ABSENCE OF THE VAGINA. 
Three Operations-Establishment of the Menstrual Flow. 
By Montrose A. Fallen, M.D., Professor of Gynaecology, St. Louis 
College of Physicians and Surgeons. 
[Extract from S7. Louis Med. and Stirg. Journal, Vol. VII, No. i, N. S., 
January io, 1870.] 
Miss , from one of the Gulf States, was placed 
under my care for treatment on the 30th of August, 1869. 
She was within a few days of twenty years of age, and 
had, since the age of fourteen, experienced the menstrual 
molimina without any show of menses; and at the age of 
seventeen her health was of such a precarious character 
that she was sent North, hoping that a change of climate 
might effect something towards its amelioration. This was 
of no avail, and the constantly recurring molimina, with 
all of their usual bad symptoms, alarmed her parents so 
much that medical advice was sought upon her return 
home. For more than a year the medical gentleman in 
charge prescribed such remedies as chalybeates, sea bath- 
ing, horseback exercise, alteratives, etc., but to no purpose. 
A local examination was then insisted upon, when a sup- 
posed imperforate hymen was discovered, and its puncture 
was advised, because her medical attendant, who is among 
the most prominent physicians of the South, thought he 
could detect some fluid, when a rectal-digital examination 
was made at the Hme of the menstrual molimen. This 
supposed retention of menses was not found upon any 
subsequent examination made in St. Louis, either by Drs. 
Papin, Bauer or myself, although we examined her some 2 
Absence of the Vagina. 
two weeks subsequent to the " period." If such took place 
it must have been produced by a haemorrhage from the 
ovaries at the time when the Graafian vesicle was ruptured, 
and the blood must have been absorbed almost as rapidly 
as it was poured out. Fortunately, the proposed puncture 
of the imffcrforate hymen was delayed several months, 
otherwise its performance would, in all probability, have 
been followed by unexpected results, as either the bladder 
or rectum would have been penetrated. In the meantime, 
so alarming were her symptoms that her parents sent her 
to St. Louis to a medical gentleman, an intimate friend of 
the family, with a request that she be treated as he deemed 
most advisable. Upon her arrival here she was placed 
under my care, and then I obtained the above history, as 
well as the following facts : 
During six years past she had had frequent attacks of 
epistaxis (vicarious menstruation?) and vertigo, more 
particularly at each menstrual molimen, with great lumbar 
and sacral distress, and at that period during the last two 
years she also had fainting spells, with heart palpitations, 
co-added to the other symptoms. Auscultation revealed 
no organic heart trouble, but the chloro-anaemic souffle was 
marked, and also heard in the large veins about the base 
of the neck. The urine was about normal. The mamma 
were well developed. 
A physical examination discovered nothing externally 
which would lead one to suspect anything beyond a mere 
imperforate hymen. The external genitalia were well 
developed, the capillary growth abundant, the labias (majora 
and minora), as well as the glans of the clitoris, perfect, 
and [the meatus urinarius and urethra were normal in 
position. Hypogastric palpation, conjoined with the recto- 
digital examination, permitted the finger to make out, on 
either side of the median line, high up in the pelvis, two 
small, round, hard bodies, which, when firmly pressed 
upon from below, whilst the other hand pushed strongly 
down from above, produced a slight sickening pain. These Absence of the Vagina. 
3 
bodies were presumed to be the ovaries, as in the median 
line, and a little in front, a third one was felt, apparently 
of denser or firmer structure, lying across the pelvis (of 
the approximate size of a hickory nut), and which was the 
undeveloped uterus. Below this body, between the rectum 
and the bladder (determined by a catheter being introduced 
and pressed somewhat firmly against the has fond and 
above the base of the trigonum vesicae), the space was 
comparatively nothing, so thin that the catheter could move 
the finger backward in the rectum, or the finger could push 
the instrument forward in the bladder. Absence or atresia 
of the undeveloped vagina, with undeveloped uterus, was 
pronounced to be the condition, and an operation for its 
relief was proposed and accepted. Such a grave condition 
as this demanded other counsel, and I asked for the opinion 
of several of my medical brethren before I assumed the 
responsibility of such an intricate undertaking. Drs. 
