ACQUIRED ATRESIAS AND STENOSES.
Their most frequent cause is un doubtedly puerperal necrosis and ulceration; as is proven by the extensive literature of acquired vaginal atresia.' In the thirty-six cases which Trask has collected, not less than fifteen were due to childbirth. As is the case with vesico-vaginal fistula, it is the prolonged pressure in tedious labors rather than traumata incidental to artificial deliveries which forms the starting-point of the pathological changes. Rarely are other injuries the cause, 88 in Matheyssen's ' case, where vaginal adhesions had occurred from a fall upon the genitals against the edge of a chair, at the age of four years. Schulze ' had a case in which it was caused by a fall against the shaft of a wagon, and Hennig one due to a girl three years old being run over. Osgood, Banyan, Thomas, and others, have observed cases of traumatic origin which were acquired in childhood. Cicatricial strictures and adhesions occur relatively frequently in connection with the wearing of pessaries, especially when retained for a long time. The Prague ana tomical collection contains an example of the kind which occurred in a woman sixty-eight years old, who had worn a pessary thirty-four years for prolapsus. Other foreign bodies may also lead to prolapsus. Ch. II. Carter and I (comp. foreign bodies) have seen very marked cicatricial stenosis in consequence of the introduction of spools of cotton. Cauteri zations have also been seen to cause them. Thus in the cases recorded by Madame Boivin and Dugiqs, a Nyoman injected half a glassful of sul phuric acid into the vagina to produce an abortion, and entirely obliterated the upper of the cha,nnel; the uterus ruptured and death occurred when labor began later on. And Levy,' who had to do a efesarean sec tion, on account of such an atresia, and Lombard,' report two cases due to cauterization with sulphuric acid. And after an operation atresias and cicatrioial stenoses have been seen to occur, not only following the use of cauterizing agents (ferrum candens and the galvano-cautery), but even after a polypus operation (O'Reilly).* But diseases are moat often the cause, especially puerperal ulceration, and diphtheritic destruction in the course of other diseases, such as cholera (White, Nelaton); typhus (13Ohni, L. Mayer, A. Martin); erysipelas (Renouard, Bourgeois); acute ex
anthemata, especially variola, (Richter, Murray, Scanzoni, Hennig). Ex tensive syphilitic ulceration has been repeatedly seen to cause incomplete and complete vaginal occlusion (Lisfranc, T. G. Thomas).
But the vaginal affection is sometimes purely a local one. Thus Simpson calls attention to a variety of vaginal inflammation occurring in children, which he calls vaginitis adhesiva, and the peculiarity of which consists that it leads to adhesions without precedent ulceration. And the ulcerative form of adhesive vaginitis in adults which Hildebrandt has described, may lead to more or less extensive occlusion of the vaginal lumen.' If a ring-shaped or spiral cicatricial stenosis, either congenital or acquired in early childhood (see above), is present, it may lead in the course of a pregnancy to a secondary atenosis by adhesive inflammation of the hyper-plastic folds of mucous membrane, if the vaginitis has led to epithelial defects or superficial losses of substance. I have observed a very marked case of this kind in a primipara.' There was an apparently complete closure between the upper and middle.third of the vagina; and only at the apex of the blind sac, which was strongly drawn over to the left, was an opening the size of a pin's head, which just admitted a sound. At ono sitting the tissue gave way, with but little hemorrhage, to dilatation with sound and finger; a large amount of the retained yellowish mucus was evacuated, and the part of the fornix above the stenosis, together with the normal portio vag. became accessible to finger and speculum. Although the tissue which was torn only consisted of mucous membrane, it contained a cicatricial and resistant spiral ring at least .8 of an inch broad; and after complete opening of the vagina two fingers could hardly be passed through it, while the walls of the canal above and below were of normal elasticity and width.