Colpocleisis BY BARTON COOKE HIRST, M.D. Philadelphia, Pa. REPRINTED FROM The American Journal of Obstetrics Vol. XXXIII. No. 2,1806. NEW YORK WILLIAM WOOD A COMPANY, PUBLISHERS 1896 COLPOCLEISIS. I should preface this brief paper with the statement that I present it to the Society more in the hope of obtaining than of imparting information. The scant courtesy that colpocleisis receives in American gynecological literature must strike any one who investigates the subject. In the article by Jewett in Keating and Coe’s System it is not mentioned at all. In Parvin’s translation of Winckel’s book it is expressly stated that all reference to colpocleisis is omitted. Skene neglects it altogether in his description of the operations for vesico-vaginal fistula. This attitude of Ame- rican writers is in contrast with the German and English gyne- cologists, who generally give colpocleisis an important place among the operative procedures for vesico-vaginal fistula, and from some of them, at least, comes the emphatic statement that stagnation of urine in the vagina and the formation of stone need not be feared. The disfavor with which colpocleisis is regarded in this country may be traced, I think, to Emmet’s strong and unqualified condemnation of it. He declares that a patient is better off if urine dribbles over her person constantly than if she has continence at the expense of closure of the vagina. It is in the hope of hearing whether the experience of our members is in accord with Emmet’s that I bring this subject before the meeting. Curiously enough, I have had two patients at one time in the Philadelphia Hospital whose vesico-vaginal fistuhe could not be closed by the usual methods. I have seen my fair share of this affection in the past ten years, and have had to contend with some peculiarly difficult cases, hitherto with uniform success, so that I can be absolved, I think, from the fault of resorting to colpocleisis unnecessarily. Granting, then, that in a small pro- portion of cases a patient must choose between closure of the vagina and incontinence of urine, is it unwise for her physician 1 Read before the Section on Gynecology, College of Physicians of Phila- delphia, December 19th, 1895. 2 hikst: colpocleisis. to counsel the former? For one, I cannot see that it is. The verdict of my patients would so far be in favor of colpocleisis without reserve. Whether they shall have reason to regret their vesical continence in the future remainsto be seen. Mean- while I should be thankful to hear the experience of my colleagues in sitnilar cases. As to the technique of the opera tion there is little to say. Any one who has investigated the matter at all is familiar with Simon’s operation. It is sufficient to state that the operation is easy to perform, and is eminently satisfactory in its immediate results, at least, in the establish- ment of perfect continence. The objections to the operation do not seem unanswerable. These are stagnation and decomposition of urine in the vagina, chronic cystitis, the development of surgical kidney, the forma- tion of stone, sterility, and menstruation into the bladder. The first could be avoided, it seems to me, by a denudation of the vaginal wall up to the level of the fistulous opening. If this is done there should be no vaginal pocket in which the urine could collect. Cystitis would be thus avoided. I think that the ope- ration is unjustly blamed for surgical kidney. It has been my experience that in many cases of bad, neglected fistulse surgical kidney exists in consequence of the fistula. It cannot be ex- pected, therefore, that closure of the fistula in such a case will stay the progress of the disease in the kidneys. It is expressly stated by several prominent German operators that a vesical cal- culus need not be feared after the operation. Thesterility after colpocleisis is, of course, a serious matter, but if the patient chooses to accept the consequences the physician need not con- cern himself about it. Finally, the menstruation into the blad- der is not necessarily attended with ill effects or even with dis- comfort, A. R. Simpson reports a case in which menstruation was absent until colpocleisis was performed; then the function re- turned naturally. One of my cases seems to be particularly well adapted to the operation. The uterus had practically been destroyed in labor; the uterine cavity, or what was left of it, is obliterated and the entire cervix has disappeared. Needless to say the woman does not menstruate.