Difference between revisions of "Paper - Anatomy, pathology and development of the hymen"

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| [[File:Mark_Hill.jpg|90px|left]] This historic 1904 paper by Gellhorn described the understanding of female human genital development associated with the hymen at that historic time. This was a lecture presented at the 1904 meeting of the American Gynecological Society by the candidates elected to Fellowship Twenty-Ninth Annual Meeting.
+
| [[File:Mark_Hill.jpg|90px|left]] This historic 1904 paper by Gellhorn described the understanding of female human genital development associated with the hymen at that historic time. This was a lecture presented at the 1904 meeting of the American Gynecological Society by the candidates elected to Fellowship Twenty-Ninth Annual Meeting. Note with that the paper contains historic clinical terminology that would not be used today. There has been long history of different theories of embryological development associated with the female vagina, as there was presented [[#Development|here for the hymen]].
 
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By George Gellhorn, M.D.,  
 
By George Gellhorn, M.D.,  
 +
 
St. Louis, Mo.  
 
St. Louis, Mo.  
  
 +
==Introduction==
 +
In a discussion of the female genital organs the hymen must be given separate consideration. An exact knowledge of the anatomy and pathology of the hymen is important not only from a practical point of \'iew, but also because it affords valuable evidence concerning the development of the female genitaha. Systematic investigations of the nature of the hJ^nen, however, meet with some difficulty inasmuch as suitable post-mortem material is not easily obtained and portions of tissue excised during life are not often at our disposal. The observations imderlying this article are based upon the microscopic examination of fifteen specimens of hymen, as follows:
  
 +
# From a fetus 8 inches long.
 +
# From a fetus 9^ inches long.
 +
# From a fetus lOf inches long.
 +
# From a fetus of 25 weeks.
 +
# From a fetus of 7 months.
 +
# From a fetus of 8 months.
 +
# From a newborn (macerated).
 +
# From a girl of 3 days.
 +
# From a deflorated girl of 19 years.
 +
# From a virgin of 20 years.
 +
# From a virgin of 20 years.
 +
# From a deflorated girl of 30 years.
 +
# From a virgin of 62 years.
 +
# Caruncle from a woman of 49 years.
 +
# Caruncle from a woman of 76 years.
  
In a discussion of the female genital organs the hymen
+
==Anatomy==
must be given separate consideration. An exact knowledge
+
The hymen is a membrane situated at the junction of the vulva and vagina, partially closing the entrance of the latter. Older reports speak of the site of the hymen as being sometimes higher up in the vagina. Cumston/ in a medicolegal essay, refers to a trial for rape, in 1777, at which trial it was admitted by the medical authorities that the hymen was in some cases situated an inch or an inch and a half "beyond the vagina." Krimer^ found, in a woman of twenty years, the hymen high up, 2 cm. above the vaginal entrance, the vulvar orifice seeming at first sight to lack the membrane altogether. Turnipseed' and Fort* stated that the hymen in the negress is situated from one and a half to two inches above the entrance of the vagina and is of greater density than that of the white woman. These statements were at once contradicted by Hyatt^ and Smythe;° and inasmuch as no similar observations have since been recorded, we are safe in attributing them to inaccurate examination or erroneous diagnosis.
of the anatomy and pathology of the hymen is important
 
not only from a practical point of \'iew, but also because it
 
affords valuable evidence concerning the development of the
 
female genitaha. Systematic investigations of the nature of
 
the hJ^nen, however, meet with some difficulty inasmuch as
 
suitable post-mortem material is not easily obtained and
 
portions of tissue excised during life are not often at our
 
disposal. The observations imderlying this article are based
 
upon the microscopic examination of fifteen specimens of
 
hymen, as follows:
 
 
 
1. From a fetus 8 inches long.
 
 
 
2. From a fetus 9^ inches long.
 
 
 
3. From a fetus lOf inches long.
 
 
 
4. From a fetus of 25 weeks.
 
 
 
5. From a fetus of 7 months.
 
 
 
6. From a fetus of 8 months.
 
 
 
7. From a newborn (macerated).
 
 
 
8. From a girl of 3 days.
 
 
 
9. From a deflorated girl of 19 years.
 
 
 
10. From a virgin of 20 years.
 
 
 
11. From a virgin of 20 years.
 
 
 
12. From a deflorated girl of 30 years.
 
 
 
13. From a virgin of 62 years.
 
 
 
14. Caruncle from a woman of 49 years.
 
 
 
15. Caruncle from a woman of 76 years.
 
 
 
 
 
 
 
Anatomy. — The hymen is a membrane situated at the  
 
junction of the vulva and vagina, partially closing the entrance  
 
of the latter. Older reports speak of the site of the hymen  
 
as being sometimes higher up in the vagina. Cumston/ in  
 
a medicolegal essay, refers to a trial for rape, in 1777, at  
 
which trial it was admitted by the medical authorities that  
 
the hymen was in some cases situated an inch or an inch and  
 
a half "beyond the vagina." Krimer^ found, in a woman of  
 
twenty years, the hymen high up, 2 cm. above the vaginal  
 
entrance, the vulvar orifice seeming at first sight to lack the  
 
membrane altogether. Turnipseed' and Fort* stated that  
 
the hymen in the negress is situated from one and a half to  
 
two inches above the entrance of the vagina and is of greater  
 
density than that of the white woman. These statements  
 
were at once contradicted by Hyatt^ and Smythe;° and  
 
inasmuch as no similar observations have since been recorded,  
 
we are safe in attributing them to inaccurate examination or  
 
erroneous diagnosis.  
 
 
 
Aside from the human female, the hymen, according to
 
Hirst,' is formed in the ape, bitch, bear, donkey, hyena, and
 
giraffe; and according to Nagel,* also in the horse, cow, and
 
pig. Bischoff," on the other hand, states that the hymen is
 
lacking in the anthropomorphic apes.
 
 
 
The macroscopic appearance of the hymen is in the
 
majority of cases that of a semilunar fold. Next to the
 
crescentic form in frequency is the annular variety, in which
 
the hymeneal opening is circular in shape. Less frequently
 
other forms of hymen are found. The septate hymen has
 
two openings separated by a bridge of tissue. The cribriform
 
hymen shows a number of small openings resembling a sieve.
 
The fimbriated hymen has small papillary excrescences upon
 
its free edge. In the imperforate hymen, the membrane is
 
completely occluded. INIost modern text-books give instructive illustrations of these and other even more unusual
 
varieties, and a glance at these pictures explains the macroscopic differences better than words.
 
 
 
 
 
 
 
 
 
Hymen of a Iftus of twenty-five weeks (Case 4). (ieneml survey : h, hymen ;
 
c. epithelial mantle; c eomieetive-tissue stroma: va. \asina with papjlL-e; vu,
 
vvilva: ^ laljiuni minus; /.m, labium majus.
 
 
 
 
 
 
 
% Ir
 
 
 
 
 
 
 
 
 
Hymea of a fetus ol eight mouths (Case 6) : /, fibrous band connecting
 
the slender basal papillEe (p) with the hymen proper (h) and shutting off a
 
mass of epithelial cells (e); rti, vulva; m, vagina.
 
 
 
 
 
 
 
Fig. 3.
 
 
 
 
 
 
 
 
 
Hymen of a fetus of seven months (Case 5): ni, vulva; h.vu, vulvar side of
 
hymen; h.va, vaginal side of hymen.
 
 
 
 
 
 
 
The color of the hymen is white or hght pink. In the
 
fetus it is, Hke the vagina, distinctly white and in marked
 
contrast to the pinkish color of the vestibule. I shall refer
 
later to this decided difference in color. The thickness and
 
consistence of the hymen vary widely from a structure
 
delicate as a spider's web to a dense, ligamentous, even
 
cartilaginous or "bony" membrane.
 
 
 
In its position and relation to the vulva the hynaen in the
 
fetus projects forward into the cleft between the labia in the
 
form of two apposed longitudinal lips. (This condition exists
 
also in the newborn and in the young child, while in the
 
virgin the membrane is generally supposed to be stretched in
 
a more or less vertical plane when the indi\'idual is Ijang in
 
dorsal posture. Cullingworth,'" however, pointed out that
 
on separating the labia minora in such a manner as not to
 
disturb the situs of the structures lying behind them, the
 
hymen can be seen in the same position as in the fetus and
 
infant — i. e., eversion of closely apposed longitudinal lips.
 
 
 
In the hymen we distinguish, first, the base, the point at
 
which it rises from the underlining tissue; second, the edge,
 
which is differently shaped according to the individual case;
 
and third, two sides or surfaces, the inner (upper, vaginal)
 
and outer (lower, vulvar) surface. \Miile, according to
 
Dohrn," one week after the first appearance of the h^nnen
 
it is as fully developed as is usual in the newborn, the microscopic picture varies with the age of the bearer. The h_\Tnen
 
is composed of a dense connective tissue covered on either
 
side with epitheUum. In the fetus it projects in the form of
 
a long slender fold exhibiting on either surface numerous
 
filiform and conical papillfe. Kolliker,'^ Dohrn" and others
 
describe these papillae only upon the inner surface, but
 
Schaffer'^ had already pointed out that they are almost invariably found also on the vulvar side. Among the papillje which
 
in their turn frequently possess smaller secondary papillae,
 
there is one of conspicuous length found with great frequency
 
upon the vaginal side springing from the base of the hymen or immeiiiatelT below it and extendio^ more or less panDd to
 
tbe hTmen itself. This foki of tissue is oonsadered bj SdaSet
 
&s tbe inDer, vaginal lameila (see p. 171 1; while Kkin" sees
 
in it tbe rPTnna.nt of tbe septum betB-eec tbe Mulknais ducts.
 
Tbe epitbelium is of tbe usual multilaTered pavement Qpe.
 
Tbe cells of the faoLsal la^^er are cubsooqrliQdiic, dien
 
follows a layer of lower cabk: cells and several la^cts of
 
polrbedral cells -wfaidi beoome graduallj Sattened tomrd dbe
 
surface. ik» outensost layers oonsistJng of tfain, plate-Iike
 
cells. KeratiiiizatioQ does sot occur in this earir stage, the
 
nucki tbrougbout taking tbe stain readily. UsoaDy the
 
epitbelium is slightly higher upon tbe Taginal sui&oe. TTie
 
epitbeHmn iiprai tbe vul-rar ade in these cases has a someirhat compressed appearance; the layeis fo&oving the basal
 
layers are not poJyhedraJ bat mariEfidlr flattenpd. This condition is -risible in tbe hymens of the sixdi and serentfa fetal
 
months (Tigs. 2 and 3).
 
 
 
Tbe hymen of the Deirbom is of omsdcEaUy greater size.
 
A very long papilla was in one of my spedmess foimd upon
 
tbe vulTar sde Case S. Fig. 4i. From the time betveea
 
birth and nineteen years no specimens were at my
 
Case 9 ''nineteien years; and Case 10 ftwenty years ; ]
 
witbin tbe rather compact hymen nnmeroas sixst and a few
 
longer slender papilla which peneizated deep into the qiitheJial mantle, without, hcwerer, altenmg ifae smoodi outer
 
surface- On the other hand, in a seoond case of twenty yea*%
 
(Case 11), the smfaoe of tbe hymen dxfw&A indentations,
 
corresponding with the large jajslte there present. The
 
latter possessed ntimerous secondary japills (Tig. 5j. The
 
same appearance was present in the hymen of thirty years
 
{Qzse 12 ). Tbe process from the inner surface of vhidi we
 
hare spoken abore was in this case maiiedly increased in
 
H2e- The epihelial mantle in all of these eases was Toy
 
tiiick but nowhere comiSed. The comaectiTe tissne m the
 
hymen of the fetus, newborn and adult,!? dense widmnnaeioas
 
nadei. Only in the papllke is the stroctore somewfaat looser.
 
 
 
 
 
The bundles of connective tissue seem to be directly continuous with the vaginal connective-tissue fibres. In the
 
amount of nuclei as well as in the density of the fibres, the
 
hymen is readily distinguished from the vulva. The blood
 
supply is rather rich. Numerous bloodvessels and capillaries
 
are seen even in the tips of the finest papillae, and in the
 
hymen of the adult wide lumina are visible (Fig. 5).
 
 
 
In the last specimen, that of a virgin of sixt\-two years
 
(Case 13), the rather short hymen presents, on cross-section, a
 
somewhat tongue-shaped appearance and is covered with a few
 
layers of cells with scanty protoplasma, but well-staining
 
nuclei. The connective tissue shows no papillar}- elevations
 
except a few low ones on the vulvar side. It is greatly
 
increased, especially near the base, and its fibers form large
 
bundles, with markedly diminished blood supply.
 
 
 
To study the distribution of elastic fibers in the h\-men,
 
Weigert's stain was used. Broadly speaking, a gradual
 
increase both in number and thickness of the elastic fibres
 
takes place throughout the e.xistence of the membrane. In
 
the fetal hymen elastic fibers are present as soon as the membrane is formed, but they are very delicate and can be seen
 
only with the oil-immersion lens. Running along the base
 
of the epithelium can be seen a fine elastic fiber. This fiber
 
closely follows the contours of the hymen and seems to form
 
an uninterrupted elastic membrane. Only in some of the
 
finer papillse is the continuity lacking in the earher stages,
 
but in the fetal h\-men of eight months the elastic membrane
 
has reached even these points. This membrane does not send
 
any processes into the adjoining tissues, and nowhere do
 
elastic fibers penetrate into the epithehal mantle. In the
 
connective-tissue stroma there are but a few thin, short
 
elastic fibers which run in a longitudinal direction, parallel
 
to the connective-tissue fibers. The capillaries near the tip
 
of the hymen have no elastic fibers. Only the larger vessels
 
near the base have a very fine, internal elastic membrane.
 
An outer circular laver of elastic fibers in the adventitia of arteries is visible only in a few instances in the eight months'
 
hymen. From this external membrane a few very delicate
 
fibers emerge into the adjacent bundles of connective-tissue
 
fibers and there assume a longitudinal direction. ■
 
 
 
In the hjTnen at full term the elastic fibers are readily seen
 
with the oil immersion. In the papillte they appear in long
 
bundles which enter into the finest ramifications of the
 
papillae. They surround the capillaries in the papillje and
 
near the free edge, without, however, entering into closer
 
union with them. In the vessels of the deeper layers, the
 
deUcate internal elastic membrane, upon which lies the
 
endothehum, can be readily distinguished from the outer
 
elastic membrane in the adventitia. The two membranes are
 
connected by a very few elastic fibrils. in the transverse
 
sections of larger arteries of the base such anastomotic fibers
 
in the circular muscular layer between the two membranes
 
are numerous. iThe elastic fibers emanating from the adventitia are hkewise increased in number. The fibers in the
 
connective tissue run both longitudinally and transversely,
 
and increase in quantity but not in size nearer the base.
 
 
 
In the adult, the elastic fibers in general are thinner and
 
less nimierous in the higher portions near the edge than
 
toward the base. In the latter the field of vision is almost
 
entirely filled with a network of dehcate fibers surrounding
 
the connective-tissue bundles. In the hymen of a girl of
 
nineteen (Case 9), a few months after defloration, the newformation of elastic fibers at the torn edge is excessive. The
 
elastic membrane at the base of the epithelium, which consisted of but a single fiber in the fetus, is composed of a
 
complex arrangement of delicate fibers which are wound
 
about themselves. In general, the elastic fibers may be
 
divided into two groups, one more or less circular around the
 
hymeneal opening, the other extending radially towards the
 
base.
 
 
 
 
 
 
 
 
 
Fin. 4.
 
 
 
 
 
 
 
 
 
Hyiucii (if (he iirwliorii (Case 8): (i. loiifr. slender papilla on vulvar surl'ac
 
Ximicrous lil()i)(lvc's«-l.s in coniicetive-tissup struma.
 
 
 
 
 
  
Fig. .5.  
+
Aside from the human female, the hymen, according to Hirst,' is formed in the ape, bitch, bear, donkey, hyena, and giraffe; and according to Nagel,* also in the horse, cow, and pig. Bischoff," on the other hand, states that the hymen is lacking in the anthropomorphic apes.
  
 +
The macroscopic appearance of the hymen is in the majority of cases that of a semilunar fold. Next to the crescentic form in frequency is the annular variety, in which the hymeneal opening is circular in shape. Less frequently other forms of hymen are found. The septate hymen has two openings separated by a bridge of tissue. The cribriform hymen shows a number of small openings resembling a sieve. The fimbriated hymen has small papillary excrescences upon its free edge. In the imperforate hymen, the membrane is completely occluded. INIost modern text-books give instructive illustrations of these and other even more unusual varieties, and a glance at these pictures explains the macroscopic differences better than words.
  
  
  
Hymen nf the adult (I'asc 11. Iweiil\ years). Larsje i)apilla-. Hieh Mood
+
Fig. 1. Hymen of a Iftus of twenty-five weeks (Case 4). (ieneml survey : h, hymen ; c. epithelial mantle; c eomieetive-tissue stroma: va. \asina with papjlL-e; vu, vvilva: ^ laljiuni minus; /.m, labium majus.
supply. .\uNierous lymph s|)aees and \ cs.sels.  
 
  
  
 +
Fig. 2. Hymea of a fetus ol eight mouths (Case 6) : , fibrous band connecting the slender basal papillEe (p) with the hymen proper (h) and shutting off a mass of epithelial cells (e); rti, vulva; m, vagina.
  
Fig. e,.
 
  
 +
Fig. 3. Hymen of a fetus of seven months (Case 5): ni, vulva; h.vu, vulvar side of hymen; h.va, vaginal side of hymen.
  
  
Sensory nerve-endings in hymen excised on account of vaginismus (from  
+
The color of the hymen is white or hght pink. In the fetus it is, like the vagina, distinctly white and in marked contrast to the pinkish color of the vestibule. I shall refer later to this decided difference in color. The thickness and consistence of the hymen vary widely from a structure delicate as a spider's web to a dense, ligamentous, even cartilaginous or "bony" membrane.
Amann): p, pavement epithelium surrounding a papilla, which is almost
 
entireh- filled by an enlarged end-bulb of Krause.  
 
  
 +
In its position and relation to the vulva the hynaen in the fetus projects forward into the cleft between the labia in the form of two apposed longitudinal lips. (This condition exists also in the newborn and in the young child, while in the virgin the membrane is generally supposed to be stretched in a more or less vertical plane when the indi\'idual is Ijang in dorsal posture. Cullingworth,'" however, pointed out that on separating the labia minora in such a manner as not to disturb the situs of the structures lying behind them, the hymen can be seen in the same position as in the fetus and infant — i. e., eversion of closely apposed longitudinal lips.
  
