Fig. 175.—Diagrams showing the development of the vagina and the uterus from Müller’s ducts.
Fig. 175.—Diagrams showing the development of the vagina and the uterus from Müller’s ducts.
The most important malformations of the vagina andthe uterus arise from arrest, at any stage, of this normal developmental process.
Very rarely the uterus is completely absent, or it may be represented by a small band of muscular and connective tissue stretched across the pelvis. In other cases the cervix is well formed, while the body of the uterus is but poorly developed.
We have seen that this condition is often associated with pathological anteflexion of the uterus.
Uterus Unicornis.—Sometimes there is arrest in the development of one of Müller’s ducts, so that the uterus becomes one-sided or one-horned and presents only one formed Fallopian tube. In such a case both ovaries may be present.
Uterus Didelphys.—Müller’s ducts may unite only as far as the top of the vagina, no fusion whatever taking place in the uterine portion. In such a case two separated uterine bodies are produced; the condition of double uterus exists (Fig. 176).
Fig. 176.—Uterus didelphys and double vagina.
Fig. 176.—Uterus didelphys and double vagina.
Uterus Bicornis Duplex.—In this variety of malformation development has proceeded a step farther than in thepreceding variety. The uterine bodies have become externally united. There is, however, no fusion of the cavities. Two cavities are present, opening into a double vagina.
Uterus Bicornis Unicollis.—Here the development of the cervix and the lower part of the uterus is normal. The upper parts of the body of the uterus have not become fused, and diverge sharply from each other. The organ is two-horned (Fig. 177).
Fig. 177.—Uterus bicornis unicollis (Winckel).
Fig. 177.—Uterus bicornis unicollis (Winckel).
Uterus Cordiformis.—In this variety the two halves of the uterus are united throughout. Externally on the fundus there appears a slight depression, which, with the broad body of the uterus, demonstrates the imperfection of development. The name is derived from the resemblance to the conventional heart-shape.
Uterus Septus.—In this variety development has progressed so far that externally the uterus presents the normal appearance. The septum that divides the two ducts has, however, failed to disappear, and a divided uterus results. The septum may extend throughout the body of the uterus, or it may be less perfectly formed. Often one side of the uterus is better developed than the other (Fig. 178).
Malformation of the Vagina.—Malformation of the vagina is frequently present with malformation of the uterus. The septum that divides Müller’s ducts may persist throughout the whole length of the vagina, forming a double vagina; or the septum may have partly disappeared,being present in various stages of perfection. In double vagina each orifice may be guarded by a distinct hymen.
Sometimes one of the canals of a double vagina is much better developed than the other. The orifice of the poorly developed canal may be closed at its lower extremity, so that the malformation is never recognized by the woman or physician unless the closed canal becomes distended with blood or other secretion. A variety of vaginal cyst may be formed in this way.
Fig. 178.—Uterus septus (Cruveilhier).
Fig. 178.—Uterus septus (Cruveilhier).
Unilateral Vagina.—In this variety of malformation one of the ducts of Müller fails to develop at all. The condition always occurs with uterus unicornis. The vaginal canal is smaller than normal and may be situated to one side of the median line.
Absence of the vaginararely occurs. There may be no sign whatever of this structure, or it may be represented by a fibrous cord. The external genitals may also be absent, or they may be well developed.
If the uterus and ovaries are well developed, much trouble may arise from retention of menstrual blood.
An attempt should be made, by means of a transverse incision between the rectum and the urethra, to reach thecervix, and, if possible, to make an artificial vagina by transposition of skin from the buttocks. Such treatment is usually unsatisfactory, as a patulous canal cannot be maintained. It may be necessary to remove the uterus and appendages.
Sometimes the vagina is absent in only part of its course, being open below and represented above by a fibrous cord; or the upper and lower portions may be developed, while the middle portion is imperforate.
Fig. 179.—Transverse septum of the vagina (Heyder).
Fig. 179.—Transverse septum of the vagina (Heyder).
These conditions are more amenable to operative treatment than in the case of complete absence of the vagina. The intervening septum should be incised, and the patulous condition maintained by the passage of bougies if necessary.
Sometimes the lumen of the vagina is obstructed by the presence of transverse bands or crescentic folds, which have been described as supplementary hymens (Fig. 179).
Ahematocolposis produced when the vagina becomes distended with menstrual blood above such an obstruction.
Hermaphroditism.—A true hermaphrodite is an individual who possesses the organs of both sexes in a condition of perfect function. The existence of true hermaphroditism is denied by many authorities of the present day, though the older writers firmly believed in it. The coexistence of testicles and ovaries has never been proved beyond doubt in the human subject. It is doubtful if there are any cases, recorded as true hermaphrodites, in which the demonstration of the condition is not open to serious criticism; such individuals are in reality pseudo-hermaphrodites. The term hermaphrodite is still, however,very commonly applied to any individual of doubtful sex.
