fluids in the vaginal cul-de-sac, and purulent catarrh of the dilated portions of the vagina and uterus, which in turn leads to increased dilatation. This process finally causes another perforation through a thinned portion of the uterine wall, and the same changes are repeated. The pus becomes putrid, ulceration of the inner surfaces of the uterus and Fallopian tubes follows, and death resulting from pelvic peritonitis and exhaustion.* Lateral pyocolpos may also follow incision of the vaginal sac, provided the opening be too small, e. g., Braus's case.† In one case reported by Breisky himself, the left-sided lateral pyocolpos, from a congenital rudimentary vagina, had not been preceded by a hematometra.‡ According to Veit, the unobstructed portion of the vagina in unilateral atresia may be recognized by its position with regard to the tumor, and by a crescent-shaped orifice, with its concavity towards the closed side. In my cases, this was not particularly characteristic. The walls of the sac are subject to variations in tension, partly from a decrease of the contained fluid by absorption during the intermenstrual intervals, and partly resulting from contractions of the walls. If any doubt exist as to the dimensions or origin of the tumor after it has been incised or punctured, these questions may be decided by a microscopical examination of the material obtained by scraping out the sac with a spoon. In lateral pyocolpos pressure upon the tumor will evacuate more or less putrid pus through the os uteri and vagina. Finally, other tumors originating in the uterus or ovaries, e.g., myomata (Breisky's case), or a cystoma or sarcoma may be mistaken for lateral vaginal atresia and hemato- or hydrocolpos. An exploratory puncture or incision will determine the diagnosis in such cases. The prognosis is good, as long as the accumulation of the secretion is confined to the uterus and vagina. Unfortunately, such cases are rare, for usually the distension extends to the tubes, and all these are dangerous, since rupture of the tubes is very liable * See cases by Wrany, Rokitansky, and Breisky, l. c., p. 32. Berliner kl. Wochenschrift, Nos. 10 and 11. Archiv f. Gynaecol, Bd. vi., pp. 89–102. to follow the most careful evacuation of the hematometra (e. g., Ponfick's and others). Rupture is most frequent in unilateral hematocolpos, as has been proven by Puech. My own case unfortunately resulted fatally from this accident. It is, in a great measure, due to the fact that in such cases the affection is far advanced before a physician is consulted. Treatment.-After a vaginal atresia has been recognized, the first question in regard to the treatment is, as to whether there is a retention of secretions or not. If there is not, but if the atresia is associated with a normal uterus as ascertained by examination per rectum, its incision is indicated when the symptoms render the patient uncomfortable, even though no retention tumor be yet developed. Fischel has considered this condition in detail. Acting in harmony with this view, I once incised an acquired atresia of the middle portion of the vagina, originating after the puerperal period. Upon puncture of the septum, at first only a tablespoonful of thick mucus was evacuated. The incision was followed by dilatation with gentian root of the constricted canal, with a favorable result. In 1882, I performed a similar operation, with good results, upon a woman who had had one child, had previously menstruated normally, but later, probably in consequence of an infectious colpitis, suffered from an extensive atresia of the upper part of the vagina, not attended, however, by any considerable hematocolpos, though the atresia had existed for several months. But if neither the uterus nor ovaries can be reached through the vagina, the formation of an artificial canal will be of no benefit, since it cannot be kept open, and will not lead to any evacuation. Two patients of this kind whom I treated in Rostock, had Basedow's disease, in addition to the atresia; in these cases, since the patients suffered much, I took great pains to establish and keep open an artificial canal to the uterus, thinking that perhaps there might be a cavity and some retained blood in this organ, which was very small and hard, but the attempt failed. If there be an atresia, with accumulation of secretions, these must be thoroughly evacuated, and the canal kept open, so that not only the menstrual fluids may be discharged, but that conception and labor may occur. The operative measures necessary to accomplish this are, in many respects, dangerous, directly from the possibility of injuring adjacent organs, indirectly from the probability of causing rupture of the tubes and septic infection. Even experienced operators have injured the bladder, rectum, or peritoneum in cases where the atresia was extensive, and the septum between the bladder and rectum very thin; he who has operated upon such cases knows how thin this septum, through which a canal must be formed, may be. In such a case, I adopted the following method: I introduced a catheter, and evacuated the bladder; then passed the right index finger into the rectum, and around the tumor; a trocar, held in the left hand, was forced through the septum lying between the catheter and the finger. After some blood had flowed through the canula, a bistoury was passed by its side, the opening enlarged to the right and left, and the cavity evacuated as thoroughly as possible. In this case, hematocolpos