Vaginal atresias with duplexity of the genital canal which have been operated upon for the relief of retention, have so far only been seen uni laterally.' They cause hrematometra and hmmatokolpos lateralis. In a simple vaginal canal they may be seated at the hymen, where, as is by no .means always the case, that organ is double. The case that Simon and Veit observed together is of this kind. Much more commonly more or less of the lower end of one half of the vagina is wanting. (Fig. 16.) Unilateral accumulation of menstrual blood causes molimena ex-reten tione to oocur together with regular menses, and a tumor to appear at the side of an apparently simple uterus. It was therefore long overlooked, and is even now usually recognized only at the autopsy. Only since about 1860, has the subject been elucidated by the observations of Hoist,' Veit,' and Simon,' as also by Schroder's • critical studies of the diagnosis of hmatocele retro-uterina. Since that time the number of cases observed has grown very numerous.' Puech (comp. below) has drawn attention to the great preponderance of closure of the right side, finding it in 20 out of 28 cases; and the cases not included by Puech in his lists confirm his conclusions. With rare exceptions the uterus is bicorned to a vary ing degree in all these cases.
It is very evident that in this affection also the symptoms will not appear until menstruation sets in. Thereafter they increase with each menstrual epoch. Their regular appearance in youth is a circumstance whichVeit has laid stress upon for differential diagnosis.' They are ex actly analogous to the troubles caused by congenital atresia with simple genital canal, and are due to the development of retention tumors, here characterized by their lateral situation. If the closure is not quite high tip in the vagina, the blind sac is driven down, and, though not situated near the vaginal entrance, may cause opening of the vulva and a moderate prolapse of the vagina. Urinary difficulties are comparatively frequent.
Menstruation may remain quite normal in type and quality, though it is sometimes irregular; the complications which occur are due to the fICCOM panying unilateral stasis and catarrh of the patent portion of the uterus and the vagina, and the patients often suffer from leucorrhcea. As is noticed in the section upon uterine diseases, the distension of the womb may be very considerable here also; and as Puech points out, rupture of the tubal blood-sacs occurs relatively more frequently here than with sim ple atresias, it being observed 3 times in 32 cases as against only 25 times in 500 cases of the simple variety. And spontaneous perforation with evacuation into the vagina can more easily occur here than in the latter class of cases. In Puech's 32 cases it was seen 4 times, the perfo ration always occurring in the septum colli uteri. (Fig. 17.) Two recent cases observed at Tfibingen (Neudorffer, Tueffel) belong here.
Unfortunately, however, perforation at this point causes the relief ob tained from the hmmatometra, to be but a temporary one. The patient
remains exposed to the dangers of pyometra and pyokolpos, as I first proved in two cases of my own. This occurred from the appearance of a purulent catarrh of the mucous membrane of the utero-vaginal space. The necessary conditions are a partial stagnation of the retained blood and an imperfect outflow from the small orifice in the septum cerv. ut. Pur ulent decomposition manifestly begins in the open side. When purulent catarrh has once set in, the retained secretion causes still further dilatation and explains the obstinacy of the process. As the pus accumulates the tumor enlarges; until finally an abundant flow of matter comes from the cervix and the vagina of the patent side. Immediately the patient feels relieved. But the sac soon refills, and the pus in the course of time becomes thin and very foul-smelling. The patient loses flesh from the constant loss, and the attacks of pain and the evacuation of the malo dorous pus annoy both the sick woman and her friends. More than this: A number of serious dangers threaten the patient from extension of the inflammation to the tube, from ulceration of the diseased mucous mem brane, from the development of pelvio-peritonitic abscesses, and from the secondary consequences of these occurrences. The lesions found by Rokitansky and by Wrang' post-mortem bear out this opinion. Neither case was diagnosed during the patient's life. The latter one occurred in Seyfert's clinic, and Saxinger has lately completed the description of it given by Neudarfer in his dissertation by a careful history. Its entire clinical aspect is that of a pyometra lateralis.
We can only designate the prognosis of cases of luematometra and luematokolpos, which are left to themselves, as unfavorable, even when spontaneous perforatio septi and evacuation occurs. Pyometra and pyo kolpos regularly set in, and bring renewed danger to the patient. These eases, therefore, always require artificial aid.
The diagnosis of unilateral vaginal atresia is connected intimately with that of unilateral luemato- or pyometra with retention. As Veit remarks, it is not difficult when we once fully appreciate the possibility of the occur rence of the abnormality, and remember that the symptoms are those of hmatometra with flowing menses. The anamnesis will reveal the char acteristic symptom of menstrual colics during the formation of the lateral and vaginal tumor. If there is pyometra and pyokolpos lat., our patients will tell us that after the above-mentioned. troubles have been present for some time, there suddenly occurred an evacuation of blood. This gave great'relief, but only for a time; new retention pains appeared at the old place, and an abundant purulent genital flow set in. Often they will tell us that considerable quantities of thin foul-smelling pus have been voided from time to time, to their great temporary relief.