Bauer and Papin were therefore called in, and after a 
thorough examination, accorded with the views before ex- 
pressed. Therefore, on the first day of September, 1869, 
(the patient having been duly forewarned of the possible 
dangers, both immediate and prospective), chloroform was 
administered, and another most careful examination made 
as before, and no contra-indications being presented, the 
operation was proceeded with, as follows : 
The patient's bowels having been well cleared out, and 
the bladder emptied, she was chloroformed and placed 
upon her back, with the legs flexed on the abdomen, and 
the buttocks brought well over the edge of the table. The 
external genital fissure was carefully divided with the 
scissors, when a male catheter (silver) was introduced into 
the bladder to serve as a guide, and the left forefinger 
passed into the rectum. The connective tissue between 
was lacerated by means of lateral sweeps of the right 
forefinger, to the depth of about three and a half inches 
anteriorly and four inches posteriorly, when the uterus was 
felt above a tense membrane, which I supposed to be the Absence of the Vagina. 
4 
peritoneum. The haemorrhage for the moment was pro- 
fuse, but was readily checked by firm pressure of iced 
water sponges. After the parts were well cleansed, and 
all bleeding had ceased, the bladder and rectum were easily 
-pushed into the space which should have been occupied by 
the vagina, of which not tke slightest trace could be seen. 
I then remarked to Drs. Papin and Bauer that I would 
not attempt to penetrate the peritoneum, but would plug 
the canal, hoping that pressure would produce its absorp- 
tion. I felt that if it were the peritoneum the success of 
the operation would be endangered by a traumatic peri- 
tonitis. I deemed it advisable to await further develop- 
ments. This opinion being concurred in, a glass tube 
three inches in length and seven-eighths of an inch in 
diameter was inserted, and retained in place by means of 
a compress and a T bandage. The patient, when the 
anaesthesia had passed off, complained very much of rectal 
and vesical trouble resulting from pressure of the tube, but 
otherwise was quite comfortable until about five o'clock in 
the evening, some six hours after the operation. I then 
found that the bladder was filled, and required evacuation, 
which somewhat relieved her. At seven o'clock a fever 
had set in, which increased until nine o'clock (the pulse 
being 128 per minute), when Dr. Washington saw her 
wirh me, and we concluded to give her camphor 
and belladonna every two hours (one grain each of the 
opium and camphor, and one-fourth of a grain of bella- 
donna), which quieted her pain in a few hours, and by nine 
o'clock the next morning the pulse came down to ninety. 
She never had any fever after the second day. The urine 
was regularly drawn oft', the parts syringed with warm 
water, and the plug removed twice daily for about eight 
days, during the whole of which time the patient's condi- 
tion was improving, notwithstanding the drainage was very 
profuse, and the odor of which was most offensive unless 
the syringed water was thoroughly saturated with the bisul- 
phite of soda, or slightly impregnated with the perman- Absence of the Vagina. 
5 
ganate of potassa. The stream-injected by means of the 
Davidson syringe-at first gave rise to intense lumbar pain, 
but this gradually diminished, until on the tenth day it could 
be thrown in with considerable force without producing 
much uneasiness. On the twelfth day after the operation 
she went down stairs to dinner, and from the eighth day 
she had been enabled to remove the plug, evacuate her 
bladder and bowels, and readjust it without any difficulty. 
On the morning of the thirteenth day after the operation, 
which was about the period of the menstrual molimen, 
the removal of the glass plug was followed by blood, which 
was dark and thick. It was slightly perceptible during 
that day, also on the next, and had been noticed the day 
before. This bloody discharge, however, was attributed 
to a supposed rupture of some adhesions at the upper end 
of the canal, and no further attention was paid to it at the 
time. A digital examination on the morning of the four- 
teenth day revealed considerable contractility of the cicat- 
ricial tissue in the upper third of the canal, but as the plug 
still penetrated easily, nothing was done for the moment. 
On the evening of the 16th or 17th of September, the 
patient, contrary to my orders, removed the plug, and 
danced nearly the whole night, and when she retired early 
next morning-between four and five o'clock - was so 
fatigued that she forgot to reintroduce it, and when she 
awakened about 2 p. m., endeavored to do so, but failed, 
and did not again succeed, notwithstanding she made 
repeated efforts towards its accomplishment. Not being 
informed of this condition of affairs, and presuming that 
the plug was in situ, I did not visit hei' again until the 
evening of the 19th of September, when, to my great 
chagrin, I discovered the entire upper half of the canal 
completely obliterated by firm contractions of a most un- 
yielding nature. There was nothing to be done save 
another operation, to which she courageously submitted on 
the second day after (Sept. 21st), and which was but a 
repetition of the formei* operation, only it was confined to 6 
Absence of the Vagina. 
the lipper half of the tract, the same gentlemen (Drs. 
