A ease of Congenital Occlusion of the Vagina, relieved by opera-
tion. By Geo. L. Upshur, A. M., M. D.; Surgeon to U. S.
Marine Hospital, Norfolk; Member of Am. Med. Association;
Fellow of Med. Soc. of Virginia, &c., &c.
The subject of this notice was a negro girl, aged 18, the pro-
perty of Dr. Southall, of Smithfield. She was admitted into the
Norfolk Slave Infirmary, October 8th, 1852.
About eighteen months ago, she commenced to have symptoms
characteristic of the approaching catamenia, recurring every
four weeks with great regularity, and continuing at each return
about four days, but without any discharge from the vagina. A
round, well defined tumor had gradually appeared above the
pubes, becoming larger after every return of the menstrual symp-
toms, and giving the appearance, when she entered the Infirmary,
of one advanced to the fourth month of pregnancy. Eight months
ago she began to suffer from distension, and recently the pressure
of the tumor upon the rectum and bladder has given her a great
deal of pain. There are, also, evident contractions of the uterus,
as if it were making a strong effort to get rid of its contents.
These symptoms have been so severe and so continuous for the
last two months as to unfit her for work, and oblige her to remain
almost constantly in the recumbent position. The patient was
well grown, and the mamma and external genitals fully deve-
loped, the clitoris and labia being of the ordinary size and shape,
and the pubis covered with hair.
She stated that she had repeatedly felt the venereal desire, and
four times had attempted to consummate the venereal act, but
without success. Upon examination I found that the finger would
pass into the vagina only about an inch and a-half, being ar-
rested by a firm, thick septum, perfectly smooth, and offering a
complete barrier to further ingress. By pressing upon the tu-
mor when the finger was in the vagina, fluctuation could be
easily felt. On introducing one finger into the rectum, and a
catheter into the bladder, and inclining the former upward, and
the latter downward, the finger came in contact with the catheter
just behind the terminus of the vagina, nothing appearing to be
between them but the coats of the rectum and bladder. The tu-
mor could also be felt from the rectum, sinking low down into
the pelvis, and giving decided fluctuation when gently struck.
The introduction of the speculum showed that the vagina was
perfectly formed, as far as it went. There was no enlargement
at its uterine extremity—no cul-de-sac formed. It seemed as if
nature had lacked for materials to form an entire vagina, but as
far as she progressed she had done her work perfectly.
On the 15th of October I performed the operation, in the pre-
sence of Drs. Moore, Rose, Robt. Tunstall, Southall, and H.
Nash. The bladder and rectum being first evacuated, the patient
was placed upon the table, as in the position for lithotomy, ex-
cept that the hands were not bandaged to the ankles. Chloro-
form was then administered, and as soon as she became insensi-
ble, I introduced the speculum up to the terminus of the vagina,
and distended the parts as far as possible. The instrument was
held in position by an assistant who, at the same time, made
pressure upon the uterine tumor. A second assistant retained
a catheter in the bladder, in such a position that I could easily
touch it with the forefinger of the left hand introduced into the
rectum. Taking the view that in the space bounded by the rectum
and bladder, and the vagina and ostincae, there was nothing but
cellular tissue, I desired to have such guides in the operation as
would prevent me from wounding any portion of the pelvic vis-
cera, my object being to make a passage up to the os tincae
directly in a line with what would have been the axis of the
vagina had it been complete. The tumor above, and the finger
and catheter behind and in front, performed the part of such
guides.
The operation was commenced by perforating the centre of the
obstruction with an ordinary trochar, which was pushed in to the
depth of an inch, and the opening widened by a crucial incision
with the scalpel, so as to admit the forefinger of my right hand.
The speculum was now withdrawn, the finger introduced, and the
obstructing tissue torn in every direction as far as I could reach.
The dense and unyielding nature of the tissue rendered this part
of the operation tedious and difficult, and so fatigued the hand
that I was glad to accept the aid of Drs. Moore and Tunstall.
The way being opened as far as we could reach with the finger,
the speculum was again introduced, passing in this time about
four inches, and being arrested apparently about an inch short
of the os tincjn. Pressure being still made upon the tumor, I
carefully divided layer after layer with the scalpel, until I reached
the os tincae, which was immediately made known by an abun-
dant flow of a fluid resembling tar in color and consistency, and
perfectly inodorous.
The hips being lowered so as to promote the discharge, the
patient was left for four hours. At the end of this time thirty*
two ounces had been discharged, and the flow was still going on
with regular uterine contractions, which continued for twelve
hours, until every particle of the secretion had come away. The
whole quantity amounted to forty-eight ounces, or about three
pints. The patient having rallied entirely at the end of eight
hours, was put to bed, and ordered half grain of sulph. morph.,
and perfect quiet to be observed.
