ATRESIA OF THE GENITAL PASSAGES OF WOMEN. 
A PAPER READ BEFORE THE CHICAGO MEDICAL SOCIETY, JULY I9TH, 1880, 
By EDWARD W. JENKSAM. D., LL. D., 
PROFESSOR OF MEDICA I, AND SURGICAL DISEASES OF WOMEN AND CLINICAL GYNECOLOGY 
in Chicago Medical College. Compliments of 
DR. EDWARD W. JENKS, 
Chicago, III. 
1600 (old No. 820) Indiana A ve. 
AND 
70 Monroe St. [Reprinted from “Chicago Medical Journal and Examiner” for September, 1880. 
ATRESIA OF THE GENITAL PASSAGES OF WOMEN. 
A PAPER READ BEFORE THE CHICAGO MEDICAL SOCIETY, JULY I9TH, 1880, 
By EDWARD W. JENKS, M. D., LL. D., 
Professor of Medical and Surgical Diseases of Women and Clinical Gynecology 
in Chicago Medical College. 
“Les examples persuadent bien mieux que les simples 
raissonnements, et Vexperience donne la perfection d tous 
les arts.”—Maurigeau. 
Definition.—The term atresia, of Greek derivation (« privative and 
perforation) and meaning in its literal sense an imperforate 
condition or entire absence of a canal or orifice, is by custom or conven- 
tionally used more liberally: thus, atresia is the term sometimes made 
use of to designate partial obliteration of a canal; e. g., atresia vaginae, 
meaning literally an absence or entire obliteration of the vagina; but 
custom allows this term to be applied to a condition of the vagina 
where even the principal part of that passage is perforate, if only a 
little of it be imperforate. Atresia will, therefore, be made use of in 
this paper not in its literal but in its customary or conventional sense. 
History.—In reviewing the history of atresia, we find earliest mention 
made of it in the writings of Hippocrates and Aristotle. Hippocrates, 
in discussing the diseases of women, makes frequent mention of 
‘‘obstructed uterus” and “closed neck.” He uses the terms rather 
freely, it is true, but in one instance at least there is no doubt that he 
is dealing with a case of atresia. He says : “After accouchement the 
genital parts are sometimes closed by adhesions. I have also observed 
this when the orifice of the genital parts was ulcerated. Phrontis 
experienced what women suffer in whom the lochial discharge does not 
take place from this cause, furthermore she suffered pain in the parts. 2 
and on touching them observed that there was occlusion; she mentioned 
this, and upon treatment the lochia made its appearance; the woman 
was cured and remained fertile.”* 
Aristotle furnishes us with more precise details. He points out the 
origin of atresia, whether accidental or congenital, the possibility or 
impossibility of cure, and the accidents which ensue with the arrival 
of the catamenia. “ There are some women in whom from birth the 
os uteri is somehow closed; in others this is the result of disease; some 
of these cases are quite remediable, others not at all.” Again: ‘‘In 
some women the os uteri is closed from birth up to the time when the 
menses are established, then with violent pain the os is torn open by 
the menstrual impulse, but with other women the obstruction must be 
dissected away by the physician; some women die after the obstruction 
has been forcibly removed or its attempted removal has failed.” 
Celsus has surpassed all his predecessors in describing means for 
overcoming atresia; he recommended first a crucial incision through 
the membrane and then its entire excision. For dressing he used a 
kind of tent, for which he substituted later in the treatment a leaden 
pipe (fistulam plumb earn). 
Pliny cites the case of Cornelia, the mother of the Gracchi, as 
furnishing an example of atresia interfering with delivery. 
Aetius classifies atresias, dividing them into three varieties, according 
to the location of the obstacle: first at the labia, second in the vagina, 
third at the mouth of the uterus. He also describes means for over- 
coming each of these varieties and enters into minute details of the 
subject. 
Such, then, was the condition of affairs when science sought refuge 
with the Arabian physicians, and such it remained in their hands. 
That they did but little to advance the knowledge of this subject is 
largely due to the character of the Mohammedan laws, which forbade 
the examination of women by men; and hence the practice of obstetrics 
and gynecology fell almost entirely into the hands of the midwives. 
Avicenna, however, classified the varieties of atresia according as they 
interfered with menstruation or delivery ; he also described a method 
of overcoming atresia by tearing an opening with the finger as well as 
the older methods of operating with a cutting instrument. 
At the end of the fifteenth century Benivieni drew attention to the 
first observation of imperforate hymen. In the sixteenth century 
Wier, Fabricius ab Aquapendente, Cabral and Felix Plater imitated 
* IiittrC’s Hippocrates, Paris, 1855-61. 3 
Benivieni by inserting in their works facts which Jean Schenck 
collected some years later; although they form a compiled work, still 
the “ Observationes Medicce Rariores” is a book of great merit, and it 
is to be regretted that it was not more frequently consulted. By taking 
no notice of it many writers condemned themselves to mutual repetitions 
and barren paraphrases. Still facts multiplied and happily observation 
continued to have its followers. Bauhin, Ruysch and Bartholin made 
many valuable additions to surgery and gynecology; while with 
grateful recollection we may also cite the names of Guillemeau, 
Dalechamps, Mauriceau and Roonhuysen. 
Still, notwithstanding the impulses given to the work by these men, 
progress in this branch of surgery was slow enough. Bibliographers 
displayed no great zeal in research, and the most eminent surgeons 
were careless of recording success or failure in their operations. 
This condition only reached an end with the middle of the eighteenth 
century, and to Heister is due the honor of taking the initiative in 
the reform which followed. Instead of imitating his predecessors, he 
collected facts and wrote, so to say, at their diction the two chapters 
which he devotes to this affection. Following him a host of writers 
have touched upon the subject, but they have all been surpassed by 
Boyer, whose method and perspicuity are inimitable. 
Since then the subject has been treated anew, and at greater or less 
length, but still with a deplorable slothfulness of research. In a 
subject where personal experience is necessarily limited, and where 
conclusions cannot have the force of law's unless based upon a 
considerable number of facts, we are often content with the precepts 
furnished by learning easy of acquisition, and we believe that our own 
task is finished when we have gathered together a score of cases; but 
these are not the means by which we carry conviction, or by which we 
definitely establish a course of operations both difficult and eminently 
dangerous. 
Nevertheless, if our age has been disdainful of research it has 
certainly not made sport of such material as has come in its hands—it 
has been registered by the press, and been given a broad publicity, and 
it has known how to realize notable progress in an operative point of 
view; cases reputed hopeless have been attacked with success, and bold 
surgery has reached its utmost limits. 
Fuech, to whom I am greatly indebted for much pertaining to the 
history of my subject, is of the opinion that Amussat and Debrou are 
the two names distinguished above all others among moderns in the 
treatment of atresia. 4 
Coming down to our own day, and without particularizing individual 
achievements, we will merely add that the brilliant results which have 
been accomplished in this branch of surgery in our own and other 
lands are not confined to a limited few—their names are legion ; hence 
a complete modern history of the surgery of atresia would make too 
lengthy an article, and include a long list of names, many distinguished 
and some obscure. 
' Varieties of Atresia.—Of atresia of the generative passages of 
women, w7e recognize the three following varieties in accordance 
with their localities: (1) Vulvar, (2) Vaginal and (3) Uterine. Any 
one of these varieties may be congenital or accidental, also complete 
or incomplete. The three kinds wdiich have been named may be 
associated together in one individual, either congenitally or from 
traumatic causes. 