Papin and Bauer) being present and assisting. On the 
second day after the operation I found the glass plug to be 
too small, and it was changed for a No. 2 Barnes' dilator 
(water bag), which answered most admirably, whilst some 
other glass tubes could be manufactured of a more suitable 
size, which, however, could not be done, so one of silver 
was made by Mr. F. A. Durgin, silversmith, of most 
beautiful workmanship and finish, 3 3-8 inches long and 
1 3-16 inch in diameter. 
Oct. <fh.-The cavity is completely covered by a tissue 
resembling the vaginal, and in the cul-de-sac superiorly 
a puckered fold, looking like a fistulous opening, is ob- 
served. No probe, however, can be passed into it. 
Oct. loth.-Upon withdrawing the tube this morning, it 
was covered with blood ; and this is the date of the return 
of the menstrual molimen. 
Oct. nth and nth.-Bloody discharge still continues. 
Oct. 13th.-Cessation of bloody discharge. 
During all these days the lumbar and sacral pains so very 
distressing prior to the operation, occurring at the menstrual 
molimen, were scarcely appreciated. From this date 
nothing particular was noticed until the 27th of the month, 
■when the -patient again removed the plug to go to another 
half where she danced all night, and it cotild not be intro- 
duced as before, after a similar imprudence. 
Oct. f&th.-The canal was so much contracted that the 
finger could be passed with great difficulty through the 
lower third, above which no contractions existed. The 
introduction of the finger gave rise to extreme pain, and it 
was grasped as if by a sphincter muscle, After some 
twenty minutes of steady pushing, the parts were found to 
yield, when I introduced the middle finger, after an effort 
of half an hour more, when the thumb of the left hand was 
forcibly and suddenly pushed in, and the parts again lace- 
rated as in the preceding operations. No chloroform was 
administered, as the patient dreaded the nausea which fol- Absence of the Vagina. 
7 
lowed the second operation. There was but slight haemor- 
rhage ; and a No. 3 Barnes' dilator was introduced and 
kept in situ for forty-eight hours, without being removed, 
when it was found that the original opening was intact. 
The parts were well syringed with tepid bisulphite of soda 
water, and the silver plug introduced. She arose from her 
bed in three days afterwards, and within a week was walk- 
ing about the house. 
Nov. menstrual molimen again at hand, and 
a free bloody discharge, with none of the old pains. 
Nov. Sth and gth.-Bloody discharge still going on ; 
no pains. 
Nov. loth.-Bloody discharge ceased; and from this 
date no further contractions have taken place, the canal 
remaining well opened and covered with a tissue very like 
the vaginal. 
Dec, \th, $th, and 6th.-Bloody discharge as before. 
The uterus has not increased in size, but remains very 
much as when first examined ; but the general health of the 
patient has most' materially changed for the better. . Her 
appetite is excellent, and she has increased more than 
twenty-five pounds in weight. There have been no faint- 
ing spells, vertigo, or epistaxis, since the first operation; 
and the immunity from pain in the loins and about the sacral 
region, which she now enjoys, is most satisfactory to herself 
and very gratifying to her friends. 
The question may naturally be asked, whence comes the 
periodical flow of blood per vaginam? I can scarcely 
believe it to be otherwise than a transudation of blood, re- 
sulting from engorgement of the generative circle of blood 
vessels so intimately connected from the bulb of the vesti- 
bule to the bulb of the ovary, and the pampinifrom plexus, 
always incidental to the maturation of the ovum and the 
rupture of a Graafian vesicle. 
Four periods of menstrual molimina have passed since 
the operation, and at each time none of the old troubles 
have appeared, but instead the artificial passage has given 8 
Absence of the Vagina. 
exit to blood, and the health is better than ever since before 
the age of fourteen. From a condition of misery, she has 
passed into one of happiness-of almost complete woman- 
hood ; and however much doubt clouded the prognosis, the 
excellent result obtained fully justifies the hazard and re- 
pays the intense anxieties of rhe operation. The case is a 
unique one, none of those reported being exactly similar. 
The operation of Amussat,* performed February 29th, 1832, 
was for menstrual retention ; and, although successful for 
the relief of the trouble, the canal became almost oblite- 
rated. Prof. T. Gaillard Thomas seems to regard this as 
an operation for atresia vagina rather than for its absence. 
Vide Thomas on Diseases of Women, p. 138. In a case 
operated on by De Haer,+ January 25th, 1761, where there 
was absence of the vagina, with symptoms of menstrual 
retention commencing at the age of sixteen and continuing 
eight years, the tract was opened by a knife and the 
bladder laid open, resulting in death on the third day. 