 +
In the hymen we distinguish, first, the base, the point at which it rises from the underlining tissue; second, the edge, which is differently shaped according to the individual case; and third, two sides or surfaces, the inner (upper, vaginal) and outer (lower, vulvar) surface. \Miile, according to Dohrn," one week after the first appearance of the h^nnen it is as fully developed as is usual in the newborn, the microscopic picture varies with the age of the bearer. The h_\Tnen is composed of a dense connective tissue covered on either side with epitheUum. In the fetus it projects in the form of a long slender fold exhibiting on either surface numerous filiform and conical papillfe. Kolliker,'^ Dohrn" and others describe these papillae only upon the inner surface, but Schaffer'^ had already pointed out that they are almost invariably found also on the vulvar side. Among the papillje which in their turn frequently possess smaller secondary papillae, there is one of conspicuous length found with great frequency upon the vaginal side springing from the base of the hymen or immeiiiatelT below it and extendio^ more or less panDd to tbe hTmen itself. This foki of tissue is oonsadered bj SdaSet &s tbe inDer, vaginal lameila (see p. 171 1; while Kkin" sees in it tbe rPTnna.nt of tbe septum betB-eec tbe Mulknais ducts. Tbe epitbelium is of tbe usual multilaTered pavement Qpe. Tbe cells of the faoLsal la^^er are cubsooqrliQdiic, dien follows a layer of lower cabk: cells and several la^cts of polrbedral cells -wfaidi beoome graduallj Sattened tomrd dbe surface. ik» outensost layers oonsistJng of tfain, plate-Iike cells. KeratiiiizatioQ does sot occur in this earir stage, the nucki tbrougbout taking tbe stain readily. UsoaDy the epitbelium is slightly higher upon tbe Taginal sui&oe. TTie epitbeHmn iiprai tbe vul-rar ade in these cases has a someirhat compressed appearance; the layeis fo&oving the basal layers are not poJyhedraJ bat mariEfidlr flattenpd. This condition is -risible in tbe hymens of the sixdi and serentfa fetal months (Tigs. 2 and 3).
  
 +
The hymen of the Deirbom is of omsdcEaUy greater size. A very long papilla was in one of my spedmess foimd upon tbe vulTar sde Case S. Fig. 4i. From the time betveea birth and nineteen years no specimens were at my Case 9 nineteien years; and Case 10 ftwenty years ; ] witbin tbe rather compact hymen nnmeroas sixst and a few longer slender papilla which peneizated deep into the qiitheJial mantle, without, hcwerer, altenmg ifae smoodi outer surface- On the other hand, in a seoond case of twenty yea*% (Case 11), the smfaoe of tbe hymen dxfw&A indentations, corresponding with the large jajslte there present. The latter possessed ntimerous secondary japills (Tig. 5j. The same appearance was present in the hymen of thirty years {Qzse 12 ). Tbe process from the inner surface of vhidi we hare spoken abore was in this case maiiedly increased in H2e- The epihelial mantle in all of these eases was Toy tiiick but nowhere comiSed. The comaectiTe tissne m the hymen of the fetus, newborn and adult,!? dense widmnnaeioas nadei. Only in the papllke is the stroctore somewfaat looser.
  
fl.B.Streedain del
 
  
 +
The bundles of connective tissue seem to be directly continuous with the vaginal connective-tissue fibres. In the amount of nuclei as well as in the density of the fibres, the hymen is readily distinguished from the vulva. The blood supply is rather rich. Numerous bloodvessels and capillaries are seen even in the tips of the finest papillae, and in the hymen of the adult wide lumina are visible (Fig. 5).
  
 +
In the last specimen, that of a virgin of sixt\-two years (Case 13), the rather short hymen presents, on cross-section, a somewhat tongue-shaped appearance and is covered with a few layers of cells with scanty protoplasma, but well-staining nuclei. The connective tissue shows no papillar}- elevations except a few low ones on the vulvar side. It is greatly increased, especially near the base, and its fibers form large bundles, with markedly diminished blood supply.
  
Genitals of a fetus of twenty-five weeks (Case 4). The longitudinal folds
+
To study the distribution of elastic fibers in the h\-men, Weigert's stain was used. Broadly speaking, a gradual increase both in number and thickness of the elastic fibres takes place throughout the e.xistence of the membrane. In the fetal hymen elastic fibers are present as soon as the membrane is formed, but they are very delicate and can be seen only with the oil-immersion lens. Running along the base of the epithelium can be seen a fine elastic fiber. This fiber closely follows the contours of the hymen and seems to form an uninterrupted elastic membrane. Only in some of the finer papillse is the continuity lacking in the earher stages, but in the fetal h\-men of eight months the elastic membrane has reached even these points. This membrane does not send any processes into the adjoining tissues, and nowhere do elastic fibers penetrate into the epithehal mantle. In the connective-tissue stroma there are but a few thin, short elastic fibers which run in a longitudinal direction, parallel to the connective-tissue fibers. The capillaries near the tip of the hymen have no elastic fibers. Only the larger vessels near the base have a very fine, internal elastic membrane. An outer circular laver of elastic fibers in the adventitia of arteries is visible only in a few instances in the eight months' hymen. From this external membrane a few very delicate fibers emerge into the adjacent bundles of connective-tissue fibers and there assume a longitudinal direction.  
(/) of the lowest portion of the vagina (ji) turn inward at the vaginal
 
entrance and run parallel to the hymen (/i), thus simulating l)ilamellation;
 
h, bladder.  
 
  
 +
In the hymen at full term the elastic fibers are readily seen with the oil immersion. In the papillte they appear in long bundles which enter into the finest ramifications of the papillae. They surround the capillaries in the papillje and near the free edge, without, however, entering into closer union with them. In the vessels of the deeper layers, the deUcate internal elastic membrane, upon which lies the endothehum, can be readily distinguished from the outer elastic membrane in the adventitia. The two membranes are connected by a very few elastic fibrils. in the transverse sections of larger arteries of the base such anastomotic fibers in the circular muscular layer between the two membranes are numerous.  The elastic fibers emanating from the adventitia are hkewise increased in number. The fibers in the connective tissue run both longitudinally and transversely, and increase in quantity but not in size nearer the base.
  
With growing age the elastic fibers perceptibly increase in  
+
In the adult, the elastic fibers in general are thinner and less nimierous in the higher portions near the edge than toward the base. In the latter the field of vision is almost entirely filled with a network of dehcate fibers surrounding the connective-tissue bundles. In the hymen of a girl of nineteen (Case 9), a few months after defloration, the newformation of elastic fibers at the torn edge is excessive. The elastic membrane at the base of the epithelium, which consisted of but a single fiber in the fetus, is composed of a complex arrangement of delicate fibers which are wound about themselves. In general, the elastic fibers may be divided into two groups, one more or less circular around the hymeneal opening, the other extending radially towards the base.
quantity and size and take the stain very readily. In the hymen of sixty-two years (Case 13), the elastic tissue is  
 
stained ad maximum after being exposed to the stain but
 
five minutes. The network at the base of the epithehum consists of a thick, entangled mass. The elastic fibers throughout the hymen are shorter and in some places seem to have
 
nodular swellings.  
 
  
Smooth muscle fibers have repeatedly been found in the
 
normal hymen (Savage,'^ Budin," Hirst'). Their presence,
 
however, is not the rule. In my specimens I found them but
 
once, in the hymen of nineteen. In this case in. the deeper
 
layer near the vulvar side could be seen a few fibers that
 
took the yellow color of the picric acid in Van Gieson's stain,
 
though rather diffusely. This hymen was well formed but
 
not unusually thick. On the other hand, the very fleshy
 
hymen of a girl of twenty (Case 11, Fig. 5) did not contain
 
any muscular elements. The fleshy appearance in this case
 
was produced by an increase of connective tissue and the
 
very rich blood supply. In certain pathologic conditions,
 
such as atresia — congenital or acquired — smooth muscle
 
fibers have been found with greater uniformity. Henkel"
 
and V. Tussenbroeck'* found numerous smooth muscle fibers
 
in their cases of hymeneal atresia. In the wall of h}Tneneal
 
cysts Palm'' and Ziegenspeck^" detected traces of smooth
 
muscle fibers.
 
  
In order to demonstrate nerves and nerve endings in the
 
hymen the methods of INIarchi and Azoulay and the nigrosin
 
and uran carmine methods were employed. Numerous
 
attempts to find the structures in question proved unsuccessful. The great difficulties of staining the peripheral nervous
 
system are well known, and failure in demonstrating the
 
nerves should, in the first place, be referred to faulty technic.
 
The nature of my material made it impossible for me to
 
employ the methylene-blue method, which is supposed to
 
give the best result. The possibility of a fault on my part,
 
therefore, prevents me from passing a definite judgment on
 
the question of the nerve supply of the hymen. The literature on the subject, moreover, is extremely meager. Only
 
older reports (E. Klein,^' Budin'°) speak in a somewhat
 
sweeping way of "the highly vascular and nervous mucous
 
membrane." On the other hand, authors who have studied
 
the nerve supply of both the internal and external genital
 
organs since the introduction of more perfected laboratory
 
methods (v. Gawronsky," Koestlin"^) do not mention the
 
hymen at all, though their researches are very exhaustive
 
otherwise. Wechsberg*' stained an excised portion of an
 
atresic hymen with hemalaun and eosin and found "here and
 
there nerves in transverse and longitudinal sections." The
 
only author who gives a detailed description of nerves in the
 
hymen is Amann.^^ He found in two hymens excised for
 
vaginismus Krause's terminal bulbs well developed in the
 
papillse (Fig. 6).
 
  
In this connection I may be permitted to speak of a number
+
Fig. 4. Hymen(if (he iirwliorii (Case 8): (i. loiifr. slender papilla on vulvar surl'ac Ximicrous lil()i)(lvc's«-l.s in coniicetive-tissup struma.
of clinical observations which I have made during the last
 
year or two. I am aware that the value of such observations
 
with regard to the question in hand is very limited, but I
 
think that these investigations possess a certain interest.  
 
  
As is well knovra, fear or anticipation of being hurt produces, in a great many women, to a certain extent, the
 
sensation of pain. If we succeed in eliminating this psychic
 
factor, we obtain a more objective criterion as to the presence
 
of pain. Thus I have tried to determine the sensitiveness of
 
the hymen w^th regard to mechanical and thermic irritations.
 
If the attention of the patient be diverted, I find that one
 
can exert pressure and even sHght traction upon the intact
 
hymen by means of a dressing forceps ■n'ithout causing any
 
pain. In women after defloration in whom the hymen is well
 
preserved aside from one or two lateral lacerations, the
 
hymeneal lips may be pressed or pierced without pain.
 
Neither is there any thermic sensitiveness. If the vestibule
 
is carefully avoided, the patient cannot state whether she is
 
touched with a hot or cold instrument. Following the experiments of Calmann,^^ who examined the sensibilitj' of the vagina and uterus, by means of small test tubes filled with
 
hot and cold water, I arrived at the same results as far as
 
the hymen was concerned. In two instances pain was caused
 
by the slightest touch. One of these was a girl of eighteen,
 
with an intact hymen, who suffered from pruritus vulvae;
 
the other was a prostitute of twenty-seven, with myrtiform
 
caruncles, who w^as recently infected with gonorrhea. In
 
these cases the sensitiveness may have been due to the pathologic condition of the genitals. From the above observations
 
I am inclined to believe that the pain in defloration is due
 
to the psychic condition of the indi\-idual and to the forcible
 
dilatation of the vaginal entrance. Especially the latter seems
 
to play an important role. In a nulhparous woman of thirtytwo whose hjTneneal lobes were not sensitive to touch or
 
pressure, coition was extremely painful until a gradual dilatation of the vaginal entrance by means of tubular specula was
 
effected. The normal dilatation by coition had not taken
 
place on account of some anomaly on the part of the husband.
 
  
I have digressed somewhat from my subject not because
+
Fig. .5. Hymen of the adult (I'asc 11. Iweiil\ years). Larsje i)apilla-. Hieh Mood supply. .\uNierous lymph s|)aees and \ cs.sels.
I am able to bring any positive proofs about the presence or
 
absence of nerves in the hymen, but because I think that
 
these clinical notes make the existence of a very rich nerve
 
supply rather improbable. Possibly future attempts to
 
decide the question liistologically may be more successful.  
 
  
According to Kollmann,"^ in the newborn mucous glands
 
are found in the fold between the hjTnen and labia minora.
 
These glands, which are in great number in the labia minora
 
and surround the entire vaginal entrance, are found also in
 
the fossa navicularis in immediate proximity to the h'STuen,
 
and represent simple or ramified tubules 0.3 to 0.7 mm. in
 
length. In the hymen itself distinctly glandular structures
 
were found by Ruge^' and RinchevaP" upon the inner surface
 
in a case of atresia. Klein," in the hymen of a fetus 27 cm.
 
in length (five months), observed glandular invaginations of
 
the epithelium of the outer surface. Such invaginations have
 
been described by Schatfer as crypts. Similar blind ducts were also found by Fleischmann.^ In his case there was one,
 
13 mm. in length in the left side of the iiymen, another in
 
the right side 6 mm. long. The epithelium of these ducts
 
was directly connected with that of the surface. In.Piering's^
 
case, small, well-filled vesicles with thin walls were found
 
near the free edge almost completely surrounding the
 
hymeneal orifice. Upon histologic examination these vesicles
 
were found to be lymphectasias.
 
  
The latest and most exhaustive researches have been by
+
Fig. 6. Sensory nerve-endings in hymen excised on account of vaginismus (from Amann): p, pavement epithelium surrounding a papilla, which is almost entireh- filled by an enlarged end-bulb of Krause. fl.B.Streedain del
R. jNIeyer.^" He found six different varieties of glands or
 
gland-like structures in the h\Tnen of the fetus and newborn;
 
viz.: (1) glands of the vaginal type upon the inner, vaginal
 
side; (2) remnants of the Wolffian ducts; (3) glands or glandular tubules situated about the base of the hymen in the
 
sulcus nymphohymenalis and in the fossa navicularis and at
 
times extending into the base of the hymen; (4) real glands
 
of the outer, vnilvar surface; (5) invaginations of the epithelium of the outer surfaces; (6) genuine pavement cell cysts
 
underneath the outer surface. I myself found glands in one
 
instance. The hymen of the eight months' fetus (Case 6)
 
had at its base a few transverse lumina of glands lined with
 
a cuboidal epithelium. These were at some distance from
 
the surface and showed, in several sections, no communication with the latter. No serial sections, however, were made.  
 
  
Henle^' found exceptionally "erectile tissue" in the hymen.
 
So far as I know this observation has not yet been corroborated by others.
 
  
The elasticity of the hymen is under rare circumstances
+
Fig. 7. Genitals of a fetus of twenty-five weeks (Case 4). The longitudinal folds (/) of the lowest portion of the vagina (ji) turn inward at the vaginal entrance and run parallel to the hymen (/i), thus simulating l)ilamellation; h, bladder.
so great that it remains unruptured even at childbirth. As
 
a rule, however, the first coition or accidents such as falling
 
astride of an object or violent exercise will rupture the delicate
 
membrane. The number of tears which divide the hymen
 
into "lobes" varies in the individual case. Heahng takes
 
place with considerable new-formation of elastic and connective tissue. Very rarely such tears unite; if such should
 
happen a cicatrix may remain.  
 
  
  
Parturition definitely destroys the form of the hymen.
+
With growing age the elastic fibers perceptibly increase in quantity and size and take the stain very readily. In the hymen of sixty-two years (Case 13), the elastic tissue is stained ad maximum after being exposed to the stain but five minutes. The network at the base of the epithehum consists of a thick, entangled mass. The elastic fibers throughout the hymen are shorter and in some places seem to have nodular swellings.
Only small rests — carunculse myrtiformes — resembling warts,
 
are left. ^Microscopically, the caruncle represents a compact
 
tissue of rather conical shape and set wdth a few short papillae.
 
The caruncle of long standing (Case 15, seven ty-si.x years)
 
appears merely as a dome-shaped elevation whose papillae
 
have disappeared. The blood supply of the younger caruncle
 
(Case 14, forty-nine years) is very rich; that of the older very
 
scanty. The superficial layers of the epithelium are cornified
 
and the keratinization extends into the deeper laye'rs between
 
the papilla^. The process of cornification is present only
 
about the hymen and, in a very few places, in the adjoining
 
vaginal mucosa, but not in the adjacent portion of the
 
vestibule. The elastic tissue is greatly increased both in
 
quantity and in the size of the individual elastic fiber, and
 
fills almost the entire field of vision.  
 
  
As to the formation of caruncles, Schroder " holds that the  
+
Smooth muscle fibers have repeatedly been found in the normal hymen (Savage,'^ Budin," Hirst'). Their presence, however, is not the rule. In my specimens I found them but once, in the hymen of nineteen. In this case in. the deeper layer near the vulvar side could be seen a few fibers that took the yellow color of the picric acid in Van Gieson's stain, though rather diffusely. This hymen was well formed but not unusually thick. On the other hand, the very fleshy hymen of a girl of twenty (Case 11, Fig. 5) did not contain any muscular elements. The fleshy appearance in this case was produced by an increase of connective tissue and the very rich blood supply. In certain pathologic conditions, such as atresia — congenital or acquired — smooth muscle fibers have been found with greater uniformity. Henkel" and V. Tussenbroeck'* found numerous smooth muscle fibers in their cases of hymeneal atresia. In the wall of h}Tneneal cysts Palm and Ziegenspeck^" detected traces of smooth muscle fibers.
hymeneal lobes during childbirth are compressed and undergo
 
gangrene, while Bellien'^ believes that the lacerations of the  
 
hymen, during labor, extend through the base of the membrane into the perivaginal connective tissue; cicatrization and  
 
consequent shrinking of these tears produce caruncles.  
 
