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for the other cases recorded, death occurred so rapidly as to leave no
time for the development of peritonitis. Such are the cases of
imperforate hymen, related by Brodie, Moore and Paget ; by Boyer,
Ueces, de Haen, Locatelli, Maisonneuve (2 cases), Munck, of vaginal
atresia ; by Hemman and de Pauly of atresia of the cervix. I have
seen a woman succumb rapidly to peritonitis caused by atresia of the

In lateral hsematometra the natural terminations are similar to the
preceding: spontaneous rupture of the obstacle, perforation of the
septum between the two lallopian tubes (Fig. 216), passage of the

Fig. 216. — Breisky, Pyometra and Pyokolpos due to atresia of one half of a
rudimentary vagina in a uterus septus. Archivfilr GynaeJcologie, Bd. ii, S.
48. Berlin, 1871. wZ, right vagina ; ?(rf, right uterus filled with pus ; vg,\eit
vagina ; ug, left uterus ; o, orifice through which the pus retained in the
right uterus was discharged externally through the left uterus and vagina.

blood from the horn into the Fallopian tube, and from this into the
peritoneal cavity, peritonitis caused by repeated crises, or finally,
passage of the fluid into the normal uterus and vagina, and subsequent

In all these cases consumption may supervene and cause death ; for
dyspepsia, vomiting, continued pain and constant lessening of the
interval between the crises, wear out the best constitution and lead to
marasmus. Occasionally the menopause, by putting a stop to the
discharge, or rather to the sanguineous fluxion, at the same time puts
an end to all accidents.

To sum up, a cure can only take place when the obstacle gives way.
Tolerance is established when the menses are deviated, when amenor-
rhoea superA^enes, or when the menopause is established. Apart from
these exceptions, there is always danger of death, and as nothing
aft'ords any indication as to which of these terminations will occur, the
wisest course is to avoid all by opportune intervention.

Dijferential diagnosis. — Without having any pathognomonic signs,
strictly speaking, retention of the menses nevertheless causes a number
of characteristic symptoms, such as absence of all discharge, the coin-
cidence in time between the commencement of the symptoms and the



expected advent of menstruation, the expulsive nature of the pains,
their duration from three to eight days, and their recurrence after
about a month's interval, their localisation in the loins, hypogastrium
and perineum, and lastly, the appearance of a tumour either at the
vulva or above the pubis, or in both places simultaneously.

When all these symptoms have been observed it is easy to diagnose
atresia ; but it is different when some are wanting or when they are
not well marked. In such cases a number of unjustifiable mistakes
are sometimes made : menstrual retention from atresia confounded
with prolapsus uteri, sciatica, ascites, cystocele, uterine polypus,
amenorrhoea, or even with pregnancy. Sometimes hsematocele, pelvi-
peritonitis and purulent tumours of the pelvis, ovarian cysts, hydatid
cysts, fibroma, cancer and hydrometra may be mistaken for retention,
and vice versa. Amenorrhcea is not attended by periodical exacerba-
tions, nor, above all, by a hypogastric tumour. In pregnancy the
knowledge of the antecedents, the mode of development of the tumour,
the state of the areola of the breasts, especially if the patient has never
had children, the results of auscultation (negative in retention, positive
in pregnancy) with the physical signs revealed by digital examination,
are sufficient to establish the distinction. There is one feature common
to hydrometra and hsematometra, viz. occlusion of the cervix; but
special and distinctive symptoms also always exist : hydrometra is
consecutive to amenorrhoea, and has generally a slow commencement ;

Fig. 217. — Freiind of Breslau, two cases of lateral hsematometra and ha?uiato-
kolpos from atresia ot" a rudimentary vaginal canal of double uterus.
Beitrdge zur Gebiirtshiilfeuml Gynaehologie, Bd. ii, Heft i, S. 2(3. Berlin,
1872. Vertical section : td, right Fallopian tube ; Ird, right round liga-
ment; ovd, right vaginal orifice; av, vaginal atresia; ff/, left Fallopian
tube ; Irg, left round ligament ; ovg left vaginal os ; li, hymen.



accidental hsematometra begins suddenly, and is preceded by a disease
affecting the cervix. The course of development of the tumour is not
identical — in the first it takes place without pain, and almost con-
tinuously ; in the second it is painful, and is produced in monthly
stages. Lastly, in the one there may be sanguineous discharge, in the
other there is none.