I. Vulvar Atresia.—(a.) The labia majora may be adherent, but 
on account of their conformation and relative anatomy such adhesions 
do not prevent the exit of the menstrual blood, but sometimes do 
interfere with micturition and then calculi are formed, which of them- 
selves require surgical interference. 
(■b.) The adherence of the labia minora, like the same condition of 
the greater lips, is the result of accident or disease, giving rise to the 
same difficulties of voiding urine. Unlike adhesions of the labia majora, 
adhesions of the labia minora may cause retention and accumulation 
of menstrual blood. 
Atresia of both the greater or lesser lips may be consequent upon 
small-pox, measles, or any constitutional or local disorder that can 
cause inflammation and denudation of their mucous surfaces. Such 
occurrences are without doubt more common in infancy and childhood. 
(c.) Atresia of the hymen is one of the forms included under the 
heading of vulvar atresia, although not usually so designated, but it is 
generally spoken of as an imperforate condition. Imperforation of the 
hymen is of more frequent occurrence than either of the other forms 
of vulvar atresia. M. Puech*, who has written an excellent monograph 
on the subject considered in this paper, mentions one hundred and 
fifty-one cases, of which some were simple and some complicated with 
atresia in other parts of the genital passages. This author has 
observed seven cases, and from various sources has collected accounts 
of one hundred and forty-four others, making the above total of one 
hundred and fifty-one. He does not include in his list any cases 
* De l’atresia des voies genitales de la femme, par le Dr. Albert Puech, in 4° 163 p. Paris, 1864. 5 
occurring prior to the age of puberty, and states that if such were to 
be added, one would be authorized in regarding imperforation of the 
hymen as an abnormality the most common. Emmet*, with his vast 
experience, mentions having met with only four cases of retention of 
the menses due to an imperforate hymen. 
II. Vaginal Atresia.—This form may be congenital or accidental, 
as is the case with the other atresias, and also, like them, may be com- 
plete or incomplete. Courtyf and Puech| recognize three varieties 
of congenital atresia, viz.: simple, complicated and complex. They 
are called simple when the vagina alone is involved; complicated 
when there is atresia of both the vagina and the neck of the uterus; 
and complex when the vagina, being double, one of the canals is 
imperforate. The comparative frequency corresponds to the order in 
which they are here named, the last one mentioned being extremely 
rare. Its rarity can be readily inferred from the fact that Rokitansky 
observed only three cases among sixty-two of congenital vaginal atresia, 
all of the subjects being adults. 
Courty mentions the infrequency of this form of atresia, and states 
that “none have been observed except by M. Leroy, M. Rokitansky 
and M. Deces.” 
There are probably some unrecorded cases, and some that Courty 
has not heard of. The writer has seen one case in the person of a 
Polish woman, who came to his clinic to be treated for uterine disease. 
She was single and twenty-four years of age. I am of the opinion 
that the adhesion, which was in the left vagina, might have been from 
vaginitis, as it was very easily made perforate, after which her double 
vagina was several times shown to the class, and the uterus examined 
by touch and by speculum, sometimes through one vagina and some- 
times through the other. Some of the peculiarities of this case will 
be further spoken of when describing the cases which I have tabulated 
as coming under my own observation. 
III. Uterine Atresia.—Atresia occurs less frequently in the uterine 
canal than in any other part of the generative passages. From all 
published accounts obtainable by Puech, the grand total sums up only 
fifty-six cases. There is not the least doubt that there have been many 
cases, recorded and unrecorded, which were unknown to this writer, 
especially in our own country, where surgical gynecology has had so 
many valuable contributions. 
* Principles and practice of Gynecology, by Thomas Addis Emmet. Philadelphia, 1869; page 211. 
t Courty, Traiti? Pratique des maladies de l’uterus, des ovaries et des trompes. Paris, 1872. 
t Op. citat, page 11. 6 
The same might be said of the statistics of Puech as regards other 
varieties of atresia already mentioned, and the first thought regarding 
them might be that they are of but little importance; but, although 
incomplete, they are none the less valuable as showing the relative 
frequency of the different varieties of atresia. 
Nonat*, in his chapter on “Imperforations, or complete congenital 
atresia” of the uterus, states that “sometimes there is seen the opening 
of the mouth of the womb, completely masked by a sort of membra- 
nous diaphragm, being a dependence and prolongation of the mucous 
membrane which covers the lips of the uterine neck. When this 
membrane is obliterated, the cervical canal is found of the normal 
caliber.” 
J. Cloquetf calls attention to this fact, also, by stating that “ Ruysch 
reports the case of a woman in labor three days without advance. 
The head could be felt in the vagina, covered with a membrane of great 
density, which closed the vagina. Ruysch incised the hymen, without 
any result. He then divided the second membrane, wdiich was situated 
more deeply, when the accouchement was rapidly and happily termi- 
nated.” 
The obliterations are, as a rule, limited to the inferior portion of 
the neck. After diligent search I have been unable to find an account 
of a single instance where there existed an obliteration above the os 
internum, or even of the entire isthmus. 
Atresias are first distinguished according to their location, and sec- 
ondly, all are included under the division of congenital or accidental. 
By most writers the congenital are called imperforations, while the 
accidental cases are termed obliterations. 
Etiology and Pathology.—Of the etiology of congenital atresia or 
imperforation, it can only be said that there is arrest of development. 
The arrest in the complete atresias occurs in the early part of embryonic 
life. In vaginal atresia, it often happens that arrest of development 
seems to be confined to the canal alone, while the other genital organs 
develop as usual. This arrest of development may be complete or 
partial and in either instance the vagina fails to become a distensible 
canal. In some instances there is complete atresia, but the develop- 
ment occurs notwithstanding the existence of imperforation. Under 
such circumstances, by rectal examination, the vagina can be felt as a 
hard, fibrous cord. The presence or absence of this cordlike vagina 
is of major importance as bearing upon prognosis and treatment. 
* Nonat, Mai. de l’uterus. Paris, 1869; page 103. 
t Diet, des Sciences Mcdieales. Bruxelles, 1829; art. Imperforation. 7 
The etiology of congenital atresia is explained by Puech and others 
about as follows: 
The female generative organs are developed in three zones. The 
internal zone has its origin in a blastema lying close to the Wolffian 
body. The ovaries are developed along its internal border, the Fal- 
lopian tubes along its external border, while the uterus is formed where 
the two borders meet, constituting the “genital cord.” 
The external zone is developed from a tubercle which makes its 
appearance at the caudal extremity. This, at first a simple elevation, 
is bisected by a groove, which deepens until it becomes a cul-de-sac, 
forming the cloaca. As for the tubercle, after dividing, it forms two 
slight elevations on each side of the groove—the upper two of these, 
uniting above but remaining separate below, form the labia majora and 
the clitoris, while the two inferior elevations develop into the labia 
majora. 
The intermediate zone, from which the vagina is formed, is developed 
in the blastema, situated between the rectum and the bladder, imme- 
diately above the median perineal aponeurosis. This develops into a 
canal running from the vulvar opening to the neck of the uterus. 
In cases of imperforation of the neck of the uterus the origin of the 
trouble is the same, development having stopped in the internal zone; 
exception being made in cases where the obstruction is due to a reflection 
of the mucous membrane of the vagina over the neck of the uterus. 
Of accidental atresia or obliteration of the vagina there are patho- 
logical causes easily discerned. Injury or disease being the only causes, 
it simply remains in individual cases to determine the character of the 
injury or the relationship between obliteration and some co-existing 
disease. A vagina fully developed may be closed from the adhesion 
of its walls or its caliber may be diminished, constituting partial 
obliteration by the reparative process, which succeeds sloughing or 
true vaginal ulceration. I have myself seen three cases of almost 
complete vaginal atresia complicated with vesico-vaginal fistula. 