  
I am inclined to ascribe to the elastic tissue a certain role
+
In order to demonstrate nerves and nerve endings in the hymen the methods of INIarchi and Azoulay and the nigrosin and uran carmine methods were employed. Numerous attempts to find the structures in question proved unsuccessful. The great difficulties of staining the peripheral nervous system are well known, and failure in demonstrating the nerves should, in the first place, be referred to faulty technic. The nature of my material made it impossible for me to employ the methylene-blue method, which is supposed to give the best result. The possibility of a fault on my part, therefore, prevents me from passing a definite judgment on the question of the nerve supply of the hymen. The literature on the subject, moreover, is extremely meager. Only older reports (E. Klein,^' Budin'°) speak in a somewhat sweeping way of "the highly vascular and nervous mucous membrane." On the other hand, authors who have studied the nerve supply of both the internal and external genital organs since the introduction of more perfected laboratory methods (v. Gawronsky," Koestlin"^) do not mention the hymen at all, though their researches are very exhaustive otherwise. Wechsberg*' stained an excised portion of an atresic hymen with hemalaun and eosin and found "here and there nerves in transverse and longitudinal sections." The only author who gives a detailed description of nerves in the hymen is Amann.^^ He found in two hymens excised for vaginismus Krause's terminal bulbs well developed in the papillse (Fig. 6).
in the formation of caruncles. As described above, the
 
elastic fibers are unequally distributed within the hymen, the  
 
portions nearer the base containing more and thicker fibers
 
than the periphery. So long as the hymen is preserved in  
 
its entirety, or only torn into a few large lobes which but
 
little alter the form of the hymen, the upper more delicate
 
fibers encircling the hymeneal opening exert an action counter
 
to that of the radial fibers which tend to retract toward the  
 
base. If, however, the hymen, in childbirth, is torn into a
 
number of small pieces, each piece retracts owing to the  
 
more powerful action of the radial fibers. For some time
 
after, one is able to pull each caruncle to its original length,  
 
but after long standing the retraction results in an atrophy of the entire caruncle to a great extent through insufficient
 
circulation. Regarding the retraction of elastic fibers, we
 
know from numerous examinations that only the fibers of  
 
thin or medium size are really elastic. Thick fibers, such as
 
are found in old age, are unyielding, and only such were
 
observed in the caruncle referred to above.  
 
  
Pathology. The pathology of the hj-men may be divided
+
In this connection I may be permitted to speak of a number of clinical observations which I have made during the last year or two. I am aware that the value of such observations with regard to the question in hand is very limited, but I think that these investigations possess a certain interest.
into: (1) inflammations; (2) malformations; (3) neoplasms.  
 
  
Inflammation of the hymen may start primarily in this  
+
As is well knovra, fear or anticipation of being hurt produces, in a great many women, to a certain extent, the sensation of pain. If we succeed in eliminating this psychic factor, we obtain a more objective criterion as to the presence of pain. Thus I have tried to determine the sensitiveness of the hymen w^th regard to mechanical and thermic irritations. If the attention of the patient be diverted, I find that one can exert pressure and even sHght traction upon the intact hymen by means of a dressing forceps without causing any pain. In women after defloration in whom the hymen is well preserved aside from one or two lateral lacerations, the hymeneal lips may be pressed or pierced without pain. Neither is there any thermic sensitiveness. If the vestibule is carefully avoided, the patient cannot state whether she is touched with a hot or cold instrument. Following the experiments of Calmann,^^ who examined the sensibilitj' of the vagina and uterus, by means of small test tubes filled with hot and cold water, I arrived at the same results as far as the hymen was concerned. In two instances pain was caused by the slightest touch. One of these was a girl of eighteen, with an intact hymen, who suffered from pruritus vulvae; the other was a prostitute of twenty-seven, with myrtiform caruncles, who w^as recently infected with gonorrhea. In these cases the sensitiveness may have been due to the pathologic condition of the genitals. From the above observations I am inclined to believe that the pain in defloration is due to the psychic condition of the indi\-idual and to the forcible dilatation of the vaginal entrance. Especially the latter seems to play an important role. In a nulhparous woman of thirtytwo whose hjTneneal lobes were not sensitive to touch or pressure, coition was extremely painful until a gradual dilatation of the vaginal entrance by means of tubular specula was effected. The normal dilatation by coition had not taken place on account of some anomaly on the part of the husband.
membrane itself or may originate in adjacent organs and
 
tissues. As to the latter or secondary form, it is to be expected
 
that the hymen, as a part of the vagina, may be affected by
 
inflammatory processes which originate in the vagina and
 
descend toward the vaginal entrance. Thus the different
 
varieties of colpitis, including those that are produced by
 
affections of the uterus, may lead to inflammation of the  
 
hjTnen. Acute infectious diseases such as cholera, variola,  
 
scarlatina, measles, etc., not infrequently produce secondary
 
inflammations of the entire vaginal tract and, as we shall
 
later see, play an important role in the origin of acquired
 
atresia. On the other hand, the inflammatory process may
 
ascend from the vulva. Gonorrheal infection here deserves
 
the first place. Contamination with the colon bacillus, or  
 
ascarides emigrating from the neighboring anus may cause
 
inflammation, and irritation from lack of cleanliness produces
 
a similar effect. The inflamed hjTnen has a markedly
 
reddened appearance and bleeds easily. Occasionally small
 
excoriations are seen. The surrounding tissues have in
 
general the same appearance. The microscopic changes in
 
the inflamed hymen have not as yet been studied in detail,
 
but in analogy with similar processes in the vagina we may
 
expect to find round-cell infiltration in the connective tissue
 
and a desquamation of epithelium so that this layer is either
 
very much thinner or, in places, is altogether absent.  
 
  
The same pathologic conditions may, after defloration,
+
I have digressed somewhat from my subject not because I am able to bring any positive proofs about the presence or absence of nerves in the hymen, but because I think that these clinical notes make the existence of a very rich nerve supply rather improbable. Possibly future attempts to decide the question liistologically may be more successful.
affect the hymeneal lobes and, after childbirth, the mjTtiform caruncles. Thus, in a case of recent gonorrhea, I found the  
 
mjTtiform caruncles considerably thickened, deep red in
 
color and extremely sensitive.  
 
  
Primary inflammation of the hymen is due either to  
+
According to Kollmann," in the newborn mucous glands are found in the fold between the hjTnen and labia minora. These glands, which are in great number in the labia minora and surround the entire vaginal entrance, are found also in the fossa navicularis in immediate proximity to the h'STuen, and represent simple or ramified tubules 0.3 to 0.7 mm. in length. In the hymen itself distinctly glandular structures were found by Ruge^' and RinchevaP" upon the inner surface in a case of atresia. Klein," in the hymen of a fetus 27 cm. in length (five months), observed glandular invaginations of the epithelium of the outer surface. Such invaginations have been described by Schatfer as crypts. Similar blind ducts were also found by Fleischmann.^ In his case there was one, 13 mm. in length in the left side of the iiymen, another in the right side 6 mm. long. The epithelium of these ducts was directly connected with that of the surface. In.Piering's^ case, small, well-filled vesicles with thin walls were found near the free edge almost completely surrounding the hymeneal orifice. Upon histologic examination these vesicles were found to be lymphectasias.
masturbation or coitus. In two girls who admitted masturbation, I found the otherwise intact hymen considerably thickened, grayish-white and edematous. Gosselin^' describes
 
cases in which onanism led to pathologic sensitiveness of the  
 
hymen.  
 
  
In some cases the hymen, though normal, is particularly
+
The latest and most exhaustive researches have been by R. jNIeyer.^" He found six different varieties of glands or gland-like structures in the h\Tnen of the fetus and newborn; viz.: (1) glands of the vaginal type upon the inner, vaginal side; (2) remnants of the Wolffian ducts; (3) glands or glandular tubules situated about the base of the hymen in the sulcus nymphohymenalis and in the fossa navicularis and at times extending into the base of the hymen; (4) real glands of the outer, vnilvar surface; (5) invaginations of the epithelium of the outer surfaces; (6) genuine pavement cell cysts underneath the outer surface. I myself found glands in one instance. The hymen of the eight months' fetus (Case 6) had at its base a few transverse lumina of glands lined with a cuboidal epithelium. These were at some distance from the surface and showed, in several sections, no communication with the latter. No serial sections, however, were made.
rigid; in others its orifice is large enough for the introduction
 
of the penis without laceration. In any of these cases where
 
there is a pushing back or dilatation of the membrane, it
 
thickens, inflames, and becomes very sensitive (Pozzi'*).
 
Fritsch^'^ considers this rigidity of the hymen as secondary
 
The impotent husband with a non-erectile penis or suffering
 
from precocious ejaculation does not succeed in perforating
 
or lacerating the membrane. The continuous insults lead to
 
inflammation of the introitus vaginje and hjinen, and even
 
to a purulent discharge. Inflammation of the hjTnen is the  
 
foremost factor in vaginismus.  
 
  
It might be supposed that the specific lesions of syphihs
+
Henle found exceptionally "erectile tissue" in the hymen. So far as I know this observation has not yet been corroborated by others.
and chancroid would occasionally be found upon the hjTuen.  
 
The text-books on venereal diseases, however, which I consulted, make no special mention of such an occurrence; only
 
Veit'' pictures a hymen whose posterior margin is destroyed
 
by a hard chancre.  
 
  
As to dermatologic affections of the hjTnen, recent Hterature contains the report of Carriere.^* This auther observed
+
The elasticity of the hymen is under rare circumstances so great that it remains unruptured even at childbirth. As a rule, however, the first coition or accidents such as falling astride of an object or violent exercise will rupture the delicate membrane. The number of tears which divide the hymen into "lobes" varies in the individual case. Heahng takes place with considerable new-formation of elastic and connective tissue. Very rarely such tears unite; if such should happen a cicatrix may remain.
three cases of vuhdtis impetiginosa in children. In these
 
eases the major and minor lips and the hymen were, at first,
 
reddened and swollen. After a few days, the affected parts
 
showed an eruption of miliary vesicles which afterward
 
opened and gave rise to small ulcerations, the latter containing
 
staphylococci.  
 
  
Traumatisms of the hymen have been extensively dealt with by Veit.*' The majority of injuries occur in the first cohabitation and in childbirth, and as such traumatisms must be
 
considered physiologic, they have been spoken of in the first
 
part of this paper on the normal anatomy of the hymen.
 
Veit is quite right in distinguishing this class of hymeneal
 
injuries from the severer ones produced by violent or abnormal coition. In such cases a profuse hemorrhage from the
 
torn hymen may occur which demands medical interference.
 
The literature on this subject is rather extensive and has been
 
thoroughly considered by Veit. I agree with this writer that
 
in cases of copious hymeneal hemorrhage other adjacent parts
 
must have been injured. In one case in my recollection the
 
young, newly married woman was brought into the clinic
 
almost pulseless. Upon examination a deep tear of the
 
hymen was found which commenced in the left upper
 
quadrant and extended through the paraurethral tissue into
 
the base of the clitoris.
 
  
Malformations of the hjTiien are either congenital or
+
Parturition definitely destroys the form of the hymen. Only small rests — carunculse myrtiformes — resembling warts, are left. ^Microscopically, the caruncle represents a compact tissue of rather conical shape and set wdth a few short papillae. The caruncle of long standing (Case 15, seven ty-si.x years) appears merely as a dome-shaped elevation whose papillae have disappeared. The blood supply of the younger caruncle (Case 14, forty-nine years) is very rich; that of the older very scanty. The superficial layers of the epithelium are cornified and the keratinization extends into the deeper laye'rs between the papilla^. The process of cornification is present only about the hymen and, in a very few places, in the adjoining vaginal mucosa, but not in the adjacent portion of the vestibule. The elastic tissue is greatly increased both in quantity and in the size of the individual elastic fiber, and fills almost the entire field of vision.
acquired. Total absence of hymen, reports of which are
 
found in older literature, has not been observed by modern
 
authors, and such authorities as Breisky" and Schaifer,"
 
while not denying the possibihty, consider this phenomenon
 
exceedingly rare. It can, however, occur only simultaneously
 
with total absence of the entire genital tract, which in its turn
 
is found only in embryos incapable of surviving. In this
 
connection I might mention as a curiosity the intentional
 
destruction of the hymen practised in several parts of India
 
and throughout China. Ploss^' relates that the native nurses
 
employ digital cleansing of the vagina in earhest childhood
 
so thoroughly that the hymen in time disappears altogether.  
 
Thus not even the native physicians in Cliina know anything
 
about the existence of a hymen. Ploss himself examined a  
 
girl of European descent, but born in China, and found no
 
trace of this structure. Similar customs resulting in the total
 
demohtion of the hymen exist among several Indian tribes
 
in South America and certain savage nations of the Malay Archipelago. These manipulations, however, are not dictated
 
by a desire for cleanliness, but rather by immoral reasons.  
 
  
The existence of a true double hymen— one behind the  
+
As to the formation of caruncles, Schroder " holds that the hymeneal lobes during childbirth are compressed and undergo gangrene, while Bellien'^ believes that the lacerations of the hymen, during labor, extend through the base of the membrane into the perivaginal connective tissue; cicatrization and consequent shrinking of these tears produce caruncles.
other — has not been proved. Breiskj^' saw, in two newborn
 
females, a very thin membrane closing the lower portion of  
 
the vagina, close behind a well-formed hymen, and, furthermore, a firm septum retrohymenale in a \irgin fifty-four
 
years old. Both he and Dohrn" consider these septa due to
 
a coalescence of folds of the vaginal mucous membrane
 
immediately behind the hjTnen. Such a formation is facihtated, as Dohrn points out, by the fact that at this point the
 
lumen of the vagina is narrow even pre\'ious to the appearance of the hymen. ]Moreover, Piana and Bassi^' found that
 
in this area epithelial conglutinations in the human fetus are
 
"physiologic." We shall speak later of the h\Tiien bilamellatus of Schaffer in reference to double hymen.  
 
  
A double hymen — one beside the other — has repeatedly
+
I am inclined to ascribe to the elastic tissue a certain role in the formation of caruncles. As described above, the elastic fibers are unequally distributed within the hymen, the portions nearer the base containing more and thicker fibers than the periphery. So long as the hymen is preserved in its entirety, or only torn into a few large lobes which but little alter the form of the hymen, the upper more delicate fibers encircling the hymeneal opening exert an action counter to that of the radial fibers which tend to retract toward the base. If, however, the hymen, in childbirth, is torn into a number of small pieces, each piece retracts owing to the more powerful action of the radial fibers. For some time after, one is able to pull each caruncle to its original length, but after long standing the retraction results in an atrophy of the entire caruncle to a great extent through insufficient circulation. Regarding the retraction of elastic fibers, we know from numerous examinations that only the fibers of thin or medium size are really elastic. Thick fibers, such as are found in old age, are unyielding, and only such were observed in the caruncle referred to above.
been found in cases of double vagina and is easily explained
 
in the light of embryologic studies of the development of the  
 
genital tract.  
 
  
In connection with these cases of hymen duplex cum
+
==Pathology==
vagina septa it must be emphasized that congenital malformations of the hjTnen are impossible without anomalous
+
The pathology of the hymen may be divided into: (1) inflammations; (2) malformations; (3) neoplasms.
development of the rest of the internal genitals. This holds
 
true especially of the most frequent form of malformation of
 
the hymen, viz., atresia.  
 
  
Nagel' and Veit'° forcibly declare that only a minority of
+
Inflammation of the hymen may start primarily in this membrane itself or may originate in adjacent organs and tissues. As to the latter or secondary form, it is to be expected that the hymen, as a part of the vagina, may be affected by inflammatory processes which originate in the vagina and descend toward the vaginal entrance. Thus the different varieties of colpitis, including those that are produced by affections of the uterus, may lead to inflammation of the hjTnen. Acute infectious diseases such as cholera, variola, scarlatina, measles, etc., not infrequently produce secondary inflammations of the entire vaginal tract and, as we shall later see, play an important role in the origin of acquired atresia. On the other hand, the inflammatory process may ascend from the vulva. Gonorrheal infection here deserves the first place. Contamination with the colon bacillus, or ascarides emigrating from the neighboring anus may cause inflammation, and irritation from lack of cleanliness produces a similar effect. The inflamed hjTnen has a markedly reddened appearance and bleeds easily. Occasionally small excoriations are seen. The surrounding tissues have in general the same appearance. The microscopic changes in the inflamed hymen have not as yet been studied in detail, but in analogy with similar processes in the vagina we may expect to find round-cell infiltration in the connective tissue and a desquamation of epithelium so that this layer is either very much thinner or, in places, is altogether absent.
atresias of the female genitals can be considered as of congenital origin. Those of the hjTnen, hymen imperforatus, are
 
found only where other parts of the Miillerian ducts are
 
malformed. That form of hjTneneal atresia which is caused
 
by a conglutination of the h^nneneal folds in utero, the rest
 
of the genitals being normal, cannot be classified as a congenital atresia, a "\4tium primos formationis." All other
 
cases of atresia which show a normal formation of the  
 
internal genitals — and these form the great majority — must be considered as acquired. C. v. Tussenbroeck,'" through
 
the microscopic study of a case of "hymeneal" atresia,
 
opposes this theory of Nagel and Veit. Her original publication in the Dutch language was not at my disposal, so that
 
I had to rely on a short abstract in the ZenfralblaU fiir Gyndkologie and on one of her drawings reproduced in an article
 
by Stratz.^' v. Tussenbroeck points out that while the  
 
normal hymen consists only of vulvar and vaginal epithelium
 
and connective tissue between the two epithelia, her case of
 
hymeneal atresia contained in the intermediary tissue also
 
smooth muscle fibers and bloodvessels but showed no signs
 
of a previous inflammation. She takes the stand that in this
 
case no hymen has been formed and that the septum consisted, in the first place, of the lower ends of the atresic
 
jNIiillerian ducts with their surrounding secondary layer of
 
smooth muscle fibers, and, secondly, of the floor of the imperforate sinus urogenitalis. The patient, a girl of twenty-four
 
years, possessed otherwise perfectly normal internal and
 
external genitals.  
 
  
While Stratz, Treub and Bolk expressed their agreement
+
The same pathologic conditions may, after defloration, affect the hymeneal lobes and, after childbirth, the mjTtiform caruncles. Thus, in a case of recent gonorrhea, I found the multiform caruncles considerably thickened, deep red in color and extremely sensitive.
in the discussion following this demonstration of v. Tussenbroeck, Pincus,^^ who strongly seconds the \'iews of Nagel,  
 
points out that the absence of signs of pre\'ious inflammation
 
is no positive proof against the supposition of an acquired
 
atresia, and Henkel," in a similar case of hymeneal atresia,  
 
was able to show microscopically the presence of a chronic
 
inflammatory condition and to demonstrate numerous mast
 
cells and leukocytic wander cells.  
 
  
A critical review of the numerous cases reported as congenital atresias convinces one of the strength of Nagel's
+
Primary inflammation of the hymen is due either to masturbation or coitus. In two girls who admitted masturbation, I found the otherwise intact hymen considerably thickened, grayish-white and edematous. Gosselin^' describes cases in which onanism led to pathologic sensitiveness of the hymen.
theory. In the light of this theory, cases of pregnancy and  
 
childbirth with imperforate hymen are readily understood.
 
