a thorough examination, preferably under ether, by using simultaneously a hand on the abdomen, a finger in the rectum, and a catheter in the bladder, and, taking the presence or absence of menstrual molimina into consideration, to find out whether the patient has a uterus and ovaries or not. If there is no uterus, no attempt should be made to make a vagina. It is not only hardly justifiable to expose the patient to the dangers of the operation merely in the hope of forming an organ of copulation, but experience has shown that the hope is futile. Where there is no uterus the artificially formed vagina closes again. The situation is entirely different if there is a uterus and the menstrual flow takes place internally. Then the operation becomes imperative, in order to save the patient's life, and by proper care the new-formed vagina may be kept pervious. If even ovaries are present, impregnation and childbirth may take place, but would be attended by great danger.

Modus Operandi.-The patient is placed on her back with her knees drawn up. The vulva is stretched from side to side. The mucous membrane is seized with a tenaculum, and a transverse incision made midway between the urethra and the anus. Now the operator works his way slowly and very carefully up between the bladder in front and the rectum behind, using a pair of closed blunt scissors and his forefinger to tear the connective tissue between both, and keeping a metal catheter in the bladder and his left forefinger in the rectum, until he reaches the os, which can be felt from the rectum. He introduces the scissors through the os, when the accumulated mucus and blood flow out. With a dilator he stretches the cervical canal about half an inch, washes out the uterus with warm solution of bicarbonate of sodium (3j-Oj) and after that with creolin (1 per cent.).

A hollow glass plug (Fig. 219) in proportion to the size of the newformed vagina is introduced into it, covered with antiseptic gauze and cotton, and held in place by a T-bandage. I think it is an improvement to have a hole (a) at the bottom of the plug in order to allow escape of fluid, and one (b) on each side of the rim from which a string goes to the bandage surrounding the pelvis.'

The wound heals over the plug, epithelial cells growing out from the vulva in the course of a month, during which time the plug is taken out and cleansed every day and the vagina disinfected. If healing is slow, it may be furthered by painting the raw surface once a day with a weak solution of nitrate of silver (gr. ij-3j). The patient should wear the plug daily for at least an hour during a whole year, but as this is tiresome and hurts some, she is liable to neglect it, and then the canal shrinks again from the uterus downward, and it becomes necessary to dilate it gradually or repeat the operation, which is 1 John Reynders & Co., cor. Fourth ave. and Twenty-third st., have made such plugs for me.

still more difficult and dangerous than the first time, when the tissue yields more easily.1

Other Methods for Keeping the Canal Open.-Instead of the permanent use of the plug, some prefer, after granulation is well estab

FIG. 219.

a

Vaginal Glass Plug.

lished-say, the end of a month-to dilate with finger and speculum every two or three days-a very painful procedure.

To cut out flaps of the surrounding skin and turn them into the new-formed vagina is not advisable, on account of the hairs growing on these parts; but flaps of mucous membrane have been obtained from the vulva and used with success. Thus, Küstner cut loose the labia minora to their posterior end, split them open by a longitudinal

1 On Jan. 25, 1890, I operated on Annie K, American, fifteen and a half years old, for absence of vagina, combined with uterus unicornis. She had for some time complained of severe abdominal pain; had a temperature of 101° and a pulse of 128. The hymen was normal, but the vagina was only a quarter of an inch deep. Through the abdominal wall, the vagina, and the rectum was felt a hard, slightly elastic swelling, nearly filling the pelvis, especially in the left side, and extending up into the left iliac fossa. I had to form a vagina to the full length of my indexfinger, 24 inches, and there was so little tissue between the bladder and the rectum that only a thin transparent membrane was left between the artificial opening and the rectum. There was no cervix, but the os could be felt far upward and backward. Finally, I succeeded in introducing the scissors into the os. A considerable amount of thick yellowish mucus, mixed with old blood, flowed out. The tumor diminished, and was washed out as stated in the text. She improved immediately, and made a good recovery, and menstruated three times while she was under my observation. She was ordered to use her glass plug one hour every day, but soon got tired of it. When I saw her again, about a year later, the upper half of the vagina had contracted again to the size of a cervical canal, just admitting the sound. She had a cyst in the left iliac fossa, without connection with the genitals, from which I evacuated a yellowish clear fluid. This was thereafter successfully treated with injection of iodoform ether, and I have not seen her since.

incision, and stitched them together so as to form a sac outside of the vulva, which sac he then stitched to the artificial canal formed between the rectum and bladder. In another case he successfully lined the hollow with the mucous membrane of a part of the resected intestine of another patient.

If the atresia is only partial, the wound may be covered by stitching the edges of the upper and lower segments of the vagina together.' Oophorectomy.-If absence of the vagina is combined with absence of the uterus, but active ovaries are present, causing menstrual molimina, the ovaries should be extirpated by laparotomy.

2. Double Vagina.-The vagina may be divided by a more or less complete longitudinal partition into two halves, each of which corresponds to one Müllerian duct. Commonly, but not always, double vagina is combined with double uterus.

The two halves of the vagina may be unequally developed, the larger one alone being used for coition. If this one is closed above, fecundation can, of course, not take place.

Instead of a long partition there may only be found a more or less narrow band as remnant of the original septum between the Müllerian ducts.

As a rule, a fully-developed double vagina does not give any trouble, and is discovered accidentally. If childbirth takes place, the septum is more or less completely torn.

