While it may not always be possible to avoid this danger, the recognition of its importance will always contribute to the safety of the operation. Therefore Puech, Rose, and others advise above all that the operation be done as speedily as possible. This depends, however, as we have said, more upon the patient than upon the surgeon. It is important also to operate at the middle time between two menstrual epochs, so as to avoid encountering a renewed increase of volume of the retention tumor from the menstrual flow. During evacuation, not only must all external pressure be avoided, but the abdominal pressure must be removed. This latter result is to be obtained by skilfully conducted and complete arues thesia.' Much stress has been laid upon the importance of gradually emptying the tumor with a trocar, or by means of repeated aspiration with a canula or a Dieulafoy aspirator. But few cases have terminated favorably when this method was employed; and the unfavorable ones show us that the possible ill consequences of the operation are not to be averted in this way.
Though the plan appears to be a rational one, it is an unfortunate fact that with incomplete evacuation the dangers of septic infection are in creased. If septic infection does occur, the dangers of a secondary rup ture of the tubal sac are much greater, since the septic tissue-changes largely increase the friability of its walls; and the ulceration caused ex ternally by pelvio-peritonitic abscesses may also lead to a solution of con tinuity. It is my opinion that no small proportion of the ca,ses of tubal rupture have occurred in exactly this way; and I believe that Spiegelberg is right when, as reported by Elischer,' he classifies a number of Roae's c,ases of tubal rupture under the heading of septic infection. Here also, I think, belongs the above-mentioned and extremely interesting case of Billroth-Steiner. For the sudden collapse to be looked for in tubal rupture was absent, and the peritonitic symptoms first appeared accom panied with high fever upon the evening of the third day Chills, pleu risy, a foul-smelling genital discharge, and an erysipelas beginning at the genitals, followed. The autopsy showed that besides the septic exudatea which were found mixed with blood in the true pelyis, there were several small openings into the tubal sac, the tissue around which was in a state of decomposition.
If many cases of tubal rupture are dependent simply upon septic in fection, we are entitled to hope that with a more thorough prophylactic antisepsis many of these patients may be saved.
It would certainly be proper during the operation to take care that the retained blood be gradually evacuated, so as to avoid any sudden altera tion in the contents or position of the pelvic organs, and prevent a too rapid change of pressure. This must not prevent our fulfilling the antiseptic indication which demands that there be a free outflow of the retained blood. It has been sought to accomplish this by opera ting at two different times, the first time puncturing with trocar or exploring needle, and the other time doing the incision. The opera tion should under all circumstances be done at one sitting, and a suffi ciently free opening be made at once. We can provide for a slow outflow by allowing the thickened fluid to run out slowly through the preliminary puncture (see below) before making the freer incision. A few minutes are enough t,o allow a gradual adaptation of the pelvic organs to the altered relations. In seven cases of luematometra, with broad atresm, I was compelled to operate in two e,ases where a unilateral tubal sac had been diagnosed; yet no evil results followed from the operation. I thoroughly agree with Emmet in that the most important point in the unilateral operation is to establish a free outflow; and I attribute our good results very largely to our appreciation of this fact. (Comp. table.)
Bennert recommends that we distend the vaginal canal by permanent irrigation during the operation, and for a few days afterwards, so as to prevent a too rapid change of position of the pelvic organs.
We have no recorded cases to show whether this idea of Rennert's would really render an adherent tubal sac less dangerous, since the case of hymenal or retro-lymenal atresia in which he used it, was not complicated with luematosalpinx.
But not even all these precautions will avert all the dangers of a tubal blood sac. And it may be proper in some cases of hasmatosalpinx to do laparotomy and extirpate the tumor, or, if that is impossible, to practise incision and drainage. In both cases the laparotomy operation must pre cede the atresia operation, and in the latter the tubal sac must be stitched to the abdominal walls before the incision is made.' The third danger in the operation for vaginal atresia is that of septic infection, which has caused death in many cases with symptoms exactly like those of puerperal fever. Several gynecologists have preferred to divide the atresia with the thermo-cautery, thinking to protect the surface of the wound from infection by the eschar more thoroughly than by means of the ordinary antiseptic measures. It is very evident that this could only be done with very accessible or narrow atresias, such as atresia hymenalis or retro-hymenalis (M. Dune,an'), or with lateral luematokolpos (Neugebauer). For in cases where the guidance of the fingers is indis pensable, and where we work in the immediate vicinity of bladder, rectum, and peritoneum, some instrument which is not red hot must be employed. In suitable cases the method has been successful enough; but according to my experience, we can dispense with it entirely. The electrolytic action of the constant current has also been tried. Lefort ' reports that he thus succeeded in making an artificial passage through a vaginal atresia, on which ton previous operations had been tried in vain. He passed a cop per wire into the funnel-shaped blind sac, which was 14 inches long, and applied the constant current. He says that menstruation thereupon appeared regularly, the speculum could be introduced, and the portio seen. Several of the older observers thought that the entrance of air and the decomposition of the retained blood was the cause of the infection. Vidal' claimed as the cause of the entrance of air the previous dilatation of the uterus, which was; then unable to close. Scanzoni also calls atten tion to the danger of a septic endometritis, caused by the entrance of air; Clarke,' who believes that rupture of the tubes is caused by ulceration, fears the entrance of air, lest it start up the destructive process, and seeks to prevent it by the exhibition of secale and turpentine. It is undeniable that the decomposition of the stagnating menstrual blood which is left behind, is much more often the cause of septic endometritis and pelvio peritonitis than is the direct infection of the wound during the operation; explainable perhaps in that the bacteria find a very suitable nutriment in the decomposing semi-fluid matter. Infection during and after tbe opera tion will be avoided by the general care in reg,ard to the minute clean liness of instruments and of the fingers which is now the rule. When it is necessary we may disinfect the entire seat of operation, use the spray, and avoid all untrustworthy dressings; and afterwards frequently change the dressings after having steeped them in an antiseptic fluid.