There was a very marked similarity in the history of these three cases. 
In each one the fistula and atresia were in consequence of inflammation 
and sloughing following delayed labor and the unskillful delivery of a 
dead child. Two cases are reported by Courty* of accidental vaginal 
atresia associated with vesico-vaginal fistula. 
Prolonged and difficult labors or the improper use of obstetrical 
instruments are among the most frequent causes of this form. Partial 
* Op. citat., p. 398. 8 
or complete obliteration may also follow easy non-protracted labors, 
and where instruments are not brought into requsition; yet, in conse- 
quence of impaired vitality, inflammation and loss of substance of the 
vagina ensue, and subsequently atresia. Chemical agents locally 
applied to the uterus or vagina in the treatment of diseases of those 
parts, syphilis, vaginitis from any local or constitutional cause, or any 
disease which produces ulceration or sloughing of the vagina, are 
among the causes of this affection. Puech mentions three cases 
resulting from attacks of cholera. Courty* states that excessive and 
improperly performed coition, diphtheria, typhoid fever, caustic appli- 
cations to the neck of the uterus, and particularly small-pox, are some 
of the causes of atresia. Thomasf makes mention of a vaginal atresia 
produced by the passage of a sharp stick of wood; also of one caused 
by the retention for two hours of the trunk of a dead foetus, the head 
having been previously delivered. This same author also alludes to 
an excellent article written upon this subject by Dr. Trask, based upon 
thirty-six cases, fifteen of which were due to prolonged labor. I have 
myself treated two cases of complicated vaginal atresia caused by the 
improper use of obstetrical instruments in childbirth. 
There are some peculiar differences between congenital and acci- 
dental atresia and notably the following: If an atresia of the vagina 
is congenital, the canal is usually adherent throughout its entire length. 
On the contrary, if it is accidental, only a portion of the canal will, as 
a rule, be obliterated ; the upper extremity, the lower extremity or the 
middle portion of the vagina will be imperforate, while the remaining 
portions will be perforate. 
Symptoms and Prognosis.—Vulvar atresia, with the exception of 
that form where the hymen alone is involved, is, as a rule, discovered 
in early childhood. On the other hand, attention is not usually called 
to the remaining forms until there are some pronounced symptoms 
indicative of their existence, such as inability to perform the marital 
act, or delayed menstruation, the patient being considerably beyond the 
age at which the catamenia is usually established. It has frequently 
happened that girls have for a long time, even for years, been under 
treatment for amenorrhoea until health had disappeared, when finally 
an atresia was found to have been the sole cause of the non-external 
appearance of the menstrual flux. A girl may have the molimen 
menstruate, and yet the flow of blood from the mucous surface of the 
uterus which occurs coincidently, instead of being discharged from 
* Op. citat. 
t Diseases of Women. By T. Gaillard Thomas, M. D., etc. Philadelphia, 1874, 4th edition, p. 162. the genital passage is retained by means of an imperforate hymen, and 
sometimes for a long period without the general health being affected. 
It is when the accumulation becomes so great that an additional amount 
threatens to rupture the Fallopian tubes or uterus, or be forced 
through the tubes into the peritoneal cavity, or there is evidence of 
blood poisoning, that the health begins to be impaired. A physical 
examination under any of the circumstances just mentioned is demanded 
and should be insisted on. With any patient, when there are indica- 
tions of atresia in any part of the genital passages with impairment of 
health, it is a duty on the part of the physician to make a physical 
examination for the purpose of ascertaining whether any local cause 
for the symptoms exists. Besides this there are often in such cases 
other questions hinging upon the physician’s opinion aside from mere 
health. There are questions of happiness or misery to the individuals 
and families involved, if marriage is contracted, when the woman has 
any abnormality about the sexual organs. This topic needs no elab- 
oration. The duty of the physician is obvious. One point I would 
insist upon, is that marriage or even an engagement should not be 
permitted if the woman has never menstruated, unless competent 
medical opinion sanctions it after thorough physical examination. 
On this particular point, a case of interest, to myself at least, came 
under my observation. A young lady of an excellent family, while 
away from home, became engaged to a young man whom she met for 
the first time on the occasion of the visit. Soon after returning to 
her own home her mother wrote to the young lady’s fiance that there 
were reasons why the engagement should not be continued until med- 
ical opinion authorized it. The girl had never menstruated, although 
well developed in person — in fact the external organs of generation 
were perfect, even the mammary glands being of more than usual size. 
Several medical gentlemen of eminence were consulted, and all of them 
concurred in the opinion that marriage was allowable. She did marry 
and just nine months from the day of marriage gave birth to a healthy 
boy, and has since had other children; but her menstrual history has 
been peculiar. She menstruated for the first time after she had 
weaned her first child. Menstruation has never lasted for an entire 
day, but usually only during four or six hours. Except when preg- 
nant or nursing, it has been regular, unattended by pain, sometimes 
quite profuse in quantity, yet never of longer duration than before 
mentioned. 
The number of patients with atresia of the genital passages of all 
varieties which have been treated by me is seventeen. Of this number 10 
eleven were congenital, and six were accidental. For the purpose of 
illustrating what has already been said, and what still remains to be 
considered within the limits of this paper, the cases referred to are here 
tabulated as folloivs: 
TABLE OF CASES OF ATRESIA OF GENITAL PASSAGES OF WOMEN. 
No. 
I. Congenital Variety. 
Age. 
Remarks. 
1 
Yulvar atresia of labia minora. 
4 
Operation and cure. 
2 
Vulvar atresia of labia minora. 
12 
Operation and cure. 
3 
Vulvar atresia of labia majora. 
14 
Operation and cure. 
4 
Imperforate hymen. 
10 
Operation and cure. 
5 
Imperforate hymen, with vaginal 
walls adherent for an inch and a 
half in the inferior portion of the 
canal, constituting true vaginal 
atresia. 
20 
Signs of blood-poisoning from retention, the vagina 
being distended with menstrual blood so that fluct- 
uation was plainly discernible. Operation success- 
fully made. 
6 
Complete vaginal atresia. 
22 
Operation begun but not completed, for reasons given 
in the text. No menstrual accumulation. 
7 
Double Vagina. Complete vaginal 
atresia. 
28 
Atresia of one vagina, probably from vaginitis. Dila- 
tion easily accomplished. 
8 
Absence of Uterus. 
34 
Patient married; was subject to epileptic convulsions 
occurring every four weeks. 
9 
Complete uterine atresia. 
20 
Patient single. Case reported in one of my clinical 
lectures in Obstetric Gazette, January, 1880. 
10 
Partial vaginal atresia, interfering 
with labor. 
25 
Labor could not be completed until the parts were 
incised. 
11 
Atresia of the upper portion of the 
Vagina. 
30 
Patient married. A rudimentary uterus could be felt 
very indistinctly per vaginam, but plainly per rec- 
tum. No menstrual accumulation. 
No. 
II. Accidental Variety. 
Age. 
Remarks. 
12 
Partial vaginal atresia in upper por- 
tion of canal, caused by application 
of caustics to the uterus. 
31 
Patient married. Uterus could barely be touched with 
the finger. Operation and cure. 
13 
Partial vaginal atresia, with vesico- 
vaginal fistula. 
29 
First operated upon for atresia, the vagina barely ad- 
mitting the little finger—a second operation was 
required for the fistula. 
14 
Partial vaginal atresia, with vesico- 
vaginal fistula—urethra obliter- 
ated. 