Apseudo-hermaphroditeis possessed of a distinct sex, and has either ovaries or testicles, though the external genitals and other secondary sexual characteristics may present the appearance of a double sex.
Inmale pseudo-hermaphroditismthe individual has testicles, and the external genital organs simulate those of the female.
Infemale pseudo-hermaphroditismthe individual has ovaries, and the external genital organs simulate those of the male.
In male pseudo-hermaphroditism the condition of hypospadias is usually present, the lower surface of the urethra and the perineum being split. The penis may be very small and imperforate, the urethra opening at its base. The fissure of the perineum closely resembles the vagina, and the split scrotum may be mistaken for the labia. Cases of this kind are on record in which the individuals, ignorant of their true sex, have for years indulged in sexual connection with men.
In female pseudo-hermaphroditism there is hypertrophy of the clitoris and the prepuce, with approximation of the labia majora and contraction or occlusion of the ostium vaginæ, giving the genitals the appearance of the masculine type.
The secondary sexual characteristics of both varieties of pseudo-hermaphrodites—the distribution of hair, mammary development, shape, voice, etc.—are usually of the feminine type.
It is often exceedingly difficult to determine during life the true sex of the individual in cases of hermaphroditism. The only absolute test of the sex is the determination of the genital glands.
The labia should be carefully palpated to determine whether or not testicles are present. Rectal examination should be made to determine the existence of uterus or ovaries. The sexual inclinations of the individual shouldbe observed. The discharge from the genitals during sexual excitement should be examined for spermatozoa.
The presence of a uterus is not necessarily indicative of a female, as a uterus may be associated with a perfect penis and testes; and a periodic discharge of blood from the genitals has been found in men.
If conception occurs, of course, all doubt is removed. If the sex cannot be definitely determined by such examination, it is best to consider the case one of male pseudo-hermaphroditism, which is the usual form, and to treat the individual as a male.
Menstruation, or the regular periodical discharge of blood from the uterus, is a phenomenon that occurs only in the human race and in some monkeys. The anatomical changes that accompany menstruation have not yet been definitely determined. In some species of monkey—Semnopithecus entellusandMacacus rhesus2—the following changes appear to take place at the menstrual periods: The endometrium first becomes swollen and congested as a result of the growth of the stroma, and increase in the number and size of the blood-vessels. The vessels in the superficial part of the stroma degenerate and break down, and blood is extravasated into the meshes of the stroma network. The extravasated blood collects into lacunæ which lie close beneath the uterine epithelium. Finally the lacunæ rupture and the blood escapes into the cavity of the uterus, forming the menstrual clot. Then a fresh epithelium grows over the torn surfaces, new blood-vessels are formed, the stroma shrinks, and the endometrium of the intermenstrual period is restored.
Nothing is known with any degree of certainty regarding the cause and significance of menstruation. There is much diversity of opinion in regard to the coincidence of ovulation and menstruation. Heape has shown that for monkeys ovulation and menstruation are not necessarily coincident; in forty-two menstruating specimens ofS. entellusnot one had a recently discharged follicle in either ovary. In monkeys, therefore, menstruation may take place without ovulation, and it isprobable that the same is true for the human female. Ovulation and conception may occur in the human female when menstruation is absent; pregnancy not infrequently occurs during the amenorrhea associated with lactation, and in India, where the girls are married at a very young age, pregnancy and child-birth occur before menstruation has begun.
Leopold (quoted by Hirst) in an examination of twenty-nine pairs of ovaries removed on successive days up to the thirty-fifth after a menstrual period, found a Graafian follicle bursting on the eighth, twelfth, fifteenth, sixteenth, eighteenth, twentieth, and thirty-fifth days after the menstrual period. Thus ovulation frequently occurred without menstruation during the intermenstrual interval. In five cases there was no ovulation at the menstrual period, or menstruation occurred without ovulation.
It seems probable, therefore, that the ripening of the ovum in the ovary is independent of the process of menstruation, though the increased blood-supply to the generative organs during menstruation may, to a certain extent, determine the time of ovulation when a sufficiently ripe ovum is present.
Though menstruation in women is analogous to the rut or “heat” of other animals, yet there are some points of difference: The lower mammals breed only at times of “heat,” and these times of “heat” occur in the wild state only at certain periods of the year, which are dependent upon climatic conditions, the young being born at the season of the year best suited for their survival. Some domestic animals, like the cow, probably as a result of domestication, have no regular breeding time. In the lower mammals “heat” and ovulation appear to be coincident, and these are the only periods during which the female seems normally to have any sexual desire.