Oct. ,16th.—Patient rested well last night, and feels tolerably
comfortable this morning. Pulse 80, soft and regular; tongue
natural, and appetite good. Upon examining per vaginam, I
could easily feel the uterus. The organ was larger than it is in
the unimpregnated state, and the os sufficiently patulous to ad-
mit the end of the finger in other respects. There was nothing
remarkable about it. The patient did not complain of pain from
the introduction of the finger, nor was there the slightest sore-
ness from pressure over the abdomen. In the evening, finding
that no urine had been discharged since the operation, I intro-
duced the catheter, and drew off thirty ounces. Ordered milk
and bread diet in small quantities.
17th.—Had a restless night, with slight shivering and thirst..
Soreness upon pressure over the whole abdomen, but particularly
in the hypogastric region. Pulse 110, moderately full; skin-
dry; tongue covered with white fur; anorexia; thirst; bowels
constipated, and vaginal discharge whitish, and beginning to be
fetid. Ordered an ounce of sulph. magnes. to be given at once,.
and the vagina to he syringed with warm water dashed with
vinegar, three times a day. Warm fomentations to the abdomen.
18th.—Less soreness than yesterday over the abdomen. Va-
gina very tender to the touch ; discharge feculent; bowels moved
once ; complains bitterly when the syringe is introduced. Con-
tinue treatment.
19th.—General symptoms as yesterday. Vagina hot and tu-
mefied ; discharge very fetid; great pain upon introducing the
finger; urine drawn off night and morning since the day after
the operation. Continue treatment.
20th.—Parts very tender, and very little discharge from them.
Administered chloroform, and made a minute examination with
the speculum. Vaginal surface intensely red, swollen, and
bleeding upon the slightest touch. Os tineas scarcely discernible
for the tumefaction around. In the evening there was some in-
■erease of fever, and the patient complained of great soreness. I
fear the introduction of the speculum has done harm. Ordered
fifteen grains Dover’s powder at bed-time.
21st__Patient passed a very restless night. Intense pain
over hypogastrium ; pulse 112, small and compressible ; thirst;
dry skin; decubitus on the back, with legs drawn up. Ordered
a dozen leeches to the back.
Hyd. Chlorid mit. gr. xii.
Pulv. opii, gr. iv.
Tart. Emet. gr. iv.
M. Pil. 12—S. one pill every two hours.
22d.—No improvement. Bowels constipated; pulse 120;
feeble; tongue dry; complains of agonising pain along the sa-
crum ; some tympanites. Continue pills. Ordered an enema of
soap-suds and castor-oil, which produced one evacuation, with
comparative relief. Hot fomentations around the hips and hypo-
gastrium.
23d.—Fever continues. Discharge from the vagina is sanious
and fetid; pain in the sacrum somewhat relieved. Added one
grain of quinine to each of the pills, and gave them as before.
Ordered f.-xii. of magnes. citrat., to be taken at two draughts.
Injections (vaginal) of pyroligneous acid, laudanum and water.
Continue fomentations.
Evening.—Pulse 130, and feeble; pain diminished; tongue
moist, and coated white; discharge from the vagina large and
sanious, (I believe this to be the return of the catamenia ;) bowels
moved once; patient sleeps, and is sweating profusely; when
aroused says she feels very weak. Continue treatment, with milk
toddy.
24th.—Patient ptyalised; pain greatly diminished ; pulse 100,
small, but larger than yesterday; no appetite, but partakes
freely of milk toddy and soup; sanious discharge still going on.
Discontinue medicine.
25th.—All the symptoms better; passed urine to-day sua
sponte, the first time since the operation; discharge from va-
gina less, but still sanious.
From this time Jane improved rapidly, so that on the 5th of
November I was able to make a very thorough examination of
the vagina. The lacerations had healed entirely, but there was
so much contraction as barely to admit the forefinger up to the
os tincse; the constriction, however, -was dilatable, and I intro-
duced a sponge tent. In the course of a few hours this gave so
much pain that it was removed by the nurse, but was again in-
troduced on the next day, and borne with less inconvenience.