19 
First operated for atresia, which occupied the middle 
portion of vagina, not permitting a view of the fis- 
tula or cervix uteri—then opened the urethra. Af- 
terwards operated for the fistula, which was bounded 
on one side by the cervix uteri. 
15 
Partial vaginal atresia, with vesico- 
vaginal fistula. 
27 
This case was similar to the one above except as re- 
gards the obliterated urethra. 
16 
Vaginal and uterine atresia or com- 
plicated atresia. 
30 
Caused by protracted efforts on the part of several 
physicians to deliver the patient of a dead child at 
full term. Following delivery there was severe 
pelvic inflammation, pelvic abscesses, and a dis- 
charge of pus for months. The upper portion of the 
vagina and the cervix uteri were occluded. Men- 
strual accumulations were found, and alarming 
symptoms occurred at menstrual dates from threat- 
ened rupture. Successful operation. (Detroit Re- 
view of Medicine, June, 1876.) 
17 
Vaginal atresia, with large uterine 
fibroid. 
38 
Reported in Chicago Medical Gazette, in March, 1880. 11 
COMMENTS ON THE FOREGOING CASES. 
It will be observed that in the above list numbers 1, 2, 3 and 4 were quite 
young subjects, and consequently no serious trouble had resulted from the 
abnormality. But little comment is necessary in connection with them. 
The discovery of the malformation, whether accidental or resulting from the 
watchful care of mothers, led to speedy cure before the occurrence of menstrual 
accumulations. Two of the number, however, had attained the age at which 
the menstrual function is usually established, while No. 3 had, previous to 
the surgical operation, experienced the molimen menstruale very markedly and 
menstruated soon after. 
I shall now allude to the remaining cases at greater length than in the 
remarks of the tables, but will not in every instance follow the order in 
which they are tabulated, but in such sequence as seems proper from their 
mutual relations. 
Case No. 5 was a domestic, who had been dismissed from employment 
and denied admission to the homes of her friends because of the belief that she 
was pregnant. One lady, however, by whom she had been employed, requested 
her own physician to see her and determine the cause of her enlarged 
abdomen. This physician, who was not a regular one, but who was accred- 
ited with great shrewdness as a diagnostician, declared the girl in the latter 
months of pregnancy, and so she was again sent out in disgrace. A benevolent 
gentleman, and one of the most distinguished public men of Michigan, learning 
in some way of this girl, and believing the story of her innocence to be a true 
one, sent his housekeeper to provide a place for her, and desired me to ascer- 
tain the cause of her peculiar appearance. I found, as I then believed, an 
imperforate hymen only, and by rectal examination an accumulation of men- 
strual blood. When I came to operate in this case, however, I found more than 
an imperforate hymen—there was atresia of the lower portion of the vagina 
to the extent of an inch or more. After incising there was a discharge of 
several ounces of menstrual fluid of the usual tarry consistency, whereupon 
the vagina and uterus were syringed out with warm water. The operation 
itself requires no special comment in this place ; suffice it to say that it com- 
bined the tearing and cutting processes, followed by the use of vaginal plugs 
until the parts were healed. 
The patient numbered 6 in the list was a young lady twenty-two years of 
age, who had been treated by regulars and irregulars, of all kinds and creeds, 
during a period of several years, to “bring on her courses.” Among the multi- 
tude of her medical attendants not one had suggested the propriety of making 
a physical examination until she became the patient of Dr. G., a painstaking 
and skillful physician of the town where she resided. I was called to see the 
patient with him, and we discovered the cause of the amenorphcea to be a 
complete vaginal atresia, but there was no accumulation of menstrual blood. 
The organs of generation exterior to the vagina were well developed, as were 
also the mammary glands. The mons veneris was covered with hair, which 
is not usually the case unless the ovaries are developed. By examining per 
rectum a uterus could be felt, although quite small. By means of a sound in 
the bladder and a finger in the rectum, the vagina could be plainly felt as a 
large round cord. An operation to construct a vagina, or rather to dilate the 
rudimentary one already existing, was proposed and begun by carefully open- 
ing the canal for about an inch and a half and using tents to keep it open. 12 
This was prior to the adoption of the mode of exploration by dilating the 
urethra and examining the interior of the female bladder with a finger. 
I deemed it my duty to say to the mother of the girl that marriage, under the 
circumstances, should not be thought of, but that if the operation ultimately 
succeeded then would be the time to decide the matrimonial question. The 
girl, it seems, was engaged, but was willing to wait until the propriety of mar- 
riage could be decided by the success or failure of the surgical procedures. 
The lover, however, learning the true state of affairs, suddenly emigrated to a 
milder climate, and the girl herself was so disgusted with his course that she 
pulled out the tents from the partially constructed vagina, and vowed she 
would lead a life of celibacy. Consequently what might have been accom- 
plished in her case will never be known. In my own mind, there is no doubt 
that complete success would have attended the operation in due time; that is 
to say, a vagina would have been opened, not constructed, in evidence of 
which was the fact that the cordlike vagina could be so distinctly felt. 
Patient No. 7, with a double vagina, has been sufficiently spoken of under 
the head of vaginal atresia. This case represents that rare form of atresia 
designated by Puech, Courty and others as complex, viz.: a double vagina, 
with one canal imperforate. 
Case No. 8 was referred to me by Dr. Dayton, of Lima, Indiana, with whom 
I saw her, and from whom I learned the peculiarities of her medical history. 
She was thirty-four years of age, a brunette of spare form, and had been 
married for several years, the exact number I did not learn. Following her 
marriage she had become subject to epileptic convulsions; at least they were 
so designated, but they may have been merely epileptiform, or hystero- 
epileptic. These convulsions occurred once a month, and coincident with a 
marked molimen menstruate, and occurred at no other time. Her external 
organs of generation were well developed, giving sufficient evidence of fully 
developed ovaries. She acknowledged possessing a keen sexual appetite, and 
her husband stated that it was at times rather aggressive. The vagina was 
simply a pouch of normal length, but without the vestige of a uterus to be felt 
within or beyond it. But by rectal exploration a rudimentary uterus of minute 
size could be plainly felt, as could also the converging round and broad 
ligaments. As it was manifest that the epileptic or epileptiform convulsions, 
occurring as they did coincident with the molimen menstruate, were of ovarian 
origin, I proposed Battey’s operation as affording the only possible means of 
relief, but the patient would not consent to it, and, soon after, passed beyond 
my observation. 
Patient No. 9. An account of this case was reported in the Obstetric 
Gazette for January, 1880, as a clinical lecture, by Dr. Helm. The patient 
alluded to, an inmate of Mercy Hospital of this city, was a girl of twenty, with 
perfectly developed external organs of generation, the mammae, indeed, being 
larger than common. The patient longed to be relieved of the distressing 
symptoms which marked her case, and which occurred once a month, such as 
congestive headache, severe pelvic and abdominal pains, etc. These symptoms 
had of late been progressive, and had attained such severity as to be alarming. 
There was no accumulation of menstrual blood; the vagina was of normal 
appearance, size, and length; but the cervix uteri appeared by speculum 
examination as a mere nodule, without the least indication of a uterine canal. 
