CONGENITAL MALFORMATIONS OF THE VAGINA.
We will only here consider-those maliormations which give rise to dan gers which we must try to prevent, or cause physiological disturbances of function which we can endeavor to rectify. There must be no important developmental fault in uterus and ovaries, so that the difficulties which our surgical interference is called upon to allay are those due to vaginal malformations alone.' We will, therefore, have chiefly to deal with the congenital atresias and stenoses of the simple and divided vagina., and those cases in which lon gitudinal septa exist.
The mode of origin of these malformations is not entirely clear. The presence of longitudinal vaginal septa may be due to a survival of a struc ture which normally disappears at about the ninth weel of embryonal life, namely the septum of the coalesced Miillerian ducts; but the causes of atresia are not so simple.
There is some reason to believe that the supposition is correct which explains atresias of the upper and middle portions of the vagina as being due to the loss of the existing lumen of the divided or united vaginal por tions offlees ducts. Inflammatory compression, etc., after loss of the vaginal epithelium in the fcetus, ma.y perhaps cause pathological con traction of the original lumen; but we can hardly understand how, when there is a complete upper and a lower vestibular portion of vagina, an inter mediate portion may be absent.' It is different when the lower vaginal part is wanting. Of course there may have been a total defect of the lower parts of the Miillerian ducts, and their ends may not have reached the aditusuro-genitalis• thus ending as blind sacs, and causing the vagina to be absent in part.
There are very great difficulties in the way of a decision as to the genesis of individual cases, both clinically and pathologically. The clinical ob server may even be unable to decide whether a simple atresia in an adult is congenital or not; the history will often leave us unable to exclude stenosis acquired in early childhood; since other undoubted congenital malformations may be absent; and the cicatricial contractions and bridges which generally point to an acquired atresia, may have been left by a late fcetal inflammation. Hymenal atresia, however, is excessively rarely found as an acquired condition.' It is of relatively late fcetal formation, since, as Dohrn ' has recently shown again, the first traces of the hymen are only shown at the nineteenth week of fcetal life. The union of the hy menal folds would therefore e,ause a hymen imperforatus.
Let us first consider congenital atresia with a simple genital canal. For
practical purposes we may divide them into those of the lowest portion of the vagina, and those that lie above that portion, and into broad and nar row atresias, in accordance as they involve broader or narrower vaginal zones.
The breadth of the atresia is of course partly dependent upon the amount of stretching the part undergoes from the accumulated men strual blood; it may be of membranous thinness, or 1.2 inches thick. The older authors record cases where the atresias were three, four, or more inches broad. White is said to have successfully operated upon one five inches long. These figures are not to be taken exactly, and probably only represent the length estimated by the surgeon.
Atresias which involve the entire length of the vagina, are probably only found in connection with atrophied uteri.
Among seven specimens' of congenital arena of the simple vagina, which are contained in the patholog-anatom. collection in Prague, there is but one case of high-seated atresia of some breadth (1.2 inch), while two specimens show total atresia with atrophy of the uterus. In the remaining four cases the atresia was in the lower third or near the en trance. In five cases of total atreSia in the living subject, I observed rudimentary development of the uterus; and in three cases there vms no trace of the organ at all. In one large handsome woman, twenty years old, with large and well-developed mammEe, but undeveloped nipples, I found a regular vulva with ruptured hymen; but the labia minors were very small, and there was exceptionally little hair upon the mons veneris. The vagina formed a blind sac 2i inches long, and its columns were im perfectly marked. A careful recto-abdominal examination showed no trace of the uterus; tbe plicm Douglassii lay directly against the bladder. In the left inguinal region of the abdominal cavity was an elongated, smooth, somewhat movable body, the size of an almond; on the right side, deeper and more difficult to rea,ch, was a similar one. The pelvis was but little inclined; and though the hips were broad, the pubic arch was muTow. The palpably incorrect statement was made that there had been occasional slight menstruation since the sixteenth year. The case re minded me vividly of the one Steglehner observed, of female external genitals with the presence of the testicle, though I could not demonstrate the existence of the vasa deferentia. I was told, however, that the patient had been repeatedly noticed to manifest erotic inclinations for young girls, which would point towards hermaphroditism.