Recovery was perfect. The patient was kept strictly to bed; no inter nal examination was allowed; and cloths soaked in chlorine water were placed over the external genitals. Only on the day after the operation was there a moderate sanguineous flow. At the next examination, (January 4th, l876,) I found the opening plenty large enough to admit a finger, though the hymenal flaps were thick. The vagina, greatly lengthened and dilated, was much folded upon itself, the anterior and posterior walls being in apposition. During the examination there occurred violent vaginal con tractions, which the patient herself could feel. January ith: Hymenal opening relaxed; remnants over iltith of an inch thick; edges slightly ex coriated. In the vagina was a little mucus. The thickened and hyper trophied vagina contracts palpably upon the finger. No formed vaginal portion can yet be distinguished; but a long tubular speculum shows the es as a star-shaped and gaping opening. Abdominal tumor gone. Dis missed at request on same day. (Table No. 3.) The other congenital atresias of the simple vagina do not give way and dilate so mach under the pressure of the retained blood. Their connective tissue texture and their thickness enables them to resist; so that dilatation of the lower portions of the vagina and opening of the vulva do not occur. On the contrary, the lower part of the vagina is usually narrow, or cone shaped, although there may be considerable eccentric hypertrophy of the upper portion. Viewed from below, the atresia sometimes appears flat; but this is more commonly seen with extensive vaginal defects and atrophy of the uterus, than in circumscribed vaginal atresia. In an exceptional case (comp. Fig. 12), the upper dilated retention-sac sppeared like a rounded and enlarged portio vaginalis at the extremity of the blind lower portion of the vagina; and in the specimen the likeness is even more striking, since a central opening has been made.
In a woman of twenty-one, who was married three years, the molimena had lasted a year, and had culminated in the development of a distinct hEematornetra. The vagina ended .6 inch above the well-developed hymen, and formed a blind sac directed somewhat to the left. From the vulva the limiting membrane appeared as a tough, flat, whitish wall, through which fluctuation could be distinctly appreciated when pressure was made upon the abdominal tumor. In two preparations now lying before me, in which there is marked atrophy of the vagina and the uterus, the closure is effected by a tough membrane, in which there are slight furrows to the right and the left.
This form of vaginal closure can be seen by vaginal examination to be of more than membranous consistency; but the thickness of the septum cannot be so determined. Nevertheless it is very important to find this out; and a e,areful rectal examination must be made for the purpose. The free hand must press the vaginal surface of the septum against the finger, which is in the rectum; and thus an attempt at least at a proxi mate estimation must be made.' A combined vesical and vaginal exami nation might be made in the same way, but it need only be had recourse to in exceptional instances.
It must not be forgotten, when estimating the height of the stresia, that the lower portion of the vagina may have been considerably enlarged by repeated attempts at cohabitation, examples of which are numerous enough. (Comp. among others, Kussmaul, 1. c.) It is worthy of mention
that cases have been found in which there were several septa lying one above the other in the vaginal tube. Thus Thompson ' reports a case of double occlusion of the vagina, deficiency of the upper part (?), and atresia of the orifice, with retention of catarrhal secretion between the layers, while Inematometra was present above. Charrier mentions a similar ease.' Steiner 4 records a case from Billroth's clinic in which with a congenital atresia of the upper portion of the vagina, there was an acquired closure at the introitus. It is the only case I know of in which an acquired atresia occurred at the hymen. (Fig. 15.) The patient was eighteen years old, and was said to have fallen with violence upon the pubic region, against a block of wood when two years old. Soon afterwards tne mother noticed that the child's external genitals were suppurating; and two years after an abscess, which broke spontaneously, is eaid to have formed. It was stated that the suppuration continued until the child's twelfth year. From that time to her seventeenth year the girl remained well. Since then molimin. menet. and fonnation of h%matometra and htematosal pinx. " The examination of the external genitals showed a complete atresia of the vagina by a peculiarly hard, tense hymen containing many cicatricial bands. In its lower portion was an extremely fine opening, into which the smallest sized sound could just be passed. On incision there was first found a blind sac an inch long; it was the rudimenary vagina filled with masses of smegma, and was separated from the blood retention tumor by a stenosed area half an inch in' depth. This was opened under full antiseptic precautions, and a large quantity of tar-like ilood evacuated." The patient died on the fifteenth day of septic peri tonitis and pleuritis. The tubal blood sacs showed in places some de composed and rnptured spots.
For differential diagnosis we need only exclude acquired atresias and marked stenoses. In the first case we will find cicatricial bands and an irregular lumen, with traces of inflammatory and ulcerative processes.
But we should remember that irregular cicatrices may not always point to an acquired atresia, but may be the remains of fcetal inflammations. The presence of other developmental anomalies, especially absence of the hymen, may enable us to decide as to the congenital origin of the atresia. The history is valuable, since it will show that the symptoms began at puberty; but it will not always enable us to exclude atresias acquired in early childhood. But it will always give us valuable data in regard to atresias acquired later. Marked stenoses, which occeasionally cause the same retention-symptoms as do the atresias, are much rarer as congenital defects; and ae,quired stenoses can often be distinguished from the atresias only with difficulty. Sometimes the history of the case is, that, after pro longed retentio mensium, there occurred a sudden evacuation of blood, and the patient was relieved. The lumen must be demonstrated with the sound.