The monkeys examined by Heape menstruated throughout the year and yet seemed in the free state to have definite breeding times.
The human female, with but few exceptions, menstruates throughout the year and may breed at any time. The exceptions in the case of the human female are of interest. Dr. Frederick A. Cook,3ethnologist to the first Peary North Greenland Expedition, says of the Esquimaux living in the extreme north, from the seventy-sixth to the seventy-ninth parallels of latitude: “The passions of these people are periodical, and their courtship is usually carried on soon after the return of the sun; in fact, at this time they almost tremble from the intensity of their passions, and for several weeks most of their time is taken up in gratifying them. Naturally enough, then, the children are usually born at the beginning of the Arctic night.” In Queensland the natives are also said to have a special breeding season.
Menstruation usually begins in this country at the fourteenth year. The time of the first appearance of the process is influenced by race, climate, and environment. As a rule, it begins earlier in warm climates and later in cold climates. It is earlier in girls who lead luxurious, indolent lives than in girls of the working classes.
During the first year or two of menstrual life menstruation is often very irregular. It may be absent for several months after its first appearance, or recur at varying intervals before it becomes regularly established. Irregularity at this time calls for no treatment.
Precocious menstruationrarely occurs at a very early age. It has been known to begin, and to recur with regularity, from the time of birth. In such cases there is a corresponding premature development of the sexual organs.
Themenstrual dischargeconsists of blood, mucous secretion from the uterus and vagina, and epithelial cells from the endometrium.
The normal duration of the flow is from two days to a week. The amount of fluid discharged is from 2 to 9 ounces. Menstruation occurs every twenty-eight days,counting from the beginning of one period to the beginning of another. The menstrual interval is subject to considerable individual variations, which appear to be within the limits of health. It sometimes occurs with regularity every two, three, or five weeks. When it occurs every two weeks, the alternate flows are often but small in amount. The occurrence of, or the attempt at, menstruation every two weeks, in a woman who had previously menstruated monthly, is sometimes a symptom of beginning uterine disease.
Menstruation commonly ceases at about the forty-fifth year, when the menopause appears.
Most of the disorders of menstruation have already been considered as symptoms of the various lesions of the genital organs that have been described in the previous pages.
There are some disorders of menstruation, however, often unaccompanied by discoverable lesions, which now demand consideration.
Amenorrhea.—Amenorrhea is the absence of menstruation. Failure of the menstrual blood to be discharged from the vagina, such as occurs in cases of atresia, is not necessarily amenorrhea; menstruation may have taken place, though the most marked phenomenon of this process, the discharge of blood, is concealed.
The term primary amenorrhea, oremansio mensium, is applied to those cases in which menstruation has never appeared. Secondary amenorrhea, orsuppressio mensium, is applied to those cases in which menstruation has ceased after having once been established.
Amenorrhea is due to defective development of the organs of generation; to premature atrophy, such as occurs in superinvolution of the uterus; to lesions, pathological and traumatic; to acute and chronic general diseases; and to psychical disturbances.
Menstruation is often absent during the acute diseases, such as typhoid fever, and it may remain suppressed until the general health is fully restored.
Amenorrhea may also occur in any chronic debilitating condition. It is common in chlorosis, anemia, phthisis, and malaria.
It frequently results from changes of climate and surroundings, and continues until the person becomes adapted to the new environment. It is seen in emigrants from other countries, and in women who move from the country to large cities. It is often caused by overwork, physical and mental, and by insufficient food. It is not uncommon in studious school-girls.
Amenorrhea is sometimes due to the excessive general development of fat, even in young woman who are apparently in good general health.
Amenorrhea is frequently associated with insanity. It may be caused by fright, grief, or anxiety. The fear of pregnancy after illicit coitus sometimes produces it.
In some unusual cases amenorrhea is present without any discoverable cause. The woman may be in perfect general health, and the sexual organs may be well developed, at least so far as can be determined by physical examination.
In amenorrhea there is often a general periodical disturbance that marks the times at which the menstrual bleeding should occur. There may be headache, flashes of heat, nervousness, nausea and vomiting, and a feeling of fulness and pain in the pelvis. Various cutaneous eruptions may occur as the result of amenorrhea, as in other diseases of the genital apparatus.
The poor health, mental and physical, that usually accompanies amenorrhea is often thought by the patient and her friends to be the result, rather than the cause—as it really is—of the arrested bleeding.