As to the differential diagnosis of various kinds of atresia, a careful
examination enables us to discover the special characteristics which I
have already pointed out in describing their history. It will be


Fig. 218. — Id. horizontal section : av, vaginal atresia ; vo, left vagina open.

remembered that lateral tumors (haematometra, hydrometra or pyo-
metra), in cases of double genital system usually project into the
normal vagina or uterus (Eig. 218), so as to be partly covered by
them on one side, and to jut out beyond them on the other, especially
in the upper part corresj)onding to the cornu and to the Fallopian tube
on the side of the seat of obliteration (Fig. 218).

Treatment. — Out of the great number of cases recorded there are
eight only in which the breaking up of the tumour has occurred spon-
taneously. The age of the patients thus cured varies from 18 to 23.
The time is that of a paroxysm : the necessary prelude, a series of
violent colics. The seat of the obstacle was five times at the vulva,^
twice at the vagina,^ once at the cervix.^ In four cases only was this
natural perforation produced by gangrene of the obstacle under the
influence of continuous pressure of the accumulated blood and of
uterine contractions. In that recorded by Allaire d'Hcricy^ the
symptoms had lasted for seventeen months ; the tumour was the size

' Wier, De prestigiis dcemonum, lib. ii, cap. xxxviii. — Schenck, Ohserva-
tioncs viedicoB rariores. Lugduni, 1643, lib. iv, p. 532. — Bartholin, Cenhtr. v.,
Obs. xliii. — Eschenbach, Obs. mcd. cliir., p. 8. — Lafitte, Revue thcrapeutique
du Midi, t. X, p. 44. — Scanzoni, op. cit., p. 476 : " A girl of nineteen suffered
for two years from severe dysmenorrhoia due to imperforate hymen, when
during an attack of pain tliis membrane suddenly iui)tured allowing tlie escape
of about a kilogramme of fcL^tid and decomposed l)lood. Immcdiatel.y after tliis
accident we were called and ascertained that the rui)ture had taken place ; the
hymen hung down from tlie vagina in several irregular shreds."

^ Dclisle, Journal general de medecine, t. Ixvi, ]). 91. It may be admitted
that the seat of the second obstacle was at the cervix. — Kiwiscli, in Scanzoni,
op. cit., p. 487. -The orifice in this case was irregular and funnel-sliaped.

^ P\iech, op. cit., ol)s. xiv, p. 56.

* Gazette medicate de Paris, 1832, p. 513.


of a small heii^s egg, and the hymen presented two blackish points,
the one at the centre, the other at the side ; the latter opened first
and gave issue to the contents. In that of Demaux^ obliteration of
the vagina had been preceded by a difiicult labour, and sounds had to
be used to dilate the opening which had formed in the centre as the
result of sphacelus. In the two last^ gangrene completed the opera-
tion which the surgeon had not the courage to finish. We cannot,
therefore, count on the efforts of nature to bring about a happj termi-
nation to a disease the course of which is beset with dangers. We
must not, however, conclude that operation is always indicated. We
have to consider the real dangers incurred by operation, the still
greater perils which may result from the progress of the disease, as well
as the abolition of the reproductive functions which always occurs.
These three elements of the question are evidently the three principal
sources of indication, or contra-indication, to the active intervention
of art. The elements furnished by the intensity of the disease, its
seat and its nature, must also be taken into account. The more the
organs have been distended by the menstrual blood and the more they
have lost their power of contraction, the greater likelihood there is of
metro-peritonitis and purulent infection finding a favorable field for
development. Whatever the size of the tumour may be, if it is
bordered by one or two small lateral tumours formed by the distension
of the Pallopian tubes, we have reason to fear a fatal result; the
operation, perilous as it may be, in this case is the only means of
preventing death. With reference to the seat of atresia, imperforation
of the hymen and membranous occlusion of the vagina and cervix
may be classed together as the least dangerous forms ; after them and
in order of increasing gravity come partial absence of the vagina,
complete absence of this organ, and lastly absence of the vagina with
imperforation of the cervix. From another point of view operation
as a rule is much more dangerous in acquired than in congenital

Whenever an operation is indicated it should be performed as soon
as possible, as delay only aggravates the danger owing to the increas-
ing dilatation of the uterus at every monthly period. Operation is only
absolutely contra-indicated when the uterus is atrophied and there seems
no likelihood that the menses will be established; before operating
therefore we must ascertain that the uterus exists, and that the morbid
symptoms are owing to distension of this organ and not to any other
cause. Operation is also contra-indicated when the existence of vesical
or rectal fistulce allows the escape of the menses by the urethra or anus.
In such cases intervention should only be resorted to when the operation
is easy and the fistula small and susceptible of cure ; here also, how-
ever, there is not strictly speaking retention, and therefore the opera-
tion is not urgent. The age of the patient may also be an absolute

