In every case the indication is to open the sac, and keep it so; so that a free evacuation of the retained contents may be secured and the func tional activity of the genital system be restored. Unfortunately we can only completely fill the indication in exceptional cases, when the genital canal is a simple one and a thin septum and atresia hymenalis is present. In other cases it is rarely possible, although we may obtain fair results. In unilateral atresia the prospects of establishing a permanent opening by surgical means are better.
As is well known, the dangers attendant upon operation in these cases are by no means slight. Many examples show us that not only operations upon difficult cases with extensive defects of tissue, but simple measures in thin-walled and superficial atresias may lead to most fatal results. The correctness of the warnings which Dupuytren, Labatier, Cazeaux and others have given us in regard to these operations have been proven by the fatal cases which have occurred in the practice of such experienced surgeons as Langenbeck, Schuh, 1161aton, Billroth, cte.
The dangers of the operation are: 1. Injuries to neighboring organs. (Bladder, rectum, peritoneum.
2. Rupture of tubes distended with blood.
3. Septic infection.
The first danger is one which is only present when broad atresias caus ing considerable technical difficulties, are to be operated upon. The second and third, however, are present in all varieties. NVe will proceed to a more detailed consideration of these points.
In large defects and atresias of the vagina, where there is not simply an adhesion, but a connective-tissue obliteration of the lumen of the canal, a bloodless dilatation is out of the question, and injuries to the bladder and rectum can easily occur, and have been repeatedly done. To avoid them Emmet ' advises that after opening the dome of the blind sac with knife or scissors, a blunt instrument, a finger or the handle of the scalpel, is to be forced into the sac to enlarge the opening. While the atresia is being divided the bladder must be protected by a cathe ter, and the rectum by a finger introduced into it. Or the finger of the operator may be passed into the bladder, while an assistant may place his finger in the rectum. This is necessary even when the apex of the retention-tumor can be attained without the preliminary division of an atresiad stretch of tissue; since the bladder hiss been injured by the direct puncture of a trocar.' Where cutting instruments are used there may be considerable hemorrhage, as occurred in one of Hildebrandt's cases,' and tamponade may be necessary when irrigation, ice, etc., fail to control it.
Nevertheless a bad result even in cases of broad atresia occurs less fre quently from operative injuries than from rupture of the tube or septic infection. The former accident has especially attracted the attention of surgeons. To Rose belongs Ile credit of having demonstrated its impor tance by the collection of numerous cases which have been verified by post-mortem examination."rhe connective-tissue adhesions of the dilated
tube to neighboring organs, especially to the parietal. peritoneum, are of importance for the correct understanding of the mode of origin of these tears. They have been observed among others by G. Gosselin,' and recently, in Winckel's case,' by Birch-Hirschfeld. They are also to be seen in two preparations of the Prague collection, in which tubal rupture oc curred after the operation for hiematometra. The diminution in size and the change of position which occur in the uterus and the portion of the vagina above the atresia, after the evacuation of the Inematometra, cannot be followed by the adherent tubal sae; and the sudden contraction of the emptied tumor and the increased pressure from the abdominal walls, t,o which it is subjected, causes a rupture of the thin walls of the sac. In addition to this Nacke lays stress upon the sudden diminution of the pressure to which the tubal sac is subjected; which is especially to be feared when the hoematometra is large.' The uterine contractions, to which attention was directed by the older authors, and to which the pre ponderating influence in the occurrence of rupture has been ascribed more recently by Steiner, Billroth,' and Freund,' may act in one of three ways. It may directly express the uterine contents into the tube. This, hovrever, can wily occur in those rare cases where the ostium uterinum is much dilated. I know of but a single case of the kind, which has just been described in a foot-note. Then rupture from a sudden and consider able incre,ase of pressure in the tubal sac may occur from the propagation of uterine contractions into the tubes. It is not probable, however, that the chief cause of the occurrence is to be found here; for violent contrac tions may have been present before operation without causing rupture, and rupture may occur without any specially noteworthy contractions. Filially, contractions of the uterus and of the hypertrophied portions of the vagina may directly increase the tension to which the tube is already subjected by the changes in position and diminution in size of the emptied organs. This latter seems to be an important factor in influenc ing rupture. Nevertheless it is not to be regarded as alone responsible, since important and sudden increases of pressure may spring from other causes, such as the action of abdominal pressure. It seems to me that the tension upon the adherent tubal sac in consequence of the change in size and position of the evacuated organ, is the most important purely mechanical factor in causing tubal rupture. It hardly needs to be men tioned that in the times when the anatomic,a1 relations of the tubes in luematometrp, were less thoroughly appreciated tlusn they are now, acci dental external pressure upon the tumor or upon the abdominal walls may have determined a rupture.