V. Gu^rard*^ compiled about fifty instances of this sort from
 
literature and added five observations of his own. This goes
 
to prove that atresia may occur at any time in the adult.
 
Even repeated atresias may take place. In this respect the third case of v. Gu^rard is unique. The patient in the  
 
seventh month of her first pregnancy complained of intense
 
pain in the genitals. Although she had pre\-iously been
 
operated upon twice for atresia h\-menalis, the vagina was
 
now fomid completely occluded by a firm and extremely
 
sensitive membrane. After total excision of this membrane
 
all symptoms promptly ceased, and normal delivery took
 
place at term.  
 
  
In the majority of instances, however, the formation of
+
In some cases the hymen, though normal, is particularly rigid; in others its orifice is large enough for the introduction of the penis without laceration. In any of these cases where there is a pushing back or dilatation of the membrane, it thickens, inflames, and becomes very sensitive (Pozzi'*). Fritsch^'^ considers this rigidity of the hymen as secondary The impotent husband with a non-erectile penis or suffering from precocious ejaculation does not succeed in perforating or lacerating the membrane. The continuous insults lead to inflammation of the introitus vaginje and hjinen, and even to a purulent discharge. Inflammation of the hjTnen is the foremost factor in vaginismus.
atresia dates back to earlier years of life. A careful anamnesis
 
in such cases will often reveal its cause. Neugebauer," with
 
his well-known assiduity and admirable thoroughness, has
 
gathered almost 1000 cases of gynatresias from Uterature.  
 
In 479 of these cases the atresia was undoubtedly acquired.
 
In almost 300 the anamnesis was negative. Neugebauer
 
himself says that it would be a mistake to interpret the lack
 
of data in the history in favor of the congenital origin of the
 
malformation. He refers to atresias in general, and it is clear
 
that the same reasons must pertain to hjTiieneal atresias.
 
The etiologic factor is furnished either by acute infectious
 
diseases such as were enumerated above, which lead to
 
inflammatory processes in the genital system, or by vulvovaginitis due to gonorrhea or other causes. The inflammation subsequent to an acute infectious disease may make
 
itself manifest at once or may remain unnoticed, as for
 
instance in the case reported by Thienhaus.*^ In the latter
 
event the result of the inflammation, viz., more or less firm
 
coalescence of the hymeneal folds, will not be noticed until
 
at puberty the menstrual flow is obstructed. Even if, at that
 
time, signs of pre\'ious inflammation should not be found in
 
the imperforate hymen, this would not speak against the
 
atresia being acquired. ]\Ieyer" has proved from literature the
 
acquired origin of atresia even in the absence of any scars,  
 
and Odebrecht" points out that cicatrices acquired in infancy
 
completely disappear within a few years on account of increased cellular vitality. If several sisters present hymeneal atresia, the inference is justified that the children were simultaneously affected by the same acute infectious disease.
 
Pincus cites a very interesting case reported by Madge."
 
Four sisters, two to ten years old, had hymeneal atresia; the
 
fifth child, a boy, had phimosis. Pincus rejected the supposition of heredity in this case and is inclined to ascribe this
 
coincidence to the action of some obnoxious factor common
 
to the five children, such as baths, sponges, or towels.  
 
  
This somewhat lengthy consideration may be thus summarized : In all cases of hymeneal atresia with normal functionating genital system, the condition is acquired. Here the
+
It might be supposed that the specific lesions of syphihs and chancroid would occasionally be found upon the hjTuen. The text-books on venereal diseases, however, which I consulted, make no special mention of such an occurrence; only Veit pictures a hymen whose posterior margin is destroyed by a hard chancre.
occluding membrane causes the retention of menstrual blood
 
and leads to hematocolpos, hematometra, etc.  
 
  
The hterature on the histology of hjTiieneal atresia is not
+
As to dermatologic affections of the hjTnen, recent Hterature contains the report of Carriere.^* This auther observed three cases of vuhdtis impetiginosa in children. In these eases the major and minor lips and the hymen were, at first, reddened and swollen. After a few days, the affected parts showed an eruption of miliary vesicles which afterward opened and gave rise to small ulcerations, the latter containing staphylococci.
very great. The reports of v. Tussenbroeck'' and Henkel"
 
have been recorded above. A recent contribution to this subject was furnished by Wechsberg.'^ The patient, a girl aged
 
fourteen years, had had measles, chicken-pox and whooping cough. She came to the hospital with the symptoms of
 
hematocolpos, which an examination revealed to have been
 
caused by an imperforate hymen. Wechsberg excised a small
 
portion of the membrane. Upon microscopic examination
 
both surfaces of the specimen showed papillae, those upon
 
the vaginal side being the larger. The vulvar surface was
 
covered by pavement epithelium, the vaginal side by a single
 
layer of high cylindric cells. On the vaginal side, however,
 
there were at one point, on the outer surface of a conspicuously
 
large papilla, ex'idences of keratinization. On the vulvar
 
side, cornification was seen throughout the uppermost layers
 
of the epithelium. Within the connective-tissue stroma there
 
were smooth muscle fibers, numerous lymph spaces and  
 
vessels, and a few nerves. There was no round-cell infiltration
 
nor other signs of previous inflammation such as cicatricial
 
tissue.  
 
  
Wechsberg refers to a similar case reported by Rincheval"
+
Traumatisms of the hymen have been extensively dealt with by Veit.*' The majority of injuries occur in the first cohabitation and in childbirth, and as such traumatisms must be considered physiologic, they have been spoken of in the first part of this paper on the normal anatomy of the hymen. Veit is quite right in distinguishing this class of hymeneal injuries from the severer ones produced by violent or abnormal coition. In such cases a profuse hemorrhage from the torn hymen may occur which demands medical interference. The literature on this subject is rather extensive and has been thoroughly considered by Veit. I agree with this writer that in cases of copious hymeneal hemorrhage other adjacent parts must have been injured. In one case in my recollection the young, newly married woman was brought into the clinic almost pulseless. Upon examination a deep tear of the hymen was found which commenced in the left upper quadrant and extended through the paraurethral tissue into the base of the clitoris.
in which there was found multilayered pavement epithelium  upon the outer surface, while the inner surface was lined with
 
cylindric epithelium which in places presented glandular
 
invaginations into the dense connective tissue.  
 
  
In the observation of Kochenburger" the excised hjTnen
+
Malformations of the hymen are either congenital or acquired. Total absence of hymen, reports of which are found in older literature, has not been observed by modern authors, and such authorities as Breisky" and Schaifer," while not denying the possibihty, consider this phenomenon exceedingly rare. It can, however, occur only simultaneously with total absence of the entire genital tract, which in its turn is found only in embryos incapable of surviving. In this connection I might mention as a curiosity the intentional destruction of the hymen practised in several parts of India and throughout China. Ploss^' relates that the native nurses employ digital cleansing of the vagina in earhest childhood so thoroughly that the hymen in time disappears altogether. Thus not even the native physicians in Cliina know anything about the existence of a hymen. Ploss himself examined a girl of European descent, but born in China, and found no trace of this structure. Similar customs resulting in the total demohtion of the hymen exist among several Indian tribes in South America and certain savage nations of the Malay Archipelago. These manipulations, however, are not dictated by a desire for cleanliness, but rather by immoral reasons.
had multilayered epithelium on its outer surface and cuboidal
 
epithelium on its inner side. Kochenburger considered the
 
latter to be the basal layer of the epithelium after the upper
 
layers had been macerated by the accumulated blood in the
 
occluded vagina and had been cast off. This epithelium
 
resembled that found upon erosions of the portig vaginalis
 
uteri. In corroboration of this \'iew the upper layers of the  
 
pavement epithelium were seen to persist in some places
 
while in others they had undergone degenerative processes,
 
but were still in connection with the basal layers. From his
 
findings Kochenburger deduced that in hymeneal atresia the
 
origin of epithelial cells resembling cylindric epithelium is
 
due to pressure, infiltration, imbibition, atrophy, and necrosis.  
 
Wechsberg, however, maintains that in his and Rincheval's
 
cases the cylindric epithelium is primary inasmuch as no
 
signs of cell degeneration could be detected; staining for
 
mucous degeneration resulted negatively, and the cylindric
 
cells themselves were high and took the ordinary stains
 
readily. In his opinion, the differentiation of the cylindric
 
epithelium primarily present in the vagina of the embryo
 
into pavement epithelium had not taken place in the small
 
portion excised. Upon the rest of the hymen and on the
 
walls of the vagina multilayered pavement epithelium was
 
found.  
 
  
These arguments of Wechsberg in favor of an embryonal
+
The existence of a true double hymen— one behind the other — has not been proved. Breiskj^' saw, in two newborn females, a very thin membrane closing the lower portion of the vagina, close behind a well-formed hymen, and, furthermore, a firm septum retrohymenale in a \irgin fifty-four years old. Both he and Dohrn" consider these septa due to a coalescence of folds of the vaginal mucous membrane immediately behind the hjTnen. Such a formation is facihtated, as Dohrn points out, by the fact that at this point the lumen of the vagina is narrow even pre\'ious to the appearance of the hymen. ]Moreover, Piana and Bassi^' found that in this area epithelial conglutinations in the human fetus are "physiologic." We shall speak later of the h\Tiien bilamellatus of Schaffer in reference to double hymen.
origin of the atresia in his case are not convincing. It would
 
be strained to suppose that only the very small portion which
 
was excised should have remained in an embrj'onal state. Nor
 
is the absence of degenerative signs sufficient proof. I believe
 
Kochenburger is right in comparing this condition with the  
 
erosion of the portio vaginalis uteri. In this affection, after
 
the upper layers have been destroyed by the pathologic  process and have entirely disappeared, only the basal layer
 
remains, the cells of which under the irritating influence may
 
be stimulated to more excessive growth of size and length.  
 
They even invade the underlying tissue, forming the so-called
 
glands of erosion, and I am inclined to ascribe a similar
 
origin to the glandular formations mentioned in Rinchcval's
 
case.  
 
  
Neoplasms of the hymen are very rare. To this group
+
A double hymen — one beside the other — has repeatedly been found in cases of double vagina and is easily explained in the light of embryologic studies of the development of the genital tract.
belong the cysts. I found in literature a total of 17 cases of  
 
hymeneal cysts reported by Bastelberger,^° Doderlein,^"
 
Piering,^' Ziegenspeck," ■" Miiller," Goerl,^^ Ulesko-Stroganowa,'* Palm," ^° Marchesi," Lannelongue and Achard,"
 
Theilhaber,^* and Ricci.^' These cysts occur on either side
 
of the hymen, but more frequently on the outer surface.
 
They may attain the size of a cherry and are occasionally
 
multiple. Ulesko-Stroganowa's case presented one cyst on
 
either side. In the case of Ricci, there was a small cyst in
 
the wall of the larger cyst. In Ziegenspeck's third case two
 
smaller cysts were found at the base of the main -cyst. Piering
 
observed a number of very small transparent cysts around
 
the edge of the hjinen. Microscopically, the hymeneal cysts
 
have been carefully studied. On the outside they are covered
 
with the hymeneal epithelium. Beneath this lie layers of
 
more or less dense connective tissue with well-developed
 
papillae and numerous capillaries, in some cases combined
 
with smooth muscle fibers. The inner surface is lined with
 
epithelium, usually of the pavement variety, varying in  
 
thickness. In other cysts the epithelium has a more cuboidal
 
or even cylindric character (iSIarchesi). This variation
 
depends upon the source of origin, which we shall presently
 
consider. The cysts may contain detritus and epithelium, or
 
a homogeneous, yellowish-brown, jelly-like substance, or else
 
a watery fluid. The latter may consist of lymph fluid
 
(Piering), or may contain blood corpuscles (Ulesko-Stroganowa). Ricci's cyst, the size of a cherry, which he so carefully examined, contained 1 c.c. of a thick, dark-brown liquid, the microscopic examination of which revealed
 
epithelial cells in large number, detritus of blood corpuscles,
 
fat droplets, glossy masses of amber color apparently consisting of red corpuscles and fat drops, and a small amount of
 
hematic pigment.  
 
  
Cysts of the hymen may develop in four different ways,  
+
In connection with these cases of hymen duplex cum vagina septa it must be emphasized that congenital malformations of the hjTnen are impossible without anomalous development of the rest of the internal genitals. This holds true especially of the most frequent form of malformation of the hymen, viz., atresia.
viz. :
 
  
1. By invagination and separation ("Abschniirung") of  
+
Nagel' and Veit' forcibly declare that only a minority of atresias of the female genitals can be considered as of congenital origin. Those of the hjTnen, hymen imperforatus, are found only where other parts of the Miillerian ducts are malformed. That form of hjTneneal atresia which is caused by a conglutination of the h^nneneal folds in utero, the rest of the genitals being normal, cannot be classified as a congenital atresia, a "\4tium primos formationis." All other cases of atresia which show a normal formation of the internal genitals — and these form the great majority — must be considered as acquired. C. v. Tussenbroeck,'" through the microscopic study of a case of "hymeneal" atresia, opposes this theory of Nagel and Veit. Her original publication in the Dutch language was not at my disposal, so that I had to rely on a short abstract in the ZenfralblaU fiir Gyndkologie and on one of her drawings reproduced in an article by Stratz.^' v. Tussenbroeck points out that while the normal hymen consists only of vulvar and vaginal epithelium and connective tissue between the two epithelia, her case of hymeneal atresia contained in the intermediary tissue also smooth muscle fibers and bloodvessels but showed no signs of a previous inflammation. She takes the stand that in this case no hymen has been formed and that the septum consisted, in the first place, of the lower ends of the atresic jNIiillerian ducts with their surrounding secondary layer of smooth muscle fibers, and, secondly, of the floor of the imperforate sinus urogenitalis. The patient, a girl of twenty-four years, possessed otherwise perfectly normal internal and external genitals.
hymeneal epithelium (cases of Bastelberger, Ziegenspeck,  
 
Goerl).  
 
  
2. From rests of embryonal tissue within the substance of  
+
While Stratz, Treub and Bolk expressed their agreement in the discussion following this demonstration of v. Tussenbroeck, Pincus,^^ who strongly seconds the \'iews of Nagel, points out that the absence of signs of pre\'ious inflammation is no positive proof against the supposition of an acquired atresia, and Henkel," in a similar case of hymeneal atresia, was able to show microscopically the presence of a chronic inflammatory condition and to demonstrate numerous mast cells and leukocytic wander cells.
the hymen. This mode of origin is claimed by Ricci for his
 
case. He cites the observation of Pestalozza,^ who found
 
ectodermal embryonal rests within the stroma of a hjTnen.  
 
  
3. By conglutination or coalescence of converging hymeneal
+
A critical review of the numerous cases reported as congenital atresias convinces one of the strength of Nagel's theory. In the light of this theory, cases of pregnancy and childbirth with imperforate hymen are readily understood. V. Gu^rard*^ compiled about fifty instances of this sort from literature and added five observations of his own. This goes to prove that atresia may occur at any time in the adult. Even repeated atresias may take place. In this respect the third case of v. Gu^rard is unique. The patient in the seventh month of her first pregnancy complained of intense pain in the genitals. Although she had pre\-iously been operated upon twice for atresia h\-menalis, the vagina was now fomid completely occluded by a firm and extremely sensitive membrane. After total excision of this membrane all symptoms promptly ceased, and normal delivery took place at term.
folds. This mode was first suggested by Dotlerlcin, who
 
observed a pronounced development of folds upon the outer
 
side which in places approximate. When the tips of these
 
folds become completely conglutinated, a space is shut off,
 
which at first is filled with epithelial cells. By gradual
 
necrosis and liquefaction of the central cells a lumen is
 
formed and a cyst produced. Doderlein's view is strongly
 
supported by Schaffer." According to this writer, the folds
 
of the embryonal hymen are usually obliterated by the
 
upward growth of the connective tissue. In many instances,  
 
however, these folds coalesce at the end of the papilla, thus
 
leaving a pocket of epithelium. One of my own specimens
 
shows that fibrous bands may extend from any point of the
 
papilla to the hymen and separate a mass of epithelium
 
which may eventually give rise to a cystic cavity (Fig. 2).  
 
  
4. By retention of contents : (a) In lymph spaces (Piering) ;
+
In the majority of instances, however, the formation of atresia dates back to earlier years of life. A careful anamnesis in such cases will often reveal its cause. Neugebauer," with his well-known assiduity and admirable thoroughness, has gathered almost 1000 cases of gynatresias from Uterature. In 479 of these cases the atresia was undoubtedly acquired. In almost 300 the anamnesis was negative. Neugebauer himself says that it would be a mistake to interpret the lack of data in the history in favor of the congenital origin of the malformation. He refers to atresias in general, and it is clear that the same reasons must pertain to hjTiieneal atresias. The etiologic factor is furnished either by acute infectious diseases such as were enumerated above, which lead to inflammatory processes in the genital system, or by vulvovaginitis due to gonorrhea or other causes. The inflammation subsequent to an acute infectious disease may make itself manifest at once or may remain unnoticed, as for instance in the case reported by Thienhaus.*^ In the latter event the result of the inflammation, viz., more or less firm coalescence of the hymeneal folds, will not be noticed until at puberty the menstrual flow is obstructed. Even if, at that time, signs of pre\'ious inflammation should not be found in the imperforate hymen, this would not speak against the atresia being acquired. ]\Ieyer" has proved from literature the acquired origin of atresia even in the absence of any scars, and Odebrecht" points out that cicatrices acquired in infancy completely disappear within a few years on account of increased cellular vitality. If several sisters present hymeneal atresia, the inference is justified that the children were simultaneously affected by the same acute infectious disease. Pincus cites a very interesting case reported by Madge." Four sisters, two to ten years old, had hymeneal atresia; the fifth child, a boy, had phimosis. Pincus rejected the supposition of heredity in this case and is inclined to ascribe this coincidence to the action of some obnoxious factor common to the five children, such as baths, sponges, or towels.
(6) in portions of the ^YolfBan ducts within the hymen. In
 
the report of Ulesko-Stroganowa and in one of Alarchesi's
 
cases, the cysts were lined with cylindric epithelium similar
 
to that of the Wolffian ducts; (c) of a sebaceous gland. Palm
 
considers his two cysts as true atheromata. This author bases his views upon the macroscopic and microscopic
 
similarity to genuine atheromata found in other parts of the  
 
body, mainly the labia minora, and upon the supposition that  
 
the few true glands which have been found upon the inner
 
and outer side of the hjTnen (Ruge, Klein) are of a sebaceous character.  
 
