In general the objective diagnosis of atresia presents few difficulties; the retaining membrane MI generally be seen or felt, and the tumor ap preciated above it. It will be useful for diagnostic purposes to separate hymenal atresia from tho °Vier congenital vaginal atresias.
Atresia hymenea or hymenalis, not only differs in situation from more deep-seated atresias, but, since the passage is closed by a mem brane composed of a duplicature of the mucous membrane, it will, even when greatly developed, retain the characteristics of a narrow and very elastic diaphragm-like atresia. These features are important to distinguish it from deep-se,ated and depressed vaginal atresias, when the vestibule leads into a blind sac; for with the latter we never have that distension of the vulva and the perineal region which has caused hymenal atresia to be often compared to the tense bag of waters during delivery. When this vulvar and perinea] distension is great, the frtenulum laborium and the labia are dragged out of place, and the position of the hymen is altered. The relation of the membrane to the orif. urethrm indeed is not altered; but it reaches immediately down to the perineum posteriorly, and laterally presses against the internal surface of the labia. It is further to be remarked, that by many observers the imperforate hymen has been found to be unusually thick and fleshy; hence the rarity of spontaneous rupture. According to two observations, (comp. Tables No. 5 and 6), it appears to me that the hymen septus im perforatus is most prone to spontaneous opening; since in both I found thin places in the walls of the median septum.
The following case of atresia hym. is very characteristic, and deserves mention. (Figs. 13 and 14.) Christine S., seventeen years. old, always healthy, has never menstru ated. For • three months has suffered from severe monthly molimena, lasting several days. The patient has noticed a tumor growing in her abdomen, which she says extended from the external genitals up into the abdomen. Latterly she had had considerable difficulty in urination and defecation, and this had led her to apply for relief. The amenorrhcea
and the abdominal tumor, and especially the distension of the external genitals described below, had caused iier friends to suspect pregnancy and the beginning of labor; so that it was not deemed wise to permit the patient to journey from her home to Prague, without being accompanied by a midwife.
On December 27th, 1875, I found her condition to be as follows: Small strongly-built girl of healthy appearance. No fever. Breasts well devel oped, but contained no milk; papilla) and areola almost pigmentless. Pelvis well developed. Slight pigmentation along the linea alba. Ab domen swollen, mostly below the navel, where she measured thirty inches in circumference. The swelling is caused by a median tnmor, which projects above the symphysis; it is elongated and rounded, of slight lateral mobility, and reaches 8.2 inches above the symphysis. Its upper part is 3.6 and its lower portion 3.2 inches broad; the latter is slightly sensitive to pressure. The external genitals are regularly developed, and both they and the perineal region are distended so as to form a hemispherical mass, the size of a child's head. The vulva is open to the extent of two inches; and between its lips there projects a hard and tough dry vascularized membrane, of the color of ordinary skin. This membrane is laterally in connection with the internal surface of the labia, posteriorly with the anus, which is two inches long, and anteriorly with the posterior border of the urethral orifice. It is the imperforate hymen. Fluctuation is distinct, and it can be gotten between the abdominal wall and the hy menal membrane. Occasionally there is a spontaneous increase of pres sure in the tumor. Per rectum the tumor appears as a fluctuating mass, which almost completely fills the true pelvis. and compromises the cali bre of the rectum.
On the next day, under chloroform, and avoiding all external pressure, I made the usual crucial incision of the hymen. Fifty ounces of thick ened dark odorless blood at once flowed out; it contained both fresh and shrivelled blood corpuscles, and much large pavement epithelium.