Treatment.—The treatment of amenorrhea depends upon the cause of the condition. Little, if any, benefit is to be expected in those cases due to defective development of the uterus or the ovaries. If an attempt at menstruation is made, as shown by periodical local pain and general disturbance, and the uterus is found to be smalland sharply anteflexed, benefit may sometimes result from thorough dilatation of the cervix.
Most cases of amenorrhea demand general treatment. The mode of life should be regulated according to strict hygienic principles. Fresh air, sunshine, baths, and suitable exercise should be prescribed. Studious girls should be made to lead more active lives. A change of surroundings is beneficial. A visit to the seashore and salt-water baths are of advantage.
The general health should be improved by the administration of iron, strychnine, or some other tonic. Blaud’s pill and the hypophosphites are useful. Obesity should be relieved by a regulated diet and exercise. The regularity of the bowels should always be carefully attended to. Most of the so-called emmenagogues are of but little, if any, value. Benefit is sometimes derived from the use of potassium permanganate (gr. j-ij three times a day) and the binoxide of manganese (gr. j-ij three times a day). These medicines should be administered in pill form for several weeks.
Oxalic acid in doses of from ⅒ to ¼ of a grain, given in lemon syrup for a period of from one to four months, has been recommended, and is sometimes very useful.
It seems probable that pelvic massage practised for a period of several months may result in benefit.
Acute suppression of menstruationduring a menstrual period is a phenomenon to which the term amenorrhea is not properly applicable. It may be caused by exposure to cold or by some sudden emotional disturbance during the menstrual flow.
The condition may be unaccompanied by any subjective symptoms, or there may be present ovarian and pelvic pain.
Thetreatmentconsists in rest in bed, the application of warm fomentations to the lower abdomen, and hot foot-baths. Especial care of the general health should be observed at the following menstrual period.
Scanty Menstruation.—Scanty menstruation occurswhen the menstrual flow is much less than normal. It must be remembered that individual peculiarities in this respect may be within the limits of health. When one or more periods are missed, and the flow shows a continual tendency to diminish in amount, treatment may be demanded.
The causes and the treatment of scanty menstruation are those which have already been considered under Amenorrhea.
Vicarious Menstruation.—Vicarious menstruation is the discharge of blood, at the menstrual periods, from some part of the body other than the uterus. In some cases, instead of a discharge of blood, a secretion of another character takes place.
The vicarious discharge may be the only phenomenon present, or it may occur supplementary to the normal uterine bleeding.
The vicarious bleeding may take place from almost any part of the mucous or cutaneous structures. It occurs from the nose, the throat, the lungs, the stomach, the bladder, and the anus. It may occur from an ulcer or other lesion of the external surface. Sometimes the cutaneous hemorrhages appear in the form of ecchymoses.
Various secretions may take the place of the bleeding. A monthly flow of milk from the breasts has been observed, and a periodical diarrhea or leucorrhea has taken place.
Vicarious menstruation is a rare condition. It may occur in defective development of the uterus and ovaries. It is usually found in debilitated nervous women, and accompanies a deficient menstrual discharge from the uterus.
Treatment.—Direct local treatment should be applied to the vicarious bleeding only when it becomes excessive. The general health of the woman should receive attention. Treatment should be applied to any local lesion of the genital apparatus that may be discovered. The directions given for amenorrhea are also applicable here.
The menopause is the final cessation of menstruation. The age at which it occurs is dependent upon a great variety of conditions—nationality, climate, mode of life, constitutional and local diseases. In the northern countries of Europe the menopause is said to appear later than in the southern; in England, later than in America. It has been observed that country women menstruate to a later age than city women. The woman who bears a number of children in rapid succession and suckles them not infrequently has a premature menopause. The menopause may appear early in very fat women and in women who are the victims of tuberculosis, nephritis, and diabetes. Disease of the uterus, tubes, and ovaries may retard the menopause. In fibroid tumor of the uterus the menopause may be delayed for several years.
In this country the menopause occurs between the fortieth and fiftieth years—usually about the age of forty-five.
The menstrual bleeding may gradually diminish in amount until it disappears; or it may stop abruptly and permanently; or there may occur one or more intervals of amenorrhea of one, two, or three months’ duration, followed by normal menstrual bleedings, perhaps of diminished amount, before the flow finally ceases.
Profuse bleeding at the time of the menopause and slight bleeding occurring more often than monthly are, unfortunately, viewed by most women as of no moment, and as part of the normal phenomena of the change through which they are passing. The samemay be said of the apparent reappearance of menstruation, or of slight irregular hemorrhages occurring after the menopause had been established and menstruation had been absent perhaps for many months. These phenomena are not normal. They should always excite the alarm of the woman, and they demand immediate examination on the part of her physician. As a rule, the bleeding is caused by some pathological condition of the uterus—fungous growths, polypi, fibroids, or cancer. The benign lesions may disappear spontaneously with the progressing atrophy of the womb, and the hemorrhages may cease. Many women undoubtedly recover without treatment, and are thus confirmed in the belief that such irregular hemorrhages are a normal part of the menopause; and the unfortunate women with cancer are thus encouraged to delay seeking medical advice until the disease has progressed too far for cure.