1 Gazette des hopitaux, 1850, p. 567.

^ Barth, Gazette mcdicale de Strasbo^lrg, 18i4, p. 221 : Spontaneous cure
after four unsuccessful operations. — Blandin, Gazette mcdicale de Paris, 1846,
p. 57. Operation causing vesical fistula ; spontaneous cure.


contra-indication ; wliat may be attempted in the case of a young
woman of twenty ought not to be thought of in the case of a woman
of fifty. Nevertheless though, as a rule, it is wise to abstain when the
menopause is established, or when the patient has reached forty and
the menstrual periods have diminished in intensity, yet we ought to
operate after this age when blood-letting and opium prove ineffectual
and the tumour continues to progress ; for women of fifty and upwards
have succumbed in such cases to spontaneous rupture of the uterus.^
With the exception of such cases operation is indicated, and the
sooner it is had recourse to the better. Although Boyer,'-^ Dupuytren,^
Capuron^ and Cazeaux ^ have condemned it, it seems to me indicated
within the limits just stated. The distension of the Fallopian tubes by
the menstrual blood, although evidently a source of danger, is not a
contra-indication : on the one hand the prospect of imminent death, on
the other the success obtained by Amussat, Debrou and Barnotte,
authorise active intervention. We should, however, warn the parents of
the risk involved. The only real contra-indication is the extent of the
obstacle, or rather the extent of the destructions, the length and narrow-
ness of the vulvo-uterine cicatrix in cases of accidental obliteration, in
short the insurmountable operative difficulties.

If the atresia has been discovered in childhood the most suitable time
for operating is at puberty, just before the appearance of the menses.
After menstruation is established the indication is to operate as soon as
possible. Whatever the age of the patient may be, this operation, like
all others on the uterus, should only be performed in the intercalary
period, seven or eight days after menstruation ; at this time the con-
gestion is entirely dissipated, and the conditions are therefore the best
possible for avoiding inflammation.

The treatment, essentially surgical, of retention of the menses in-
cludes two important indications: — (1) To give free passage to the
blood retained above the obstacle ; (2) to maintain the patency of the
opening made.

We may make an outlet for the discharge of the blood in two ways,
indirectly or directly. The indirect method, which consists in attacking
the tumour through the abdomen, the bladder or the rectum, is only
admissible in cases of complete absence of the vagina, where it is im-
possible to reach the uterus through the recto-vesical space. The best
of these three indirect ways is evidently the rectum. I confess, how-
ever, that it seems to me more applicable to cases of atresia of the
hymen or lower part of the vagina than to those of the uterus, and in
this case it is easier to open the tumour directly through the vulva.
Although this operation, which was performed for the first time un-
successfully by Dubois,^ has been repeated in our days by Oldham,

' Duparqne, Traite des ruptures de la matrice. 1839, p. 13, 14.

" Trait(i des malad. cJururg., t. x, p. 417, 4e edit. Paris, 1831.

^ Quoted by Pif?ne, Traite dcs chirurg., of Clidlius, t. ii, p. 62.

■' Bulletin de I'Acad. de med., 13th Sept., 1839.

' Gazette des hnpitaux. 18(51, p. 31.

* See Boyer, Traite des malad. chirur., t. x, p. 447. — Boivin et Duges, op.


Baker-Brown, and Hastings-Hamilton, who penetrate from the rectum
into the tumour by means of a curved trocar, I cannot refrain from
remarking that the operator risks piercing the peritoneum twice, and
that, in order to prevent the consequences of the blood remaining in
the uterus or vagina, its effusion into the peritoneum is encouraged,
whilst, even in case of success, all that is gained is a utero- or vagino-
rectal fistula ; with which, if it occurs spontaneously, we must be
contented, but which is not desirable when gained at the risk of

The direct method consists in attacking the tumour through the
vulva and in establishing a lasting communication between the one and
the other. This method alone satisfies all indications, for, by pre-
venting accidents, it brings the parts back to their natural condition.