On the 12th November catamenia again returned, and conti-
nued until the 17th, the quantity and color being natural. Dur-
ing the flow, of course the tent was not worn, nor was any exami-
nation made. On the 20th I found that the contraction of the
upper end of the vagina had increased; it would scarcely permit
my forefinger to pass. The sponge tent was continued until she
left the house on the 27th. We informed her master that she
was not in a condition to go without treatment, and that unless
the process of dilatation was continued, there would be a risk of
the vagina becoming again closed. When she left the Infirmary,
the forefinger, by exercising a moderate degree of perseverance,
could be passed up to the os tincrn. The constriction yielding to
persistent pressure like spasmodic stricture of the urethra.
On the 27th of April last Jane was again sent to the Infirma-
ry. She stated that, until two months before, she had regularly
had her monthly flow, although the discharge was less free, and
accompanied with less pain than formerly. She had been under
no treatment since I last saw her, the use of the tent being dis-
continued from the day she left the house. Upon examination I
found it impossible to reach the os tincae, although there seemed
to be an opening up to it. The speculum was introduced, and
an attempt to find the opening made with a probe, but without
success. No tumor could be felt from the rectum, nor fluctuation
through the vagina, and yet I felt sure that there was menstrual
blood locked up in the cavity of the uterus.
A second operation was contemplated, but it was deemed ex-
pedient to communicate with her master first. Pending the re-
ceipt of his reply, the patient was seized with a profuse discharge
from the vagina of dark, grumous blood, more fetid than the pus
from a rectal abscess. The discharge came on suddenly in the
night, May 5th, and continued for five days, with entire relief to
all the symptoms. Before any further examination was made a
message was received from Dr. Southall, that her services were
required at home, and that he would not have another operation
performed yet. She was discharged on the 17th May, and I
have not heard from her since.
Remarks.—The condition of the patient, when she last entered
the Infirmary, is to be accounted for only upon the supposition
that after the tents were discontinued, the vagina continued stea-
dily to contract until it entirely closed, so far as the exit of a
tolerably consistent fluid was concerned, while the admission of
air might readily have been permitted. The contraction may
have been of such a character as to make the small opening be-
tween the uterus and os externum, fistulous or valvular in its
shape, thus locking up all secretion behind, but permitting a
tolerably free ingress from without for the air, A certain amount
of fluid having accumulated, an effort would be made to throw it
off; this would produce irritation, possibly ulceration in the
neighborhood of the constriction, and finally a breaking down of
the obstruction, and a free exit to the fluid. There must have
been an admission of atmospheric air to account for the exces-
sive fetidness of the discharge.
It is probable that another operation will be required in this
case. The first one may be considered, however, as entirely
successful, and doubtless there would have been no ultimate dif-
ficulty had the process of dilatation been continued after she left
the Infirmary the first time, or had shebeen permitted to remain
until the treatment was completed.
The operation in this case is like to that performed in a simi-
lar one by Amussat, except that the tearing was completed at
one operation, whereas in Amussat’s case it required three or
four tearings, at intervals of three days. As his case is one of
considerable interest, and bears a close resemblance in many par-
ticulars to that just reported, I will give a brief history of it,
condensed from the Medico-Chirurg. Rev. for October, 1836.
A girl, 15 years of age, was carried from Germany to Paris to
consult some of the leading surgeons there. Her mother stated
that she had enjoyed good health until about two years before,
when she began to suffer severely from periodic attacks of pain
in the abdomen, and in the region of the kidneys. At first they
were attributed to obstruction of the bowels; but it was soon dis-
covered that this was not the cause, and on examination it was
found that there was no trace of any vagina.
When she came under Amussat’s notice, in February, 1832,
the abdomen was enormously distended; at the lower part was
felt a firm, resisting, globular tumor, supposed to be the enlarged
uterus. The external parts of generation appeared to be per-
fectly normal, but on separating the labia there was no vaginal
orifice, but simply a concavity corresponding to the position of
the orifice, and lined with a smooth mucous membrane. A ca-
theter having, with some difficulty, been introduced into the
bladder, it could be distinctly felt by a finger in the rectum, “in
consequence of the great thickness of the intermediate parts
and higher up the finger met with a large, rounded, tense, and
fluctuating tumor, occupying the hollow of the pelvis. The na-
ture of the case now became apparent. The urethra, bladder
and rectum were tied together by cellular tissue, and the vagina,
in at least two-thirds of its length, “ mau quait absolument.”
The prognosis was considered unfavorable. MM. Magendie
and Marjolin thought the only thing that could be done was to
perforate the uterus from the rectum, and thus relieve it from its
contents. Boyer regarded the case as hopeless, founding his
opinion on the history of all similar cases on record. He there-
fore strongly recommended that nothing should be done. Amus-
sat, however, was unwilling to abandon the case as irremediable.