The normal changes of the genital organs that begin at the menopause are those of atrophy slowly progressing to the senile condition. The ovaries atrophy; the epithelial elements gradually give place to connective tissue; the Graafian follicles and corpora lutea are destroyed; the tunica albuginea becomes thick and shriveled. The uterus diminishes in size; the vaginal cervix may disappear; the utricular glands diminish in size and number; the endometrium atrophies. The Fallopian tubes shrink and become shortened, and the fimbriæ disappear. Similar atrophic changes affect the vagina, the external genitals, and the mammary glands.
If the woman is in good general health, and has no disease of the uterus, the tubes, or the ovaries, the menopause may become established without any marked general disturbance.
In many cases, however, very annoying general symptoms appear, and last for one or two years before the woman becomes adapted to the altered conditions.
There may be headache, flushes of heat, nervous depression, derangement of the digestive apparatus, andother functional disturbance. The woman often becomes very fat at this period. The nervous derangement may be so severe as to result in insanity.
The vaso-motor disturbances are often the most annoying. The phenomena of the “flushes” consist of a feeling of heat over the whole or a part of the body, followed by sweating and the sensation of cold or a slight chill. The flushes may occur frequently during the day, sometimes several times during an hour.
The treatment of the menopause should be directed to the maintenance of the general bodily and mental health. The diet should be carefully regulated. Too much nutritious food should be forbidden. Purgatives should be administered whenever necessary. The woman should have plenty of fresh air and the proper amount of exercise. Mental depression demands a change of locality and surroundings.
Fistulous openings may exist between the different portions of the genital tract and the neighboring structures. Such fistulæ are the result of childbirth, operative or other form of traumatism, congenital defect, cancer, syphilis, or suppuration. The accompanying diagram (Fig. 180) shows the chief varieties of fistula that occur.
Fig. 180.--Diagram illustrating the chief varieties of genital fistula:v. u., vesico-uterine fistula;v. v., vesico-vaginal fistula;u. v., urethro-vaginal fistula;r. v., recto-vaginal fistula.
Fig. 180.--Diagram illustrating the chief varieties of genital fistula:v. u., vesico-uterine fistula;v. v., vesico-vaginal fistula;u. v., urethro-vaginal fistula;r. v., recto-vaginal fistula.
Vesico-vaginal Fistula.—The most frequent form of fistulous opening occurs in the septum between the bladder and the vagina. The condition is usually caused by sloughing, the result of prolonged pressure from the fetal head at labor.
In some cases such an opening is made for therapeutic reasons by the physician, for the cure of cystitis.
Intelligent midwifery and the prompt and proper use of the obstetrical forceps have greatly diminished the frequency of vesico-vaginal fistula. It was formerly a very common disease. At the present day it is but rarely seen, at least in those parts of the country where women have competent attendance at labor.
The vesico-vaginal opening may be situated at any portion of the septum. It varies very much in size and shape. It may be a small hole barely admitting a fine probe-point, a median slit, or a large irregular opening involving the whole base of the bladder.
The appearance of the fistula varies according to the time that has elapsed since the receipt of the injury. The margins of the opening, which are at first irregular and ulcerated, become in time thin and firm from cicatricial contraction, and the size of the opening becomes similarly diminished.
The first symptom of vesico-vaginal fistula is the involuntary escape of urine from the vagina. If the condition has resulted from pressure at parturition, the incontinence of urine does not appear for five or ten days after labor, when the slough has separated. When a direct laceration of the vesico-vaginal septum has occurred, the urine will escape immediately.
The degree of incontinence varies with the size and the position of the fistula. If the opening is small and is situated in the upper part of the vagina, there may be perfect continence when the woman is in the erect position, as long as the urine remains below the level of the opening. Incontinence returns when the accumulation of urine becomes greater than this and when the woman assumes the recumbent posture. I have seen a woman with a fistula of this kind who was only troubled with incontinence at night.
The secondary symptoms of vesico-vaginal fistula are due to the irritation of the urine. Unless the greatestcleanliness be observed, great suffering may result within a few weeks after the receipt of the injury. The vagina, the labia, and the inner aspects of the thighs become inflamed and excoriated. The mucous membrane of the vagina may become covered with an offensive phosphatic deposit. If the fistulous opening be large, the fundus of the bladder may prolapse into the vagina and become covered with a similar deposit.
