2. By repeated dilatation with finger and speculum. This procedure, if done without amesthesia, is quite painful, and if done at first every two or three days, and late' _ess often, it is not liable to irritate the sexual nerves. It may not be out of place to mention expressly that the manipulation is not to be begun until the uterine cavity is entirely free from secretion, and the surface of the wound is everywhere covered with granulations; thus ensuring some safety against the dangers of infection. Until that time, about eight days, we must rely upon the canulfe to main tain the calibre of the canal.
3. By covering the surface of he new passage with mucous membrane or integument. Thus Ileppner ' proposed in 1872 to make an H-shaped incision into the skin, and thus to form skin flaps which could be sewn into the newly-formed vagina.
Without knowing anything of lleppner's process, B. Crede ' took from the left labium majus a piece of skin 2.4 inches broad and 4.8 inches long, leaving it attached to the perineum. With this he covered the wound, putting the apex towards the cervii, and stitching the edges to the bor ders of the mucous membrane. The patient was a virgin fifty years old, and had suffered from a high grade of acquired vaginal stenosis, which Crede had incised and then had dilated with a blunt instrument. The vagina was tamponed with iodoform gauze after the operation, and a catheter was allowed to remain in the bladder for five days. Three fourths of the wound healed prima int., the rest by granulation. The vagina remained enlarged, the hair of the flap causing no disturbance.
A. Martin,' who always sews the mucous membrane of the atresiad cavity to the external skin or the ne,arest sound mucous membrane, uses the vaginal mucous membrane to cover the canal in deep-seated atresias, suturing the mucous membrane of the cavity to it. Nevertheless he reports a case in which a marked cicatricial stenosis appeared.' Braith waite attempts by the transplantation of one or two strips of mucous membrane from each side of the vulva to counteract the tendency of the newly-established passage to close up.
It will readily be seen that the stitching of flaps of mucous membrane or skin into the new tract requires a field of operation freer than will usu ally be found available. If it can be done, it of course affords protection against complete obliteration, though probably not against stenosis. At
least Martin's observation would show this to be the case.
I have always employed the second of the three methods above de scribed, that of periodic dilatation, as soon as the canula first introduced has been in situ long enough. In two out of seven eases of broad atresia, I have observed a complete cure without noticeable stenosis after one or more years; two fingers or a medium-sized speculum being easily intro duced in either case. Of the remaining five cases, four were not seen after primary healing had occurred, while in the fifth a marked stenosis reappeared, though menstruation was not interfered with, and the gene ral health remained good.
Of course the result depends largely upon the extent of the atresia, and the amount of new connective tissue which is formed after the operation. The first condition is indeed beyond our control; but we may perhaps be able to limit the scar by attempting to secure a completely aseptic course for the operative wound. Where suppuration occurs, extensive strata, of the surrounding tissues will become transformed into cicatricial masses.
The table on succeeding pages gives the results of the cases which I have operated upon in accordance with the above principles.
Congenital vaginal stenoses are less dangerous to life than are the atresias. They cause no permanent retentio mensium, and only when the stricture is very tight do they lead to a temporary retention. These temporary retentions are overcome by the uterine and vaginal contrac tionS from time to time, marked dysmenorrhceal symptoms being present. The less the stenosis, and the nearer to 'the introitus vagina:, it is located, the les3 prominent will be the symptoms of irregular menstruation. Thus vaginal stenoses are generally brought to our notice as obstacles to intercourse and to childbirth.
They may occur at the hymen as a narrow opening of that membrane, or in the lumen of the vaginal canal. In the latter case we find at one or more, rarely at several places, contractions, usually of small breadth; and we perceive that the vagina is narrowed by prominent transverse or spiral ring-shaped folds. The broader stenoses are usually acquired; but there are some instances of broad congenital stenoses on record.