and hematometra alone existed, and the large opening and rapid evacuation were attended with no danger. If in addition to the uterus the tube be distended, the blood must be slowly evacuated, lest a too rapid discharge cause dragging upon and rupture of the tube, which is usually adherent to the adjacent tissues. All pressure upon the abdominal walls is to be avoided, and the anaesthetic administered when the stomach and rectum are empty, to guard against vomiting and straining. The entrance of air into the genital tract and septic infection are to be prevented by attention to the position of the patient, avoiding the high dorso-coccygeal, knee-elbow, and lateral posture, and making the incision under spray with thoroughly disinfected instruments. The parts should not be examined with the finger or sound for several days after the operation. Scanzoni and Baker Brown advised puncture of the hematocolpos through the rectum to avoid the above mentioned source of infection, but in addition to the tendency of such a small opening to unite and produce the former condition, there is always danger that gases will find entrance from the rectum into the retention sac and cause decomposition of its contents. G. Simon, therefore, recommended incision of the tumor through the bladder, thus producing a condition similar to that in the transverse obliteration of the vagina, or where the posterior lip of the os uteri is used to close a large opening in the wall of the bladder, but it is known that stone, cystitis, and pyelitis, usually supervene, and the operation, therefore, cannot be recommended. Moreover, the bladder has been injured with the trocar as in the case cited by Breisky, where septic phlegmon of the pelvic connective tissue followed, and, since the new canal is kept open with great difficulty after the puncture, Breisky has recently proposed this method: Following Emmet's suggestion, he first makes a passage through the atresia by cutting into the skin with the scissors; the assistant's finger is passed into the rectum, a catheter into the bladder, and the operator's finger pressed into the wound tears apart the tissue of the atresia, firm resisting bands only being divided with the scissors. As soon as the vicinity of the os uteri is recognized as a circular, yielding point, a long-handled lance-shaped knife, having the canula of a trocar fitted to the base of the blade by a spring, is forced through the external os, pushed forward, and an incision 1 centim. (in.) long is made on each side, thus making a wound two centim. (in.) in width; the blade is then drawn back, the canula pushed forward into the wound, and over it a branched canula introduced. Now the trocar is withdrawn, the branches of the last canula spread apart, and a fenestrated double tube of silver 6 or 7 centim. (2.3 to 2.7 in.) long, as thick as a No. 12 catheter, and perforated at its lower end, is introduced into the newly made canal. Breisky uses a silver tube 15 centim. (nearly 6 in.) long, and which fits into one of the perforations in the head of the double tube, for the purpose of introducing the latter and for irrigating through it. After a few days, when the uterus has retracted, the double tube is changed for one 6 centim. long and not so thick, which may be worn until after the next menstrual period. After the first introduction of the canula Breisky uses injections of carbolized water, places a compress wet with chlorine water upon the external genitals, gives 10 drops of wine of opium internally, applies cold compresses to the abdomen, and insists upon strict rest, and injections of a tepid carbolic solution through the canula for the first five days, twice a day, then once a day. If there be fever, give quinine internally. If one should find a second septum above the first, as in cases described by Steiner and others, this must be incised and treated in the manner just described. The earliest reported case of this kind is probably that reported by Delpech.* By this method of treatment dilatation is not made at once, but the canal is kept open simply by the canula which remains in it; later, when all danger from the hematometra has passed by, the canal may be dilated by laminaria, tupelo, etc., from time to time, a form of dilatation which will be assisted by cohabitation. OTHER MALFORMATIONS OF THE VAGINA. (A.) Absence of the Vagina. Complete absence of the vagina includes those cases where no band-like atresiæ can be found, and where the septum between the bladder and rectum is so thin that scarcely a layer of connective tissue can be recognized, still less the muscular rudiments of a vagina. This occurs only in connection with a defect of the vulva or uterus. Such cases have been reported by Dupuytren, Samter, Ramsbotham, Rossignol, Ebert, and others. Recent authors have observed the above definition, but since all cases have not been anatomically examined, the diagnosis of some remains in doubt. Rossignol found the breasts rudimentary, form slight, the face infantile, and venereal desire absent. Cunningham confirmed the diagnosis of absence of the vagina by an autopsy. (B.) Abnormal Narrowness and Shortness of the Vagina. Women or girls who have reached the age of puberty may have an infantile vagina associated either with a foetal or infantile Scanzoni measured some vaginæ with a diameter of 4 uterus. * Mémorial des Hôpitaux du Midi et de la Clinique de Montpellier, Août, 1830, ref. in Froriep's Notizen, Bd. 28, p. 240, October, 1830. |