He had but recently seen two cases of imperforation of the vulva,
where he had succeeded in re-establishing the vaginal passage,
by gradually tearing asunder the union between the urethra and
rectum with blunt instruments and with the fingers. With the
consent of the mother and daughter, he proceeded to try the
same method in this instance. We used at first a large sized
straight sound, pressing it with considerable force against the ob-
struction in the direction of the vagina “ comme pour faire un
trou.” Having continued this pressure for some moments, he
found that there was quite a deep depression left, without lacera-
tion or loss of blood; a small piece of sponge was placed in the
hollow thus made, and retained by a bandage. Three days after-
wards the operation was repeated, with the fingers, the points
being laid close to each other and then gradually separated so as
to tear the tissues gently. By having a catheter in the urethra
and a finger in the rectum the risk of wounding these organs was
avoided. When two inches of the canal were gained, he could
feel the distended uterus, and, on the 9th of March, he perforated
the tumor with a trocar, widened the opening with a bistoury,
and let off twelve ounces of dark blood.
In the course of three days, peritonitis set in, with great pros-
tration, tympanites, and a great tendency to stupor. The case
was considered very critical, but yielded at last to leeching and
mercurialization. The patient ultimately recovered, and -when
seen by Amussat in July, 1834, two years after the operation,
was in fine health, and menstruating regularly. The vagina was
very contracted, but adhesion had been prevented by the frequent
use of bougies. The true state of the parts, at that time, is
described in the following words of Amussat, after consultation
with Magendie and Marjolin: “il existait un petit vagin, qui
s’etait formd aux depens des petites et meme des grandes levies,
la muqueuse ayant etd attirde dans le vagin artificiel par la cica-
trice ; et au fond de ce vagin on decouvrait un trou, ou fistule,
qui conduisait d la matrice et par lequel Tecoulement des regies
se faisait librement.” The part of this sentence italicised de-
scribes, I believe, the state of the parts in my patient, when she last
left the Infirmary. Indeed the whole case bears a very strong
resemblance to mine, not only in regard to its history and the
condition of the genital organs, but also in regard to the mode
of relief adopted.
The danger of fatal peritonitis after the operation for occlusion
of the vagina, in cases of retained menses, is admitted by all sur-
gical writers. Even when no violence is done during the opera-
tion to the surrounding tissues, the simple evacuation of the
contents of the uterus seems to be inseparably connected with
this formidable disease. In Amussat’s case, the gentlest means
were resorted to, and the whole operation conducted with all the
caution and skill which distinguished that celebrated surgeon,
and yet the patient barely escaped with her life. M. Capuron
reported a fatal case in 1840, and was of opinion “ that when
any portion of the vagina is wanting, it is imprudent to have re-
course to any operation, under the risk of compromising the life
of the patient.”
In the July No. of Med. Chir. Rev. for 1830, Mr. Worthing-
ton reports a case in which he “ carefully divided with a scalpel
a dense cellular structure, of about half an inch in thickness,
situated at the orifice of the vagina, and gave exit to about a
pound of dark colored fluid.” Notwithstanding the abdominal
tumor subsided immediately, and the girl felt greatly relieved,
peritonitis set in three days after, and she died on the fourth
day. Professor Languebec relates a similar case, in which death
took place on the fifth day after the operation, and attributes the
tendency to inflammation to the long retention of the menses.
Boyer, who has treated at considerable length of the various
congenital defects of the female organs of generation, says,
“ death is the inevitable consequence of the accumulation of the
mensus in the uterus, where there is a complete absence of the
vagina.” I presume, then, that such accumulation is proportion-
ably fatal where there is partial absence of the vagina. He says,
too, that after patients have escaped the wounding of the rectum
and bladder during the operation, he “has known them die from
inflammation of the uterus and of the adjoining parts.”
But notwithstanding the dangers of the operation for retained
menses, especially in those cases where there is total or partial
absence of the vagina, no surgeon would be justified in refusing
to perform it. Death must be the ultimate result if the accumu-
lation is permitted to go on; this can but occur if an attempt is
made to relieve by operation, and there is certainly a chance of
success, of which the patient should always have the benefit.
Cases of congenital occlusion are fortunately very rare. I
speak not now of simple thickening of the hymen, which fre-
quently serves to retain the menses, and is perforated with a
thumb lancet, without difficulty or danger, but of that occlusion
which results from a partial or total absence of the vagina. I
can find but six cases reported since 1820, although I have care-
fully examined many of the leading Journals of England and the
United States, for 30 years past. The operation, therefore,
herein reported, has not been often performed, it is one of some
interest, and for this reason I am induced to publish it.
Norfolk, Va., July 16, 1853.