Secondary kidney disease, from infection of the ureters, may follow in time.
As the result of disuse the bladder becomes contracted, and its walls become thickened from inflammatory infiltration, so that when the fistula is closed the capacity of the bladder is much less than normal. Disuse of the urethra results also in contraction, which may be so extensive as seriously to complicate treatment.
Physical examination usually reveals the condition. The woman should be placed in the Sims, the genu-pectoral, or the lithotomy position, and the anterior vaginal wall should be examined through the Sims speculum. The examiner should, of course, determine that the involuntary flow of urine comes from the vagina, and not from the urethra. Women are often unable to tell accurately whence the urine escapes, and the single symptom of incontinence of urine is not pathognomonic of fistula.
In most cases the fistulous opening may be readily detected, and a sound passed through the urethra may be made to emerge in the vagina. In the case of small openings, however, obscurely situated in the upper part of the vagina, and especially in case of vesico-uterine fistula, it may be difficult to demonstrate the presence of a fistula. In such cases the bladder may be filled with sterile milk, which may then be seen escaping into the vagina. This is a valuable method of diagnosis in the rare cases of uretero-vaginal fistula.
Treatment.—The method of curing vesico-vaginal fistula was taught to the world by Marion Sims, who operatedsuccessfully in 1849, and who published his first article upon the subject in 1852.
Careful preparatory treatment before operation is usually necessary. Unless the vagina and the bladder are in a healthy condition beforehand, every method of operation is likely to fail.
It is necessary to treat all excoriations or ulcerations, to cure the cystitis, and to relieve the tension of all bands of scar-tissue in the vagina that may prevent proper approximation of the edges of the opening.
The phosphatic deposit should be carefully removed from the vaginal walls and the interior of the bladder with a soft sponge or cotton, and a weak solution of nitrate of silver (gr. v to ℥j) should be applied to the raw surfaces.
Frequent warm sitz-baths should be administered daily. The vagina should be washed out several times a day with large quantities of sterile hot water or with a solution of boracic acid (ʒj to the pint).
The urine, which is generally alkaline, should be rendered acid by the use of benzoic or boracic acid.
Emmet advises the following prescription: “2 drams of benzoic acid and 3 drams of borax to 12 ounces of water, of which a tablespoonful, further diluted, should be given three or four times a day.” After the urine has become acid the dose may be reduced.
Every fifth day the solution of nitrate of silver should be applied to the unhealed, excoriated surfaces. It may be necessary to pursue this treatment several weeks before the parts are brought to a healthy condition. Improvement is perceived not only in the condition of the vaginal walls and the bladder, but in the edges of the fistula, which, in place of being hypertrophied and indurated, assume a natural color and density.
In case the vaginal fistula be small, the accompanying cystitis may be difficult to cure, because there is always some residual urine in the bladder. It may then be advisable, as a preparatory step, to enlarge the fistulousopening by a clean incision in the median line, in order to secure more perfect drainage. The cystitis may be kept up by the presence of a phosphatic concretion in the bladder, which may be removed in this way. It is useless to close the fistula until the cystitis is cured.
In every case of vesico-vaginal fistula it is advisable to examine for vesical calculus, that the bladder may not be closed with a calculus in it. The calculus occasionally exists before the formation of the fistula, and perhaps assists in its production, the vesico-vaginal septum being squeezed between the child’s head and the calculus. Usually, however, the calculus forms as a result of the fistula.
When the parts have been brought to a healthy condition the fistula should be examined with a view to the method of closure. The opening should be exposed with the Sims speculum, and the edges at opposite points should be seized with tenacula or forceps and approximated. In this way the surgeon may determine the direction in which the fistula may be closed with the least traction on the sutures. When possible, it is advisable, in order to prevent shortening of the vagina, to close the fistula in the direction of the long axis of the vagina.
Fig. 181.—Sims’ vaginal dilator.
Fig. 181.—Sims’ vaginal dilator.
If the edges of the opening cannot readily be brought together, any restraining bands of tissue in the vaginal walls should be divided with scissors. If these bands are slight and superficial, they may be divided at the time of operation for closure. If, however, they are extensive, preparatory treatment devoted to the liberation of the edges of the fistula must be practised. All restraining bands should be freely divided, and after the vagina has thus been opened up, it should be distended (to prevent subsequent contraction) by introducing a vaginal plug or dilator (Fig. 181) or a rubber bag packed with sponges. Bleeding is generally controlled by the pressure of theplug. The vaginal plugs of glass or of hard rubber are made of various sizes. They should be long enough and thick enough to stretch the vagina without producing sloughing. The plug is retained by aT-bandage.
