THE VAGINA 1415 



can be pulled considerably farther down in the vagina, and a second inch of the broad ligament 

 is treated in a similar way. This second ligature will embrace the pampiniform plexus of veins, 

 and, when the broad ligament has been divided on either side, it will be found that a third liga- 

 ture can be made to pass over the Fallopian tube and top of the broad ligament, after the uterus 

 has been dragged down as far as possible. After the third ligature has been tied and the struc- 

 ture between it and the uterus divided, this organ will be freed from all its connections and can 

 be removed from the vagina. This canal is then sponged out and lightly dressed with gauze, 

 no sutures being used. The gauze may be removed at the end of the second day. In squamous 

 epithelioma, amputation of the cervix is done by some in those cases where the disease is recog- 

 nized before it has invaded the walls of the vagina or the neighboring broad ligaments. The 

 operation consists in removing a wedge-shaped piece of the uterus, including the cervix, through 

 the vagina and attaching the cut surface of the stump to the anterior and posterior vaginal walL, 

 so as to prevent retraction. In view, however, of the continuity of the lymphatic network of the 

 cervix with the lymphatics of the body, the operation is insufficient and should be condemned. 

 Complete abdominal hystt rectomy is rarely necessary, except for malignant disease. In this opera- 

 tion the entire uterus is removed. The preliminary introduction of bougies into the ureters as 

 practised by Kelly and Clark enables the surgeon to readily recognize the situations of these tubes. 

 After the abdomen has been opened the uterine vessels are secured and the broad ligaments 

 divided in a similar manner to that employed in vaginal hysterectomy, except that the proceeding 

 is commenced from above. When the first two ligatures have been tied and the broad ligament 

 divided, it will be found that the uterus can be raised out of the pelvis. A transverse incision 

 is nowmade through the peritoneum, where it is reflected from the anterior surface of the uterus 

 on to the back of the bladder and the serous membrane peeled from the surface of the uterus 

 until the vagina is reached. The anterior wall of this canal is cut across. The uterus is now 

 turned forward and the peritoneum at the bottom of Douglas' pouch incised transversely, and 

 the posterior wall of the vagina cut across until it meets the incision on the anterior wall. The 

 uterus is now almost free, and is held only by the lower part of the broad ligament on either 

 side, containing the uterine artery. A third ligature is made to encircle this, and, after having 

 been tied, the structures are divided between the ligature and the uterus. The organ can now 

 be removed. The vagina is plugged with gauze, and the external wound closed in the usual 

 way. The vagina acts as a drain, and therefore the opening into it is usually left unsutured. In 

 some cases of uterine fibroid the abdomen is opened and the tumor is removed, but the uterus is 

 not taken away. This operation is called myomectomy. This operation is suited only to solitary 

 subperitoneal or interstitial tumors (Penrose). 



The common operation for uterine fibroids is supravaginal amputation. The uterus is cut 

 away and the cervical flaps are sutured. Before the technique of hysterectomy was perfected 

 and before myomectomy was devised the favorite operation for uterine fibroids was salpingo- 

 oophorectomy, and by it a large majority of cases operated upon were cured. When it succeeds, 

 a premature menopause is induced and the tumor shrinks. The operation is useless if a woman 

 is past the menopause, and is apt to fail if the tumor is very soft or very large. 



THE VAGINA (Figs. 1157, 1175). 



The vagina (vulvouterine canal) is a musculomembranous passage, which 

 extends from the vulva to the uterus. It is situated in the cavity of the pelvis, 

 behind the bladder and in front of the rectum. Its direction is curved upward and 

 backward, at first in the line of the pelvic outlet, and afterward in that of the axis 

 of the cavity of the pelvis. Its walls are ordinarily in contact, and its usual shape 

 on transverse section is that of an H, the transverse limb being slightly curved 

 forward or backward, while the lateral limbs are somewhat convex toward the 

 median line. Its length is about two and a half inches (6.25 cm.) along its anterior 

 wall (paries anterior], and three and a half inches (8.75 cm.) along its posterior 

 wall (paries posterior}, and its wall is about 2 mm. thick. It is constricted at 

 its commencement, and becomes dilated medially, and narrowed near its uterine 

 extremity; it surrounds the vaginal portion of the cervix uteri, a short distance 

 from the os, its attachment extending higher up on the posterior than on the 

 anterior wall of the uterus (Fig. 1165). To the recess behind the cervix the term 

 posterior fornix is applied, while the smaller recess in front is termed the anterior 

 fornix. 



