As is the case with atresia, the cause of congenital vaginal stenoses is to be sought in fcetal inflammatory processes. They probably most often occur during the later period of intra-uterine development, for in the earlier ones the smaller width and less abundant epithelial desquamation offer more favorable conditions for total obliteration. Ilymenal stenosis, hymen with only a small orifice, has a different origin; as with the im perforate hymen, it is due to the rapid growth and too extensive union of the bymenal folds. Although a number of them have been recorded, the hymenal are among the rarer of the partial congenital strictures. This is probably partly due to the fact that they only come under obser vation when they form an obstacle to coitus, or in the rare cases in which pregnancy has occurred with a persistent hymen. G. Braun ' has re cently given us the history of two such cases. I myself recently had occasion to see a woman twenty-two years old, and pregnant for the first time, in whose distensible and skin-like hymen there was only a central opening into which a uterine sound could just be passed. The elasticity might of course be partly due to the softening consequent upon her preg nant condition. During the delivery the hymen became very tense, and was incised. In cases of hypertesthesia of the vaginal entrance, and of vaginismus, I have seen hymenal stenosis a few times in young women; but the membrane was always very tough and resistent; and this, as is well known, would be alone sufficient to be an obstinate hindrance to co habitation, and form the starting-point of a vaginismus.
I have encountered a number of circular stenoses in women pregnant for the first time, in whom there was no history which would point to an acquired affection. They rarely offer any serious hindrance to coitus or childbirth. As a rule, the softened tissues give way before the pressure of the head, as I have recently again had occasion to see in a case of spiral atenosis of the vaginal vault; so that active interference is unnecessary. Yet cases of marked stenoses of this nature have been recorded, which, when deep-seated, have doubtless been referred to duplexity of the hymen.' Thus Dr. Murphy found in a young and. newly-married woman a transverse membrane pierced by a small opening above th3 hymen, which he divided on account of the trouble it caused in menstruation and coitus. Hemmer saw a similar membrane at delivery.
Extensive congenital strictures of the vagina have been repeatedly seen with defective development of the rest of the genitals, though but rarely when these latter were in perfect condition. And in the latter cases we have not always satisfactory proof of their congenital origin. Scanzoni tells of a case he saw in 1851, in which in a woman who had been eight years married and who had remained sterile, Ile could barely introduce his little finger into the vagina, and coitus had never been properly ac complished. Nevertheless, the women became pregnant without dilata tion being done, and the delivery was a normal one. Beigel observed ' a ease in which the vagina was stenosed to such an extent that only a uterine sound could be passed up it. The woman was twenty-three years old, and extremely delicate; she had menstruated regularly though scantily since her eighteenth year, had been three years married, and consulted Beigel for her sterility. The breasts were well developed; but the exter
nal genitals and the pubis were unusually small. The hymen appears to have been absent, since it is only remarked that the vestibule formed a small, mussel-shaped depression. Rectal examination revealed a small but otherwise normal uterus. The walls of the vagina were unusually hard and thick; and Beigel regarded this condition as the cause of the stenosis. Attempts at dilatation with compressed sponge and laminaria were fruitless. The same observer saw a sterile woman who had been married ten years, having menstruated irregularly since her fifteenth year, and never having had any disease of the genital apparatus, in whom there was a thick-walled stenosis of the upper tbird of the vagina.
When the vaginal canal is double, an irregularity in calibre has often been noticed, without there being any extra dilatation upon the other side. Veit claims that with this condition and with a single uterus, some times only that half of the vagina is used for coitus which is not con nected with the portio vag.
We must be cautious in declaring blind canals in the mucous membrane, though they may occasionally be large enough to admit the little finger, to be rudimentary vagime. They usually lie just behind the vaginal en trance at one side of the columna rug. post., and are placed along the mucous membrane, or in the peri-vaginal connective tissue. They are often only unusually large and long lacunit of the muc,ous membrane, and are characterized by their location, their smooth surfaces and thin walls, and by the fact that their axis is often a different one from that of the vagina. In two cases of this kind, which I have observed, these canals were 1.2 and 1.6 inches long; into one I could pass a thick sound, and. into the other my little finger. Both were upon the left side; the nar rower one was in a normally menstruating old maid, with perfect genitals, and caused occasional trouble by retention of secretion; and so I slit it up; the wider one was in a case far advanced in pregnancy, with great vaginal relaxation.
The diagnosis of congenital vaginal stenosis usually presents no especial difficulties; it can be recognized by sight in the hymenal form, and with the finger when seated higher up. The decision as to its being congenital depends upon the factors already considered under the head of atresia, and is sometimes very difficult to make. Here we usually have no reten tion-tumors of blood, as in atresia, although it has exceptionally occurred above very narrow or displaced stenoses. Therefore we will miss the his tory of gradual growth which is so characteristic of atresia. If there is retention at all, we will get a history,' of temporary amenorrhcea, followed by dysmenorrhcea, and a period of ease. Married women usually, but not always, complain of difficulties in cohabitation; but if both husband and wife are inexperienced, they may not notice anything. Naturally the mere absence of a retention tumor is not sufficient to warrant us in excluding. a complete atresia; and when the stenosis is marked, the sound must be employed to demonstrate the uterine cavity.