The sound shows the cavity to be enlarged; its use causes hæmorrhage and even flooding.

The differential diagnosis is here often very difficult, as these conditions are also present in

Chronic endometritis (hæmorrhagic type),

Small fibroid tumours (interstitial or polypoidal),
Carcinoma.

Curetting the surface with microscopic examination of the scrapings, will help us in the first case.

Scrapings from a fibroid tumour to show the size and form of the muscular fibre, their rod-shaped nuclei-stained, 20; drawn by S. Delépine.

Fig. 297.

Scrapings from a spindle-celled Sarcoma to show the larger size of the spindle cells and their oval nuclei-stained, 240; drawn by S. Delépine.

The removal of the polypoidal mass, with the finger nail or nailcurette, will enable us to examine its nature; the possibility of both conditions being present, polypoidal fibroid + commencing sarcomatous degeneration, must be remembered. With an interstitial thickening,

we can only watch the progress of the case.

In carcinoma of the fundus, there is generally excavation of the uterine wall and the base of the ragged surface is harder than in sarThe examination of scrapings is not always decisive, as the cells found in sarcoma sometimes closely resemble epithelial cells.

coma.

In all cases of doubt we must watch for a few months, when the rapid growth of the tumour or the development of cachexia will clear up the case.

PROGNOSIS.

The prognosis is grave. Compared with carcinoma, its development is not so rapid nor are the symptoms of pain and offensive discharge so aggravated in the early stage. In two of the cases recorded by A. R.

Simpson the patient survived for four years after the diagnosis of sarcoma was made out, and Gusserow mentions a case where the course was prolonged for ten years.

The temporary relief procured by removal is longer of duration than in carcinoma. No case of radical cure is, as far as we know, recorded; after removal it reappears at periods varying from two to fourteen months (Clay). When it returns, the development of the new tumour is more rapid than that of the first growth.

As to the communication of the prognosis to the patient and friends, see under Carcinoma.

TREATMENT.

The tumour should be removed as soon as we suspect malignancy. Even when there is doubt, its removal will clear up the case.

The cervix should be well dilated so as to allow the finger to pass freely into the uterus. Gradual dilatation is preferable; injury of healthy mucous membrane in dilating or curetting should be avoided, as sarcomatous cells have become engrafted on a fresh wound surface. When circumscribed and polypoidal, remove it with the finger nail or nail-curette. After its removal apply carbolic acid thoroughly to its base.

When diffuse, curette the uterus. Continue the scraping till all the loose tissue and irregularities of the mucous membrane are removed. After curetting the surface of the uterus, examine with the finger to ensure that all is removed and apply carbolic acid freely. When the os is widely dilated and the seat of the growth low down, cauterisation with Paquelin's cautery would be even more effectual. Clay injected perchloride of iron after curetting, and without any bad result; the application of the caustic on a rod is safer.

Extirpation of the uterus offers the only hope of radical cure (v. p. 459).

SECTION VI.

AFFECTIONS OF THE VAGINA.

THESE We shall consider in the following order :

CHAPTER XLIII. Atresia Vaginæ.

XLIV. Inflammations of the Vagina: Vaginismus: New
Formations.

CHAPTER X LIII.

ATRESIA VAGINÆ.

LITERATURE.

Barnes-Op. cit., p. 219. Breisky-Die Krankheiten der Vagina: Stuttgart, 1879. Delaunay Étude sur le cloisonnement transversal du Vagin etc.: Paris, 1877. Dohrn-Angeborne Atresia vaginalis: Archiv. für Gynäk., X. 3. Emmet-Op. cit., p. 202. Congenital Absence and Accidental Atresia of the Vagina, etc. Trans. Am. Gyn. Soc., II. p. 437. Puech, A.-Des Atrésis complexes des voies génitales de la Femme: Ann. de Gynécolog., Paris 1875. Simpson, Sir J. Y.-Op. cit., p. 256. Simpson, A. R.-Op. cit., p. 195. Thomas-Op. cit., p. 220.

ATRESIA (a-Tρños, non-perforation) has been already defined as occlusion of the genital tract where the obstruction is complete and leads to accumulation of menstrual blood or mucous secretion. This occurs at three places--the hymen, the vagina, and the cervix uteri. Atresia of the cervix has been already described (v. Chap. XXIV). Accumulation of blood in one half of a septate uterus or vagina will be considered by itself at the end of this chapter.

PATHOLOGY.

1. ATRESIA HYMENALIS. The structure of the normal hymen has been already described (page 6). In atresia hymenalis it forms a continuous membrane, is thicker and of an almost cartilaginous toughness; this explains the rarity of spontaneous cure by rupture of the membrane. This condition is produced by the occurrence of inflammatory adhesion of the folds after their formation, that is after the nineteenth week of foetal life. When the vagina is distended with menstrual blood, the hymen bulges forwards. As the menstrual blood accumulates, the vagina distends so as to form a tense membranous-walled sac nearly filling the pelvis with a smaller firmer body (the undilated uterus) rising from its upper surface (v. fig. 300). If the tension be not relieved, the cervix next becomes dilated and may rupture. Finally the uterus itself becomes opened out, though this

does not occur till late.

During this period accumulations of blood may take place in the Fallopian tubes in the form of diverticula, usually situated towards the fimbriated end (fig. 298 and 299). These are not produced, as we should suppose, by a simple reflux of the blood from the distended uterus into the tubes but by hæmorrhage from the mucous membrane of the tubes themselves (Schroeder); the uterine end of the Fallopian tube is sometimes undilated or even entirely closed. Blood may escape gradually from the fimbriated end of the tube, and set up a localised peritonitis matting down the tube and uterus; a hæmatocele is sometimes thus produced.

2. ATRESIA VAGINALIS. The thickness of the obstruction varies in different cases, according to the extent of the original obliteration and the thinning produced by the pressure from above. The dilatation of the

Atresia vaginæ, seen from behind. Thickness of obstruction (through which a probe is passed) 3-4 mm.; of vaginal wall below atresia 2-3 mm., above it (at x) 6 mm. Dilatation of the body of the uterus is small compared with the common cavity formed by cervix and upper portion of vagina. Left Fallopian tube markedly dilated, with no distinct flexion on it, and changed at its free end into a thin-walled blood sac which had burst. Right tube undilated (Breisky).

vagina above the obstruction is remarkable; it may form a tumour filling the pelvis, pressing on the bladder and rectum, and raising the uterus above