  
Of other benign neoplasms of the hymen I have found two
+
This somewhat lengthy consideration may be thus summarized : In all cases of hymeneal atresia with normal functionating genital system, the condition is acquired. Here the occluding membrane causes the retention of menstrual blood and leads to hematocolpos, hematometra, etc.
observations of polypus" and one case of angioma.'^ The
 
original articles, however, I could not obtain.  
 
  
Of malignant diseases of the hymen there exists in literature but one case of sarcoma reported by Sanger.^' A child
+
The literature on the histology of hymeneal atresia is not very great. The reports of v. Tussenbroeck and Henkel" have been recorded above. A recent contribution to this subject was furnished by Wechsberg.'^ The patient, a girl aged fourteen years, had had measles, chicken-pox and whooping cough. She came to the hospital with the symptoms of hematocolpos, which an examination revealed to have been caused by an imperforate hymen. Wechsberg excised a small portion of the membrane. Upon microscopic examination both surfaces of the specimen showed papillae, those upon the vaginal side being the larger. The vulvar surface was covered by pavement epithelium, the vaginal side by a single layer of high cylindric cells. On the vaginal side, however, there were at one point, on the outer surface of a conspicuously large papilla, ex'idences of keratinization. On the vulvar side, cornification was seen throughout the uppermost layers of the epithelium. Within the connective-tissue stroma there were smooth muscle fibers, numerous lymph spaces and vessels, and a few nerves. There was no round-cell infiltration nor other signs of previous inflammation such as cicatricial tissue.
of three years had a profuse foul vaginal discharge, and  
 
occasionally a tumor of the size of half a finger appeared at
 
the entrance of the vagina. From the vulva hung two bodies
 
like mucous polypi, pediculated from the posterior hymeneal
 
border. There was a still larger tumor with ulcerated surface,  
 
distending the vagina and sessile on the anterior wall. There
 
existed, in addition, a number of polypoid excrescences, like
 
hydatids, occupying various portions of the vaginal membrane, and numerous metastases in the broad ligaments and
 
the rectovaginal septum. INIicroscopically the tumor proved
 
to be a typical round-cell sarcoma.  
 
  
Development. Four theories of the development of the  
+
Wechsberg refers to a similar case reported by Rincheval" in which there was found multilayered pavement epithelium upon the outer surface, while the inner surface was lined with cylindric epithelium which in places presented glandular invaginations into the dense connective tissue.
hymen have been advanced which may be briefly characterized as follows:
 
  
1. The hymen is the product of the INIullerian ducts
+
In the observation of Kochenburger" the excised hjTnen had multilayered epithelium on its outer surface and cuboidal epithelium on its inner side. Kochenburger considered the latter to be the basal layer of the epithelium after the upper layers had been macerated by the accumulated blood in the occluded vagina and had been cast off. This epithelium resembled that found upon erosions of the portig vaginalis uteri. In corroboration of this \'iew the upper layers of the pavement epithelium were seen to persist in some places while in others they had undergone degenerative processes, but were still in connection with the basal layers. From his findings Kochenburger deduced that in hymeneal atresia the origin of epithelial cells resembling cylindric epithelium is due to pressure, infiltration, imbibition, atrophy, and necrosis. Wechsberg, however, maintains that in his and Rincheval's cases the cylindric epithelium is primary inasmuch as no signs of cell degeneration could be detected; staining for mucous degeneration resulted negatively, and the cylindric cells themselves were high and took the ordinary stains readily. In his opinion, the differentiation of the cylindric epithelium primarily present in the vagina of the embryo into pavement epithelium had not taken place in the small portion excised. Upon the rest of the hymen and on the walls of the vagina multilayered pavement epithelium was found.
(KoUiker, Dohrn, Nagel, Klein).  
 
  
2. The hymen is the product of the sinus urogenitalis
+
These arguments of Wechsberg in favor of an embryonal origin of the atresia in his case are not convincing. It would be strained to suppose that only the very small portion which was excised should have remained in an embrj'onal state. Nor is the absence of degenerative signs sufficient proof. I believe Kochenburger is right in comparing this condition with the erosion of the portio vaginalis uteri. In this affection, after the upper layers have been destroyed by the pathologic process and have entirely disappeared, only the basal layer remains, the cells of which under the irritating influence may be stimulated to more excessive growth of size and length. They even invade the underlying tissue, forming the so-called glands of erosion, and I am inclined to ascribe a similar origin to the glandular formations mentioned in Rinchcval's case.
(Pozzi).  
 
  
3. The hymen is the product of both the Miillerian ducts
+
Neoplasms of the hymen are very rare. To this group belong the cysts. I found in literature a total of 17 cases of hymeneal cysts reported by Bastelberger,^° Doderlein,^" Piering,^' Ziegenspeck," Miiller," Goerl,^^ Ulesko-Stroganowa,'* Palm," ^° Marchesi," Lannelongue and Achard," Theilhaber,^* and Ricci.^' These cysts occur on either side of the hymen, but more frequently on the outer surface. They may attain the size of a cherry and are occasionally multiple. Ulesko-Stroganowa's case presented one cyst on either side. In the case of Ricci, there was a small cyst in the wall of the larger cyst. In Ziegenspeck's third case two smaller cysts were found at the base of the main -cyst. Piering observed a number of very small transparent cysts around the edge of the hjinen. Microscopically, the hymeneal cysts have been carefully studied. On the outside they are covered with the hymeneal epithelium. Beneath this lie layers of more or less dense connective tissue with well-developed papillae and numerous capillaries, in some cases combined with smooth muscle fibers. The inner surface is lined with epithelium, usually of the pavement variety, varying in thickness. In other cysts the epithelium has a more cuboidal or even cylindric character (iSIarchesi). This variation depends upon the source of origin, which we shall presently consider. The cysts may contain detritus and epithelium, or a homogeneous, yellowish-brown, jelly-like substance, or else a watery fluid. The latter may consist of lymph fluid (Piering), or may contain blood corpuscles (Ulesko-Stroganowa). Ricci's cyst, the size of a cherry, which he so carefully examined, contained 1 c.c. of a thick, dark-brown liquid, the microscopic examination of which revealed epithelial cells in large number, detritus of blood corpuscles, fat droplets, glossy masses of amber color apparently consisting of red corpuscles and fat drops, and a small amount of hematic pigment.
and the sinus urogenitalis (Schaffer).  
 
  
4. The hj-men is the product of the Wolfiian ducts (Hart).  
+
Cysts of the hymen may develop in four different ways, viz. :
I begin vnth the last and chronologically latest theory which
 
  
is advanced by D. Berry Hart,'^ °^ but was in somewhat
+
# By invagination and separation ("Abschniirung") of hymeneal epithelium (cases of Bastelberger, Ziegenspeck, Goerl).
similar form pubUshed by v. Hoffmann^" in 1878. Hart
+
# From rests of embryonal tissue within the substance of the hymen. This mode of origin is claimed by Ricci for his case. He cites the observation of Pestalozza,^ who found ectodermal embryonal rests within the stroma of a hjTnen.
formulates his theory as follows: The hymen is formed by a special bulbous development of the lower ends of the two
+
# By conglutination or coalescence of converging hymeneal folds. This mode was first suggested by Dotlerlcin, who observed a pronounced development of folds upon the outer side which in places approximate. When the tips of these folds become completely conglutinated, a space is shut off, which at first is filled with epithelial cells. By gradual necrosis and liquefaction of the central cells a lumen is formed and a cyst produced. Doderlein's view is strongly supported by Schaffer." According to this writer, the folds of the embryonal hymen are usually obliterated by the upward growth of the connective tissue. In many instances, however, these folds coalesce at the end of the papilla, thus leaving a pocket of epithelium. One of my own specimens shows that fibrous bands may extend from any point of the papilla to the hymen and separate a mass of epithelium which may eventually give rise to a cystic cavity (Fig. 2).
Wolffian ducts aided by an epithelial involution from below
+
# By retention of contents : (a) In lymph spaces (Piering) ; (6) in portions of the Wolffian ducts within the hymen. In the report of Ulesko-Stroganowa and in one of Alarchesi's cases, the cysts were lined with cylindric epithelium similar to that of the Wolffian ducts; (c) of a sebaceous gland. Palm considers his two cysts as true atheromata. This author bases his views upon the macroscopic and microscopic similarity to genuine atheromata found in other parts of the body, mainly the labia minora, and upon the supposition that the few true glands which have been found upon the inner and outer side of the hjTnen (Ruge, Klein) are of a sebaceous character.
of the cells lining the urogenital sinus. The terminal parts
 
of the Miillerian ducts are at first solid epithelial cords, the
 
epithelial mass being derived from the bulbous termination
 
of the Wolffian ducts. These Wolffian bulbs after having
 
mapped out the vaginal portion of the uterus and the fornices
 
of the vagina, coalesce, break down in the center and form
 
the lumen of the vagina. The coalesced Wolffian bulbs, then
 
protrude into the urogenital sinus and thus form the hymen.  
 
The epoophoron, the paroophoron, and the Wolffian ducts  
 
near the uterus and upper part of the vagina are all useless
 
and dangerous relics to women, giving rise to many pathologic conditions simple as well as malignant. Only at the
 
lower end of the Wolffian ducts do we get an actual normal
 
utilization in the development of the hymen, the relining of
 
the vagina and cervix with an ectodermic multilayered
 
epithelium and the opening up of the imperforate eminence
 
of Miiller where the IMiillerian ducts end blindly.  
 
  
This theory was accepted by Keith" and Garrigues" and
+
Of other benign neoplasms of the hymen I have found two observations of polypus" and one case of angioma.'^ The original articles, however, I could not obtain.
seems to be supported by a case of persistence of the urogenital sinus recorded by Purslow." This case is interesting
 
enough to be quoted more in detail. A well-developed girl
 
aged twenty-three years sought medical aid for dysmenorrhea.
 
Micturition was always normal. The pubic hair was well
 
developed. On separating the labia, there was seen an
 
unusually well-marked hymen having a crescentic opening
 
in front, which would admit the index finger. Immediately
 
within the hymen, but quite distinct from it, was a firm
 
fibrous ring contracting the opening into the vagina, and just
 
admitting the tip of the little finger; but the finger could not
 
be forced through this narrowed part of the canal, which gave
 
the impression of being about 1 cm. in length. A catheter
 
passed through the hymeneal opening readily into the bladder,
 
and urine was v^dthdrawn. The clitoris was not enlarged.
 
The constriction, together with the hymen, was divided by deep incision wdth a bistoury, and the orifice was well
 
stretched until it would admit three fingers. It was then
 
ascertained that the constricted portion communicated at its
 
upper end wth a capacious vagina, and that at the junction
 
the bladder opened by an aperture which admitted the tip
 
of the finger and appeared to have very Uttle sphincter power.
 
There was no trace of a urethra. In this report there are
 
several important points of information lacking. From the
 
history we do not know whether the patient in her childhood
 
had suffered from any acute infectious disease which might
 
have led to inflammation and consequent stricture of the
 
vagina. WTiat was the condition of the uterus and appendages? Was the dysmenorrhea due to a malformation of the
 
internal genitals, or did it cease after the operation?
 
  
In Hart's theory there are several weak points. In the
+
Of malignant diseases of the hymen there exists in literature but one case of sarcoma reported by Sanger.^' A child of three years had a profuse foul vaginal discharge, and occasionally a tumor of the size of half a finger appeared at the entrance of the vagina. From the vulva hung two bodies like mucous polypi, pediculated from the posterior hymeneal border. There was a still larger tumor with ulcerated surface, distending the vagina and sessile on the anterior wall. There existed, in addition, a number of polypoid excrescences, like hydatids, occupying various portions of the vaginal membrane, and numerous metastases in the broad ligaments and the rectovaginal septum. INIicroscopically the tumor proved to be a typical round-cell sarcoma.
first place, it is difficult to understand that an organ should
 
form an intrinsic part of the human economy only at its lower
 
end while the rest forms a dangerous anomaly. Secondly,
 
systematic researches of other investigators result in an
 
altogether different conception of the course of the WolflBan
 
ducts. Until recently the majority of observers believed that
 
the Wolffian ducts terminated at or near the cer\nx uteri in
 
the upper part of the vagina. This view can no longer be
 
held. Beigel, Dohrn, and v. Ackeren first described rests of  
 
the Wolffian ducts along the entire length of the vagina, and
 
Klein,'" in 1897, demonstrated in serial sections the course
 
of the Wolffian ducts at either side of the vagina and the
 
termination of these ducts in the hymen. These sections
 
were taken from the genitals of the newborn and of a girl,  
 
aged four and one-half years. The findings of Klein were
 
confirmed by many observations of Meyer^° in the fetus and
 
newborn. He found in seventeen cases larger remnants of
 
the Wolffian ducts in the vagina and especially within the
 
hymen. Here the ducts entering the base of the hjTnen from
 
the posterior wall of the vagina run upward within the
 
hymeneal tissue and usually open at the outer side near the free edge. It must be noted that v. Ackeren, Meyer, Klein,  
 
and Groschuff, Seitz and Hengge, the last three working with
 
Klein, actually found the Wolffian ducts within the hymen.  
 
Nagel suggests that the ducts of Bartholin's glands might be  
 
mistaken for the Wolffian ducts and I feel inclined thus to
 
interpret the pictures given by Hart.  
 
  
While Hart holds that the vagina is derived only in its
+
==Development==
upper two-thirds from the Miillerian ducts and in its lower
+
Four theories of the development of the hymen have been advanced which may be briefly characterized as follows:
third from the sinus urogenitalis, all other theories have as  
 
their premise that the vagina in its entirety is of Miillerian
 
origin.
 
  
According to the next theory, that of Pozzi,'* the origin of
+
# The hymen is the product of the Mullerian ducts (Kolliker, Dohrn, Nagel, Klein).
the hymen is intimately connected with that of the vulva.
+
# The hymen is the product of the sinus urogenitalis (Pozzi).
On either side of the sinus urogenitalis and below the urethra
+
# The hymen is the product of both the Mullerian ducts and the sinus urogenitalis (Schaffer).
lie two corpora spongiosa which, after surrounding the
+
# The hymen is the product of the Wolfiian ducts (Hart). I begin vnth the last and chronologically latest theory which s advanced by D. Berry Hart, but was in somewhat similar form published by v. Hoffmann" in 1878.  
meatus urinarius, extend upward to the base of the clitoris.  
 
From the superficial portion of these spongious organs which
 
remain in the fetal state, the hymen develops. I'ozzi bases
 
his theory upon the aspect of the external genitals and the  
 
analogy with the frenulum in masculine hypospadias, and
 
upon the following clinical observations: (1) the existence
 
of the hymen in total absence of the vagina; (2) the presence
 
of a single hymen in cases of double vagina; (3) the existence
 
of a urethral hymen— r. e., a prolongation of the ring around
 
the meatus, partly or even entirely covering this orifice, which
 
goes to prove the close relationship between the different
 
parts of the hymen and the ring which surrounds the meatus.  
 
  
Cases of hymen existing in the absence of the vagina are
+
Hart formulates his theory as follows: The hymen is formed by a special bulbous development of the lower ends of the two Wolffian ducts aided by an epithelial involution from below of the cells lining the urogenital sinus. The terminal parts of the Miillerian ducts are at first solid epithelial cords, the epithelial mass being derived from the bulbous termination of the Wolffian ducts. These Wolffian bulbs after having mapped out the vaginal portion of the uterus and the fornices of the vagina, coalesce, break down in the center and form the lumen of the vagina. The coalesced Wolffian bulbs, then protrude into the urogenital sinus and thus form the hymen. The epoophoron, the paroophoron, and the Wolffian ducts near the uterus and upper part of the vagina are all useless and dangerous relics to women, giving rise to many pathologic conditions simple as well as malignant. Only at the lower end of the Wolffian ducts do we get an actual normal utilization in the development of the hymen, the relining of the vagina and cervix with an ectodermic multilayered epithelium and the opening up of the imperforate eminence of Miiller where the IMiillerian ducts end blindly.
occasionally found. In addition to those cited by Pozzi
 
himself and by Neugebauer,** I have seen in recent literature
 
reports by Loefqist" (ten cases), Krevet,'^ and Strauss.''
 
On the other hand, in the majority of cases of total absence
 
of the vagina, no trace of a hjTnen can be found. Loefqist
 
himself does not consider his cases as supporting the theory
 
of Pozzi who, as he points out, ignores the results of embryologic studies altogether and thus denies facts verified by the microscope. In my opinion the microscopic examination of  
 
the atresic vagina or rather of the tissues behind the hymen  
 
will possibly throw light upon this point. The vagina must
 
either have been normal and become obliterated afterward or
 
have been atrophic from the beginning. At any rate, the  
 
INIiillerian ducts must have reached the sinus, for otherwise
 
the origin of a hjTnen is inexplicable. In corroboration of
 
this, absence of the hymen in absence of the vagina is the
 
more frequent occurrence. An example is to be seen in the
 
case recorded by Veit" in which there was a uterus bipartitns,
 
but no trace of the vagina nor of the hymen could be found.
 
Even according to Pozzi's theory, the hymen is only then
 
formed from the vulva when there exists an opening which
 
the corpora spongiosa can surround. Pozzi's second argument of the presence of one hymen in double vagina is
 
balanced by observations of double hymen in double vagina.
 
Only last year two further cases were observed by Benno
 
MuUer" and ^Marchand."
 
