Nevertheless the dilatation causes hypertrophy, and not thinning of the vaginal walls. In the specimens which I examined, the thickness of the hypertrophied vaginal wall above the atresia was ith to id of an inch; and in two alcoholic specimens it reached iths of an inch. The microscope shosved that it was the muscularis which was chiefly involved in the hy pertrophy. In the living subject I could very plainly convince myself, in four cases of atresia hymenalis, that with the hypertrophy there was a marked increa,se in the contractility of the vaginal wall.' This dilatation with hypertrophy may be well characterized by Rokitansky's term " ec centric hypertrophy." Fig. 12 gives an anterior and Fig. 11 a posterior view of a preparation (No. 164), which is opened so as to show the condition of the vaginal walls above and below the atresia.
The case was that of a girl twenty-three years old, who was operated upon by Professor Fritz, on the occasion of the meeting of the " Deutscher Naturforscherversammlung " at Prague, on September 21st, 1837, and who died upon the same day. There is no history nor record of autopsy; the preserved specimen appears as follows: External genitals normal; remains of hymen small, and absent at the rear; frenulum lab. preserved; vaginal entrance large. The lower part of the vagina below the atresia stretches 2.8 inches posteriorly and to the left, and two inches anteriorly and to the right, measured from the pos terior commissure. The mucosa is everywhere well preserved, without scars; the vaginal wall averages -A, of an inch in thickness. This lower portion of the vagina is closed from above by a convex mass with smooth mucous membrane, which bears some resemblance to an enlarged portio vaginalis. It is formed by the depressed and closed portion of the vagina, and is pierced towards its middle by an angular opening, which leads into the anterior wall of the upper and greatly dilated portion.
Above the atresia the vagina is perfectly smooth, much dilated, and ita walls are * of an inch thick. Its length is about two inches. The collum is also dilat,ed; the isthmus is marked by a constriction which can be seen externally; and the internal os is large and prominent. Length of collum is 1.4 inches. Its mucous membrane shows the net-work of an arbor vitEe; and over the body it has been somewhat shrunken by the spirit. The uterine wall at its thickest cervical part is .8 of an inch, in
the body it is .6 of an inch in thickness. The body cavity is small as compared with the common c,avity formed by the collum and the upper segment of the vagina. Uterus is 4.4 inches long, 3.8 inches broad be tween the opening of the tubes, and 1.8 inches broad at the isthmus. The left tube is much dilated, though it is not bent; and 1.2 inches from the ost. abdom. it is transformed int,o a thin-walled blood sac about .8 of an inch in breadth, which shows a longitudinal tear with irregular edge& In the neighborhood of this sac, the parietal layer shows peritonitie pseudo-membranous adhesions. Ovaries large and smooth; left shows false membranes. Right adnexa are free, tube not dilated, and no blood clots upon it. No trace of a fresh superficial corpus luteum.
The amount and quantity of the retained blood, depends upon the seat and duration of the atresia. In contra-distinction to what is seen in hEematometra, the blood in hEemalokolpos often contains a considerable admixture of vaginal epithelium.
In the section on Inematometra the effects of blood retention upon the tubes will be thoroughly considered. Here we need only state that the dangers of hsemato-salpinx only exceptionally end in a spontaneous and favorable way. This occurs wheu the membrane causing the atresia is thin enough to give way finally before the ever-increasing pressure of the retained fluid, aided by the force of the utero-vaginal and abdominal pressure. This occurred for instance in Zannini's case, where a girl twenty years old had hymenal atresia and retentio mensium for seven year& And the point of rupture is not always at the most favorable spot; Schaible saw one perforate the rectum, and in the cases of unilateral atresia to which we shall shortly refer, it most frequently occurs through the sep tum uterinum.
From the rarity and uncertainty of spontaneous evacuation, we must regard the prognosis of vaginal atresias which are left to themselves as bad, and the indications for operation are pressing in every case.
The diagnosis of congenital vaginal atresia will be aided by the history. It will be stated that the menses have never set in, though there occurred at first typical and later atypical molimena. In the meantime a tumor had developed. If the atresia is high up, it has grown upwards; if low down it has appeared in the pelvis, and has caused difficulties in urination and defecation.