Cauterisation has been tried, but without success, by Felix Plater^
and Gaspard Bauhin.^ Caustics in fact have inconveniences which are
not compensated by any advantage; it is difficult to use them, and
impossible to limit their action, and the orifice is made at the cost of
a more or less considerable loss of substance and of the inevitable
formation of cicatricial tissue. On the contrary, incision and tearing,
either alone or aided by dilatation, are the most suitable means for
opening up a vulvo-uterine passage, incisions or puncture suflicing for
thin membranous occlusions, incision, dissection and dilatation being
necessary for obliterations of considerable depth. As the modes of
procedure vary according to the resistance of the obstacles, I will
describe the manner of performing each operation successively.

The bladder having been emptied by means of a catheter, and the
rectum by an enema, the patient should lie on her back on the edge of
the bed, opposite a window, in the position required for examination
by speculum, the pelvis raised, the thighs and legs flexed and apart.
An anesthetic should be given, unless especially contra-indicated;
and, in most of these operations, the bladder should be raised by
means of a sound introduced into its cavity and the rectum should be
drawn down by the index finger.

I. Imperforate hymen. — The plan which seems to me the best is the
following, proposed by Puech.^ Having made the hymen bulge out,
the centre is seized with forceps, whilst the right hand, with curved
scissors or bistoury, removes a circular piece of membrane. The genital
organs are then explored with the index finger, a gutta-percha bougie
of medium size being afterwards substituted for the finger to close the
opening. By this means the blood is prevented from gushing out and
the uterine and vaginal cavities are enabled to recover their normal
condition, whilst the air, having greater difficulty in penetrating into
the uterine cavity, exerts a less injurious inffueuce on it. As a rule,
this operation is not followed by any serious consequences ; but we

cit., t. i, p. 272. Congenital absence of the vagina. Puncture by the rectum.
Peritonitis ending in death.

^ Observationum , lib. iii. Basilese, 1614, lib. i, p. 241.

2 Theatrum anatomiciim. Paris, 1621, lib. i, cap. xxxix. p. 133.

3 Op. cit., p. 98.


must not forget that metro-peritonitis may occur and cause death, as
has happened twice out of 135 operations.^

II. Atresia of the vagina. — In cases of membranous im perforations,
a trocar or straight bistoury is plunged into the obstacle, and incisions
are made in various directions till the finger passes easily. In more
extensive atresia there are various modes of procedure, but only two
deserve description.

1. The plan followed by Amussat^ in 1832 consists in more or less
violent pressure exercised by the finger or a soft body, with the object
of pressing the vulval mucous membrane into the groove corresponding
to the entrance of the absent vagina. After a time this yields, and
after several attempts, repeated at longer or shorter intervals, the
tumour is reached, when the last barrier may be removed by the trocar.
This plan is more seductive than perfect. It can neither be employed
in accidental atresia, nor in cases where the rectal and vesical walls are
separated by a tissue of much resistance. It is very slow. Amussat
required six sittings and ten days to reach the uterus ; Parey^ four
sittings and thirteen days, besides which, after the second sitting, the
sensibility was so great as to make the latter attempts very painful.
The patient operated upon by Bernutz ^ was discouraged after five
attempts, in spite of her great desire to be cured.

3. Dupuytren^s plan ^ consists in the use of the bistoury, combined
with separation of the cellular tissue. It is effected in a single sitting.
The following is the description of it as modified by Puech,^ By means
of a male catheter the bladder is kept raised. The index of the left
hand is then passed as far into the intestine as possible to guide the
bistoury and to protect the rectum. A transverse incision is then
made in the centre of the obstacle, or in the vulval fossa if the vagina
is entirely absent; when the cellular tissue is loose, the operator may,
with the finger, catheter,'^ or handle of the bistoury, separate the vesical
and rectal walls till the tumour is reached ; when it is thick or very re-
sistant it must be carefully dissected, separating the tissues with the
handle or the finger rather than cutting them, and when necessary
cutting with a probe-pointed bistoury. The operator must proceed
slowly and circumspectly, stopping occasionally to examine with the
finger to ascertain how far he is from organs that must be avoided.

1 shall merely mention electricity, as it has been said to possess the
property of causing extensile in place of retractile cicatricial tissue;
this however has not been proved. When the newly-formed canal

' Quesnay in his paper Swi' les vices dcs huvieurs, printed in the Memoircs
de I'Academie de chirurgie (1743, pp. 58, 59), characterises the blood which
issues from the va<^ina after operations for atresia of the hymen as being black,
thick, often inodorous, but sometimes fcetid (De la Motte, Kpliemcrides d'Al-
lemugne, Benivenius, Merch'ren, Aquapendcnte).