  
As to Pozzi's third point, the existence of a membrane
+
This theory was accepted by Keith" and Garrigues" and seems to be supported by a case of persistence of the urogenital sinus recorded by Purslow." This case is interesting enough to be quoted more in detail. A well-developed girl aged twenty-three years sought medical aid for dysmenorrhea. Micturition was always normal. The pubic hair was well developed. On separating the labia, there was seen an unusually well-marked hymen having a crescentic opening in front, which would admit the index finger. Immediately within the hymen, but quite distinct from it, was a firm fibrous ring contracting the opening into the vagina, and just admitting the tip of the little finger; but the finger could not be forced through this narrowed part of the canal, which gave the impression of being about 1 cm. in length. A catheter passed through the hymeneal opening readily into the bladder, and urine was v^dthdrawn. The clitoris was not enlarged. The constriction, together with the hymen, was divided by deep incision wdth a bistoury, and the orifice was well stretched until it would admit three fingers. It was then ascertained that the constricted portion communicated at its upper end wth a capacious vagina, and that at the junction the bladder opened by an aperture which admitted the tip of the finger and appeared to have very Uttle sphincter power. There was no trace of a urethra. In this report there are several important points of information lacking. From the history we do not know whether the patient in her childhood had suffered from any acute infectious disease which might have led to inflammation and consequent stricture of the vagina. WTiat was the condition of the uterus and appendages? Was the dysmenorrhea due to a malformation of the internal genitals, or did it cease after the operation?
partly or totally occluding the urethra may be admitted as
 
of vulvar origin but need not necessarily be associated with
 
the formation of the hymen. According to a recent article by
 
Dickinson,*^ this "urethral hj-men" is a pathologic structure
 
due to repeated traction and found only in company with
 
hypertrophied nymphse. In addition to these remarks, a case
 
of persistent sinus urogenitalis reported by Kelly'^ is worthy
 
of note. The patient, a nuUipara, aged forty-six years, had
 
normal external genitals as far as the introitus of the vagina,  
 
where the only opening between the rectum and clitoris was
 
found. There was no hymen, and the smooth orifice beneath
 
the pubic arch had the form of a transverse sUt. From this
 
orifice a short muscular canal led directly into the bladder.  
 
Into this canal behind the orifice a double vagina opened.  
 
It is at this point, at the opening of the Miillerian ducts into
 
the sinus, that a hymen should be looked for, though Kelly
 
does not make mention of it. The absence of an external
 
hymen speaks strongly against Pozzi's supposition. In conclusion, Pozzi does not bring sufficient e\ndence to prove
 
the fact that the hymen is independent of the ]\Iullerian
 
ducts.
 
  
Schaffer," upon a careful study of an unusually large
+
In Hart's theory there are several weak points. In the first place, it is difficult to understand that an organ should form an intrinsic part of the human economy only at its lower end while the rest forms a dangerous anomaly. Secondly, systematic researches of other investigators result in an altogether different conception of the course of the WolflBan ducts. Until recently the majority of observers believed that the Wolffian ducts terminated at or near the cer\nx uteri in the upper part of the vagina. This view can no longer be held. Beigel, Dohrn, and v. Ackeren first described rests of the Wolffian ducts along the entire length of the vagina, and Klein,'" in 1897, demonstrated in serial sections the course of the Wolffian ducts at either side of the vagina and the termination of these ducts in the hymen. These sections were taken from the genitals of the newborn and of a girl, aged four and one-half years. The findings of Klein were confirmed by many observations of Meyer^° in the fetus and newborn. He found in seventeen cases larger remnants of the Wolffian ducts in the vagina and especially within the hymen. Here the ducts entering the base of the hjTnen from the posterior wall of the vagina run upward within the hymeneal tissue and usually open at the outer side near the free edge. It must be noted that v. Ackeren, Meyer, Klein, and Groschuff, Seitz and Hengge, the last three working with Klein, actually found the Wolffian ducts within the hymen. Nagel suggests that the ducts of Bartholin's glands might be mistaken for the Wolffian ducts and I feel inclined thus to interpret the pictures given by Hart.
material, propounds the following theorj-: In the fifth month
 
of fetal life every hjinen makes its appearance more or less
 
distinctly in the form of two lamellte (hymen bilamellatus) in
 
such a way that the inner lamella is formed by the vagina,  
 
the outer by the vulva. Schaffer found this mode of origin
 
53 times in 190 specimens. In many instances the two
 
lamellae unite either at once or later; in more than one-fourth
 
of his cases, they persisted more or less until full term, but
 
rarely after birth. p]ach lamella is covered with mucous
 
membrane on both sides so that the h}'men bilamellatus,
 
properly speaking, consists of four layers. Schaffer supports
 
his theory with the following observations: (1) frequency of  
 
a distinctly bilamellate form (28.8 per cent.); (2) unity of  
 
the outer lamella with a layer of vulvar mucosa around the  
 
urethral orifice and upward to the cHtoris; (3) different stages
 
of the coalescence of the two lamellce by means of transverse
 
processes or papilla?; (4) folds or ridges of mucosa which
 
spring from the frenulum labiorum, the njonphse, and the  
 
"frenulum masculinum," and end in the outer lamella,
 
usually at or near the free edge; (5) relation of the urethral
 
orifice to the outer lamella; (6) difference in the form of the
 
free edge of the outer and inner lamellae; (7) difference in
 
color and epitheHal covering of both lamellae; (8) possibility
 
of dissecting the outer lamellae from the inner; (9) analogy
 
with the portio vaginalis uteri, the growth of which is, to a
 
great extent, due to material furnished by the vagina; (10)
 
cases of single hvmen in double vagina; (11) cases of persistence of both lamellae (hjTnen duplex); (12) cases of presence
 
of hymen (outer lamella) in absence of vagina.  
 
  
The painstaking researches of Schaffer deserve earnest
+
While Hart holds that the vagina is derived only in its upper two-thirds from the Miillerian ducts and in its lower third from the sinus urogenitalis, all other theories have as their premise that the vagina in its entirety is of Miillerian origin.
consideration. A number of his observations coincide with those of Pozzi. The extension of the hymen beyond the
 
urethral orifice, in SchaflFer's description, corresponds to
 
Pozzi's "bride mascuHne" or "frenuhim mascuUnum." The
 
relation of the meatus urethrte, the folds from the surrounding vulva stretching to the outer surface of the li}'men and  
 
the possibility of dissecting the superficial layer of the vulvar
 
mucosa 'hi toto, including the outer surface of the hymen, are
 
observations common to both authors. Only the interpretation of these facts and the conclusions drawn therefrom are
 
different. This is most noticeable in the arguments classified
 
under 10 and 12.  
 
  
There are several objections, however, to Schaffer's theory :  
+
According to the next theory, that of Pozzi,'* the origin of the hymen is intimately connected with that of the vulva. On either side of the sinus urogenitalis and below the urethra lie two corpora spongiosa which, after surrounding the meatus urinarius, extend upward to the base of the clitoris. From the superficial portion of these spongious organs which remain in the fetal state, the hymen develops. I'ozzi bases his theory upon the aspect of the external genitals and the analogy with the frenulum in masculine hypospadias, and upon the following clinical observations: (1) the existence of the hymen in total absence of the vagina; (2) the presence of a single hymen in cases of double vagina; (3) the existence of a urethral hymen— r. e., a prolongation of the ring around the meatus, partly or even entirely covering this orifice, which goes to prove the close relationship between the different parts of the hymen and the ring which surrounds the meatus.
  
1. Schaffer states that in the first series of 103 fetuses, 42
+
Cases of hymen existing in the absence of the vagina are occasionally found. In addition to those cited by Pozzi himself and by Neugebauer,** I have seen in recent literature reports by Loefqist" (ten cases), Krevet,'^ and Strauss. On the other hand, in the majority of cases of total absence of the vagina, no trace of a hjTnen can be found. Loefqist himself does not consider his cases as supporting the theory of Pozzi who, as he points out, ignores the results of embryologic studies altogether and thus denies facts verified by the microscope. In my opinion the microscopic examination of the atresic vagina or rather of the tissues behind the hymen will possibly throw light upon this point. The vagina must either have been normal and become obliterated afterward or have been atrophic from the beginning. At any rate, the INIiillerian ducts must have reached the sinus, for otherwise the origin of a hjTnen is inexplicable. In corroboration of this, absence of the hymen in absence of the vagina is the more frequent occurrence. An example is to be seen in the case recorded by Veit" in which there was a uterus bipartitns, but no trace of the vagina nor of the hymen could be found. Even according to Pozzi's theory, the hymen is only then formed from the vulva when there exists an opening which the corpora spongiosa can surround. Pozzi's second argument of the presence of one hymen in double vagina is balanced by observations of double hymen in double vagina. Only last year two further cases were observed by Benno MuUer" and ^Marchand."
had abnormal genitals. In a second series of 87 cases he  
 
gives no detailed data; altogether he found hymen bilamellatus 53 times in these 190 specimens. The large percentage of cases with abnormal sexual organs in addition to the  
 
comparatively small percentage of bilameljate hymens
 
actually found, to a certain extent detracts from the value
 
of these observations.  
 
  
2. While a number of text-books (Gebhard," Chrobak and
+
As to Pozzi's third point, the existence of a membrane partly or totally occluding the urethra may be admitted as of vulvar origin but need not necessarily be associated with the formation of the hymen. According to a recent article by Dickinson,*^ this "urethral hj-men" is a pathologic structure due to repeated traction and found only in company with hypertrophied nymphse. In addition to these remarks, a case of persistent sinus urogenitalis reported by Kelly'^ is worthy of note. The patient, a nuUipara, aged forty-six years, had normal external genitals as far as the introitus of the vagina, where the only opening between the rectum and clitoris was found. There was no hymen, and the smooth orifice beneath the pubic arch had the form of a transverse sUt. From this orifice a short muscular canal led directly into the bladder. Into this canal behind the orifice a double vagina opened. It is at this point, at the opening of the Miillerian ducts into the sinus, that a hymen should be looked for, though Kelly does not make mention of it. The absence of an external hymen speaks strongly against Pozzi's supposition. In conclusion, Pozzi does not bring sufficient e\ndence to prove the fact that the hymen is independent of the ]\Iullerian ducts.
Rosthorn'*) reproduce Schaffer's statements without commenting upon them, later workers in the same field emphasize
 
that they have not yet seen the bilamellate form in a single
 
instance. I refer to Klein" and Hart." Nor have I been
 
able to observe this formation in the seven fetal hymens of  
 
my collection. Since Schaffer found the bilamellate hymen  
 
in 28.8 per cent., one would expect to find it at least once in
 
the dozen or more cases examined by Klein, Hart and myself.  
 
In only one instance, that of a girl, aged twenty years, I
 
thought at first sight to have noted a case of hymen duplex
 
(persistence of the two lamellae). The hymen was well
 
developed and of annular shape. Immediately behind the
 
hymen there was a second, well-marked, fleshy fold springing
 
from the left side of the vaginal entrance and running parallel
 
to the left half of the hymen. At about the median line this fold began to converge slightly toward the h}Tnen and ended
 
in its posterior surface a little to the right of the median line.  
 
This fold was as high as the hymen itself and exactly like it
 
in appearance. After cautiously pushing aside the h>Tneneal
 
membrane it was Seen that this fold was but the continuation
 
of a longitudinal vaginal ruga which ran directly below the
 
juncture of the posterior and left walls of the vagina. These
 
longitudinal folds or rugse are of ordinary occurrence in the
 
lowest inch of the vagina. Fig. 7 (Case 4) shows this condition in an embryo of twenty-five weeks. Hart** also notes
 
that the rug£e or columns of the lowest inch of the vagina run
 
for the most part longitudinally; above this the vagina has
 
its rugffi transverse. These longitudinal folds (Fig. 7) turn
 
inward at the vaginal entrance and run parallel or but
 
slightly converging to the posterior surface of the hjTnen and
 
fuse with the latter at irregular points, but, as a rule, below
 
the free edge,
 
  
3. As the first formation of the h}Tnen takes place in the  
+
Schaffer," upon a careful study of an unusually large material, propounds the following theorj-: In the fifth month of fetal life every hjinen makes its appearance more or less distinctly in the form of two lamellte (hymen bilamellatus) in such a way that the inner lamella is formed by the vagina, the outer by the vulva. Schaffer found this mode of origin 53 times in 190 specimens. In many instances the two lamellae unite either at once or later; in more than one-fourth of his cases, they persisted more or less until full term, but rarely after birth. p]ach lamella is covered with mucous membrane on both sides so that the h}'men bilamellatus, properly speaking, consists of four layers. Schaffer supports his theory with the following observations: (1) frequency of a distinctly bilamellate form (28.8 per cent.); (2) unity of the outer lamella with a layer of vulvar mucosa around the urethral orifice and upward to the cHtoris; (3) different stages of the coalescence of the two lamellce by means of transverse processes or papilla?; (4) folds or ridges of mucosa which spring from the frenulum labiorum, the njonphse, and the "frenulum masculinum," and end in the outer lamella, usually at or near the free edge; (5) relation of the urethral orifice to the outer lamella; (6) difference in the form of the free edge of the outer and inner lamellae; (7) difference in color and epitheHal covering of both lamellae; (8) possibility of dissecting the outer lamellae from the inner; (9) analogy with the portio vaginalis uteri, the growth of which is, to a great extent, due to material furnished by the vagina; (10) cases of single hvmen in double vagina; (11) cases of persistence of both lamellae (hjTnen duplex); (12) cases of presence of hymen (outer lamella) in absence of vagina.
nineteenth week, and as the lamell.ie, according to Schaffer,  
 
persist more or less distinctly until term, the bilamellate form
 
should be \-isible, at least remnants of it, in microscopic
 
sections through hymens of a later fetal period. None of my
 
sections, however, present this form. INIoreover, the hjTiien
 
of twenty-five weeks, pictured in Fig. 7, which simulates
 
bilamellation, does not, microscopically, show two lamella?,  
 
though the section comprises Aiilvar and vaginal portions
 
adjoining the hjTnen. With Klein I consider the high fold
 
usually found at the vaginal side as one of the numerous
 
papillae of the vagina and without importance in regard to the  
 
development of the hjTnen.  
 
  
4. Schaffer mentions the difference in color and epithehal
+
The painstaking researches of Schaffer deserve earnest consideration. A number of his observations coincide with those of Pozzi. The extension of the hymen beyond the urethral orifice, in SchaflFer's description, corresponds to Pozzi's "bride mascuHne" or "frenuhim mascuUnum." The relation of the meatus urethrte, the folds from the surrounding vulva stretching to the outer surface of the li}'men and the possibility of dissecting the superficial layer of the vulvar mucosa 'hi toto, including the outer surface of the hymen, are observations common to both authors. Only the interpretation of these facts and the conclusions drawn therefrom are different. This is most noticeable in the arguments classified under 10 and 12.
covering of the two surfaces. While I shall speak later of  
 
the epithelial coverings of the two sides of the hjTnen, I may
 
say as to the difference in color that in the fetus I observed
 
the entire hymen, both inside and outside, as white, exactly
 
like the vagina, and contrasting markedly with the grayish red appearance of the \'ulva. I observed a similar condition
 
in the h\Ti>en of a \argin of twenty-five.  
 
  
Klein, '^ in his studies of the development of the h}Tnen,
+
There are several objections, however, to Schaffer's theory :
advances the following theory: The hymen is that part of
 
the pelvic floor which is thinned out by the ampuUary
 
enlargement of the lower portion of the vagina. The anlage
 
of the hj-men is present at the beginning of the third month
 
when the IMlillerian ducts break through into the sinus
 
urogenitalis. From the third to the fifth month, the vagina
 
undergoes an ampullary enlargement in its terminal portion,
 
which in its turn leads to a stretching and thinning out of
 
the surrounding pelvic floor. I might suggest that this theory
 
does not explain the formation of the annular hymen. It is
 
only the posterior wall of the vagina which undergoes a
 
dilatation thus producing the ampulla vaginse; the anterior
 
wall remains unaffected and, consequently, a sj-mmetric
 
structure hke the annular hymen is impossible.
 
  
Klein ascribes to the Miillerian ducts an active part in the
+
1. Schaffer states that in the first series of 103 fetuses, 42 had abnormal genitals. In a second series of 87 cases he gives no detailed data; altogether he found hymen bilamellatus 53 times in these 190 specimens. The large percentage of cases with abnormal sexual organs in addition to the comparatively small percentage of bilameljate hymens actually found, to a certain extent detracts from the value of these observations.
formation of the hjTiien. In this respect, Klein's \dews
 
coincide with the most generally accepted theory, that  
 
advanced by v. KoUiker,'" v. Mihalkovicz, Budin, Dohrn, and
 
especially Nagel.' According to these writers the development of the hymen is inseparable from the development of the
 
vagina. In the human embryo of 8 to 10 mm., the INIiillerian
 
duct on either side may be divided into a proximal and a
 
distal part characterized by different kinds of epithehum.
 
The proximal portion, which later becomes uterus and tube,
 
is hollow and has cylindric epithelium. The distal part,
 
which becomes the vagina, has, in the beginning, no lumen,
 
but is filled with large protoplasmic cells of a more cubic
 
form. At about the third month, the lower ends of the
 
Miillerian ducts in their downward growth reach the sinus
 
urogenitalis and by the protrusion of their blind ends form
 
the Miillerian eminence. From this eminence the hj-men is
 
formed. The finer details of this process may, to my mind,
 
be conceived as follows. When the united Miillerian ducts reach the sinus urogenitalis they push the thin layer of  
 
epitheUum Uning the sinus forward, and by so doing they
 
make this epithelium even thinner than before. This condition is clearly seen in Nagel's picture (Fig. 8). In this stage
 
the lower ends of the Mtillerian ducts represent a somewhat
 
cone-shaped solid epithehal cord. The formation of a lumen
 
proceeds from above downward, and this canalization corresponds with the curve of the ducts themselves with its concavity anterior. Therefore the point where the lumen of the
 
ducts breaks through the solid end is, as a rule, nearer the
 
upper border of the conus, and so is responsible for the
 
production of the semilunar form of the hymen which is by
 
far the most common. The concave course of the Miilleriart
 
ducts is due to the curved abdomen of the embryo. Thereby
 
every organ in the lower part of the body, the sacrum, rectum,
 
genital tract, and sinus urogenitalis, acquires a curved axis.  
 
The extremity of the conus (]\liillerian eminence) with a more
 
or less eccentric lumen protruding into the sinus, consists,
 
at first, only of the epitheUum of the Miillerian eminence
 
covered on the outer surface with a very thin layer of sinus
 
epithelium. Only secondarily is this mass of epithehum
 
invaded by connective tissue. According to Nagel the  
 
Miillerian ducts originally are composed of large protoplasmic
 
cells of an epithelial character. Around this mass of cells
 
which gradually becomes a tube, the mesodermal formative
 
cells are grouped in a circular arrangement, thus forming
 
the first anlage of the connective tissue and muscular layer of
 
the Miillerian ducts. In other words, the connective tissue
 
appears after the ducts are established and grows in proportion
 
to, and together with, the downward growth of the ducts.
 
Thus, when the ends of the ducts protrude into the sinus in
 
the form of an epithelial protuberance, their connective tissue
 
comes down with them, grows into the terminal conus and
 
forms the inner or central layer of the protuberance.  
 
