Occlusion of the hymen is the commonest form observed. The vagina becomes slowly distended with blood, forming an elastic pelvic swelling (hæmato-colpos) upon which the uterus is, so to speak, perched. Later in the course of the disease, this organ itself (hæmato-metra) and the Fallopian tubes (hæmato-salpinx) may become affected similarly. =Indications.= In atresia of the hymen symptoms only commence after puberty; there is then congenital amenorrhœa with periodic pelvic pain and gradual formation of a pelvic swelling. On inspection the hymen is distended and the blood-tumour above it gives a bluish tint to its surface. =Operation.= After administration of an anæsthetic, careful palpation of the tubes should be made _per rectum_: if they are distended it is better to open the abdomen, ligature and remove them; if not, the hymen should be incised by means of a crucial opening and the characteristic tarry fluid allowed to escape: no hypogastric pressure should be used. Irrigation and packing with gauze may be resorted to as after-treatment, but are considered unnecessary by a large number of operators. Atresia of the vagina may be congenital or acquired. In the latter case the condition results from contraction of adhesions developed from damage done during labour; or it may follow acute septic vaginitis, the introduction of acids or irritating materials to produce abortion, or as a sequel to typhoid fever. Treatment is by slow dilatation with Hegar’s bougies over an extended period of time; relapse is common. DILATATION OF THE VULVAL ORIFICE =Indications.= This is done for vaginismus due to a pathological spasm of the levator ani and resulting in more or less complete obstruction to coitus. =Operation.= Under an anæsthetic the vulval orifice should be thoroughly dilated by means of the thumbs, and for some days subsequently graduated Sims’s ‘vaginal rests’ (Fig. 46) should be inserted twice daily and worn for twenty minutes at a time. This treatment may be necessary for a fortnight or longer. In many cases of dyspareunia the cause will be found to be due to a thick, fleshy, and unruptured hymen or to tenderness about the remnants of that organ. Under these circumstances, exsection is the better plan to pursue. The hymen is seized with a pair of toothed forceps and removed with curved scissors along its entire base of attachment. Free bleeding often occurs from the raw surface, which must be controlled by ligatures. The two almost parallel cut edges must then be carefully brought together either by continuous or interrupted suture. [Illustration: FIG. 46. SIMS’S VAGINAL REST.] COLPOTOMY OR VAGINAL CŒLIOTOMY By colpotomy is meant making an opening into the peritoneal cavity through the vagina; the operation is known as anterior or posterior colpotomy, according to whether the opening is made through the anterior or posterior fornix.