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is of considerable length throughout life. In the higher ani. mals it is small, and in man, where it is known as the vestibule of the vagina, it is a mere trace of its former self. Though the vestibule of the vagina and the vagina proper are, as we have seen, produced by separate and distinct embryonic structures, they are so closely allied that I have thought it best, in con. sidering congenital atresia of the vagnia, to regard them as forming a common canal and our subject as embracing the absence in a female child at birth, of a part or of the whole of this canal. This brings us to the cause or causes of a failure in the development of the vagina.
On this subject there is difference of opinion. I believe there are two direct and many indirect causes. The latter contributing their ill effects through the former. The direct etiologic factors are the ones that we shall discuss and are:
1. An antenatal inflammation. This inflammatory process may be sufficiently severe as to binder the growth of the walls of the vagina in a part or in the whole of their length. It may be milder, causing only a retardation or feebleness in the development of the structures of the channel, but upiting at some point its opposed surfaces or preventing the opening of the lower ends of the embryonic ducts which, as we have said, are closed in the early stages of antenatal existence. I believe a moderately severe inflammation of the Mullerian ducts will result in a practical absence of the vagina and probably of the uterus and Fallopian tubes. If the inflammation is of the uro. genital sinus, the vestibule or lower end of the common canal may alone be malformed or else accompanied by some defect in the other structures, developed from the same embryonic tissue.
2. Lack of hereditary force in development. All things else being equal the cells or organs wbich are the oldest bio. logically, by this I mean have been longest known to living matter, bave the greatest power of contributing to the prima. tive cell-ovum or spermatozoa-hereditary influences and thereby developing their kind in the offspring. Now, to prevent confusion, we must keep clearly in mind the distinction between the primary power of reproduction and the power of producing a particular type of reproductive organs-genital organs. The former bas necessarily existed from the begin. ning of living matter, while the power of reproducing the sexual organs, as they exist in man, extend to not a more remote period in the past than is represented by the higher ver. tebrata. The question that directly concerns us is, not as regards the primary power of reproduction, nor the power of reproducing organs for reproduction, but, as regards the power of reproducing the type of sexual organs found in man. Of all the useful organs the genitals of man are the most recent acquisition to living watter, as is evidenced by their absence in lower animals where the other organs exist. Now, if the preceding is true, then, the conclusion is justifiable, that man's type of reproductive organs have the least power of contributing to the primary cell-ovum or spermatozoa-hereditary in. fluences. This being true, their development is comparatively easily diverted or bindered, and hence, their appearance in the offspring is less certain to be perfect in form. The vestibule of the vagina has a stronger heredity than the vagina proper, because it has a longer biologic history, as is evidenced by its presence-uro.genital sinus-in lower animals in which the vagina is absent. It follows, therefore, tbat the lack of hered. itary force is less liable to be an etiologic factor in malformations of tbe vestibule than of the vagina proper. It may be claimed that, though there is a comparative lack of hereditary force in the production of man's genital organs, nevertheless, it is sufficient to cause them to be perfectly reproduced. As a rule, this is true, but when we observe that these organs are the most frequently malformed and that their ill development, usually, represents a lack of completeness in development or a reversion to a type of organs belonging to a lower species of animals, from which man evoluted, we are, in my opinion, justifiable in the conclusion that the lack of hereditary power is an important etiologic factor in the production of every teritologic condition of tbe genital organs.
Acquired atresia of the vagina is produced by a post-natal inflammation of the canal destroying, a part or the whole of, its mucous membrane and a subsequent union of its opposed surfaces. The inflammation usually follows a difficult confine. ment, where the presenting part of the child has been permitted to remain so long in the vagina as to cause, by pressure, a devitalization of its mucous membrane, or where traumatism has been produced by the use of forceps. It may result from specific infection or, during early childhood, neglect in clean. liness. Coition is a preventive to traumatic atresia, hence, it is comparatively more frequent in the unmarried. The clinical
aspect of the most frequent forms of vaginal atresia is well represented in the history of four cases that have been under my care. I will, therefore, confine myself largely, in the dis. cussion of this division of the subject, to a brief report of them :
1. White, 30 years old, widow, multipara, well developed. Her last confinement was very difficult and was followed by considerable vaginal inflammation. Her menses never ap: peared after this illness. For a year before she consulted me she had monthly pains of several days duration. Finally, an enlargement appeared in the middle and lower part of the abdomen, which she noticed was distinctly larger after each monthly suffering. I found, on examination, the uterus distended to the size of a seventh month pregnancy and the vagina closed at about its middle. Above the closure the vaginal cavity was distended and bulged, principally, toward the rectum and bladder. The diagnoses of retained menses from obstruction in the vagina was clear. The anterior and posterior walls of the vagina were separated from one another by making a transverse incision through the obstruction, care being exercised to avoid injuring the rectum and bladderfollowed by a careful, though thorough, dilation of the opening. On entering the dilated portion of the vagina a semisolid and dark-almost black-material began to flow away. For fear of exciting an excessive contraction of the distended uterus and causing a rupture of its walls, the escape of the retained matter was not hastened but was allowed to take place slowly. The cavities, baving been emptied, they were irri. gated with a mild antiseptic solution—ample means being provided for the return current. The mucous membrane above and that below the point of obstruction was dissected loose and drawn together over the cuff-like raw surface, made by cutting through the obstruction, and stitched in that position. The vagina was then packed with iodoform gauze. The dress. ing was changed daily and a vaginal douche given, until union of the mucous membrane over the denuded surface took place. She made a good recovery. This was a case of acquired atresia resulting from a difficult labor. Retained matter from atresia of the genital canal is liable to become infectious and cause septic poison. A distended uterus or a distended tube may rupture and pour its contents into the abdominal cavity. Such an accident necessitates an abdominal operation to repair
the damage-by washing out the cavity with a saline solution and removing the lacerated structure or, if the opening is small and of the uterus, closing it.
