A Remarkable Case of Acquired Atresia of the Vagina BY BARTON COOKE HIRST, M.D. REPRINTED FROM The American Journal of Obstetrics Vol. XXXII. No. 6,1895. NEWYORK WILLIAM WOOD & COMPANY, PUBLISHERS 1895 A REMARKABLE CASE OF ACQUIRED ATRESIA OF THE VAGINA.1 The case about to be reported possesses some features in its etiology and treatment wdiich are, I think, unique. In the comprehensive statistics just collected and published by Neuge- bauer2 there is nothing exactly like it. Rosina was delivered of her first child in July, 1892. She states that a woman physician in charge of the confinement “ cut her and then sewed her up again.” A year later another woman physician did two operations upon her vagina, the na- ture of which the patient does not know. A month or two later she fell into the hands of a gynecologist, who removed both of her ovaries. As it appeared later, this gynecologist must have operated on her without making a vaginal examination. In the following spring the woman was conscious of a swelling in the lower abdomen and suffered great pain. A few months later there was a sudden discharge of a large quantity of blood}7 fluid from the urethra (rupture of a hematocolpos into the bladder), whereupon the pain and swelling disappeared. These symp- toms, however, reappeared, and in the following winter (Decem- ber, 1894) my friend Dr. Edward Martin, whom the patient consulted, found an atresia of the vagina at its upper third, and in the line of atresia a row of silver sutures that must have been there since July, 1893. The sutures were removed and the hematocolpos opened, but in doing this a vesico-vaginal fistula was established. In a short time the vagina closed again completely, but the vesico-vaginal fistula persisted. Two attempts were made to close the fistula, without success. In the meantime there had been again a col- lection of menstrual discharge in the vagina with a reappearance of the old symptoms. It was found impossible to tap this col- lection through the vagina, or to reopen the vagina without en- i Read before the Section on Gynecology, College of Physicians of Phila- delphia. 2 “ Zur Lehre von den angeborenen und erworbeneji Verwacbsungeojimd Verengerungen der Scheide,” etc., Berlin, 1895. (One jthousai|d(clses.) HIRST : CASE OF ACQUIRED ATRESIA OF THE VAGINA. larging the vesico-vaginal fistula and endangering the ureters. An attempt was therefore made by Dr. Laine, in Dr. Martin’s absence, to evacuate the fluid by a puncture through the rec- tum. This succeeded, but the vagina refilled rapidly and the woman became quite seriously ill, with high fever, a hectic flush upon her cheeks, prostration, and rapid loss of weight. In this condition she was put under my care in the Howard Hospital. On examination I found a large vesico-vaginal fistula, an atresia of the vagina in its upper third, with extreme cicatricial contraction, and, as the result of ulceration, a mere bridge of connective tissue separating bladder and rectum. Above the point of atresia there could be felt by rectal and abdominal ex- amination a cystic tumor which was extremely sensitive. In view of the repeated failures to keep the vagina open, and on account of the likelihood of injuring both bladder and rec- tum in an attempt to make the opening large enough for a per- manently successful result, I determined to perform hysterec- tomy as the.surest means of preventing a reaccumulation of fluid above the point of vaginal closure. This was done four months ago. I found that a portion of one ovary remained from the last abdominal operation, explaining the persistence of menstru- ation. As I cut off the womb a fountain of pus gushed from the cervical canal and deluged the pelvic peritoneum. The latter was cleansed by the dry method and the cavity closed without drainage. The layer of connective tissue joining blad- der and rectum and obliterating the vagina was then punc- tured, and the purulent fluid remaining in the vagina evacu- ated. The woman made a good recovery. I have recently closed the vesico-vaginal fistula successfully, and the patient is now perfectly well. Appended is the list of ten operations by six physician* to which this patient was subjected before she was cured; Operation on the vagina during labor (Dr. Gr.) ; two plastic operations in the vagina (Dr. F.) ; a salpingo-oophorectomy (Dr. ,P.); operation for atresia of the vagina (Dr. M.); two unsuccessful operations on a vesico-vaginal fistula (Dr. M.); puncture of the hematocolpos through the rectum (Dr. L.); hysterectomy and discission of tiie vagina (Dr. H.) ; operation on vesico-vaginal fistula (Dr. H.). 1821 Spruce street.