or at most two weeks, for just as soon as the rectal opening is united and the ulceration or sinus gradually healing up, there can no longer pass any gas or fluid feces through the sinuous tract and the labial orifice.

This treatment is so little painful that the patient need not even be kept in bed. The ligature will cut through in from three to eight days, and if the elastic thread ceases its pressure the remnant of

FIG. 216.

A

Barton-Taylor's Operation for Recto-labial Fistula: A, anal end of ligature; B, labial fistula; C, incision in perineum. The fine dotted lines mark the course of the recto-labial sinus; the heavy dotted lines represent the ligature where it is imbedded in the tissues.

embraced tissue is easily severed with scissors or Paquelin's cautery. C. Cutting operations may be performed from the perineum, the vagina, or the rectum.

I. For a rectal fistula situated low down three different sutureoperations recommend themselves.

1. Emmet's Method. Split the perineal body with scissors in the sagittal plane up to the fistula, cut its wall away and unite as for ruptured perineum (p. 311).

2. Tait's flap-splitting method with circular suture (p. 360) is well adapted to these small openings.

3. Fritsch's Flap-sliding Method.-A crescent incision is made on the vaginal wall with the convexity turned down and just touching the upper border of the fistula. A similar incision is made

between the ends of the first extending half an inch below the fistula. The enclosed crescent-shaped part of mucous membrane is dissected off. Finally, the flap above the fistula is drawn down so as to cover this denuded surface and the fistula, and fastened all around with sutures to the mucous membrane or the skin.

Whichever method be used it is best first to paralyze the sphincter ani muscle by overstretching it.

II. Rectal fistula situated higher up in the vagina are, as a rule, operated on from the vagina in one of three ways: Sims's operation, as for vesico-vaginal fistula, Tait's flap-splitting operation, or Hegar's colpo-perineorrhaphia posterior.

They have strongly beveled edges, the vaginal opening being much larger than the rectal.

1. Sims's Operation (compare p. 357).-Sometimes the vaginal edges can be brought together after making lateral incisions in the vagina, but cases are occasionally met with in which no extent of division of tissue on the vaginal surface will permit of the edges being brought together. In such a case it is necessary to split the edges of the fistula on each side to a depth sufficient to permit the edges of the rectal wall to be brought together below, leaving the vaginal opening to be filled up by granulation.2

Denudation in fecal fistulæ must be made much larger than in urinary. In the lower part of the vagina the edges are, as a rule, united from side to side. In the upper, when there is much loss of substance, the edges must sometimes be brought together in a transverse line.

2. Tait's flap-splitting with interrupted suture (p. 360) may be

available.

3. German authors recommend a denudation and adaptation from side to side as in Hegar's operation for incomplete rupture of the perineum (p. 303).

Operation from the Rectum.-In exceptional cases it may be impossible to bring the rectal fistula into view on account of a cicatricial band at the outlet of the vagina. As this band works as a substitute for the lost sphincter urethra by keeping the walls of the urethra in contact (compare p. 368) it should not be divided. Under such circumstances the operation is performed from the rectal side.3

The intestine should not only be cleaned out by high enemas of water and irrigated with an antiseptic solution during the operation (p. 215), but it may even be good to try to combat the germs in the upper part of the intestine by the internal administration of naphthaline (gr. ij to viii pro dosi, up to gr. lxxx in twenty-four hours) or ! H. Fritsch, Centralblatt f. Gynäk, 1888, vol. xii. p. 806. 2 T. A. Emmet's Gynecology, p. 662.

Emmet, l. c., p. 666.

salicylate of bismuth (gr. x every two hours). The sutures are put in near the edge on the rectal side, but should go out a quarter of an inch from the edge on the vaginal side.

Entero-vaginal Fistula.'-If the fistula is only lateral it may be closed by denudation and suture like another fecal fistula. In a case of vaginal anus it must be ascertained if the lower part of the bowel is pervious, as it is evident that no closure must be attempted unless an exit can be given to the fecal matter.

Different operations have been performed or proposed for the relief of this kind of fistula.

1. If there is a double opening the spur between the two may be cut by introducing Dupuytren's enterotome, or another strong pair of forceps, to the depth of one and a quarter inches, and the edges of the fistula denuded and united by sutures.

2. Laparotomy may be performed, the intestine cut loose from the vagina or uterus, and the ends united by enterorrhaphy.

If the lower end is closed or too narrow an anastomosis may be effected between the upper end and the large intestine.

