In the light of these observations we can understand the reports which wo occasionally see of the rare complication of a high grade of stenosis with pregnancy, and where the stenosis was relieved with disproportion ate ease, and was only present to a slight degree after delivery.' Naturally, vaginal obliteration is not solely dependent upon morbid processes which are confined to the mucons membrane; the accompanying phlegmonous inflammation of the peri-vaginal connective tissue often plays an important part in it. Thick eicatricial bands and great shrink age are the more common the more layers of tissue in the vagina and its neighborhood have been affected by the loss of substance. Hence the very large atresias from masses of new connective tissue after puerperal phlegmons, and the callous obliteration of the vagina in syphilitic peri proctitis and peri-vaginitis, which often accompany stenoses and chronic nicenttions of the rectum. And the rare affection which Marconnet first described as peri-vaginitis phlegmonosa dessicans,' in which form of in flammation the entire vaginal mucous membrane is cast off, may, if it be sunived, lead to extensive stenoses or obliteration.
The course of acquired atresia differs from that of the congenital form, only in that the symptoms, being dependent upon some especial etiologi cal moment, do not necessarily begin at puberty, and that they are not infrequently accompanied by other pathological appearances, due to the same cause. Thus we find puerperal vaginal obliterations comparatively frequently with vesical fistulre, and syphilitic stenosis with chronic ulceration, stenosis, and fistula of the rectum. For the rest, their course is the same as that of congenital occlusions; the menstrual blood accu mulates above the atresia, if the same causes which have led to the atresia have not caused amenhorrhcea also.
The treatment does not differ from that of congenital atresias and sten oses. But there is one difficulty which often makes our task a very thankless one. That is, that the ulcerative processes which are at the base of the malady frequently cause extensive and firm cicatricial adhe sions of the vagina, with partial destruction, approximation, and fixation of neighboring structures. Thus, besides the frequent complication with fistulw which we have already mentioned, there is often a loss of tissue of the portio vag. in puerperal atresias.' Nevertheless vve have the records of not a few cases of complete cure. One of the most interesting of them, by Dieffenbach,' may be mentioned here. A lady whose vagina had become completely closed in consequence of injuries received in childbed, permitted a physician to attempt to re establish the passage. 13ut the doctor, instead of reopening the vagina, made his way into the bladder; thus adding a large vesico-vaginal fistula at the introitus to her atresia. Another physician sought to make his way to the uterus more posteriorly, and get into the rectum. The latter false passage, however, closed of itself. Dieffenbach succeeded in open ing the vagina by a most difficult operation; and he kept it open by using bougies of gradually increasing sizes for a long time. The vesical fistula, large enough to admit a finger, was not cured, as the patient be came disgusted after an unsuccessful attempt to close it had been made.
On account of the difficulties which the dense cicatricial masses accom panying large fistulEe add to the operation for htematometra, Kleinwitchter' prefers to follow Hegar's proposal, and leave it unopened, and prevents further menstruation by castration. Acute sepsis caused a fatal termi nation in the case lie operated upon.
If the atresia occurs during gravidity, and is a broad one, as occurred in the cases which Levy, Lombard, and others have recorded, it may form an irremovable obstacle to spontaneous or even artificial delivery per vias naturales. In these cases the Ctesarean section is indicated, though under conditions which render the prognosis of the worst for the mother, since the free outflow of the lochia is interfered with. It has never yet been
successfully done by the old methods. Porro's operation is the only one available, as is admitted even by those who would restrict tho indications for it in favor of the simple sectio Cfesarea..
Acquired vaginal stenoses are seen much more frequently than are com plete closures. If a broad extent of vaginal surface is involved, treatment offers hardly fewer difficulties than in the class of cases we have just been considering. Such is the tendency of the stenosed cicatricial tissue to contract that the results of dilatation are but temporary in the majority of cases. Here also the best results are obtained when opemtion is done during childbirth. Then the atresiad zone is loosened and stretched, the incisions are more easily made, and the amount of dilatation attained is much gre-ater than could be gotten at any other time; thus giving us better prospects of permanent benefit. Even under these circumstances, however, complete cure can only be attained when there are no extensive cicatricial masses present. I observed a case of probably acquired stenosis in a primipara twenty-six years old, with a justo minor pelvis. Unfor tunately the history is wanting. The ring-shaped stenosis was situated in the upper third of the vagina, and was bounded by hard, cicatricial bands. The tips of two fingers could barely be passed into it. Since her sixteenth year the patient had menstruated regularly, abundantly, and without pain every four weeks. She saw blood last about the middle of Febraary, 1877, and claimed that March 14th was the date of conception. Pains began on December 8th at 2 A.m., the child being in the first occi pito-posterior position. On December 9th, 2 A.m., the os was sufficiently dilated to admit the tips of the fingers. The collum was driven down deep into the pelvis, and lay against the stenosis. This latter was in the same condition as before labor, and formed an entirely unyielding ring through which the tips of two fingers could just be passed. 5 A.m., the os was somewhat more open, lying close behind the stenosis. Edges of latter moderately swollen; pains very violent. Three small cuts with the scissors opened the stenosis at once, so that three fingers could be passed in. 5-If A.M., os the size of a quarter dollar, rupture of membranes; chloroform for the pains. 5.45 A. m., another incision into the right bor. der of the stricture, and a superficial incision of the cervix. Pains very marked, but the intervals qniet and painless. 6.45 A. M., under the in fluence of violent pains the obstacle gives way; the head descends, and hems are expressed. As the heart-sounds were weak and irregular, at 7.15 A.m., extracted easily with forceps. Male child, premature, 17.6 inches long, and weighing 50 cunces. Circumference of vertex 30 inches. After a normal puerperium the stenosis returned about as before, but with edges lees sharp than at first.
I have since that time had four analogous cases in which cicatricial ste noses formed obstacles to delivery in primiparx.
It is proper to mention in this connection the irregular ligamentous bridges which originate in the vagina from the adhesion of deta,ched folds of vaginal or cervical mucous membrane.
Occasionally we find pessaries which have been worn for years, and which have caused ulceration, more or less imbedded and fixed by granulation and cicatricial tissue, and by these bands above mentioned. When there are no such foreign bodies, the bands are important from the tension and injury they may be subjected to during coitus and childbirth. In one of my cases, there was a broad fleshy band 1.1 inches long and .4 inch broad, which extended from the anterior lip of the os uteri to the left side of the vagina. It was inserted 1.6 inches from the introi tits and formed a serious obstacle to intercourse. It occurred in a wontan twenty-two years old, after her first confinement. Division of the bridge, which was very vascular, and required a few sutures, easily relieved her.