By rectal examination, the uterus was found to be about three-fourths of an 
inch in length, thus indicating arrest of development with atresia. This patient, 13 
as before remarked, was the subject of a clinical lecture, and the condition of 
things as described was shown to my class. As no uterine canal could be found 
by ordinary means, I clipped off with scissors a small fragment of the rudi- 
mentary neck, but no further signs of a canal were discovered; still this 
procedure proved of great service, as the loss of blood near the time of 
approaching molimen materially lessened her sufferings. The only chance of 
a radical cure seemed too formidable to advise until milder means had been 
exhausted. The radical cure was removal of the ovaries; but, from the fact 
that the abstraction of blood immediately preceding the molimen menstruate 
had so greatly alleviated her sufferings, I advised the periodical abstraction of 
blood, by means of leeches applied to the perineum. As long as I continued 
to hear from the patient, this plan proved successful. 
Case No. 10 was in the person of a primipara whom I attended in labor. 
She was a woman of unusual size, with a correspondingly large pelvis. Labor 
progressed favorably until the child’s head was in the pelvic excavation, when 
it stopped. Making a careful examination, I now discovered that there was par- 
tial atresia of the lower portion of the vagina. Here the obstructing membranes 
being put upon the stretch by the process of labor gave the appearance of a 
broad band, and,while in this tense condition, I made an incision through them 
fully three inches in length. The incision once made, labor was completed 
in a brief space of time. The atresia was simply a semilunar-shaped hymen, 
which, not having been previously ruptured, remained an obstacle to the free 
egress of a full-sized foetus. 
The case of patient No. 11 presented some similarities to that of No. 8. The 
remarks in the tabulated list in connection with this case comprise about all 
that is requisite for this paper. This woman consulted me for the purpose of 
ascertaining whether or not she could be successfully treated for sterility. She 
was thirty years of age, of spare form. The external organs of generation were 
not perfectly developed; the labia presented a shriveled appearance; the mons 
veneris was scantily supplied with hairs; the mammae were small, with but 
little gland structure; the vagina was sufficiently capacious, but not of usual 
length, ending in a blind pouch, which gave no appearance of a uterus, which 
organ was only discoverable by firm pressure in the hypogastrium, or by rectal 
examination, in either of which cases a rudimentary uterus could be readily 
felt. The case was simply one of partial vaginal atresia of the congenital 
variety, with non-development of the uterus. I could not advise or institute 
any surgical procedures or treatment, as there were no urgent symptoms 
making such demands. 
The remaining cases which I have tabulated are all non-congenital, the 
results of either injury or disease. 
Patient No. 12 consulted me on account of uterine disease, for which she had 
already been receiving treatment during the previous two years. This was at 
a time when all real or fancied uterine diseases were subjected to the applica- 
tion of caustics. Such had likewise been the local treatment in the case of the 
patient now under consideration. She said that the stick of caustic had often 
been left in the mouth of the womb; that the treatment had been very 
painful, and particularly the last time the caustic had been applied, when a 
large stick of it had been used. For some days she was unable to walk, and 
finally a discharge of pus and blood set in. Three or four months had now 
elapsed since the last application, but, although the painful symptoms had 
subsided and the discharge of pus ceased, she was conscious of something 14 
abnormal, as coition could not be perfectly performed, and all attempts caused 
severe pain and oftentimes discharge of blood. An examination revealed the 
vagina almost obliterated in the upper portion, so that a finger could with great 
difficulty be made to force its way to the cervix uteri, while the cervix itself 
was bound to the left side of the vagina by firm adhesions. The cause of this 
partial atresia was, without doubt, the free use of caustic, which was dissolved 
in the vagina instead of the uterus. A cure was effected by means of cutting 
with scissors a portion of the adhesive bands, and by constant use of vaginal 
plugs. 
Cases 13,14 and 15 will receive but little comment, as a brief allusion will be 
sufficient. A full and succinct history of each one would be of more interest 
as relating to vesico-vaginal fistula than to the subject under consideration. 
Every one familiar with vesico-vaginal fistula knows that one of the most 
frequent complications met with is that produced by the presence of cicatricial 
tissue, which is often in the form of bands of greater or less dimensions. It may 
be considered an unusual case, as far as my own experience goes, that has no 
cicatricial bands in the vagina. The patients here referred to, however, had 
more than cicatricial bands, in consequence of the causes producing fistula. 
There resulted, in each case, almost complete obliteration of the vagina, fully 
entitling each one to be designated as incomplete vaginal atresia. In No. 13 
the little finger could with difficulty be crowded into the vagina, requiring two 
operations preliminary to the one for the fistula, and also the use of dilators. 
Not until after the first operations had been performed could either the neck 
of the uterus or the opening into the bladder be felt or seen. Nos. 14 and 15 
were similar to the case just mentioned, there being vaginal obliteration to 
such an extent as to necessitate an operation before the fistula could be seen 
or felt. 
Patient No. 16 was a case of unusual interest to the writer, at least. It was 
one of those cases of which it is extremely difficult to describe all the partic- 
ulars ; so that one not seeing and examining the patient can scarcely get a clearly 
correct opinion of the complications and difficulties of the operations made 
for her relief. I am not alone in this opinion, for several gentlemen present 
at the time I operated expressed themselves similarly. Among this number 
was Dr. Johnson, of Detroit, a former pupil and assistant of Simon, of Heidel- 
berg, and Dr. H. 0. Perley, Asst. Surgeon U. S. A., at that time a resident of 
Detroit. An account of the case was published in the Detroit Review of Medicine 
for June, 1876, from which I will give a brief abstract: * 
“ Mrs. C., of Ohio, consulted me on January 12,1876, with reference to an 
operation for atresia, which she stated was caused by the delivery of a dead 
child May 10,1875. She was confined to her bed for six weeks after delivery 
on account of inflammation of the womb and vagina; subsequently abscesses 
formed within the pelvis, and discharged externally from time to time up to 
the date of her visit to me. Three months after delivery there were symptoms 
indicating the appearance of the menses, with some constitutional disturbance. 
A month later there was again the molimen menstruale, with increased pain and 
more general disturbance ; the pain was progressively severe with each return 
of the menstrual date, and had become so alarming that, at the time of her 
visit to me, both she and her husband earnestly desired that some step be 
* “Atresia vaginae et uteri; produced by instrumental delivery of a dead child; operation and 
cure.” By Edward W. Jenks, M. D., Professor of Medical and Surgical Diseases of Women, Detroit 
Medical College, Detroit. Review of Medicine, June, 1876. 15 
taken for her relief before the return of another attempt at menstruation. 
* * * * * Physical examination of the generative organs revealed 
a laceration of the perineum to the margin of the sphincter ani externum; the 
vagina was closed superiorly, nor could any portion of the uterus he felt in 
this canal, neither could I, by any means of speculum and probe, find any trace 
of the upper part of the vagina in the abundant cicatricial material which 
obliterated it. It seemed at first as if the vagina was about the normal length, 
and that it was only a short distance to the neck of the uterus, and yet it could 
not be felt. This state was further explained by a rectal examination. By the 
rectum the body of the uterus was felt very high and retroverted, and appar- 
ently held in that position by firm adhesion, as if the inflammation had 
extended to the pelvic peritoneum simultaneously with the vaginal and 
uterine inflammations. Besides this the vagina was an unusually long one, and 
its apparent length at this time is explained by still another reason, namely, 
the great size of the patient, who weighed two hundred and eighty pounds. 
The abdominal walls, burdened with fat, rendered conjoined manipulation of 
little service in diagnosis or in the subsequent operation. The same condition of 
the labia majora made the vagina seem long, and rendered ocular examination 
more difficult than usual.” ***** 
“ The patient being placed in the exaggerated lithotomy position, the pelvic 
organs were fixed by the pressure of an assistant’s hand on the hypogastrium. 