3. It has also been proposed to loosen the intestine and insert it in the rectum from the vagina.

4. After having made an artificial rectovaginal fistula, colpocleisis may be performed under it.

General Remarks about the Operation for Fecal Fistula.-In operations from the vagina or the perineum Simon's position (p. 359) should be used. It is often a help to introduce a small Sims speculum under the symphysis pubis and lateral retractors on the sides of the vagina. In operations from the rectum Sims's position or the genupectoral should be used.

Silver-wire sutures are preferable. If used in the rectum they should be turned down toward the anus sa as not to offer any resistance to the exit of the feces. They may be left in two weeks while silk must be removed at the end of the first week. The bowels should of course be emptied before operating. After the operation they are best let alone for three days. After that daily loose passages should be secured by means of medicines (pp. 217 and 313). The patient may urinate herself.

Thirty-nine cases have been collected by H. L. Petit, Annales de Gynécologie, vols. xviii., xix., xx., 1882-83.

PART IV.

DISEASES OF THE UTERUS.

CHAPTER I.

MALFORMATIONS.

MALFORMATIONS of the uterus may be due to excessive development and precocity, to arrest of development or to irregular development. Those due to arrest of development correspond again either to the first or the second half of fetal life. By bearing in mind the history of the normal development of the uterus (p. 30) the many abnormal forms of uteri due to arrest of this development are easily understood. Since the uterus is formed by the fusion and further development of the middle part of the Müllerian ducts we have no difficulty in realizing that that part may originally have been absent or may have been destroyed, or that the originally solid filaments may have failed to become tunneled, or that the muscular tissue which should be formed around them may do so in an imperfect way, or that fusion does not take place between the two tubes, or does so only partially, or that only one of the tubes undergoes its regular development, while the other stays rudimentary or is absent.'

A. Excessive Development and Precocity.-Sometimes the uterus in the new-born child has the size and shape of that of a girl at puberty (p. 33).

As to menstruation during early childhood we refer to what has been said on p. 235.

B. Arrest of Development during the First Half of Intra-uterine Life-1. Absence of Uterus.-Complete absence of every vestige of a uterus is a rare occurrence. It may, however, be found in otherwise well built women, but it is mostly combined with other defects in the genitals or in other parts of the body.

Diagnosis.-The total absence of the uterus cannot be diagnosticated in the living woman, and even in post-mortem examinations the pathologist must be on his guard.

Those who want more information about malformations than that warranted by the limits of this book are referred to my article on the subject in the Amer., Syst. of Gynecol., vol. i., pp. 238–257.

2. Rudimentary Uterus.-In some extremely rare cases the uterus has only been represented by a solid fibrous or muscular mass. In others it consists of a membranous vesicle.

In none of the cases of rudimentary uterus authenticated by autopsy was there any menstrual flow, but often molimina.

3. Uterus Duplex Separatus or Uterus Didelphys.-This variety is produced when the two Müllerian ducts do not even come in contact with one another in that part of their course in which they usually melt together forming the uterus. Consequently there are two entirely separate uteri, but each of them represents only one-half of the total organ. Each half has at its upper end one Fallopian tube and one round ligament. At the lower end the double cervix opens into a single or double vagina, or this organ may be more or less defective. The uterus didelphys is mostly found in still-born children, but occurs also in adults. Pregnancy and childbirth may be entirely normal.

It is hardly possible to diagnosticate this uterus from a uterus bicornis in the living woman, through the closed abdominal wall.

4. Uterus Unicornis.-The one-horned uterus is due to the development of one of Müller's ducts, while the other is absent or stays rudimentary. It is always very long, forms a curve with the concavity turned outward, and ends in a point without fundus.

The diagnosis may sometimes be made by bimanual and rectal examination, by the shape and position. Pregnancy and childbirth may take their normal course.

But attached to the point where the cervix merges into the body of the unicorn uterus is sometimes found a rudimentary horn. If pregnancy takes place in that, the condition is a very grave one, the rudimentary horn being incapable of producing the necessary muscular tissue to form a sac for the growing fetus. The condition is, then, practically the same as in tubal pregnancy, from which it cannot be distinguished clinically. Even anatomically the examiner may be led into error, if he does not bear in mind that the round ligament forms the line of demarkation between the uterus and the tube (p. 58). A tube, be it ever so narrow, if situated inside of the round ligament, is a horn of the uterus, while the Fallopian tube starts from the same point as the round ligament and extends outward.

The treatment is also like that for tubal pregnancy—namely, a strong electric current for the purpose of killing the fetus, or removal by means of laparotomy.

In very rare cases menstrual blood has accumulated in the rudimentary horn, forming a tumor (hematometra). In such a case lapa

I have seen one in performing laparotomy on a girl twenty years old. In this case the vagina was normal.