Paper - Transverse septal atresia of the lower third of the genital tract
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Hart DB. Transverse septal atresia of the lower third of the genital tract. (1897) Trans Edinb Obstet Soc. 22: 18-21. PMID 29613129
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VIII. Transverse Septal Atresia Of The Lower Third Of The Genital Tract
By D. Berry Hart, M.D., F.R.C.P.E.,
Lecturer on Midwifery and Diseases of Women, School of the Royal Colleges (Surgeons’ Hall), Edinburgh.
The usually accepted form, and by far the simplest, of atresia vaginae is that known as atresia hymenalis. Here the hymeneal opening has not formed, the menstrual blood is dammed back, and when an incision is made through the septum a large quantity of chocolate-like blood escapes. The genital organs in such cases may be otherwise normal.
A few rare instances have been recorded where the occluding septum was higher up than the ordinary site of the hymen, and such anomalous cases have been usually regarded as double hymen, or as due to inflammatory adhesions. Such instances deserve, however, very careful scrutiny, as they are opposed to ordinary developmental views, and, instead of being brushed aside, they must be fairly met and explained if possible. What are often termed anomalies are really proofs of the erroneous nature of current explanations.
I have had under my care three cases of atresia hymenalis, all in private practice. Of these I describe only two as types.
The first case to be recorded occurred in the practice of Dr James Smith. There was the usual bulging membrane at the site of the hymen, and on rectal examination one could feel the vaginal distention. With all antiseptic precautions the hymen was freely incised, the blood allowed to evacuate’ slowly, and then, as the uterus was not involved, in the distention, the vagina washed out and plugged with iodoform gauze. The recovery was complete, and no further trouble was experienced.
The second case was one of the rare anomalous forms, and requires special record. It occurred in the practice of Dr MacGibbon, and was also seen at first, and in my absence, by Dr Fordyce. When seen by them on Sept. 20th, the girl, aged 14, was suffering from retention of urine, and the history was that she had never menstruated, had had pain in the back for a few days previous to this occasion, and also a month before. On examination by inspection, a tumour was noted projecting at the hymen when the labia majora were separated. The urine was drawn off, and this urgent symptom relieved.
When I saw her soon afterwards the septum had ruptured and a large amount of the characteristic blood escaped.
On examination I then found a very unusual condition. The external genitals and hymen were normal, but on passing my finger through the vaginal orifice I felt a transverse septum an inch from the hymen and with a laceration on the left side. A week afterwards I passed my finger through the laceration, broke down the septum, and found the parts above normal.
Examination on the 11th of November showed that an inch from the hymen a ring could be felt admitting the index finger easily. The organs were otherwise normal.
The question now arises, in view of such cases, as to the developmental origin of the vagina, or, to put it as embryologists do, What is the Anlage of the vagina?
The ordinary view is that the vagina is developed from the ducts of Muller, and that the urino-genital sinus takes no part in its formation. The ducts of Muller are at one period of their development double, While the urino-genital sinus is always single. The occasional double hymen at the ordinary hymeneal site is so easily explained by the supposition that we have in this anomaly a persistence of the double ducts of Muller, that it has been unhesitatingly accepted as a proof of the origin of the vagina in its whole extent from these canals.
In a recent communication I endeavoured to show that the hymen was developed from two bulbs (the Wolffian bulbs) which formed at the lower ends of the Wolffian ducts, and that the epithelial cells from these bulbs proliferated into the Mullerian vagina, rendering it solid, the lumen being formed by the central cells breaking down. I did not discuss then what I now wish to consider, viz., the Anlage of the vagina.
- 1 Journal of Anatomy and Physiology, Oct. 1896.
In a sagittal mesial section of a female foetus of about 12-25 mm. in length, the vagina appears to be formed by the coalesced Mullerian ducts, and to end at the top of the narrow urino-genital sinus in the eminence of Muller. Below this eminence the Wolffian ducts open, and lower down we have the cloaca into which the urino-genital sinus and bowel open.
In a foetus somewhat further advanced (end of second month) we find a condition established as shown in Keibel’s diagram (fig. 1).