I then, with sharp-pointed scissors, carefully cut a portion of the cicatrix in 
the presumed direction of the uterus, occasionally ascertaining the safety of 
my incisions by introducing a finger into the rectum, and the sound into the 
bladder. I soon found my finger and sound in close proximity, showing the 
necessity of great caution lest I should cut either into the peritoneum or into 
the bladder. After cutting through upwards of two inches of cicatricial tissue 
I reached the uterus; but, as there was no indication as to the locality of the 
os uteri, I separated a portion of the neck from its morbid vaginal adhesions, 
yet the os was not apparent, nor was there anything in the appearance of the 
enucleated neck to indicate the route into the cavity of the uterus; so I then 
cut with a pair of very delicate and sharp-pointed scissors in the direction of 
the uterine canal for about an inch, when there gushed out between two and 
three ounces of menstrual blood. The uterine canal being now discernible, I 
enlarged the opening still more and cut away the cicatrix from the newly 
made os. A tent of lint wras put in the uterine canal and the newly opened 
portion of the vagina packed with the same material, when the patient was 
put in bed. But little blood was lost during the operation aside from the 
menstrual blood, and when the patient was restored to consciousness she was 
kept free from pain by moderate doses of morphine per rectum. The next 
day the lint was removed and a fresh quantity put in with the finger, for the 
purpose of preventing union by first intention. The patient complained but 
little of pain, and after the removal of the first tampon there was but little 
oozing of blood. The fourth day after the operation, word was brought me 
that Mrs. C. had a ‘ chill,’ and complained of quite severe pain in the abdomen. 
It was several hours before I sawr her, but when I did I was gratified to learn 
that the rigor and pain were simply the ushering in of the menstrual flow, and 
that she was now free from pain. The catamenial discharge continued five 
days, as was her former custom. This I considered a happy occurrence, so 
soon after the operation, as the danger of closure of the wounds, especially 
within the uterus, was by this opportune discharge greatly diminished. The 16 
patient rapidly recovered her usual health, and three weeks later returned to 
her home.” * * * * * “ In conclusion, there are certain 
points of interest in connection with this case to which attention is directed: 
First.—The dangers as marked by the symptoms of rupture of the Fallopian 
tubes or regurgitation of menstrual blood into the peritoneal cavity, if the 
operation had been much longer postponed. Second.—The complications from 
traumatic causes, viz.: a retroverted uterus, bound down by peritoneal adhe- 
sions, obliterating a portion of the uterine canal, and the locality of the cervix 
uteri obscured by a great quantity of vaginal cicatricial tissue, to which may be 
added the difficulties attending any manipulation on account of the size and 
obesity of the patient. Third.—The advantage of operating just preceding the 
regular catamenial date, as was manifested in this case, by the menstrual blood 
keeping the newly opened canals pervious in a better manner than could be 
done by tents, or any other device.” 
Case No. 17 was reported in the Chicago Medical Gazette in March, 1880, under 
the following heading: “ Supposed Inversion of the Uterus—Fibroid develop- 
ment of Posterior Half of Uterus, and Vaginal Atresia.” A full relation of the 
peculiarities of the case would contain much that is not pertinent to the subject 
of this paper. It will suffice to say that there was almost complete vaginal 
atresia, the perforate portion of the canal barely admitting a small sized probe. 
The atresia was overcome by lacerating or tearing with the finger, so that a 
diagnosis of the exact condition was easily determined. The spherical char- 
acter of the tumor together with the atresia was what led to the belief that it 
was a case of inverted uterus. The atresia doubtless had its origin in vaginitis, 
which I judged, from the history of the case as related to me, was caused by 
the application of caustics, employed for some reason past discovery in the 
treatment of the patient. 
Treatment.—The treatment to which I have subjected my own 
patients has been set forth in the reports of individual cases, but the 
subject is of sufficient importance to be more fully discussed. 
At the Baltimore meeting* of the American Gynecological Society 
an excellent paper was read by Prof. Isaac E. Taylor, of New York, 
entitled, “Atresia of the Vagina, Congenital or Accidental, in the 
Pregnant or Non-pregnant Female.” I was not present at the meeting, 
and, owing to delay in publishing the society’s transactions, did not 
have the privilege of reading Dr. Taylor’s paper until the principal 
portion of this one was written. Dr. Taylor’s essay I consider a val- 
uable addition to the literature of the subject, as his own experience 
has been large and varied. He has also drawn from the experience 
of others. The subject is one which has not been written upon very 
extensively, the literature consisting chiefly of the reports of cases. 
Dr. Taylor’s paper possesses an interest in one particular, to which I 
have merely made brief allusion: that is, the association of pregnancy 
with complete vaginal atresia. It does not discuss the whole subject 
* In September, 1869. 17 
of atresia, for he announces in the first clause that he desires to confine 
himself “to cases of complete congenital atresia and to accidental 
absence or atresia of the utero-vaginal canal in the pregnant and non- 
pregnant woman.” This writer further states that, “ Cases of congenital 
absence of the vagina are rare; cases of the same nature existing 
during pregnancy and involving two lives are still more so.” 
He relates a case of complete congenital atresia of the vagina, where 
the woman became pregnant and was safely delivered, at full term, of 
a living child. He also refers to a case of Dr. Simmons, extracted 
from the St. Louis Medical Examiner for February, 1847, of a similar 
character, and yet, in each one, the physicians were unable to find the 
minutest opening between the lower or more external portion of the 
vagina and the uterus. By Dr. Simmons this question is asked: “In 
what manner did conception take place?” Dr. Taylor, referring to 
his own case, and in the same connection speaking of Dr. Simmons’, 
gives a “solution of the mystery.” As the discussion of this question 
is not strictly pertinent to the present paper, it will not be further 
considered. 
The treatment of all forms of atresia cannot be otherwise than sur- 
gical, and, with the exception of certain forms of partial atresia, all 
may be considered of great importance, requiring care, caution and 
skill. Even the operation for an imperforate hymen, so simple in 
itself, has many times proved fatal. Bernutz* lost four patients; 
Thomasf mentions two fatal cases, one of which, indeed, was his own. 
Sir James Y. Simpson collected the history of several cases where the 
operation proved fatal; while, scattered through medical literature in 
general, may be found the reports of many of these operations, which 
resulted in the death of the patient. Simpson mentions a case of 
death, in which there was occlusion of the vagina from adhesion, the 
septum being quite thin; but, as the menstrual blood was retained, a 
small incision was made, through which there poured out, during a 
number of days, large quantities of the usual dark grumous fluid. 
Surgical fever set in on the third day after the incision was made, and 
in a few days more the patient died. An autopsy revealed a distended 
uterus with inflamed walls, and inflammation extending thence to the 
peritoneum. The mistake made by the operator in this case was the 
small incision and neglect to wash out the cavity, as undoubtedly the 
entrance of air had caused decomposition, resulting in death from sep- 
ticemia. This is a point which will be discussed later. 
* Clin. M6d. sur les Mals des Femmes. Tome 1, p. 3ft3. 
t Diseases of Women. By T. Galllard Thomas, Prof., etc. Phila., 1879. 18 
“ It is conceded,” says Dr. Taylor, “ that, no matter what the exact 
nature of the obstruction may be, the accidents which cause death after 
operation are almost identical.” While I would accept this as in the 
main true, it still seems to me that the statement requires modification. 
There are three causes producing death, which are not identical in 
their nature; they are septicemia, inflammation and rupture. Conse- 
quently, it seems to me, that it could with greater propriety be said 
that the deaths which occur in consequence of operations, no matter 
what be the nature of the obstruction, are generally due to septicemia, 
inflammation or rupture; in some instances to a combination of these 
causes, and occasionally to the shock of rupture alone, without the 
supervention of either septicemia or inflammation. Unquestionably 
septicemia ranks first as the most fatal, particularly after operations 
for vulvar or vaginal atresia. This being the case, the prophylaxis of 
blood-poisoning is of paramount importance, and should not be lost 
sight of in any surgical procedure, or in the after-treatment. 