2. Wbite, 60 years old, multipara, widow, well developed though very anemic. Two years before she consulted me she bad considerable vaginal inflammation, wbich lasted several weeks, but after it subsided sbe experienced no inconvenience. About three months before she came under my care she began to have pain in her pelvic cavity. On physical examination I found the vagina closed near its middle and an enlargement, about the size of an orange, above the obstruction. The atresia was cut through and the enlargement proved to be due to a carcinoma of the cervix uteri. Finding the cancerous growth so extensive as to forbid a radical, I limited my efforts to a palliative operation, and informed her family of the hopelessness of her condition. At the expiration of a couple of weeks she was sent home where, as the result of the operation, she improved temporarily, but died within eight months. This, of course, was a case of acquired atresia and probably would never bave been recognized, as the uterine discharges bad ceased, if the carcinoma of the cervix had not developed. No doubt many women, after the menopause, bave atresia of the vagina, as a result of senile vaginitis, which is never discov. ered, because there is usually no uterine discharge to be retained and, hence, no untoward symptoms manifested.
3. White, 13 years old, brunette, well developed for her age, health good, except for the nonappearance of her mer and a few days suffering every four or five weeks during the last several months. The mother recalls that in early child. hood this girl had a profuse vaginal discharge. The diagnosis of vaginal atresia with retained menses was made by her phy. sician, Dr. Gamble, who kindly referred her to me for opera. tion. The closure was at the upper portion of the canal. Above the obstruction was a distension of the vagina representing an accumulation from several menstruations. The same operation was performed on this patient as on the first one reported. She has made a good recovery, but there is some show of the past inflammation at the upper extremity of the vagina. Though this patient never had a sign of her monthly sickness until after the operation, which fact points to congeni. tal closure, I am constrained to believe it was a case of acquired atresia, resulting from a failure on the part of her
parents to recognize the importance of having her properly cared for when she bad vaginitis—as was evidenced by the vaginal discharge in early childhood.
4. Though this case does not represent a perfect closure of the vagina I will report it because it possesses many interesting features which I desire to bring forward in this discus. sion: White, more than 30 years old, married several years, no defect in general development, menstruated regularly. Never was pregnant except with the child for the delivery of wbich I was called, by Drs. Huddleston and Justice, in consul. tation at her home, in adjoining county. The vagina seemed closed at the junction of its lower and middle third. At one point of the obstruction there was a depression which led into an opening about half the size of an ordinary lead pencil. I reached her home at noon and, as she had been in labor since the evening before, we concluded to open the closed vagina and deliver with forceps. By forcing one finger gently, but firmly, into the depression the obstruction was overcome and the cervix uteri reached. The cervix was well dilated, and we gradually stretched the opening that we had made through the obstruction—taking care not to tear the rectum or bladderuntil we believed we could insert the forceps and with safety deliver the child. The delivery was successfully accomplished. No effort was made to cover the raw surface, caused by the destruction of the vaginal closure, as we believed the great dilation that was made, with the after-treatment sbe would receive, would, probably, prevent a recurrence of the obstruction. She bas bad no further trouble and, with her child, was enjoying good health when I last heard from her.
In my opinion this was a case of congenital obstruction in which the development of the vagina was not interfered with, except to the extent of preventing the lower end of the canal, which as we have above said, is closed in the early stages of embryonic existence, from being properly opened. The small opening through the obstruction had given an outlet to the menstrual flow. The efforts at coition bad enlarged the vesti. bule of the vagina and caused it to assume, in copulation, the function of the vagina proper. This has been known to occur in total absence of the vagina. In some of the lower animals, as the marsupials, copulation is a normal function of the urogenital sidus, which in the woman is represented by the vagi. nal vestibule. Imperforate hymen must not be confused with