Fig. 1. From Keibel’s model of organs in foetus about 8th week. The hymen develops below the level of the cross (X).
We see here the relatively long urino-genital sinus with the eminence of Muller at its top where the Qlucts of Muller end. Here the hymen is stated to develop, and as the urino-genital sinus is believed to be represented in the adult solely by the shallow vestibule, it is said to shorten considerably. Certainly in the newly-born infant the hymen is more deeply placed, and the vestibule somewhat pit—like.
If, however, the hymen develops, as I have indicated, by the formation of the Wolffian bulbs, it is evident that the upper part of the urino-genital sinus must enter into the formation of the lower part of the vagina. The occasional double hymen is really a persistence of the Wolffian bulbs, and not the lower ends of the Mullerian ducts, which, so far as our present knowledge goes, seem to end blindly in the eminence of Muller.
What happens, therefore, at or about the third and a half month in the development of the vagina is as follows :-——Below the level of the eminence of Muller, and therefore at the top of the urinogenital sinus, the hymen develops by the formation of the Wolffian bulbs. These block the top of the sinus at first, but by their coalescence and central breaking down, aided by the involution from below, the hymeneal opening is established.
The adult vagina, therefore, has its lower third developed from the urino-genital sinus, the upper two-thirds from the ducts of Muller.
There can thus arise three defects in development in the lower part of the vagina, viz.—
- We may have a transverse septum at the site of the hymen due to the persistence of tissue between the lower ends of the coalesced Wolffian bulbs and the involution below from the urino-genital sinus (fig. 2).
- There may be a transverse septum at the ends of the coalesced ducts of Muller an inch above the hymen. This was the condition in the second case.
- There may be a persistence of the Wolfiian bulbs, so that we get a persistent narrow sinus after operation, between the hymen and the Mullerian vagina above. Of this I have seen one case, but have no notes, unfortunately.
Fig. 2. Section of a 3.5 months’ female foetus (§). The three possible atresia conditions can be seen.
In regard to the treatment of such cases, I recommend free incision after the parts have been thoroughly shaved and cleansed. While the blood- is escaping, the purified finger can be passed in to ascertain the conditions of the organs, and if the uterus is not involved, the vagina can then be washed out with a mild antiseptic. Should, however, the uterus be dilated, I would avoid this washing out, and merely receive the discharge into antiseptic diapers.
Prof. Simpson said the Society were indebted to Dr Hart for a very valuable and instructive contribution in the paper he had read. He (Prof. Simpson), like many of the other Fellows, had met in practice with cases such as Dr Hart had described, where there was an atresia of the vagina at a point higher up than the level of the hymen, and had set them down as due to defective development. But it was only in looking at Dr Hart’s illustrations and hearing his explanation of them that the nature of the imperfection became manifest. The session had been inaugurated by a first-class Presidential Address, and this first communication embodied first—rate original scientific work.
Dr Haultain said that he had met, while operating with Dr Halliday Croom on a case of atresia vaginae, with a distinct space filled with fluid between the hymen and the true atresia of the vaginae, the latter of which was at least three-quarters of an inch in thickness. Though at the time unable to account for the peculiar sacculated condition of the atresia, it was now evident, from what Dr Hart had demonstrated, that the space was due to a want of complete fusion in the genital cleft, and also between the Mullerian eminences.
Dr J. W. Ballantyne said that, like Prof. Simpson, he had been much impressed by the value of Dr Hart’s demonstration and contribution. He thought it afforded an explanation of the considerable depth of the pouch formed by the vulvar canal in cases of absence of the upper part of the vagina, for he had never been able to understand how pressure alone could so deepen it. Further, his explanation of the transverse septa in the vaginal canal seemed a much more adequate one than the commonly accepted theory of a foetal or intra-uterine adhesive coloitis gluing together the walls, and so producing a septum.
Cite this page: Hill, M.A. (2019, October 13) Embryology Paper - Transverse septal atresia of the lower third of the genital tract. Retrieved from https://embryology.med.unsw.edu.au/embryology/index.php/Paper_-_Transverse_septal_atresia_of_the_lower_third_of_the_genital_tract
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