After this operation the woman should be kept in bed for a week or ten days. The urine should be drawn with the catheter without removing the plug. When suppuration begins the plug will become loosened and may be removed. Emmet says: “It is remarkable how much absorption of the cicatricial tissue takes place in a few weeks when judicious pressure has been maintained by this instrument.”
After removing the plug, vaginal douches should be resumed until healing is complete.
It will be seen from this consideration that the preparatory treatment may be severe and may extend over a long period. Such extensive treatment is not by any means always necessary; when, however, it is required, it is useless to proceed to operation without it.
Operation.—The operation consists in freshening the edges of the fistula with the knife or scissors and bringing them into apposition with the interrupted suture. Different forms of suture have been used by various operators. If the parts are in a healthy condition and are properly denuded and approximated, it makes no difference in the result what form of suture is used. As in all forms of plastic work, I prefer silkworm gut shotted. The operation is most easily performed with the woman in the Sims position, the vagina being exposed with the Sims speculum. The lithotomy or the genu-pectoral position is preferred by some operators. The edge of the opening should be seized with the tenaculum or with tissue-forceps, and a continuous strip of tissue should be removed all around the fistula, extending from the mucous membrane of the bladder out upon the vaginal surface for a quarter or three-eighths of an inch. The vaginal mucous membrane usually retracts somewhat as soon as it is liberated from the fistulous margin, so that theraw surface is broader than the strip removed. It is advisable to avoid any injury to the mucous membrane of the bladder, as free bleeding may take place from this structure. The denuded surface should extend as near as possible to the mucous membrane of the bladder without involving it.
The denudation should be extended some distance beyond each angle of the fistula, in order to secure perfect apposition in these positions.
The length and shape of the needle used for closing the opening varies with the fancy of the operator. As a rule, a small needle, straight or curved at the point, is most convenient (Fig. 182).
Fig. 182.—Fistula-needles.
Fig. 182.—Fistula-needles.
The needle should be introduced about an eighth of an inch from the edge of the vaginal mucous membrane, and should be made to emerge at the edge of the mucous membrane of the bladder. It should be reintroduced and emerge in the reverse order on the opposite side (Fig. 183). The sutures should be placed about a quarter of an inch apart.
After the sutures have been introduced, and before they have been shotted or tied, the bladder should be thoroughly washed out with a warm boric-acid solution. The operator should make sure that no blood-clot is left in the bladder. After the sutures have been shotted a light gauze tampon may be placed in the vagina. A permanent soft-rubber catheter may be introduced through the urethra, or the urine may be drawn every three or four hours after the operation. If care is given to the cleanliness of the catheter, it is perhaps best to retain it in the bladder for three or four days, after which the urine may be drawn every four hours. The catheter should be removed twice in twenty-four hours for purposes of cleansing. The eye of the catheter frequently becomes obstructed by blood-clot.
It should not be forgotten that the bladder is often much contracted in old cases of vesico-vaginal fistula,and as the capacity is diminished more frequent catheterization than usual is necessary.
Boric or benzoic acid should be continued during the convalescence.
The gauze tampon should be removed on the second day.
The bowels should be moved on the second or third day. The sutures may remain for two weeks. The woman may sit up at the end of two weeks.
Fig. 183.—Vesico-vaginal fistula with the sutures introduced.
Fig. 183.—Vesico-vaginal fistula with the sutures introduced.
The operation described here—more or less modified in order to meet the requirements of different cases—will result in cure in the great majority of instances. Often much depends upon the ingenuity and the mechanical skill of the operator. Sometimes two or three operations are necessary before the opening can be completely closed, the operator closing part at each sitting.
In the case of a small fistulous opening it may be necessary to enlarge it by free incision before the denudation and the introduction of the sutures can be properly accomplished.
In the very rare cases which are incurable by operationkolpokleisis, or closure of the vagina, has been practised by some. The operation was performed by removing a circular strip around the circumference of the vagina, immediately above the ostium vaginæ, and approximating the raw surfaces by a transverse row of sutures. This operation makes of the bladder and the vagina one urinary pouch into which menstrual blood and uterine discharges flow. It should never be practised. I quote from Emmet in this connection: “From my own observation I have learned that it is but a question of a few months, a year, or possibly two years, before serious consequences must arise after leaving a receptacle, like a portion of the vagina, in which the urine may stagnate. To give a retentive power for so short a time is not a sufficient compensation for the suffering and consequences that supervene. As the result of my experience, I would urge that the operation never be resorted to under any circumstances. The maximum has now been reduced to 2 or 3 per cent. of cases where the resources of the surgeon cannot overcome all the difficulties that may be presented in closing a vesico-vaginal fistula.”
