In addition to this absence of the vagina, we may meet with marked congenital stenosis, the vagina, from the uterus to the external genitals, having a very na,rrow lumen; so that a speculum the size of the small finger can scarcely be inserted. Such cases of congenital uniform steno sis of the vagina do not appear to be very common. They are met with in obstetric practice, but descriptions are seldom given. I have seen only two such cases, and in both sterility existed.
Mrs. H., aged thirty years; external genitals small; vagina narrow, examination could only be made with the smallest sized speculum; mar ried two years; sterile; introduction of the penis impossible. Dilatation of vagina was accomplished with sponge-tents and valvular specula, but conception did not occur; the husband had already passed his sixtieth year.
Mrs. Sch., aged twenty-seven years; married two years; stenosis more marked than in last case. Coition was not possible, although the hus band was very capable. Same treatment; after complete dilatation of the vagina a pronounced antefiexion of the uterus was discovered; this was likewise treated. Conception occurred a few weeks later. The woman when in her thirty-sixth week of pregnancy perished with her husband when the steamer Neptune foundered on the Bieler lake, July 25th, 1880.
The majority of cases of congenital stenosis of the vagina exist in the form of a membrane which is transversely or circularly situated, and contains a number of smaller or larger openings. These septa, when deeply situated, may be obstructions to cohabitation. In this class belong cases of double vagina. If the uterus and its adnexa do not offer obsta cles t,o conception, then this abnormality seldom interferes, although cop ulation may be rendered difficult. Only then can these septa determine sterility when one half of the vagina is wide in its lower portion, so that it can readily receive the penis, but ends above in a blind pouch, so that the emitted semen cannot reach the os externum. In a case of this kind, where the woman had normally given birth to a child, but then remained sterile, I was compelled to believe that the penis penetrated into the blind pouch, on which account I removed the septum, and the operation was soon followed by pregnancy. The remains of the embryonal septum, which occasionally is seen as a band running from behind and a little to the side and forward, hardly affect the act of generation. Even as the
congenital, so may also the acquired atresia and stenosis produce impo tentia coeundi and sterility. Into the method of production I can not here enter. In case of atresia, conception only becomes possible when it is overcome by an operation. Even afterwards, however, the new formed canal is so narrow, on account of the amount of cicatricial tissue, that the prognosis is by no means so favorable, especially when the canal is mther long. In like manner may acquired stenosis and strictures prove obstacles to fertility. Here, also, the possibility and the probability of conception depends on the degree and extent of the narrowing. It often. happens, further, that the process which has led to the atresia or ste.no sis—as for example, puerperal diseases--has caused changes in the internal genitals, which in themselves are capable of producing sterility. The malformations of the external genitals which are frequent accompani ments of acquired stenoses, such as laceration of the perineum, etc., are also to be taken into account Tumors of the vagina may aiso cause sterility, and it is apparently im material whether these start from the walls of the vagina or from the vaginal portion. Cysts are specially to be considered. They may, from their size, fill up the vagina in such a manner that immissio penis be comes impossible, or at least they direct the glans penis entirely away from the os externum. If the tumors spring from the external os into the vagina, then we have in addition to consider the obstruction in the cervical canal, and further the hemorrhages and the accompanying catarrh are by no means favorable for tho semen. In a similar manner do the various kinds of hernia and of prolapse of the vagina act, such as cysto cele, rectocele, enterocele. In case sterility is present, then the accom panying pathological condition of the genitals rather than the affection itself is the cause, since the prolapsed portion may be replaced before coition, or offer little resistance to the act. Of course the emitted semen can be ejected by the spontaneous return of the prolapse. The frequency with which, in beginning prolapsus uteri, which is generally preceded by a sagging of the vaginal walls, conception still takes place, greatly reduces the importance of these affections as obstacles to conception. Still, defi nite statements concerning this cannot be formulated.