below; it is difficult to prevent these sutures from catching up either bladder or rectum, but this should, if possible, be avoided. Care is required in the introduction of the first mesial suture as it is the guide for the others.

Simon's operation for Kolpokleisis.

Fig. 393.

The patient is in the lithotomy posture: the sound has been passed through urethra and fistula, and is seen in the upper portion of the vagina; the perineum is drawn back with the speculum and the labia majora with spatule. A band-like piece of tissue has been removed from both the vaginal walls above the ostium: the raw surface is left unshaded in the Figure. The vaginal mucous membrane is held tense by four pair of forceps outside the raw surface, the shaded area within the latter is the upper third of the vagina. An end of the last suture has been passed through one raw surface, the second end is being carried through the other raw surface (H. and K.).

The results of this method are satisfactory as regards the production of complete continence. There is no liability to stagnation of urine or formation of concretions (Hegar and Kaltenbach). Hæmatometra will not occur unless there has been atresia of the cervix uteri. If menstrua

tion has been in abeyance, it will probably return after the operation; in a case operated on by A. R. Simpson, the patient had not menstruated

Fig. 394.

Same operation as seen in section to show relation of raw surfaces (shaded dark), position of sutures and common receptacle above for urine and menstrual blood. The bladder and urethra are in upper part of figure (H. and K.).

for a year, but a few weeks after the operation the menstrual blood appeared in the urine.

CHAPTER LIV.

THE RECTUM: COCCYGODYNIA.

LITERATURE.

Allingham-Diseases of the Rectum : Churchill, 1871.

Chadwick-On the Functions of the Anal Sphincters: Am. Gyn. Trans., 1877. Cripps-Cancer of the Rectum : Churchill. Hart-Physics of the Rectum and Bladder: Edin. Obst. Trans., 1882. Ruedinger-Topographisch-chirurgische Anatomie des Menschen, vierte Abtheilung. Storer-The Rectum in its relation to Uterine Disease: Am. Jour. of Obst., Vol. I., p. 66. Syme-Diseases of the Rectum: Edin., 1859. Van Buren-Diseases of the Rectum: H. K. Lewis, 1881.

Not only is the gynecologist frequently consulted about rectal mischief, but as a matter of fact female patients sometimes refer rectal disease to the uterus or vagina; therefore, in investigating gynecological cases, one has occasionally to satisfy himself that the rectum is not the seat of the affection.

Vaginismus may be caused by fissure of the anus, as we have already seen, and pruritus vulvæ by ascarides from the rectum passing into the vagina.

PHYSIOLOGY OF THE RECTUM.

The anatomy of the rectum has been already considered (p. 34., Vol. I.). The relations of the axes of rectum, anus, vagina and urethra, to one another and to intra-abdominal pressure are of importance. As we have already seen, the vagina and urethra are parallel to one another and to the plane of the brim.

Strictly speaking, the surface whose outer boundary is the brim of the bony pelvis is not a plane surface, inasmuch as the various points in the outline of the brim are not on the same level. The vagina is thus, properly speaking, parallel to the internal conjugate of the brim.

The rectum runs, in its lower 14-inch, close behind the vagina and parallel to it; the anal canal turns directly backwards so as to cut the vag

In this way the lowest portion of the rectum becomes roofed in above by the sphincter tertius and open below. Intra-abdominal pressure drives this portion downwards; and the rectal contents, elongated by peristalsis and depressed by intra-abdominal pressure and eversion of the mucous membrane, are finally brought into the relaxed anal canal from which intra-abdominal pressure readily expels them. Ruedinger's diagram (Fig. 37, Vol. I.) shows well how the levator ani will reinvert the everted mucous membrane.

Inattention to the proper evacuation of the bowels leads to non-sensitiveness of the mucous membrane and is thus one factor in constipation.

EXAMINATION OF THE RECTUM.

This may be done in three ways:

(a) By finger (v. Vol. I., p. 107),

(b) By speculum,

(c) By eversion of the anterior rectal wall through digital pressure in the vagina (Storer).

By Speculum.-The anal speculum has usually an oval fenestra; it is passed into the anus in the direction of its long axis, and rotated so that each portion of the anal lining comes opposite the aperture (Fig. 397).

Storer's method is as follows. Place the patient on her side; pass two fingers (or one) half way into the vagina, with the pulps of the fingers on the posterior vaginal wall. Then press these downwards and backwards, and thus evert the rectal mucous membrane through the dilatable sphincter ani which is at the same time pressed open with the fingers of the other hand. This method is most easily employed in multiparæ.

DISEASES OF THE RECTUM.

Women are especially liable to rectal disease owing to the distention of parts accompanying parturition, as well as from their habitual neglect of the regular evacuation of the bowels. As rectal diseases often simulate those of the vagina, a sketch of the more important of them is necessary in a manual of gynecology. We shall therefore consider the following affections:

Displacements of the rectum,

Fissure of the anus,

Piles,

Recto-vaginal fistula ;

Functional disturbance of Rectum-Constipation.