The forms of operation in which the cervix uteri is utilized to assist in the closure of a vesical fistula, as a result of which the menstrual blood and the uterine secretions are discharged into the bladder, are contraindicated for similar reasons.
Urethro-vaginal fistulais much less common than vesical fistula. Unless the neck of the bladder be involved, there may be perfect control of urine; though, of course, when the urine is voided it will escape from the ostium vaginæ, and not from the external meatus.
Thetreatmentof urethro-vaginal fistula is essentially the same as that already described for vesico-vaginal fistula. The edges should be denuded, and the opening into the urethra closed over a large-sized catheter. The line of union should be in the long axis of the urethra.
Vesico-uterine Fistula.—In this form of fistula the opening usually extends from the bladder into the cervicalcanal. It is caused by labor in which the anterior lip of the cervix is lacerated. The lower portion of the cervical laceration may unite, leaving the fistulous opening above.
Thediagnosisof the condition is made from observing urine escape from the cervical canal, or by injecting the bladder with milk or other colored fluid. A sound introduced in the cervix may be brought in contact with a probe passed through the urethra and bladder into the fistula.
If these methods of examination are not satisfactory, endoscopic examination of the interior of the bladder will reveal the abnormal opening.
Thetreatmentconsists in dividing the anterior lip of the cervix and the vaginal wall down to the fistulous tract; thorough denudation of the walls of the fistula; and closure of the whole incision by interrupted sutures.
Uretero-vaginal Fistula.—This condition is usually the result of injury to the ureter by operation. It may occur from the destruction of tissue caused by pelvic abscess, which discharges through the vaginal vault. In extensive vesico-vaginal fistula caused by sloughing after labor the bladder-wall may become rolled out so that the ureter opens into the vagina.
If but one ureter is involved, one-half of the urine will be discharged in the natural way and the other half by the vagina.
Thetreatmentconsists in directing the ureter into the bladder by plastic operation performed through the vagina; or by performing celiotomy, dissecting out the ureter, and implanting it in the fundus of the bladder.
Recto-vaginal Fistula.—Recto-vaginal fistula is usually caused by parturition. The destruction of tissue is sometimes due to syphilis. In the latter case cure is difficult, and sometimes impossible.
Thesymptomof the condition is the passage of feces and flatus into the vagina.
Sometimes but a very small opening exists, situated immediately above the sphincter muscle; in other cases the greater portion of the recto-vaginal septum is destroyed.
The condition may be recognized by placing the woman in the lithotomy position and exposing the posterior vaginal wall by the Sims speculum placed under the pubic arch.
Thetreatmentconsists in operation similar to that described under the consideration of vesico-vaginal fistula. The woman should be prepared as for a plastic operation upon the perineum. The rectum should be thoroughly emptied before operating. The sphincter ani should be stretched. It is always advisable, when possible, to close the opening from the vagina.
The mucous membrane of the rectum should be injured as little as possible, in order to limit the bleeding. It may be necessary to relieve tension on the edges of the fistula by making, on each side of the vaginal aspect of the opening, an incision parallel to the long axis of the vagina.
In case of a small fistula situated immediately above the sphincter ani, it is sometimes difficult to denude and to introduce the sutures. It then becomes necessary to divide the perineum and the sphincter ani to the fistula, denude the edges, and to introduce sutures as in a case of complete median laceration of the perineum. Sometimes the recto-vaginal fistula is much larger on the vaginal than on the rectal aspect—is, in fact, funnel-shaped, the destruction of tissue having been greater upon the vaginal surface. If in such a case the edges of the fistula cannot be brought into apposition after freeing all restraining bands, it may be necessary to split the edge of the opening, so that the rectal wall is freed and may be brought together by sutures introduced through the rectum, leaving the vaginal opening to be filled by granulation. The rectal sutures may be introduced by placing the woman in the Sims position and exposing the anterior rectal wall with the Sims speculum.
The after-treatment resembles in all respects that prescribed after operation for laceration through the sphincter ani. The sutures should be removed in two weeks.
Before considering in detail the diseases of the urethra and bladder, it will be necessary to describe the modern methods of examining these structures.
The examination of the urethra and bladder has been very much facilitated by the methods and instruments that have been popularized in this country by Kelly. The following apparatus is required: a female catheter; a urethral calibrator; a series of specula with obturators; a head-mirror and light or an electric headlight; long, delicate toothed forceps (Fig. 184); an inclined plane or several hard pillows for elevating the pelvis; small balls of absorbent cotton about the size of a pea, or strips of absorbent gauze cut 1 inch in width and about 10 inches long, for drying out the bladder.