Bernutz f states, in reference to this case, "by way of 
warning against the employment of the knife in these cases, 
instead of using the finger, as in the case recorded by 
Amussat," that "the difference in the relative mortality of 
these proceedings has induced me to separate cases of con- 
genital absence of the vagina requiring the process of 
separating the parts by means of the finger, from other 
cases of fibrous obliteration, congenital, or acquired in 
early life, for which alone the knife must be resorted to, 
although it is always under circumstances of extreme 
danger." 
This statement, however, is not in accordance with the 
experience of American gynaecologists; for Sims and 
Emmet never use the knife, but the scissors, finding that 
less haemorrhage, inflammation, and contraction take place 
*Obs. d'AMUSSAT, Seance de 1'Institut, 2 Dec., 1835. Gazette Medicate, 
1835, pp. 785 and 817. 
fBERNUTZ & Goupil (p. 17, Vol. I.), Clinical Memoirs of the Diseases 
of Women. Sydenham Soc. Transl. Absence of the Vagina. 
9 
when they are used. In a case of acquired atresia upon 
which I operated more than a year ago, where the scissors 
were used in conjunction with laceration, and retained 
menses were evacuated, the patient recovered and has since 
become pregnant. In a case reported by Stolz,* the genital 
fissure was divided externally by the scissors, and the recto- 
vesical space lacerated by the fingers. This operation was 
performed only when he discovered the condition after 
dividing a supposed imperforate hymen. There was no 
menstrual retention, and no discharge ever took place after- 
wards. The object was to permit cohabitation after mar- 
riage ; but the report states that the vagina was completely 
obstructed and filled with a cellulo-fibrous material. For 
the purpose of marriage was a similar operation performed 
by Dr. Emmet,f and the operation was not only successful, 
but the patient married after seven months. This is the 
only case reported where there can be no doubt about con- 
founding atresia with absence of the vagina. All others 
seem somewhat vague and uncertain. A. Bcrard, in 
1840, reports a case by laceration of the recto-vaginal sep- 
tum, for retained menses, which was also successful. 
reports successful cases by Cabaret, Ven- 
tura, Desgranges, Delpech, Jefferson, Coste, and 
Willaume ; but it is probable that all of them were atresia? 
of the vagina, and not absences, as the operations were for 
retained menses. Langenbeck and McFarlan lost their 
cases. Frcteau§ reports a remarkable case, where he made 
a puncture about three-fourths of the depth of the tract to the 
menstrual collection, and drained it off by means of a 
canula; but at the end of a few days this cicatrized, and 
the menses passed by the bladder ever afterwards-in all 
probability the result of a wound of that organ. 
These are about all of the cases of absence of the vagina 
* Colombat (Meigs'translation). Philadelphia, 1850. p. in, 
t Vesico-vaginal Fistula, etc., etc., p. 230. 
+ Velpeau-Mcdecine Operatoire. Vol. IV., p. 356. 
§ Journal general de Mcdecine (XLIII., p. 54), quoted by Bcrard. 10 
Absence of the Vagina. 
that I can collect, and no one of them is similar to that one 
at present reported. I will state why the operation was 
performed : 
ist. It was distinctly stated by her medical attendant, a 
gentleman whose opinion was weighty, that an accumula- 
tion of blood took place every month, within the pelvis. 
2d. The patient was failing under the irritation of re- 
peated menstrual molimina,and every reasonable effort had 
to be made to overcome the amenorrhoea. 
3 <7. If any blood were effused at the period, it was 
thought it could be evacuated and its flow established 
by the natural outlet. 
4///. Marriage was contemplated. 
In conclusion, I think the physiologico-pathological 
reasons were well grounded, leaving the proposed marriage 
entirely out of the question ; and the success obtained bears 
out my opinions, as well as those of Drs. Papin, Bauer, 
and Washington, for whose friendly co-operation in this 
case I must again express my thanks. 
1525 Olive Street. Dec. 15th, 1869. 
Postscript.- 'January 1870.-The patient is now 
undergoing the bloody efflux per vaginam, with none of 
the difficulties she experienced before the operation. No 
change in the tract of the vagina since the last examina- 
tion. and no'increase in size of the uterus. 
February $th, 6th.-The blood per vaginam, passed 
as usual. There was no pain, but some slight sacral 
heaviness. The tract of the vagina is as before. The sil- 
ver plug is being worn as usual. The uterus is not in- 
creased in size, and there is no communication from it to 
the vagina. General health most excellent. 
Errata.-In line 29, p. 2, for "labise," read "labia." Line 33. p. 6, 
comma after word "finger" to be omitted. Line 12, p. 8, for "atresia 
vagina'' read "atresia-vaginae."