Treatment.-If the septum interferes with coition or impregnation, it may be split lengthwise. Both halves are distended with specula and retractors, so as to put the septum on the stretch, and then it is severed midway between the anterior and posterior walls by means of the thermo- or galvano-cautery.

A mere band oftener causes dyspareunia and dystocia, and may be severed with scissors. If there is any bleeding, it is checked by cautery, styptic cotton, or tampon. If the band is fleshy, it is preferable to tie near the two ends and cut out the middle piece.

Double Vagina with Atresia.-Double vagina may be combined with atresia on one or both sides. If one side is pervious, menstruation and impregnation may take place, and the condition is, therefore, often overlooked for a long time. The right half is much more liable to be closed than the left. The uterus is with few exceptions two-horned.

Menstrual molimina, due to retention in the closed half, are present, combined with menstrual flow through the open half. The tumor formed by the retained fluid bulges very much into the latter, and may distend the vulva and interfere with micturition. The upper part of the tumor lies on the side of the uterus. The lateral atresia leads much more frequently to spontaneous rupture than 1O. Küstner, Centralblatt für Gynäk., vol. xvi. No. 23, p. 533, June 10, 1893.

atresia of the single vagina, and the perforation always takes place in the septum of the cervix uteri; but this does not effect a cure. The contents are only partially evacuated, air and microbes enter, the stagnating fluid becomes purulent or putrid (lateral pyocolpos and pyometra), and causes inflammation and ulceration of the walls. The inflammation may extend to the tubes and the peritoneal cavity. At times the tumor increases again in size until, after great pain, a new discharge takes place through the opening in the septum. For diagnostic purposes it is of importance that pressure on the vaginal tumor causes a purulent discharge through the os uteri of the open half of the vagina.

Diagnosis.-Lateral atresia has been taken for hematocele, but the history of a chronic disease with monthly exacerbations, and the shape and position of the tumor, will help to avoid this mistake. In lateral atresia the tension of the wall often varies at different times, and if it is not very great it is sometimes possible to invaginate the lower part of the tumor and feel the muscular ring formed by the os.

If the septum is situated very high up, the tumor may also be confounded with cysts adherent to the uterus or a myoma in the wall of the latter. An exploratory puncture may become necessary to settle the diagnosis.

Treatment.-Sims's speculum is introduced in the open half, and the septum slit open with knife, scissors, or preferably thermo- or galvano-cautery. În cases of double atresia one side is first opened, as in atresia of the single vagina, and afterward the septum incised.

3. Blind Canals.-Immediately above the entrance of the vagina, laterally, are occasionally found blind canals, which may be an inch and a half long and wide enough to admit the little finger. They are lined with smooth mucous membrane, and are probably only unusually developed lacunæ. They are without practical importance, except that they may become receptacles for gonococci. If the affection cannot be cured with injections, it may become necessary to lay the canals open.

4. Faulty Communications.-Familiarity with the history of development (p. 31) allows us to recognize as consequences of developmental arrest certain abnormal conditions sometimes met with. Thus we have complete atresia-i. e. absence of any opening on the cutaneous surface leading into the intestinal or urogenital canal, while under the skin is found a common cloaca into which open bladder, vagina, and rectum. The next step in development is represented by cases where this cloaca has an opening on the surface of the body. The rectum opens apparently into the vagina or vulva (atresia ani vaginalis or vestibularis.) It may have a sphincter or not. In other cases the vagina and the urethra apparently open into the rectum, but in reality these cases are only modifications of a persistent cloaca.

If the development has been arrested still later, the partition between the rectum and the urogenital sinus may have been formed, but the urethra seems to open into the vagina. This is really due to a persistent urogenital sinus.

Complete atresia is only found in non-viable fetuses. The other conditions hardly ever become the object of operative interference. If the rectum opens into the vulva or vagina, an artificial anus might be made; but if there is a sphincter, it might lose its innervation, and the patient be left in a worse condition than she was before. In very rare cases there is a normal anus, but a communication between the rectum and vagina higher up-a congenital rectovaginal fistula. This may be closed in the same manner as the acquired fistula.

It is likewise very rare that a ureter opens into the vagina instead of the bladder. This may be loosened and fastened with sutures in the wall of the bladder.'

CHAPTER II.

VAGINAL ENTEROCELE.

VAGINAL ENTEROCELE, or vaginal hernia, is a tumor formed by the intestines, and sometimes the omentum or ovary, by inverting the vaginal wall. Sometimes the protrusion takes place through an opening in the muscular coat of the vagina, so that there is a hernial ring, and the prolapsed intestine is only covered by the mucous membrane. Commonly this protrusion begins in Douglas's pouch, but it may also occur between the uterus and the bladder, or in the scar left by vaginal hysterectomy.

Causes. The hernia may be caused by a fall, lifting a heavy burden, straining at stool, but most commonly it is due to pregnancy and childbirth.

Symptoms. In acute cases there is a sudden pain and feeling of a rupture. If the development is chronic, there is a dragging sensation, constipation, and dyspareunia. No case of strangulation is known, but during childbirth a dangerous pressure is exercised on the tumor when it is being pushed down in front of the presenting part. On examination is found a pear-shaped, soft tumor protruding in the lumen of the vagina or descending through the vulva. It increases on cough, can be pushed up into the abdominal cavity, may give a gurgling sound on handling, and, if accessible in front of the vulva, will give a tympanitic percussion-sound.2

W. H. Baker of Boston, New York Medical Journal, Dec., 1878.

2 On account of the great rarity of this affection the following notes of the only case I have ever met with may be of interest: Elise V., æt. 27, widow, unipara,