A remarkable case of abnormality of the hymen is recorded by Heitzmann, having been observed by him in a woman aged twenty-seven years. In this instance, the hymen was represented by a swelling, smooth on the surface and separated from the nymphæ by a deep furrow. Behind this swelling, between it and the posterior commissure, there was a deep depression, into which the finger could be passed to a depth of an inch and a half or more. Anteriorly, the very firm and fleshy prominence was bounded by a ridge, from the middle of which to the urethral orifice ran a short but strong and tense septum. Right and left of this septum were small apertures, with difficulty admitting the point of a probe. Between the anterior extremity of the septum and the urethral orifice was a nodular representative of the swelling normally present in this situation. Surrounding the urethral orifice were two or three additional small nodules. The two lateral margins of the hymen were prolonged around the urethral orifice, and united in front thereof to form a raphe, which could be traced as far as the base of the clitoris. The young woman had been married for some months, and asserted that she had repeatedly had intercourse. With such a condition of the female genitals, penetration of the penis into the vagina was however quite impossible. During coitus, the penis must have been inserted into the aforesaid depression behind the swelling, which was sufficiently extensible for the purpose.
A less serious hindrance to intercourse, but one more frequently encountered, is a partial persistence of the septum of the hymeneal orifice, in such a manner that there is a projecting tongue of membrane from the anterior and posterior margins of the orifice, partially blocking this latter; or there may be a single median projection only, either in front or behind. Such processes may be remarkable alike for their size and their shape. Liman describes a cordiform hymeneal orifice, constituted by an anterior or posterior protection of the kind here described.
In cases of imperforate hymen in which the occlusion of the vagina is not complete, impregnation may in rare instances occur, even though proper intromission of the penis is quite impossible. Cases of this kind have been observed by Scanzoni, Horton, K. Braun, Leopold, Brill, Breisky, and others.
Fig. [66].
In most of these cases there was a thick, dense, “imperforate,” or rather persistent hymen, with an orifice no larger than the head of an ordinary probe, notwithstanding which pregnancy had occurred. The cases reported by Brill were of a different character, being those of two young unmarried Russian girls, with normal undestroyed hymens, who were found to be pregnant. According to Brill, such cases are by no means uncommon among the peasantry of Little Russia, where the barbarous practice prevails of adolescent girls and boys sleeping together. In these circumstances, sexual intercourse takes place, but, from fear of consequences, it is often incomplete. Hence, in occasional cases, results pregnancy in a young girl with intact hymen.
In the first complete act of intercourse, the defloration of the virgin, the hymen is as a rule torn in several directions, and in consequence there is usually moderate bleeding. The lacerations of the hymen soon skin over. When the initial coitus is effected maladroitly or roughly, more extensive lacerations are apt to occur, and the injury may not be limited to the hymen, but may extend longitudinally along the vaginal wall, and even involve the posterior vaginal fornix. Or, again, without any such extensive laceration, there may result very profuse bleeding, in consequence of abnormally profuse vascularization of the hymen. Cases are also recorded in which (presumably not from normal coitus alone, but from other, unacknowledged manipulations), whilst the hymen has been left intact, false passages have been made, leading to the formation of fistulæ, with subsequent death from haemorrhage or sepsis.
Apart from impotence in the male, the hymen may remain intact when it is not touched at all during coitus. Inexperience, as Veit remarks, will in this matter lead to results almost incredible. This author has been informed by such inexperienced married couples, that in attempts at intercourse “the penis of the man is introduced between the thighs of the woman, which are closely pressed together, the man having his legs on either side. Naturally, in this method of intercourse, the hymen escapes destruction. In such attempts at coitus, things are done which can hardly be compared with the normal act of copulation.”
In isolated instances, the introduction of the penis is prevented by congenital or acquired defects in the formation of the external genitals. Adhesion between the labia majora and the labia minora is sometimes met with a congenital deformity, which may or may not be associated with atresia of the urethral orifice; in some cases the adhesion is dependent merely upon a superficial epithelial continuity, but in others the labia are firmly adherent throughout. Less rare are acquired adhesions, the result of accident, between the labia majora and the labia minora, leading to atresia of the vulva, and thus making copulation impossible.
Intromission of the penis may be rendered quite impossible by excessive size of the labia majora, consequent upon elephantiasis, in which disease there is enormous hypertrophy of the subcutaneous connective tissue. New growths may have the same result, fibroids, for instance, lipomata, and cysts, which may attain a remarkable size in the cellular tissue of the labia, the mons veneris, and the perineum, and also in the nymphæ and in the cellular tissue between the clitoris and the urethral orifice. In a very obese woman twenty-eight years of age I saw a lipoma attached to the right labium majus. In the course of six years it had grown to such an enormous size, that it extended downwards over the thigh, blocked the entrance to the vagina, and made coitus absolutely impossible (Fig. [67]). Various forms of labial hernia are also competent to occlude the vaginal orifice.