There is another reported case, aiso, where the uterine body was well formed, but the cervix was closed, and mucus, not blood, collected in it. (Bryk.) This, of course, can only occur in amenorrhceic persons. The deeper-seated the atresia, and the more nearly normal the body of the womb, the more likely is hematometra to form. Of course there can be no conception, at all events until a passage is made and maintained through the closed spot. There are but few reported cases where pregnancy ensued after the operation for pure hematometra (not hematokolpos with imperforate hymen). Possibly the uterine mucous membrane undergoes such changes from the long-continued collection of blood, that adherenoe of the ovum cannot take place.
So that if there occur no bloody effusion into the uterine cavity, the phenomena will be simply those of a rudimentary uterus.. If effusion does occur, we have sooner or later all the symptoms of hematometra.
In those cases in which the uterus itself is membranous, yet not dis tended with blood, the diagnosis may be made by the blind-sac ending of the vagina, and by rectal examination. Through the anterior rectal wall we can feel the reg-ularly shaped uterine body, while the characteristic lower prolongation is entirely absent, or is only indicated by a diffuse thickening. If the cervix appears normal externally, and there is atresia of the canal, the sound will give us information. But it is usually only when hematometra forms that we are called upon to make a diagnosis. We will then find the vault of the short vagina closed by a thick, elastic, sometimes faintly fluctuating membrane, and a fluctuating tumor can be perceived per rectum.
If the membrane is thick, the vagina is probably also involved; if the hematometra is relatively small, and the membrane relatively thin, there is probably an atresia of the external os uteri, which may sometimes be seen as a small depression upon the surface of the occluding membrane.
Amttssat and Petit have observed an exquisite case in conjundion with Boyer, Magendie, etc., which, though described as vaginal atresia, is shown by the records of the operation, and the subsequent examination by Amussat and Mme. Boivin, to have included the os uteri in the atresia.
Amutosat found in a girl sixteen years old a hematometral tumor and almost complete absence of the vagina. After long consultation it was decided to make an artificial one. Amussat penetrated gradually two inches through the loose connective tissue from the rectum, and then came to a body whose size and hardness resembled that of the uterus, though there was no cervical canal. This tumor was connected with the larger abdominal one. It was pierced with a trocar, the puncture enlarged with a bistoury, and the retained blood flowed out. Amussat could not decide whether the cavity, into which he could put his finger, was the upper part of the vagina or the uterus. He found that an arti ficial vagina one inch long had formed, partly out of the fistulous vulvo uterine canal. The vulva had sunk in towards the tumor, and had ad
hered to it; and he regarded the fistula as a utero-vaginal one. This history, together with Mme. Boivin's later examinations, justifies us in regarding the case as one of rudimentary cervix.
Specific treatment for the condition will generally only be necessary when hematometra has formed. Rectal puncture should be avoided if possible; an opening per vias naturales is to be preferred. If the partition is membranous, the trocar may be used; if thicker, we must employ the knife. Simple puncture and evacuation is not sufficient, since there is a strong tendency for the canal to contract. Lining the canal with mucous membrane, by uniting the vaginal and uterine mucosa, is advisable. The following case, which very probably belongs in this category, will illustrate the difficulties of these operation& B. A., twenty years old, well developed. Since four years, abdominal cramps for four to five days every four weeks. The abdomen enlarged, bat no menstruation set in. Two years ago an operation was done, after which there is said to have three times appeared a scanty menstruation. Then the cramps returned, and for their relief the patient applied to the gynecological clinic here.
Examination revealed a fist-sized, elastic, somewhat movable tumor, between navel and symphysis. Vagina was a blind sac 1/1., inches long. Bi-manual examination showed a cystic thick-walled tumor above the vagina, almost entirely filling the pelvis.
The vaginal was opened with the knife, the finger pressed forward, and the cyetic tumor punctured; a meconium-like mass was evacuated. The opening was enlarged with the knife, and the mucosa or the sac and the vagina united to one another. The sac turned out to be not the vagina, but the dilated uterus; and near the uterus lay a lax cystic body which slowly emptied its contents into that organ. It was finally concluded that there was a uterus bicornis, both horns of which were distended with blood, and that the cervix together with the upper part of the vagina had been obliterated. This diagnosis was strengthened by the results of examination a year later, when through theanterior rectal wall a body could be felt which resembled the corpus uteri in size and shape, and attached laterally to which was an egg-sized tumor. A fine sound could be passed from the vaginal blind sac into the womb. Men struation abundant and regular. It was very probably a case of atresia, utero-vaginalis.
It is a question whether an operation to open up the obliterated parts is justifiable simply to render cohabitation possible. With our present methods of treating wounds the dangers of the operation are much re duced. I think perhaps that the patient herself should decide. The operation is not hopeless, especially when we consider how often the im petus coeundi alone has sufficed to form a receptaculum penis when the genitals were lacking.