  
 +
2. While a number of text-books (Gebhard," Chrobak and Rosthorn'*) reproduce Schaffer's statements without commenting upon them, later workers in the same field emphasize that they have not yet seen the bilamellate form in a single instance. I refer to Klein" and Hart." Nor have I been able to observe this formation in the seven fetal hymens of my collection. Since Schaffer found the bilamellate hymen in 28.8 per cent., one would expect to find it at least once in the dozen or more cases examined by Klein, Hart and myself. In only one instance, that of a girl, aged twenty years, I thought at first sight to have noted a case of hymen duplex (persistence of the two lamellae). The hymen was well developed and of annular shape. Immediately behind the hymen there was a second, well-marked, fleshy fold springing from the left side of the vaginal entrance and running parallel to the left half of the hymen. At about the median line this fold began to converge slightly toward the h}Tnen and ended in its posterior surface a little to the right of the median line. This fold was as high as the hymen itself and exactly like it in appearance. After cautiously pushing aside the h>Tneneal membrane it was Seen that this fold was but the continuation of a longitudinal vaginal ruga which ran directly below the juncture of the posterior and left walls of the vagina. These longitudinal folds or rugse are of ordinary occurrence in the lowest inch of the vagina. Fig. 7 (Case 4) shows this condition in an embryo of twenty-five weeks. Hart** also notes that the rug£e or columns of the lowest inch of the vagina run for the most part longitudinally; above this the vagina has its rugffi transverse. These longitudinal folds (Fig. 7) turn inward at the vaginal entrance and run parallel or but slightly converging to the posterior surface of the hjTnen and fuse with the latter at irregular points, but, as a rule, below the free edge,
  
 +
3. As the first formation of the h}Tnen takes place in the nineteenth week, and as the lamell.ie, according to Schaffer, persist more or less distinctly until term, the bilamellate form should be \-isible, at least remnants of it, in microscopic sections through hymens of a later fetal period. None of my sections, however, present this form. INIoreover, the hjTiien of twenty-five weeks, pictured in Fig. 7, which simulates bilamellation, does not, microscopically, show two lamella?, though the section comprises Aiilvar and vaginal portions adjoining the hjTnen. With Klein I consider the high fold usually found at the vaginal side as one of the numerous papillae of the vagina and without importance in regard to the development of the hjTnen.
  
Fig -Sagittal section through the lower third of the Mullcriau duct in a fetus  
+
4. Schaffer mentions the difference in color and epithehal covering of the two surfaces. While I shall speak later of the epithelial coverings of the two sides of the hjTnen, I may say as to the difference in color that in the fetus I observed the entire hymen, both inside and outside, as white, exactly like the vagina, and contrasting markedly with the grayish red appearance of the \'ulva. I observed a similar condition in the h\Ti>en of a \argin of twenty-five.
4 cm. in length (from Xagel) : 1, Miillerian duet; 2, lower end of the same
 
(anlage of the vagina); 3, cylindric epithelium of the anlage of the uterus;
 
4. canalis urogenitalis.  
 
  
 +
Klein, '^ in his studies of the development of the h}Tnen, advances the following theory: The hymen is that part of the pelvic floor which is thinned out by the ampuUary enlargement of the lower portion of the vagina. The anlage of the hj-men is present at the beginning of the third month when the IMlillerian ducts break through into the sinus urogenitalis. From the third to the fifth month, the vagina undergoes an ampullary enlargement in its terminal portion, which in its turn leads to a stretching and thinning out of the surrounding pelvic floor. I might suggest that this theory does not explain the formation of the annular hymen. It is only the posterior wall of the vagina which undergoes a dilatation thus producing the ampulla vaginse; the anterior wall remains unaffected and, consequently, a sj-mmetric structure hke the annular hymen is impossible.
  
 +
Klein ascribes to the Miillerian ducts an active part in the formation of the hjTiien. In this respect, Klein's \dews coincide with the most generally accepted theory, that advanced by v. KoUiker,'" v. Mihalkovicz, Budin, Dohrn, and especially Nagel.' According to these writers the development of the hymen is inseparable from the development of the vagina. In the human embryo of 8 to 10 mm., the INIiillerian duct on either side may be divided into a proximal and a distal part characterized by different kinds of epithehum. The proximal portion, which later becomes uterus and tube, is hollow and has cylindric epithelium. The distal part, which becomes the vagina, has, in the beginning, no lumen, but is filled with large protoplasmic cells of a more cubic form. At about the third month, the lower ends of the Miillerian ducts in their downward growth reach the sinus urogenitalis and by the protrusion of their blind ends form the Miillerian eminence. From this eminence the hj-men is formed. The finer details of this process may, to my mind, be conceived as follows. When the united Miillerian ducts reach the sinus urogenitalis they push the thin layer of epitheUum Uning the sinus forward, and by so doing they make this epithelium even thinner than before. This condition is clearly seen in Nagel's picture (Fig. 8). In this stage the lower ends of the Mtillerian ducts represent a somewhat cone-shaped solid epithehal cord. The formation of a lumen proceeds from above downward, and this canalization corresponds with the curve of the ducts themselves with its concavity anterior. Therefore the point where the lumen of the ducts breaks through the solid end is, as a rule, nearer the upper border of the conus, and so is responsible for the production of the semilunar form of the hymen which is by far the most common. The concave course of the Miilleriart ducts is due to the curved abdomen of the embryo. Thereby every organ in the lower part of the body, the sacrum, rectum, genital tract, and sinus urogenitalis, acquires a curved axis. The extremity of the conus (]\liillerian eminence) with a more or less eccentric lumen protruding into the sinus, consists, at first, only of the epitheUum of the Miillerian eminence covered on the outer surface with a very thin layer of sinus epithelium. Only secondarily is this mass of epithehum invaded by connective tissue. According to Nagel the Miillerian ducts originally are composed of large protoplasmic cells of an epithelial character. Around this mass of cells which gradually becomes a tube, the mesodermal formative cells are grouped in a circular arrangement, thus forming the first anlage of the connective tissue and muscular layer of the Miillerian ducts. In other words, the connective tissue appears after the ducts are established and grows in proportion to, and together with, the downward growth of the ducts. Thus, when the ends of the ducts protrude into the sinus in the form of an epithelial protuberance, their connective tissue comes down with them, grows into the terminal conus and forms the inner or central layer of the protuberance.
  
  
 +
Fig -Sagittal section through the lower third of the Mullcriau duct in a fetus 4 cm. in length (from Xagel) : 1, Miillerian duet; 2, lower end of the same (anlage of the vagina); 3, cylindric epithelium of the anlage of the uterus; 4. canalis urogenitalis.
  
If this be the true mode of origin, the hymen is a product
 
of the Miillerian ducts exclusively. The epithelium of the sinus urogenitalis does not play any active part, but only
 
covers the outer layers of the epithelium of the ^lullerian
 
ducts in the form of a very thin cuticle. Thus it is readily
 
understood why the epithelium of the vulva can be dissected
 
from the hymen as recorded above in connection with the
 
theories of Pozzi and ScKaffer.
 
  
The ]\Iiillerian theory is further supported by the following
 
observation. It is asserted by a number of authors (Winckel,"*
 
Dohrn," Pozzi,'* Roze" and others) that the outer surface of
 
the h}Tnen is different from the inner and resembles the
 
structure of the vestibule in that it has, like the latter, no
 
papillse and that its epithelium is like that of the vestibule.
 
My sections, however, described above, show that the vulvar
 
surface has papillse as well as the vaginal surface, and I infer
 
the same from SchafTer's remarks on this subject. In my
 
sections, the papillse, it is true, are not quite as numerous nor
 
are they as high and richly ramified as those on the inner
 
side, but this difference is but comparative, and can be
 
explained by physical reasons. The hymen in the embryo
 
and in the infant, as all observers agree, protrudes into the
 
vulva. It thus hes in close juxtaposition to the vestibule and
 
its papillae are subjected to a certain degree of pressure
 
atrophy while the vaginal surface does not suffer any pressure
 
from the yielding epitheHum which at that time fills the
 
vaginal lumen.
 
  
The vestibule itself has no papillae at all; its surface in the  
+
If this be the true mode of origin, the hymen is a product of the Miillerian ducts exclusively. The epithelium of the sinus urogenitalis does not play any active part, but only covers the outer layers of the epithelium of the ^lullerian ducts in the form of a very thin cuticle. Thus it is readily understood why the epithelium of the vulva can be dissected from the hymen as recorded above in connection with the theories of Pozzi and ScKaffer.
vicinity of the hymen is perfectly smooth. It is covered with
 
but a few layers of flattened epithelium while the vulvar
 
surface of the hymen is lined with many layers of epithelium.
 
The slight difference in the number of epithelial layers
 
between the vulvar and vaginal surfaces of the hymen is,
 
again, explained by the same physical reasons. These conditions are strikingly ob\aous in the section through the vulva,
 
hymen, and vagina, of an embryo of twenty-five weeks (Fig. 1),
 
detailed above. In another section through the hymen of a
 
seven months' fetus the epithelium on the vaginal side is very thick; that on the vulvar side is only about half as thick.
 
This latter epithelium appears compressed; the cells adjoining the germinative basal layers are markedly flattened
 
instead of being polygonal, as is usually the case in multilayered pavement epithelium.  
 
  
I am well aware that the form of epithelium, because of  
+
The ]\Iiillerian theory is further supported by the following observation. It is asserted by a number of authors (Winckel,"* Dohrn," Pozzi,'* Roze" and others) that the outer surface of the h}Tnen is different from the inner and resembles the structure of the vestibule in that it has, like the latter, no papillse and that its epithelium is like that of the vestibule. My sections, however, described above, show that the vulvar surface has papillse as well as the vaginal surface, and I infer the same from SchafTer's remarks on this subject. In my sections, the papillse, it is true, are not quite as numerous nor are they as high and richly ramified as those on the inner side, but this difference is but comparative, and can be explained by physical reasons. The hymen in the embryo and in the infant, as all observers agree, protrudes into the vulva. It thus hes in close juxtaposition to the vestibule and its papillae are subjected to a certain degree of pressure atrophy while the vaginal surface does not suffer any pressure from the yielding epitheHum which at that time fills the vaginal lumen.
its changeability, cannot establish a theory, but it can
 
support \'iews which are otherwise well founded. Embryologic studies and macroscopic or clinical observations alone
 
cannot decide the question. It must be supported by
 
histologic examination, the value of which has thus far been
 
underestimated. Under this heading I should Hke to call
 
attention to certain features of the connective-tissue structure
 
which to my knowledge have not heretofore been pointed
 
out. In all sections examined the fibers of connective tissue
 
are distinctly seen to run in a straight line from the vagina
 
into the hymen. Account of this was given in the first part
 
of this paper. It may here suffice to reiterfite this observation.
 
The great mass of the hymen appears as a direct continuation
 
of the connective tissue of the vagina, and only at the base
 
a few semicircular fibers connect the hjniien with the stratum
 
of the vulva. The latter can by its looser structure be
 
differentiated from the more compact vaginal and hymeneal
 
connective tissue and so clearly shows the hymen to be of
 
  
 +
The vestibule itself has no papillae at all; its surface in the vicinity of the hymen is perfectly smooth. It is covered with but a few layers of flattened epithelium while the vulvar surface of the hymen is lined with many layers of epithelium. The slight difference in the number of epithelial layers between the vulvar and vaginal surfaces of the hymen is, again, explained by the same physical reasons. These conditions are strikingly ob\aous in the section through the vulva, hymen, and vagina, of an embryo of twenty-five weeks (Fig. 1), detailed above. In another section through the hymen of a seven months' fetus the epithelium on the vaginal side is very thick; that on the vulvar side is only about half as thick. This latter epithelium appears compressed; the cells adjoining the germinative basal layers are markedly flattened instead of being polygonal, as is usually the case in multilayered pavement epithelium.
  
vaginal origin.
+
I am well aware that the form of epithelium, because of its changeability, cannot establish a theory, but it can support \'iews which are otherwise well founded. Embryologic studies and macroscopic or clinical observations alone cannot decide the question. It must be supported by histologic examination, the value of which has thus far been underestimated. Under this heading I should Hke to call attention to certain features of the connective-tissue structure which to my knowledge have not heretofore been pointed out. In all sections examined the fibers of connective tissue are distinctly seen to run in a straight line from the vagina into the hymen. Account of this was given in the first part of this paper. It may here suffice to reiterfite this observation. The great mass of the hymen appears as a direct continuation of the connective tissue of the vagina, and only at the base a few semicircular fibers connect the hjniien with the stratum of the vulva. The latter can by its looser structure be differentiated from the more compact vaginal and hymeneal connective tissue and so clearly shows the hymen to be of
  
Bibliography.
 
  
1. C. G. Cumston. On the Significance of the Hymen Intactus.
+
vaginal origin.
Annals of Gyn. and Ped., Jan., 1904.  
 
  
2. Krimer. Hufeland's Journal, Sept., 1834; cited by Pozzi.  
+
Bibliography.
  
3. E. B. Turnipseed. Some Facts in Regard to the Anatomic.
+
1. C. G. Cumston. On the Significance of the Hymen Intactus. Annals of Gyn. and Ped., Jan., 1904.
Differences between the Negro and AATiite Races. Amer. Joum. of
 
Obst., 1877, vol. X, p. 32.  
 
  
4. C. H. Fort. Some Corroborating Facts, etc. Ibid., p. 258.  
+
2. Krimer. Hufeland's Journal, Sept., 1834; cited by Pozzi.
  
5. H. O. Hyatt. Note on the Normal .\natomy of the Vulvovaginal Orifice. Ibid., p. 253.  
+
3. E. B. Turnipseed. Some Facts in Regard to the Anatomic. Differences between the Negro and AATiite Races. Amer. Joum. of Obst., 1877, vol. X, p. 32.
  
6. A. G. Smythe. The Position of the Hymen in the Negro Race.  
+
4. C. H. Fort. Some Corroborating Facts, etc. Ibid., p. 258.
Ibid., p. 638.  
 
  
7. B. C. Hirst, in Clinical Gynecology, edited by J. M. Keating and
+
5. H. O. Hyatt. Note on the Normal .\natomy of the Vulvovaginal Orifice. Ibid., p. 253.
H. C. Coe, 1895, p. 244
 
  
 +
6. A. G. Smythe. The Position of the Hymen in the Negro Race. Ibid., p. 638.
  
 +
7. B. C. Hirst, in Clinical Gynecology, edited by J. M. Keating and H. C. Coe, 1895, p. 244
  
8. W. Nagel. Entwickelung und Entwickelungsfehler der weiblichen Genitalien. Veit's Handbuch der G^vnakologie, 1897, Band 1.
 
  
9. Bischoff. Abhandl. der K. Bayr. Akad., 1879; cited by Pozzi.  
+
8. W. Nagel. Entwickelung und Entwickelungsfehler der weiblichen Genitalien. Veit's Handbuch der G^vnakologie, 1897, Band 1.
  
10. C. J. Cullingworth. A Note on the Anatomy of the Hynien, etc.  
+
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11. F. A. R. Dohrn. Die Bildungsfehler des Hymen. Zeitschr. f.
+
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12. A. V. KoUiker. Manual of Human Microsc. Anatom)', 1860,  
+
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13. O. Schaffer. Bildungsanomalien der weibl. Geschlechtsorgane,
+
12. A. V. KoUiker. Manual of Human Microsc. Anatom)', 1860, p. 465.
etc. Arch. f. Gyn., 1890, Bd. 37.  
 
  
14. G. Klein. Entstehung des H^nnen. Wien^ 1894.  
+
13. O. Schaffer. Bildungsanomalien der weibl. Geschlechtsorgane, etc. Arch. f. Gyn., 1890, Bd. 37.
  
15. H. Savage. The Female Pelvic Organs, 1876, p. 3.  
+
14. G. Klein. Entstehung des H^nnen. Wien^ 1894.
  
16. Budin. Recherches sur rh\-nien et rorifice vaginal. Prog. M^d.,
+
15. H. Savage. The Female Pelvic Organs, 1876, p. 3.
Aug., 1879, p, 677.  
 
  
17. Henkel. Tr. Gjti. and Obst. Soc, Berlin. Zeitschr. f. Geb. und
+
16. Budin. Recherches sur rh\-nien et rorifice vaginal. Prog. M^d., Aug., 1879, p, 677.
G>Ti., 1901, Bd. 45, S. 175.  
 
  
18. C. van Tussenbroeck. Tr. Dutch Gynec. Soc. Zentralbl. f.  
+
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GjTi., 1900, No. 19, S. 506.  
 
  
19. R. Pahn. Eine Hj-menalcyste, etc. Arch. f. Gyn., Bd. 51.  
+
18. C. van Tussenbroeck. Tr. Dutch Gynec. Soc. Zentralbl. f. GjTi., 1900, No. 19, S. 506.
  
20. R. Ziegenspeck. Ueber die Entstehung von Hymenalcj'sten.  
+
19. R. Pahn. Eine Hj-menalcyste, etc. Arch. f. Gyn., Bd. 51.
Arch. f. G>-n., Bd. 67.  
 
  
21. E. Ivlein, in S. Strieker's Manual of Human and Comparative
+
20. R. Ziegenspeck. Ueber die Entstehung von Hymenalcj'sten. Arch. f. G>-n., Bd. 67.
Histology, 1872, vol. ii. p. 321.  
 
  
22. N. V. GawTOnsky. Ueber Verbreitung und Endigung der Nerven
+
21. E. Ivlein, in S. Strieker's Manual of Human and Comparative Histology, 1872, vol. ii. p. 321.
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23. R. Koestlin. Die Nervenendigungen in den weibl. Geschlechtsorganen. Fortschritte der Medicin, 1894, No. 11-12.  
+
22. N. V. GawTOnsky. Ueber Verbreitung und Endigung der Nerven in den weibl. Genitalien. Arch. f. Gyn., 1894, Bd. 47.
  
24 J. A. Amann, Jr. Lehrbuch der Mikrosk.-Gynak. Diagnostik,  
+
23. R. Koestlin. Die Nervenendigungen in den weibl. Geschlechtsorganen. Fortschritte der Medicin, 1894, No. 11-12.
1897, S. 35.  
 
  
25. A. Calmann. Sensibilitatspruefungen am weibl. Genitale.
+
24 J. A. Amann, Jr. Lehrbuch der Mikrosk.-Gynak. Diagnostik, 1897, S. 35.
Verhdl. der Deutsch. Ges. f. Gyn., 1897, ix, S. 526.  
 
  
26. J. Kollmann. Lehrb. der Entwickelungsgesch. des Menschen,  
+
25. A. Calmann. Sensibilitatspruefungen am weibl. Genitale. Verhdl. der Deutsch. Ges. f. Gyn., 1897, ix, S. 526.
1898.  
 