Owing to the dangers attending surgical operations of this variety, 
even eminent surgeons have objected to them, and advise non-interfer- 
ence; but such advice is not likely to be followed at the present time, 
when so much is being accomplished by antiseptic treatment. The 
propriety of surgical interference, or the necessity for it, can only be 
determined in each individual case. Where life or health is threatened, 
surgical procedure seems to be demanded. 
There is a peculiar feature in the history of complete or incomplete 
atresias of the generative passages, which is interesting, and has a 
bearing on treatment in cases where there is an accumulation of men- 
strual blood. This feature is alluded to by Barnes.* When there is 
stenosis or atresia of long continuance, the genital canal “undergoes 
retrograde dilatation above the seat of the stricture. This is the almost 
inevitable consequence of the futile attempts of the muscular coat to 
expel the retained contents.” This effect is seen in the most marked 
form in cases of imperforate hymen; the vagina, being the most dis- 
tensible part of the canal, dilates first, forming a large pouch; then 
the cervix uteri is distended; then the cavity of the body of the uterus; 
and lastly the Fallopian tubes. This dilatation, conservative in its 
effects by accommodating the contents which cannot be evacuated, has 
its limits. When these are reached, the danger of rupture or perforation 
at the weakest point is great. Before such an occurrence takes place, 
the imprisoned fluid, by reason of the constant pressure to which it is 
* Diseases of Women. By Robert Barnes, M. D., London, Lecturer on Obstetrics, etc. Phila. 
1878; page 206. 19 
being subjected, may be forced to ooze through the walls of the uterus 
in drops, causing septicemia or peritonitis. As analogous to this con- 
dition, the opinion is expressed by Barnes that in a similar manner 
some cases of pelvic peritonitis are produced. More commonly, in 
consequence of retained menstrual blood, equally grave results of a 
different kind may follow. The uterus, exerting great pressure upon 
the fluid, may force it into and through the Fallopian tubes, whence it 
escapes at their fimbriated extremities, or, it may be forced through 
some weakened part, producing a rupture. Either of these occurrences 
is rendered easier on account of the continued dilatation of the tubes. 
What has just been stated has an important bearing upon opera- 
tions for imperforate hymen. Again, the sudden evacuation of a large 
quantity of menstrual blood by a free incision may cause such sudden 
collapse of the uterine walls as to excite contraction of that organ, and, 
in consequence, some of the blood, by a regurgitating process, is forced 
through the entire length of the tubes into the peritoneal cavity, or else 
through the substance of the tubes themselves, rupture taking place at 
the weakest spot in the distended walls. It is thought by some that 
the more sudden the evacuation the more liable such occurrence. It is 
believed by many that the sudden admission of atmospheric air into 
the vagina is the cause of the uterine contraction, rather than the col- 
lapse of that viscus. A case is related by Beclard, in which the uterus 
burst, discharging into the bladder. Other writers have mentioned 
instances of rupture of the hymen. Puech refers to a case of sponta- 
neous cure of an imperforate hymen, by reason of ulceration of the 
obstructing membrane. Another condition demanding surgical inter- 
ference in cases of atresia is where the menstrual fluid being retained 
there is liability of blood-poisoning from absorption into the system of 
the changed blood. The patient in my own list, numbered 5, showed 
this condition in a pronounced manner. 
It might be interesting to some of my auditors to hear the reports 
of peculiar cases and the opinions of distinguished authorities, on the 
treatment of the class of abnormalities under consideration, but it 
seems needless to me in this assembly of practicing physicians to re- 
late what many are familiar with and what all can have access to in 
most of the late text-books on diseases of women. 
Without further discussion of these points, or the demands for surgi- 
cal interference, the modes of operating and the treatment requisite to 
render operations successful will be considered. 
The evacuation of retained menstrual blood can be accomplished 
with greater safety by means of an aspirator than by any other 20 
method. In cases of imperforate hymen the membrane should not be 
incised until it is first ascertained by rectal examination whether 
menstrual blood is present, and if found in considerable quantity, the 
fluid should be aspirated; and as soon as it is believed that all is thus 
evacuated, then a free opening should be made into the vagina, first 
cutting and then tearing; the vagina and, if possible, the uterus 
should be washed out with warm water until it runs out without dis- 
coloration. By so doing there is but little danger of regurgitation of 
the fluid, and the risks of septicemia are lessened. If the quantity 
is considerable, then the fluid should not all be aspirated at one 
time but at different times; for, if the contents are nearly all drawn 
away at once, the ensuing collapse excites the uterus to contractions 
which may cause the regurgitation and rupture previously referred 
to. Small openings should never be made for the purpose of gradual 
drainage, as they afford ingress to air, causing subsequent decom- 
position. 
Bernutz, who lost four patients from free incisions through the 
hymen, selected, as the time for operating, the second week after 
menstruation as the time when the organs are less liable to be dis- 
turbed. 
In cases of children, some authorities have advised no interference 
until the age of puberty, but I am of the opinion that an imperforate 
hymen or vagina, the only form of atresia likely to be discovered in 
childhood, should be operated on and kept open by tents. In children 
incisions should be avoided if possible and the canal opened by lacera- 
tion or tearing. 
The means of opening the genital canal, whether the obstruction be 
in the vagina or in the uterus, are tearing or laceration, the scalpel, 
the scissors and the trocar. The aspirator can scarcely be enumerated 
as a means of opening an imperforate or occluded vagina or uterus, 
as its use is rather for evacuating fluid therein contained. 
In some instances a combination of tearing and cutting serves the 
best purpose. As a rule I would advocate giving preference to the 
tearing process in congenital atresias, but it will be found impractica- 
ble in the accidental varieties. Emmet prefers scissors, as is well 
known to all familiar with his practice. My own choice for the 
vagina is scissors and for the uterus either very delicate scissors or a 
tenotomy knife. The tearing open of imperforate canals with the 
finger is usually the better as well as easier plan, but where union 
has occurred in consequence of inflammation or injury, tearing can be 
done only to a limited extent, for the reason that dense structures 21 
like cicatricial tissue will not readily tear and if the requisite 
force is applied one is liable to lacerate around rather than through 
it; the character of the obstruction should always determine the 
mode of overcoming it. The trocar I would avoid as much as possible, 
as about the only case w'here I deem it admissible is in uterine atresia. 
To those who practice one of the operations of Amussat the trocar is 
indispensable, but that operation, wThich consists of plunging the trocar 
through the rectum into the vagina for the purpose of evacuating the 
menstrual blood is, as a rule, unwarrantable. This may seem strong 
language, since for years this has been successfully practiced, but I 
firmly believe that the case must possess most unusual abnormality if 
menstrual blood cannot be abstracted along the route of the vagina, 
its natural and only proper outlet. The trocar has proved servicable 
in atresia of the neck of the uterus, serving in some instances indeed 
a much better purpose for opening the canal than either the knife or 
the scissors. Syme* objects to the trocar and is in favor of the knife, 
which he uses with great freedom. 
It is important after the vagina or uterus is made perforate by 
operation, that some measures be taken to keep it so by means of 
tents, plugs, or dilators. One case came under my observation.where 
a physician had plunged a trocar through an imperforate hymen, a 
large quantity of restrained menstrual blood escaped, but the incision 
closed up and a subequent operation became necessary. 
