In considering its dangers, we have described most of the steps of the operation, and there only remain a few special points to be clescribed.
In hymenal atresia, where an opening can most easily be made, the old method of cruciform incision recommended by Celsus fulfills all the in dications. Only when we find a lateral tubal blood tumor, are the above precautions in regard to free outflow, etc., necessary. Baker-Brown's' practice of ablating the hymen all the way round, and the recommendation of Vidal and Nickel, to encircle the margins of the wound with stitches after excision, are unnecessary complications in any case save when the hymen is exceptionally fleshy.
In atresias, where the lower blind sac does not end in a projection cov ered by smooth mucous membrane, an attempt at bloodless dilatation may be made with the finger or a straight metallic catheter. In some few cases astonishing results have been attained in this way. Thus in Amnesia's' well-known case, a total vaginal occlusion in a girl fifteen years old was rendered patent by simple digital pressure, and the continu ous use of sponge tents, so that eventually the collum could be incised and the retained menstrual blood evacuated. Two years later the patient was perfectly well. In a similar way Gantvoort obtained a permanently good result in a girl fourteen years old, in whom there was supposed to be an entire absence of the vagina. Bidder ' also succeeded with his fin ger in opening the apparently absent vagina in a girl seventeen years old suffering from luematometra, so that puncture of the collum could be done, and the patient relieved, although a vaginal stenosis remained be hind.
There is no doubt that in these cases there was no real defect or cica trieial stenosis, but rather a firm adhesion of the vaginal walls to one an other. Veit has claimed that this was the fact in Amussat's case; and this not so much because the membrane covering the atresia offered so little resistance as because the right passage to the portio vag. was so quickly found and so easily kept open. Since it is impossible before at tempting dilatation, to distinguish these adhesions from real obliterations, it would be well before proceeding to operate to make an attempt to force a passage in this way.
If the atresia is covered with a smooth mucous membrane, or if the attempt to effect a passage with the finger has failed, we now proceed to split the mucous membrane with scissors or knife, bearing in mind the precautions recommended above. Then we make our way with a blunt instrument through the deeper layers of tissue towards the tumor, while an assistant with a metallic catheter controls the urethra and the bladder, and with his finger guards the rectum. Tbe finger, aided occasionally by a blunt closed pair of scissors, is the best instrument that we can em ploy. If bands of firm tissue are met with, they may be divided with the latter instrument.' When we thus reach the fluctuating wall of the retention-tumor, we must palpate carefully to decide whether we cannot distinguish the region of the cervix as a soft, depressible round spot in its walls. This is often the case when only a small remnant of the fornix division of the vagina is preserved above the atresia. It cannot be felt,
of course, when the lower portion of the tumor is formed of a large sec tion of vagina, and is tense. I have repeatedly succeeded in finding it, and have experienced its usefulness in facilitating future utero-vaginal communication; since it is only when the place is properly selected that the cervix assumes its position in the lumen of the vagina. I use a long handled lancet-shaped knife, to effect the opening, either at the site of the cervix, or, if it cannot be found, at the lowest part of the vault of the tumor; the blade being protected by a large canula controlled by a spring. (Fig. 19, f.) Drawn back into the canula, and thus guarded, the knife may be safely passed under guidance of the finger to the selected spot, and applied to it. The blade is then projected until it enters the retention tumor; and then the puncture is enlarged to right and left with the knife. The opening should be about fth of an inch broad. Then the blade is withdrawn into the cauula, the knife removed entirely, and the canula pushed deep into the tumor. I then use the instrument which I call my forceps canula. (Fig. 18.) It consists in principle of a canula split into two halves, to which a strong, double curved dilatation forceps has been added. This instrument is passed over the canula, which it exactly fits, and is pushed closed into the retention sac. Now the jaws of the forceps-canula are forcibly opened, and they are fixed by means of the catch. Immediately after incision the thickened blood begins to flow out; but after the wound is dilated it appears in larger quantity. By dilating slowly, the rapidity of outflow may be controlled, and the dis turbing influence upon the position of the pelvic organs be more gradually brought to bear. The advantages of this course have been fully described above; and we may thus prevent the danger of rupture when hwmato salpinx is present, while retaining the advantages of complete dilatation at one sitting. As soon as dilatation is complete, a fenestrated double tube of German silver, about 2-11 inches long, is introduced between the jaws of the forceps mulls; thus ensuring free outflow and enabling us to make antiseptic injections. This tube has an olive-shaped end, at the apex of which is the opening of the canals.' The olive end is bent at an obtuse angle to the axis of the tube; and the whole very much resembles a Dutch clay pipe, so that we usually call it the pipe-cannla. (Fig. 19, d, e.) For. introduction, and to facilitate future washing through it, a tube of German silver about six inches long can be put into the lower opening of the olive. This can be done easily with the guidance of the fingers. When the double canula has been introduced, the forceps canula may be withdrawn, the former instrument being left in sihi. The bulb protects the mouths of the tubes from vaginal pressure, and its larger volume tends to dilate the atresiad spot. A few days later, when the uterus has contracted considerably, the tube may be replaced by a thinner one not over 2i inches long. It may be left in place for a con siderable time, though of course it should be cleaned occasionally.