The evacuation of the luematornetra is not always spontaneous; but the conditions of incomplete drainage also occurred in cases where puncture was done.' In a single case of unilateral retention, and one in which hydrometm lateralis was present,' there was an entire absence of any history of a pre vious luematometra.
In every case examination reveals a tumor beside the uterus filled with fluid, which projects more or less deeply into the vaginal lumen in accord ance with the height of the occluding septum. Often the vaginal portion of the tumor projects forward; and several times the closed half of the genital canal has been seen applied in spiral fashion to the open half. Fluctuation can be felt between the upper and the lower portions of the tumor. If the vaginal portions are unseparated; the os uteri, as Veit remarks, will take a lateral position as regards the tumor, forming an elongated, crescentic opening with its concavity directed to the occluded side. If the tension of the tumor's contents is not too great, the vaginal portion of the tumor will be recognized as being softer than the vaginal portion of the uterus. Often) as I have recently seen renewed proof of in the case Johannowsky has described, we can distinctly appreciate vari ations in the tension of the vaginal tumor, due to contractions of the sac. After the sac is opened the smooth vaginal portion may be distinguished from the uterus by the ring-shaped os. When the mucous membrane of the exposed sac is scraped with a curette, we can sometimes get epithe lium characteristic of vagina or uterus. This I succeeded in demonstrat ing in two cases in which there was only a short rudiment of the vagina present. The dia.gnosis will probably be easiest in those cases in which the unilateral atresia is at the vaginal entrance, and in which the cylin drical tumor runs the whole length of the vagina. It will be especially easy when, as in Simon's case, the bloody contents of the tumor can be seen through the transparent-sae-wall.
Pyometra and pyokolpos will give us a tumor with the same situation and characteristics; and pressure upon the vaginal tumor will cause pur. to appear freely in the vagina from the os if spontaneous perforatio sept. ut. has occurred, and from the puncture or incision if there has been an artificial opening made.
As Schroder has shown, the differential diagnosis of unilateral atresia is chiefly with luematocele periuterina; before our more exact clinical knowledge of to-day more than one case of atresia has been confounded with it. (Comp. the section on litematocele.) Besides the history, the
shape and the location of the tumor, the characters described in the foregoing sections ought to suffice for diagnosis. In high-seated atresias, forming a broad flat tumor, it is not impossible to mistake the affection for a cystic tumor of the ovary or tube attached to the uterus or true pelvis; or even, as I myself once saw, with a large laterally-seated soft myoma. In this last case an exploratory puncture will decide the matter.
The treatment of congenital vaginal atresia only becomes a necessity after puberty has set in, except in those rare cases where the collection of catarrhal secretion within the sac necessitates surgical interference in childhood. Most authorities have rightly held that the demonstration of a blood-retention tumor is a sine qua non for the operation; since only when this is made can we be certain of the dilatation of the atresia and de cide upon the direction of the incision. We are then sure also of the existence of a uterine cavity above the atresia. These considerations are of the greatest importance. It would be very desirable, if it were possi ble, to prevent the difficulties and dangers of the condition by a prophy lactic operation. At presmt we can only attempt it in cases of atresia hymenalis. The closed hymen can be recognized without any great accumulation of fluid behind it; it can be drawn down with sharp hooks and then incised. But even in these cases the differentiation of the con dition from other deep-seated atresias may be rendered difficult by excessive firmness and thickness of the membrane; and if, in the adult, amenor rhoea is present, so that retentio mensium does not occur, repeatettattempts at coitus may so invaginate and displace it as to render its recognition almost impossible. Seyfert demonstrated a case of the latter kind in my presence. But as a rule, there is no question as to the time for interfer ence. The patient does not present herself for examination until violent molimena-menstruatia and blood-stasis symptoms have set in. In fact they rather allow the accumulation to continue as long as they can bear it before seeking aid; and they do not as a rule come under our observa tion while the accumulation is confined to the utero-vaginal tube, and before the pernicious tubal blood sac with its pseudo-membranous adhesions, have been formed.