It has been a matter of considerable discussion by many surgeons 
in cases of complete vaginal atresia, how much should be done in a 
single operation. Amussatf, in 1832, in operating in a case of con- 
genital atresia, cut through the skin, and then, from fear of entering 
either the rectum or bladder with his knife, tore an opening for some 
distance with his finger and packed the orifice with a sponge; after 
three days he repeated the process, and subsequently again repeated 
it; on the tenth day he reached the tumor, which he empted with a 
trocar. The patient suffered from severe inflammation of the Fallo- 
pian tubes, but after four operations with the trocar the canal re- 
mained sufficiently open. EmmetJ advocates an opposite course from 
that pursued by Amussat, and cites cases where he accomplished at a 
single operation all that was accomplished by Amussat in ten days. 
In my own case, number 16, I unwisely followed the plan of Amussat 
for the same reason, but I have never ceased to regret that I did not 
* Taylor, Op. citat. 
t Gaz. Med. de Paris, 1835. 
t Principles and Practice of Gynecology. By Thomas Addis Emmet, 2d ed., 1880. 22 
attempt to reach the uterus at the first operation, as the peculiar 
circumstances in which-the patient was placed was the means of mak- 
ing it also the last and only one. I am convinced that the vagina 
should be made perforate with as few operations as possible, and, 
whenever it is practicable, it should be accomplished in one operation, 
exception always being made, in such cases as have been alluded to, 
where there is a large accumulation of menstrual fluid, and there is 
reason for thinking that considerable dilatation of the uterus or tubes 
exists. In a very recently published discussion on the method of 
removal of retained menstrual fluid, by members of the Obstetrical 
Society of N. Y.,* a variety of opinions was expressed — some advo- 
cating rapid removal, and others a slow process. Emmet expressed 
himself strongly in favor of a rapid evacuation, and, as to the most 
unfavorable cases, he believes them to be those of congenital absence 
of the vagina with a distended uterus. Dr. Lusk said that the danger 
was greatest from inflammation, if air entered a flabby vagina and 
uterus; while firm contraction removed danger. Dr. Munde said 
the chief source of danger was from sepsis and regurgitation through 
the Fallopian tubes. Dr. Skene believed that the chief source of 
danger is inflammation; that death more frequently is caused by it 
than by septicemia; he would give patients to understand that the 
operation is a dangerous one, and in his opinion inflammation is the 
danger most to be feared. 
Another undecided question is, whether it is better to operate 
before or after menstruation or the molimen. The history of my own 
case, number 16, leads me to give most pronounced favor to operations 
before the period. Where there is no accumulation, and the operation 
is chiefly for the purpose of relieving a deformity, then the time of 
greatest calm of the generative organs should be selected, which is ten 
or twelve days after the menstrual date. I do not believe it is wise to 
adopt a strict rule of practice, however, in regard to this matter. The 
pathological condition, as well as the exigency of the case, must be 
considered, thus in truth making each case a rule for itself. The 
same is, perhaps, true as regards operations for atresia in pregnancy; 
yet my own opinion, based solely on the experience of others, is that 
it is better to wait until labor has begun rather than to make any 
operation prior to the establishment of the labor pains. 
The question has been asked, “When should uterine injections be 
resorted to?” It is claimed that their immediate use causes inflamma- 
* Amer. Journal of Obstetrics, July, 1880, p. 609. 23 
tion, but it is quite probable that such a condition has resulted rather 
from the manner of their use; even the forcible injection has been 
used, while some have employed astringent and medicated injections. 
The use of injections is of great importance for the prevention of 
septicemia. The manner in which they are used is of equal impor- 
tance, if it is the uterus that is to be washed out. It is not positively 
necessary that haste should be exercised in employing them, as no 
great amount of decomposition and certainly no blood-poisoning can 
occur in from two to six hours; but, as a rule quite safe to follow, the 
passage should be washed as soon as practicable after the atresia is over- 
come. I have in a former paper* expressed my own views and the 
opinions of recognized authorities on the propriety, the dangers and 
the manner of using intra-uterine injections. The same general rules 
are to be followed in washing out the uterus after operating for atresia 
as in any other condition or disorder. That no harm may follow 
their use, certain requisites are important, as follows: (a.) A free outlet 
should be insured for the injected fluid. (5.) Air must not be admit- 
ted with the injected fluid. (c.) Cold, astringent, or irritating injec- 
tions, should not be made use of under any circumstances within the 
uterus, as they are apt to excite contraction, in consequence of which 
the fluid is liable to be forced through the tubes, or cause rupture at 
the weakest point. (d.) Forcible injections are to be avoided, as the 
injected fluid may be forced through the tubes, or cause rupture at 
some point already weakened by dilatation. 
In looking over all attainable literature on the subject of this paper, 
I have been impressed with the meagerness of it, and with the appar- 
ently unsettled views of the majority of writers in regard to treatment. 
There are very few exhaustive essays on the subject, the literature con- 
sisting chiefly of reports of cases, with fragments here and there in 
text-books, and the medical periodicals, the most elaborate essay being 
the one of Puech, before referred to. It is possible that one cause of 
the divided opinions regarding treatment may be due to the fact that, 
whatever the treatment adopted, cases prove fatal, and, with the neces- 
sarily limited number coming within the observation of any one indi- 
vidual, each thinks of his serious or fatal cases that, if they had been 
subjected to a different course of treatment than the one pursued, they 
might have been less serious, or even recovered. 
In concluding this paper, I will, on the subject of treatment, only 
attempt to give a summary. From the literature of the subject and 
* The Treatment of Puerperal Septicemia, etc. By Edward W. Jenks, M. D. Trans. A.m. Gyn' 
Society, 1879. 24 
the reports of cases, to which may be added my own observation 
and experience, I am led to the adoption of the following con- 
clusions : 
I. As fatal results have followed operations for the simplest varie- 
ties of atresia, the surgeon should apprise the patient, or her friends, 
of every possible danger prior to operating. 
II. In case of menstrual retention from vulvar, vaginal, or uterine 
atresia, the fluid should not be evacuated via the rectum with a trocar, 
but in the route pursued by the vagnia. 
III. When there is reason for believing that there is a large quan- 
tity of menstrual fluid distending the uterus, or Fallopian tubes, the 
safest mode of evacuating it is by means of an aspirator, prior to any 
surgical procedure for the cure of an atresia. 
IY. The evacuation of menstrual fluid should never be through 
a small orifice (with the exception of aspiration), but through a free 
opening; after which the vagina and uterus should be thoroughly 
washed out with warm water, as the best means of preventing or cur- 
ing septicemia or inflammation. 
Y. Septicemia, inflammation, and rupture of the Fallopian tubes 
are the chief disasters attending atresia, or following operations for 
its cure. 
VI. Congenital atresia of the vagina can be best relieved by tear- 
ing with the finger, as the rudimentary canal already existing serves 
a similar purpose to the surgeon that an instrumental director does in 
cutting operations; but the accidental forms require cutting, for 
which operation scissors are preferable to the knife; while in some cases 
both cutting and tearing are requisite. 
VII. There is reason for believing that when there is an accumula- 
tion of menstrual fluid within the vagina and uterus, particularly 
within the latter, that the best time to operate is immediately prior to 
the menstrual date, as the patency of the newly opened canal is thus 
better insured. 
VIII. Notwithstanding the dangers attending these operations, 
there is good reason for believing that by care and caution, and with 
a proper use of antiseptics, favorable results may be expected from 
operations for either congenital or accidental atresias. 
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