The pain of such a tumor is more or less constant, but becomes worse with each accession of blood as the menses recur.
Treatment.—The treatment consists in opening the uterus, evacuating its contents and preventing their reaccumu lation. In a ease of absence of the va gina under my observation I was obliged to evacuate the contents of the uterus through the rectum, then, with a sound in the uterus (through the opening in the rectum) as a guide the perineum was in part torn and in part cut through until the uterus was reached. The home of the patient was in a distant town, and the false opening was unfortunately al lowed to heal. The menstrual blood re accumulated and the tumor recurred, I therefore felt justified in removing the ovaries subsequently producing, by grad nal cutting and dilating, a vaginal orifice about two and a half inches long, which has persisted and is apparently lined with mucous membrane. The health of the patient is now (five years since the oper ation) very good, and she has been able to earn a living in a useful occupation for a long time.
The transplanting of flaps, obtained from prolapse operations on otherwise healthy women, to the granulating sides of the artifieial vagina in cases of com plete atresia suggested. First an open ing is made between the labia in the position to be occupied by the new vagina, and then with a finger or a blunt instrument an opening is dissected up to the external os or through it if the cervical canal has been occluded. The eavity thus formed is tamponed with iodoform gauze, and kept distended in this way until the whole surface is cov ered with healthy granulations. Then transplanting may be done in one sitting or in several. Great care is necessary in the preparation of the flaps; they must be quite thin, of uniform thickness, and removed with great care not to injure the vitality of their tissue. The flaps, as soon as dissected off, are laid with their raw surfaces together in a warm_ sterile vessel until they may be used.. After the flap or flaps have been fitted. to the granulating surface they are in tended to cover, they are kept in place' with a tampon for ten days, during which time the patient must be at abso lute rest in bed. A. Mackenrodt (Cen tralb. f. Gyniik., No. 21, '96).
In congenital absence of the vagina operation to establish an artificial vagina should be performed, even if no uterus is present and no retained menstrual fluids require evacuation, for the sake of the mental impression upon the patient, as well as when she can be rendered normal by the operation. For, when this is
not performed, coitus will be performed through the urethra. Latouche (Archives Prov. de Chir., No. 4, '97).
In congenital absence of the vagina, a crescentic ineision is made across the interlabial space, with its concavity up ward, thus getting a little shelf of mu cous membrane below the urethra to divert the escaping urine. By blunt dis section a free cellular space is created between the bladder and the rectum, to the depth of five inches. This is tem porarily packed with sterile gauze. Thiersch skin-grafts are cut from the thigh sufficient to cover well an ample plug made thus: A thin French rubber pouch is sterilized by boiling and is stuffed with long strips of iodoform gauze to its full capacity. Upon this the skin-grafts are spread, with their wet sides outward and their edges freely overlapping. Numerous small punctures are made in the rubber after stuffing, so that the gauze-contents will receive any discharge lurking about. A piece of rub ber tubing the size of one's little finger, wrapped loosely about with iodoform gauze, is now inserted into the rectum, with the view of permitting free exit of gas during the subsequent days of en forced constipation. Finally the graft covered form is carefully passed into the new vaginal space, the walls of which are held apart by three deep retractors, which on removal allow- the fresh sur faces to come into closest contact with the wet surface of the grafts. To prevent the plug from being in the least dis placed, two silk-worm-gut stitches are passed across the vulva, transfixing the gauze-packed tampon, and are tied over iodoform-plugs at either side. For four weeks the patient is kept recumbent, the vagina being packed with gauze liberally smeared with lanolin, and afterward, when the new skin is quite tough, being dilated daily with large vaginal plugs and boogies, which are worn for a few hours at a time. Inevitable stenosis by cicatricial contraction reduces the orig inal canal to smaller proportions; hence, it should be made more than ample in the original design. Robert Abbe (Med. Rec ord, Dec. 10, 'OS).