This method is the only one that I have used since 1878; it has done me good service in seven cases of broad atresias. But other methods will do as well; and the operation depends much leas upon the instruments used than upon the appreciation of the correct principles which should guide it. But from the peculiar difficulties offered by a field of operation 'where we must rely upon the touch, it is desimble to render the technical difficulties as small as possible by the use of suitable instruments.
As regards the tubes used in broad-seated atresias, their purpose is not t,o dilate the stenosed region, but to maintain the communication between the uterus and the vagina, and to provide for outflow and for antiseptic injections. To accomplish its object, the tube must partially lie in the cervix itself when the atresia is high up and near the uterus. In these cases it is important that the tube be not too large, since it would other wise interfere with the involution of the portio. The portion tlmt lies in the atresia should be somewhat thicker. I have endeavored to accom plish this with the clay-pipe canula.
If there is a considerable portion of vagina above the atresia, we need not be so careful, and any incompressible tube will answer our purpose. It may then be thicker in calibre, and must of course be provided with u number of not too small openings for purposes of drainage and irriga tion. Drainage tubes of hard rubber, German silver, or glass, have not done well; the small orifices in them soon becoming clogged.
If we have a small, membranous and vaulted atresia to deal with, we shall choose our instrument in accordance with its accessibility. bearing in mind what we have already stated as regards the advantages of a free in cision. The higher we have to opemte, the more necessary will it be for us to use canula-protected instruments; for which purpose the above described instrument is to be recommended. It cannot be done so well with the " dilating trocar" which Clinton Cushing ' has described, while Bixby's double trocar and the ordinary trocar do not allow a sufficiently free outflow, and, being difficult of access, render subsequent dilatation very inconvenient. In unilateral vaginal atresias the knife and scissors can always be used. With the aid of the duck-bill speculum, a puncture can be made into the vaginal septum, and then the entire partition be split with curved scissors or probe-pointed bistoury.' Veit and Freund
recommend the excision of a piece of the septum; but I do not see that it has any advantages over the simple incision, which I have done five times.
As to after-treatment, in addition to the precautions already mentioned in regard to the prevention of the entrance of air and the stagnation of secretion, it has been recommended by many surgeons to apply a com pression bandage to the abdomen.' I do not think its use will be of much avail either in favoring complete evacuation or in preventing rupture of the sac; and the necessary pelvic movements which the patient must make while it is being applied, might not be wholly harmless. It will be better, therefore, not to employ it save in cases where the tumor is very extensive. Here it may be useful in enabling us to apply an even exter nal pressure to replace the diminished intra-abdominal pressure, and to immobilize the lower abdomen. Even here, however, it will be simpler to apply a linen bandage over a few layers of absorbent cotton.
It is of the greatest importance to maintain a free outflow from the tumor, and to prevent the closure of the vaginal passage. If the atresia is of small extent, und the incision sufficiently large, it will not be neces sary to take any special measures to secure this. But if the new passage is broad, or long, the maintenance of its patency will be the most difficult part of the after-treatment. The extreme tendency to contraction dur ing cicatrization unfortunately but too frequently interferes with the suc cess of our efforts.
Various means have been employed to overcome this tendency.
1. By wearing or introducing glass tubes (M. Sims, Emmet). In this way cicatrization is said to occur throughout the dilated tube. A num ber of successful cases have been recorded by the American gynecologists; but instances of non-success are not wanting, though they are ascribed to the neglect or the carelessness of the patients. The method is open to the objection that it readily causes decubitus. Indeed Galabin ' saw the pressure of a Sim's dilator twice cause an opening into the bladder, in a girl eighteen years old. And it hardly seems proper to accustom young girls to these manipulations, which can scarcely be accomplished without disagreeable secondary consequences.