We must also, as Scanzoni has warned us, be careful to avoid con founding the condition under consideration, wit% spastic stricture of the vagina. We will not always succeed in excluding it at the first examina tion, especially if we do not use anwsthesia. The vaginal contraction must not occur while we are examining the patient. Spastic contraction has been seen to occur limited to the upper segment of the vagina (with spasm of the levator ani; comp. Hildebrandt), thus simulating a blind sae with a narrow orifice. If there is any doubt, it is well to postpone a de cision until a second examination has been made.
As regards the prognosis of these congenital atresias, we must recollect that the menstrual blood can flow off, and that the membranous and by far most frequent forms of the affection presents no insuperable obstacle to coitus, and is gradually dilated by it. Even when this is not the case, conception may occasionally occur, and the swelling and softening coin cident to gravidity may make the parts so yielding, that delivery may take place without any artificial aid whatsoever.
A few of the cases of marked stenosis in which childbirth occurred in this way, undoubtedly belong in this category, though most of them are acquired. Thus in van Swieten's case, the girl at sixteen years had a vagina so stenosed that a goose-quill could hardly be passed through it; but she became pregnant eleven years later, and had a perfectly natural labor, the stricture being notice,ably more yielding after the fifth month. Evory Kennedy ' observed with Dr. Johnson the first childbirth of a woman with very bad congenital vaginal stenosis, for the relief of whose difficulties in coition the sponge tent had been used. The first stage of labor lasted forty-eight hours; at the beginning the finger could only be in troduced with great difficulty; but complete dilatation gradually occurred, and, without any other assistance than that derived from ergot, the labor terminated happily. Nevertheless experience‘teaches us that this result is obtained much less frequently spontaneously, than when the proper mechanical measures are applied. We must repeatedly examine the dis tensibility of the stenosed places during birth, so that when necessary we may make incisions, which should be done in several places, and as super ficially as is compatible with our object. We may easily miss the favora ble time for operation; as happened to E. Kennedy, who delayed operat ing in a case in which the head was pressing agrainst a sickle-shaped membranous stenosis, so as to give his assistant an opportunity to examine the case, and saw a fatal rupture of the uterus occur. If the child is in a normal position it will probably be well to content ourselves with super ficial incision with knife or scissors, and to avoid the use of the forceps, since it is undeniable that dilatation will be better effected by the sponta neously advancing head than it will be by the forceps.
In any case we obtain in this way the best results as regards the cure of the stenosis, although the stricture may possibly return as puerperal in volution proceeds. Artificial dilatation of broad stenoses in non-pregnant women, whether done with tents, sounds, or dilators, gives, as a rule, insufficient and merely temporary results. In the case of thin membra nous stenoses, incision of the edges with subsequent specular dilatation is the best method. Tamponing, also, when done with the proper pree,au tions, may be of use.
In conclusion, we may mention the longitudinal septa among the devel opmental fanits of the vagina, which occasionally form an obstacle to coitus, but more frequently interfere with delivery. They occur occa sionally with uterus septus, though sometimes with a simple uterine cavity. Where the sept. vag. is extensive, it was probably originally a complete septum, in which previous confinements have made an orifice.' More rarely it is seen in virgins, marking the ununited ends of the Mill lerian ducts near the vaginal entrance. In either case it may happen that at a later delivery the advancing head may not displace the septum to one side, but may push it before it in such a way that as a sagittal or oblique situated band it may form an obstacle to delivery. In three such cases, division of the septum became a necessity. As a general thing, there are no large vessels in the septum, and it may be cut without fearing hemor rhage, in spite of its apparent succulence. Other and bloodless methods of division, such as the method by elastic ligature, which Freund bas lately recommended under other circumstances, are inapplicable here, on account of the want of time. During the puerperium the divided ends of the septum will shrink considerably.
The only other difficulty' which would lea,d us to divide such septa would be trouble in cohabitation; and also when the presence of the sep tum interferes with the local treatment of other troubles with pessaries, specula, tampons, etc. Under these latter circumstances it may be de sirable to divide a complete septum, as Gehrung ' did successfully in one case.
There is little difficulty in locating, incising or excising a hymen septus; for the fold of mucous membrane is always a thin one. Our interest in the condition is rather genetic than practical. We are easily inclined to look upon it as the remains of the ununited Mullerian ducts, and to draw therefrom conclusions as to the origin of the hymen. But the later development of the hymen is such as to disprove such an idea. I have seen hymen septus once in the living subject; there are five instances of it in the Prague collection. In two of these specimens the septum runs to the right, in one to the left, and in two it is placed fairly in the middle line.