Transactions of the Provincial Medical and Surgical Association/Volume 1/On Imperforate Hymen
ON
IMPERFORATE HYMEN.
BY JAMES MILMAN COLEY, ESQ.
BRIDGNORTH:
Member of the Royal College of Surgeons, in London; Member of the Medical and Philosophical Society at St. Bartholomew's, &c.
The obstruction in the vagina, occasioned by a
preternatural formation of the hymen, may be either
complete or incomplete. In the former case the
imperfection may remain undiscovered, until the
menstrual secretion has accumulated within the cavities
of the uterus and vagina, and has distended
the former, so as to excite suspicion of the existence
of pregnancy. As the aggregation of the menses,
and consequent enlargement of the uterus advance,
some difficulty in discharging the urine takes place,
constituting dysury; but I am not aware that any
instance has been hitherto recorded, in which retention
of urine, from the above cause, requiring the
continued use of the catheter, has occurred. Such
a disease is no where described,[1] either in the nosological
systems of Linnaeus, Vogel, Sagar, Cullen, Good, or the voluminous species and varieties of
Sauvages; and no notice is taken of it by Hawley,
in his classical "Definitiones Morborum." Should
a second edition of Good's physiological system of
nosology be required, the editor may adopt this as
a fifth variety of paruria, under the denomination of
paruria retentionis hymenalis; or it may, with propriety,
be incorporated in the common systems,
under the title of ischuria hymenalis.
In the following case, the ischury attracted the first and undivided attention of the patient and medical attendant: the preceding symptoms of vaginal obstruction, having escaped observation.
March 25, 1832, I was requested to visit a young lady, aged 16, who resided at a considerable distance from this town. She had been ill three days and nights, with retention of urine; and her medical attendant had been under the necessity of relieving her by the introduction of the catheter, twice daily, during that period. The existence of so distressing a disease excited great apprehension; and my opinion was solicited respecting its nature and treatment. I found the cause of the ischury to consist of an imperforate hymen, which, by totally preventing the discharge of the menstrual fluid, had produced a mechanical obstruction in the urethra. The external orifice of the meatus urinarius was situated in a cul-de-sac, and the hymen was tense and slightly protruded. The bladder having been evacuated, I proceeded to examine the hypogastrium, where I discovered an obvious and considerable enlargement of the uterus of an oblong shape, extending nearly to the umbilicus. The lower part of the abdomen had been increasing in bulk during the last two years, and the breasts were fully developed; in short, she appeared to be in a state of pregnancy.
The patient being laid on her back, I pushed a double-edged scalpel through the hymen, which was very thick and tough; beginning at the upper part just below the meatus. Nearly four pints of tar-like fluid gushed out; after which I continued the incision down to the perineum. An aperture was thus made capable of admitting two fingers, into which a plug of lint was introduced.
Before the whole of the menstrual fluid was discharged, the young lady became hysterical, and continued in that state while I remained with her, which was a period of four hours; and my engagements compelled me to leave her in that condition, under the care of the practitioner in attendance, from whom, on the third day after the operation, I received the following letter:
March 28, 1833.
" My dear Sir,—I feel much pleasure in informing you that our patient is, in many respects, relieved. The muscular action of the bladder has returned, and nature effects her own purpose with perfect consciousness. The bowels are relieved. There is still a discharge, a little corrosive in its character, but not grumous. I have, this morning, passed a sponge, without any difficulty, during a paroxysm of hysteria. The hysterical affection still continues with severity, but, I can say with propriety, that she is progressively, although slowly, improving.
With best regards, and thanks for your attention,
I remain, my dear Sir, your's, &c."
"To J. M. Coley, Esq."
April 16.—The wound healed. The hysterical fits return three or four times daily. The patient walks out, and has not yet menstruated. She has constant pain in the left side of the abdomen, which is tender.
May 14.—Being again in the neighbourhood of her residence, I called to inquire after her; when I was much pleased to find that she had menstruated profusely a few days after the last report. The discharge was perfectly natural; and the hysteria had subsided about a week ago.
In performing the operation of dividing the morbid vaginal membrane, great circumspection is requisite; as death has been the consequence in several instances. De Haen, in the sixth part of his Ratio Medendi, mentions a misfortune of this kind, occasioned by the operator having carried his incision, by mistake, into the bladder; and Denman lost a patient with peritonitis, produced by the operation.
The incomplete obstruction usually admits of a minute aperture at the upper portion of the hymen, through which part of the urine is forced out in drops, or a small stream, with great pain, resembling that produced by stone in the bladder. As this pain and distress exist from birth, not more than three or four years elapse before the malformation is discovered; the little patient being then able to describe her sufferings. Many such cases have come under my care, and have been permanently cured by a free incision. When allowed to proceed without relief, the disease has terminated in death. An instance of this kind is recorded by Dr. Schmiedt,[2] in which the stagnant urine, accumulated in the vagina, eroded the passage and made an opening into the rectum, which proved fatal; the patient being only eight years old.
The cure in every instance consists in the division of the false membrane, which, it should be observed, is sometimes found double, at others of extraordinary density. Various successful operations of this nature are recorded, for the particulars of which the following authors may be consulted:—Fabric, ab aquapendente Oper. Chir. p. i. cap. 82, 83, 84; Guid. de Cauliac. Tract. 6, cap. 7; Hen. Van Roonhuysen, Obs. par. i. pag. 102, 103; Paul Barbet, p. 1, Chir. 1, cap. 13; Warner's Cases in Surgery, p. 276; &c.