2 Gazette Mcdicale de Paris, 1835, p. 785.
^ Gazette des hojntaux, 1861, p. 69.

" Op. cit., t. i, p. 307.

" Saljaiier, Theses de Paris, 1848, no. 08, p. 40.
•■' O]). cit., p. 106.

" Fletcher, Medico-surgical Notes and Illustrations. London, 1831, p. 143.
— Archiv. gen. de tried., 1835, t. vii, p. 54it.


admits the index finger easily, and when a clearer perception of fluctua-
tion apprises the surgeon of the proximity of the collection of blood,
he may plunge the trocar into it, and the issue of a brown syrupy fluid
will prove to him that he has succeeded. A small quantity of the
fluid is allowed to escape by the canula. This little orifice will only
be enlarged after some time to ensure the final result. A few days
afterwards a gutta-percha catheter is to be introduced into the uterine
cavity, and injections of tepid water with a few drops of carbolic acid
are to be made through it. A small syringe should be used, and the
injections should be made with great precaution. The dressing
finished, the parts are sponged and wiped and the patient placed in
bed, care being taken to protect the bedding from being soiled by the
black blood and mucous discharge which will be excreted for some

This method is applicable to all cases ; only the use of the finger
or soft instruments may be limited according to circumstances, some-
times not being required at all. If it is logical to distinguish cases
of this kind (the most serious, and those which cause most acci-
dents), it is unnecessary, with Verneuil,i to adopt a different plan for

Accidents attending the operation. — Roonhuysen,^ Benevoli,^ Liston,*
the surgeon quoted by Dieffrnbach" and Barth^ were obliged to leave
the operation unfinished ; Roonhuysen and the surgeon quoted by
Dieff'enbach because they had involved the rectum and the others
from want of courage. On one occasion I was unable to terminate
an operation of this kind. The blending of the bladder and rectum
was so complete at a certain depth that it would have been imprudent
to have continued, for it was impossible to attempt to separate the
one from the other. The menstrual retention was caused by a
cicatricial occlusion of the whole vagina consecutive to gangrenous
suppuration after a confinement. The patient was stout, extremely
sensitive with regard to the consequences of her infirmity, and
threatened by the accidents which often accompany retention. Prom
that time the symptoms were gradually mitigated, and although the
menstrual molimen and ovarian activity were more or less felt
every month, there was no accumulation of blood in the uterus, no
deviation of the menses, nor any other pathological phenomenon,
thanks to the palliative treatment prescribed and to the progressive
tolerance of the organism.

The bladder has been injured three times : in one case a cure was
effected ; in another a vesico-vaginal fistula was formed which Blandin
could not cure ; and another time (de Haen), apart from the fistula,

' Bapport a la Societe de chirurgie sur V operation de M. Patry {Gazette
des hapitaux. 1861, p. 69).

2 Observ. vied, rariores Gerardi Blasii. Amstelodami, 1677, p, 30.

^ Related by Chambon and by Colombat.

■* Gaz. des Mpitaux, 1839, p. 183.

^ Related by Verneuil, Gaz. des. hop., 1861, p. 31.

^ Gazette mecZ. de Strasbourg, 1844, p. 222.


death occurred by the effusion of menstrual blood into the peritoneum
through the Fallopian tubes.

Haemorrhage is rarely serious ; but it may become troublesome.
This has led Camerarius, Voisin and Guerin to make several short
operations. In this case it is necessary in order not to lose the
benefit of the first incisions, to insert a foreign body, or even a dilator,
in the canal that has been hollowed out.

The consecutive accidents which may occur are varied : metritis,
inflammation of the Fallopian tubes, peritonitis, and even putrid in-
fection. Out of 66 operations there were 6 cases of death due to
the three last diseases.

I am convinced that, in accidental obliterations due to puerperal
gangrene of the vagina, the tendency of inflammations to assume
the gangrenous character may be the cause of fatal symptoms, just as
it produced the first accident and the deformity which necessitated
the operation. I lost a patient in this way. After great difficulties,
and even a little tearing of the peritoneal cul-de sac in front of the
rectum, I reached the uterus, and things progressed so well for some
days that we had hopes of success, when, concurrently with a slight

Online LibraryAmédée CourtyPractical treatise on the diseases of the uterus, ovaries and fallopian tubes → online text (page 31 of 95)