the disadvantages of colpotomy seem to outweigh its advantages, and, except for the evacuation or drainage of collections of blood or pus behind the uterus, the operation may be said to have few indications.

=Anterior colpotomy.= A posterior Pozzi's (Fig. 47) or Pean's retractor is pa.s.sed into the v.a.g.i.n.a, and the cervix is seized with a volsella and drawn downwards and backwards. A sound pa.s.sed into the bladder defines its lower limit. A T-shaped incision is now made through the v.a.g.i.n.al mucous membrane, the transverse portion just below the point to which the bladder has been found to extend (Fig. 48, _b_). This incision should pa.s.s completely through the v.a.g.i.n.al mucous membrane, but no further, and should extend across the whole width of the anterior surface of the cervix. Some operators use a simple longitudinal or a transverse incision. The v.a.g.i.n.al mucous membrane is now carefully pushed upwards with the pulp of the finger until the lower limit of the bladder is defined. Great help is gained at this stage by the use of the bladder sound. On pushing up the v.a.g.i.n.al mucous membrane still further the peritoneum is reached, and is recognized by its white glistening appearance, and by the fact that its two opposed surfaces glide freely over one another under the finger. The next step is to open the peritoneum: it is picked up with catch-forceps, and a small transverse incision is made into it with a pair of scissors; the finger is pa.s.sed through, and the incision is extended on either side, care being taken not to pa.s.s too far outwards for fear of injuring the ureters or uterine vessels.

[Ill.u.s.tration: FIG. 48. ANTERIOR COLPOTOMY.

The patient is in the lithotomy position, the speculum is pa.s.sed and the cervix pulled down by a tenaculum. The T-shaped incision has been made.

_b._ Outline of bladder.

_c._ Cervix.

_cl._ c.l.i.toris.

_l.m._ Labium minus.

_sp._ Speculum.

_u._ Urethral orifice.

_v,v',v"._ Volsella.

After the peritoneum has been opened, the pelvic organs can be carefully examined with the fingers, and the purposes for which the operation has been undertaken can be proceeded with. The next step usually consists in drawing out the fundus of the uterus, by which much more room and much better access to the pelvic organs is gained. To accomplish this, the uterus is caught with a volsella in the middle line, as high up as possible, and drawn downwards and forwards. If necessary, a second volsella is applied above the first, and so on, until the uterus is delivered. A very complete examination of the appendages can now be made, for the tubes and ovaries can be drawn out of the wound and examined directly.

When the object of the operation has been attained, and all the blood has been carefully removed by swabs, the next and final step consists in closing the peritoneal and v.a.g.i.n.al wounds. The uterus is replaced, and the peritoneal incision is closed by a single layer of catgut sutures; the v.a.g.i.n.al incision is similarly dealt with. The v.a.g.i.n.a is cleared from blood-clot and gently irrigated with an antiseptic solution. A gauze plug is inserted lightly, and the patient is put back to bed. The catheter should be used every six or eight hours for the first twenty-four hours.

=Posterior colpotomy.= A posterior speculum is pa.s.sed and the cervix drawn downwards and slightly forwards with a volsella. A transverse incision is then made through the v.a.g.i.n.al mucous membrane at the junction of the posterior fornix with the cervix. This exposes the peritoneum more or less easily, and this structure is picked up with catch-forceps, and a transverse incision made into it with scissors; a finger is pa.s.sed through this, and the incision is extended on either side. The pelvic organs can now be explored and the tubes and ovaries drawn down and examined. The peritoneal and v.a.g.i.n.al incisions are then closed by separate layers of catgut sutures.

[Ill.u.s.tration: FIG. 49. MARTIN'S TROCHAR FOR PELVIC ABSCESS.]

_To open a collection of pus in Douglas's pouch_, the best method is to pa.s.s a pair of sinus-forceps, with the blades closed, into the most prominent part of the swelling. The blades are then opened and the forceps withdrawn. The finger pa.s.sed into the abscess cavity gently breaks down any adhesions. The cavity is then irrigated with hot salt solution and a drainage tube inserted, which projects just outside the v.u.l.v.a: the lower end of the tube should be carefully packed around with cyanide gauze. The tube should be changed every day and the v.a.g.i.n.a douched with an antiseptic. Another method is to plunge a Martin's trochar (Fig. 49) into any softened spot in the swelling and then withdraw the needle, leaving a blunt dilating forceps to extend the opening.

In opening an abscess, the most stringent precautions against sepsis should be observed. The v.a.g.i.n.a must be most carefully prepared beforehand, by rubbing over with swabs and ethereal soap, and by a subsequent copious douche of 1 in 1,000 perchloride of mercury: otherwise continual reinfection of the abscess cavity occurs, and healing is much delayed.

=Lateral colpotomy--Parav.a.g.i.n.al section.=

=Indications.= The object of the operation is to increase the amount of room in the v.a.g.i.n.a in certain cases of v.a.g.i.n.al hysterectomy in elderly virgins, or in women who have a small v.a.g.i.n.a.

=Operation.= The same preliminaries are carried out as before. The incision is carried completely round the cervix at its junction with the v.a.g.i.n.a. The lateral margin of the v.u.l.v.a is then held tense, and an incision is made, beginning at the circ.u.mcervical incision running down the lateral v.a.g.i.n.al wall, through the margin of the v.u.l.v.a and on to the skin externally, ending at a point midway between the perineum and the ischial tuberosity, _i.e._ about 1-1/2 inches to the side, and in front of the perineum; the incision may be lateral only or bilateral. In sewing up, it is important to reunite the cut edges of the levator ani, or pelvic weakness will result.

CHAPTER XV

OPERATIONS UPON THE UTERUS

Pa.s.sAGE OF THE UTERINE SOUND

This is an operation which is much less frequently resorted to than formerly, owing partly to the risks of sepsis attending its performance and partly to the greater perfection of the bimanual examination.

Pa.s.sing the uterine sound should always be looked upon as a surgical operation. The facts learnt by the use of the sound are: (1) the length and direction of the uterine cavity; (2) the condition of the endometrium: bleeding as a rule follows withdrawal in fibro-myomata and endometrial disease; (3) whether a fibroid growth is projecting into the uterine cavity, and if so, how much.

[Ill.u.s.tration: FIG. 50. THE Pa.s.sAGE OF THE UTERINE SOUND. _Introduction of the point into the external os uteri._]

[Ill.u.s.tration: FIG. 51. THE Pa.s.sAGE OF THE UTERINE SOUND. _Commencement of the tour de maitre._]

The sound may be pa.s.sed in the dorsal position (Fig. 61), the cervix being held by a volsella and exposed by means of a posterior speculum, or in the left lateral position, the method usually adopted in the consulting room. In the latter the right index-finger is pa.s.sed up to the anterior lip of the cervix, the sterilized sound is taken in the left hand with its concavity backwards and its bulbous end is slid gently along the palmar surface of the finger in the v.a.g.i.n.a until the os uteri externum is reached; through this it should be pa.s.sed for about a quarter of an inch (Fig. 50). The instrument should now be steadied by the thumb and the two distal joints of the second finger of the right hand, and its subsequent movements controlled by the left (Fig. 51).

[Ill.u.s.tration: FIG. 52. THE Pa.s.sAGE OF THE UTERINE SOUND. _Completion of the tour de maitre._]