  
27. C. Ruge. Cited by Breisky.  
+
26. J. Kollmann. Lehrb. der Entwickelungsgesch. des Menschen, 1898.
  
28. Fleischmann. Eine Bildungsanomalie des Hj-men. Zeitschr. f.
+
27. C. Ruge. Cited by Breisky.
Heilk., 1886, Bd. 7, S. 419.  
 
  
29. O. Piering. Zur Kenntniss der Cystenbildung im HjTnen. Prager
+
28. Fleischmann. Eine Bildungsanomalie des Hj-men. Zeitschr. f. Heilk., 1886, Bd. 7, S. 419.
Med. Wochenschr., 1887, S. 409.  
 
  
30. R. Meyer. Ueber Driisen der Vagina bei Foten und Neugeborenen. Zeitschr. f. Geb. u. Gyn., 1901, Bd. 46.  
+
29. O. Piering. Zur Kenntniss der Cystenbildung im HjTnen. Prager Med. Wochenschr., 1887, S. 409.
  
31. Henle. Cited by Pozzi.  
+
30. R. Meyer. Ueber Driisen der Vagina bei Foten und Neugeborenen. Zeitschr. f. Geb. u. Gyn., 1901, Bd. 46.
  
32. Schroder. Schwangerschaft, Geburt u. Wochenbltt; cited by  
+
31. Henle. Cited by Pozzi.
Schauta. Lehrb. d. ges. Gyn., 1897.  
 
  
33. Bellien. Arch. f. Gyn., Bd. 6, S. 132.  
+
32. Schroder. Schwangerschaft, Geburt u. Wochenbltt; cited by Schauta. Lehrb. d. ges. Gyn., 1897.
  
34. S. Pozzi. Medical and Surgical G}aiecology. Amer. Transl.,  
+
33. Bellien. Arch. f. Gyn., Bd. 6, S. 132.
1894.  
 
  
 +
34. S. Pozzi. Medical and Surgical G}aiecology. Amer. Transl., 1894.
  
  
35. H. Fritsch. Krankheiten der Frauen, 190t.  
+
35. H. Fritsch. Krankheiten der Frauen, 190t.
  
36. Goss^lin. HyperaestMsie Vulvaire. In Clin, de la Char., 1873,  
+
36. Goss^lin. HyperaestMsie Vulvaire. In Clin, de la Char., 1873, vol. ii; cited by Pozzi.
vol. ii; cited by Pozzi.  
 
  
37. A. Breisky. Diseases of the Vagina. Cyclopedia of Obst. and  
+
37. A. Breisky. Diseases of the Vagina. Cyclopedia of Obst. and Gyn., 1887, vol.x.
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38. H. Ploss. Das Weib in der Xatur und Volkerkunde. 1899, Bd.  
+
38. H. Ploss. Das Weib in der Xatur und Volkerkunde. 1899, Bd. 1, S. 197.
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39. Plana and Bassi. Rivista CUnica di Bologna, Nov. 1874; cited  
+
39. Plana and Bassi. Rivista CUnica di Bologna, Nov. 1874; cited by Sehaffer.
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40. J. Veit. Erkrankungen der Vagina, in Handbuch der Gyn,  
+
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41. C. H. Stratz. Blutanhaufungen bei einfachen und doppelten  
+
41. C. H. Stratz. Blutanhaufungen bei einfachen und doppelten Genitalien. Zeitschr. f. Geb. u. Gyn., Bd. 46, S. 1.
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42. L. Pincus. Praktisch wichtige Fragen zur Nagel-Veit'schen  
+
42. L. Pincus. Praktisch wichtige Fragen zur Nagel-Veit'schen Theorie. Saminl. klin. Vortr., 1901, No. 299-300.
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43. V. Gu^rard. Schwangerschaft und Geburt bei undurchbohrtem  
+
43. V. Gu^rard. Schwangerschaft und Geburt bei undurchbohrtem Hymen. Centralbl. f. Gyn., 1895, S. 402.
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44. F. V. Neugebauer. Zvir Lehre von den angeborenen u. erworbenen Verwachsungen. Berlin, 1895.  
+
44. F. V. Neugebauer. Zvir Lehre von den angeborenen u. erworbenen Verwachsungen. Berlin, 1895.
  
45. O. Thienhaus. Atresia Hymenalis. Joum. Amer. Med. Assoc,  
+
45. O. Thienhaus. Atresia Hymenalis. Joum. Amer. Med. Assoc, July 20, 1901.
July 20, 1901.  
 
  
46. R. Meyer. Zur Aetiologie der GjTiatre.sien, etc. Zeitschr. f.  
+
46. R. Meyer. Zur Aetiologie der GjTiatre.sien, etc. Zeitschr. f. Geb. u. G\Ti., Bd. 34.
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47. Odeijrecht. Discussion. Zentralbl. f. Gya., 1894, S. 126.  
+
47. Odeijrecht. Discussion. Zentralbl. f. Gya., 1894, S. 126.
  
48. Madge. Tr. Obst. Soc, London, vol. xi. p. 213; cited by Pincus.  
+
48. Madge. Tr. Obst. Soc, London, vol. xi. p. 213; cited by Pincus.
  
49. Bastelberger. Cyste im Hymen. Archiv. f. G>-n., Bd. 23, S. 427.  
+
49. Bastelberger. Cyste im Hymen. Archiv. f. G>-n., Bd. 23, S. 427.
  
50. Doderlein. Ein Fall von angeborener Hj-menalcyste. Arch. f.  
+
50. Doderlein. Ein Fall von angeborener Hj-menalcyste. Arch. f. Gyn., Bd. 29, S. 284.
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51. R. Ziegenspeck. Ueber Cysten im Hyemn Neugeborener. Archiv  
+
51. R. Ziegenspeck. Ueber Cysten im Hyemn Neugeborener. Archiv f. Gyn., Bd. 32.
f. Gyn., Bd. 32.  
 
  
52. Miiller. Ein Fall von angeborener H\'menalcyste. Archiv f.  
+
52. Miiller. Ein Fall von angeborener H\'menalcyste. Archiv f. Gyn., Bd. 44.
Gyn., Bd. 44.  
 
  
53. Goerl. Cyste ira Hvmen einer Em-achsenen. Archiv f. GjTj.,  
+
53. Goerl. Cyste ira Hvmen einer Em-achsenen. Archiv f. GjTj., Bd. 42.
Bd. 42.  
 
  
54. Ulesko-Stroganowa. Zur Pathologie der Hymenal und Vaginalcysten (russ.). Monatsthr. f. Geb. u. Gyn., Bd. 2, S. 269.  
+
54. Ulesko-Stroganowa. Zur Pathologie der Hymenal und Vaginalcysten (russ.). Monatsthr. f. Geb. u. Gyn., Bd. 2, S. 269.
  
55. P. Marchesi. SuUe cisti imenali. Arch Ital. di Gin., 1900; cited  
+
55. P. Marchesi. SuUe cisti imenali. Arch Ital. di Gin., 1900; cited bj- Ricci.
bj- Ricci.  
 
  
56. R. Palm. Beitrag zur Entstehung der Cysten im Hjinen bei  
+
56. R. Palm. Beitrag zur Entstehung der Cysten im Hjinen bei Erwachsenen. Archiv f. Gyn., Bd. 53.
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62. Vascular Excrescence on the Hymen. New Jersey M. Reporter,  
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63. M. Sanger; cited by Breisky.  
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66. V. Hoffman. Tr. Germ. Gyn. Soc, 1878. Transl. in American  
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Journal of Obstetrics, 1879, vol. xii. p. 205.  
 
  
67. A. Keith. Human Embryology and Morphology, London, 1902.  
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67. A. Keith. Human Embryology and Morphology, London, 1902.
  
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68. H. J. Garrigues. Diseases of Women, 1900.
  
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Wolff'schen Gangen beim Weibe. Verhdl. der Deutsch. Ges. f. Gyn.,  
 
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71. R. Loefqist. Ausgebildeter Hymen bei Defect der Vagina.  
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73. Strauss. Miinchener med. Wochenschr., 1904, No. 4, S. 177.  
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74. B. Miiller. Ein Fall von Vagina duplex und Hymen duplex.  
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74. B. Miiller. Ein Fall von Vagina duplex und Hymen duplex. Deutsche med. Wochenschr., 1903, No. 32, S. 570.
Deutsche med. Wochenschr., 1903, No. 32, S. 570.  
 
  
75. F. Marchand. Ueber Verdoppelung der Vagina bei einfachen  
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Uterus. Zentralb. f. Gvn., 1904, No. 6, S. 161.  
 
  
76. H. A. Kelly. Operative Gynecology, 1899, vol. i. p. 288.  
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76. H. A. Kelly. Operative Gynecology, 1899, vol. i. p. 288.
  
77. C. Gebhard. Pathol. Anatomic der weibl. Sexualorgane, 1899.  
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77. C. Gebhard. Pathol. Anatomic der weibl. Sexualorgane, 1899.
  
78. Chrobak und v. Rosthom. Die Erkrankungen der weibl. Geschlechtsorgane, 1900, Bd. i.  
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78. Chrobak und v. Rosthom. Die Erkrankungen der weibl. Geschlechtsorgane, 1900, Bd. i.
  
79. A. V. Kolliker. Entwickenunggeschichte, 1879; cited by Klein.  
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79. A. V. Kolliker. Entwickenunggeschichte, 1879; cited by Klein.
  
80. F. V. Winckel. Diseases of Women. Amer. Transl., 1887.  
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80. F. V. Winckel. Diseases of Women. Amer. Transl., 1887.
  
81. Roze-Michel. L'hymen. Thfese de Strassbourg ; cited by Schaffer.  
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81. Roze-Michel. L'hymen. Thfese de Strassbourg ; cited by Schaffer.
  
82. Robert L. Dickinson. " Urethral Labia" or "Urethral Hymen."  
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82. Robert L. Dickinson. " Urethral Labia" or "Urethral Hymen." Pathologic Structures due to Repeated Traction. American Medicine, Feb. 27, 1904, vol. vii. No. 9.
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83. Veit. Die Erkrankungen der ^'ulva. HandbuchderGynakologie,  
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Bd. 3, Heft 1.  
 
  
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Dermatologie et de Syphilographie, Nov. 1903.  
 
  
85. L. Wechsberg. Zur Histologic der hymenalen Afresie der  
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85. L. Wechsberg. Zur Histologic der hymenalen Afresie der Scheide. Wiener klin. Wochenschr., 1903, No. 43.
Scheide. Wiener klin. Wochenschr., 1903, No. 43.  
 
  
86. Rincheval. Dissertation, Wiirzburg, 1889; cited by Wechsberg  
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87. Kochenburger. Zeitschrift f. Gyn., 1893; cited by Wechsberg.
 
87. Kochenburger. Zeitschrift f. Gyn., 1893; cited by Wechsberg.

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Gellhorn G. Anatomy, pathology and development of the hymen. (1904) Trans. Am. Gynec. Soc., Philadelphia, 29: 405 - 440.

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This historic 1904 paper by Gellhorn described the understanding of female human genital development associated with the hymen at that historic time. This was a lecture presented at the 1904 meeting of the American Gynecological Society by the candidates elected to Fellowship Twenty-Ninth Annual Meeting. Note with that the paper contains historic clinical terminology that would not be used today. There has been long history of different theories of embryological development associated with the female vagina, as there was presented here for the hymen.


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Female: 1904 Ovary and Testis | 1904 Hymen | 1912 Urinogenital Organ Development | 1914 External Genitalia | 1914 Female | 1921 External Genital | 1927 Female Foetus 15 cm | 1927 Vagina | 1932 Postnatal Ovary
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Anatomy, Pathology and Development of the Hymen

By George Gellhorn, M.D.,

St. Louis, Mo.

Introduction

In a discussion of the female genital organs the hymen must be given separate consideration. An exact knowledge of the anatomy and pathology of the hymen is important not only from a practical point of \'iew, but also because it affords valuable evidence concerning the development of the female genitaha. Systematic investigations of the nature of the hJ^nen, however, meet with some difficulty inasmuch as suitable post-mortem material is not easily obtained and portions of tissue excised during life are not often at our disposal. The observations imderlying this article are based upon the microscopic examination of fifteen specimens of hymen, as follows:

  1. From a fetus 8 inches long.
  2. From a fetus 9^ inches long.
  3. From a fetus lOf inches long.
  4. From a fetus of 25 weeks.
  5. From a fetus of 7 months.
  6. From a fetus of 8 months.
  7. From a newborn (macerated).
  8. From a girl of 3 days.
  9. From a deflorated girl of 19 years.
  10. From a virgin of 20 years.
  11. From a virgin of 20 years.
  12. From a deflorated girl of 30 years.
  13. From a virgin of 62 years.
  14. Caruncle from a woman of 49 years.
  15. Caruncle from a woman of 76 years.

Anatomy

The hymen is a membrane situated at the junction of the vulva and vagina, partially closing the entrance of the latter. Older reports speak of the site of the hymen as being sometimes higher up in the vagina. Cumston/ in a medicolegal essay, refers to a trial for rape, in 1777, at which trial it was admitted by the medical authorities that the hymen was in some cases situated an inch or an inch and a half "beyond the vagina." Krimer^ found, in a woman of twenty years, the hymen high up, 2 cm. above the vaginal entrance, the vulvar orifice seeming at first sight to lack the membrane altogether. Turnipseed' and Fort* stated that the hymen in the negress is situated from one and a half to two inches above the entrance of the vagina and is of greater density than that of the white woman. These statements were at once contradicted by Hyatt^ and Smythe;° and inasmuch as no similar observations have since been recorded, we are safe in attributing them to inaccurate examination or erroneous diagnosis.

Aside from the human female, the hymen, according to Hirst,' is formed in the ape, bitch, bear, donkey, hyena, and giraffe; and according to Nagel,* also in the horse, cow, and pig. Bischoff," on the other hand, states that the hymen is lacking in the anthropomorphic apes.

The macroscopic appearance of the hymen is in the majority of cases that of a semilunar fold. Next to the crescentic form in frequency is the annular variety, in which the hymeneal opening is circular in shape. Less frequently other forms of hymen are found. The septate hymen has two openings separated by a bridge of tissue. The cribriform hymen shows a number of small openings resembling a sieve. The fimbriated hymen has small papillary excrescences upon its free edge. In the imperforate hymen, the membrane is completely occluded. INIost modern text-books give instructive illustrations of these and other even more unusual varieties, and a glance at these pictures explains the macroscopic differences better than words.


Fig. 1. Hymen of a Iftus of twenty-five weeks (Case 4). (ieneml survey : h, hymen ; c. epithelial mantle; c eomieetive-tissue stroma: va. \asina with papjlL-e; vu, vvilva: ^ laljiuni minus; /.m, labium majus.


Fig. 2. Hymea of a fetus ol eight mouths (Case 6) : , fibrous band connecting the slender basal papillEe (p) with the hymen proper (h) and shutting off a mass of epithelial cells (e); rti, vulva; m, vagina.


Fig. 3. Hymen of a fetus of seven months (Case 5): ni, vulva; h.vu, vulvar side of hymen; h.va, vaginal side of hymen.


The color of the hymen is white or hght pink. In the fetus it is, like the vagina, distinctly white and in marked contrast to the pinkish color of the vestibule. I shall refer later to this decided difference in color. The thickness and consistence of the hymen vary widely from a structure delicate as a spider's web to a dense, ligamentous, even cartilaginous or "bony" membrane.

In its position and relation to the vulva the hynaen in the fetus projects forward into the cleft between the labia in the form of two apposed longitudinal lips. (This condition exists also in the newborn and in the young child, while in the virgin the membrane is generally supposed to be stretched in a more or less vertical plane when the indi\'idual is Ijang in dorsal posture. Cullingworth,'" however, pointed out that on separating the labia minora in such a manner as not to disturb the situs of the structures lying behind them, the hymen can be seen in the same position as in the fetus and infant — i. e., eversion of closely apposed longitudinal lips.

In the hymen we distinguish, first, the base, the point at which it rises from the underlining tissue; second, the edge, which is differently shaped according to the individual case; and third, two sides or surfaces, the inner (upper, vaginal) and outer (lower, vulvar) surface. \Miile, according to Dohrn," one week after the first appearance of the h^nnen it is as fully developed as is usual in the newborn, the microscopic picture varies with the age of the bearer. The h_\Tnen is composed of a dense connective tissue covered on either side with epitheUum. In the fetus it projects in the form of a long slender fold exhibiting on either surface numerous filiform and conical papillfe. Kolliker,'^ Dohrn" and others describe these papillae only upon the inner surface, but Schaffer'^ had already pointed out that they are almost invariably found also on the vulvar side. Among the papillje which in their turn frequently possess smaller secondary papillae, there is one of conspicuous length found with great frequency upon the vaginal side springing from the base of the hymen or immeiiiatelT below it and extendio^ more or less panDd to tbe hTmen itself. This foki of tissue is oonsadered bj SdaSet &s tbe inDer, vaginal lameila (see p. 171 1; while Kkin" sees in it tbe rPTnna.nt of tbe septum betB-eec tbe Mulknais ducts. Tbe epitbelium is of tbe usual multilaTered pavement Qpe. Tbe cells of the faoLsal la^^er are cubsooqrliQdiic, dien follows a layer of lower cabk: cells and several la^cts of polrbedral cells -wfaidi beoome graduallj Sattened tomrd dbe surface. ik» outensost layers oonsistJng of tfain, plate-Iike cells. KeratiiiizatioQ does sot occur in this earir stage, the nucki tbrougbout taking tbe stain readily. UsoaDy the epitbelium is slightly higher upon tbe Taginal sui&oe. TTie epitbeHmn iiprai tbe vul-rar ade in these cases has a someirhat compressed appearance; the layeis fo&oving the basal layers are not poJyhedraJ bat mariEfidlr flattenpd. This condition is -risible in tbe hymens of the sixdi and serentfa fetal months (Tigs. 2 and 3).

The hymen of the Deirbom is of omsdcEaUy greater size. A very long papilla was in one of my spedmess foimd upon tbe vulTar sde Case S. Fig. 4i. From the time betveea birth and nineteen years no specimens were at my Case 9 nineteien years; and Case 10 ftwenty years ; ] witbin tbe rather compact hymen nnmeroas sixst and a few longer slender papilla which peneizated deep into the qiitheJial mantle, without, hcwerer, altenmg ifae smoodi outer surface- On the other hand, in a seoond case of twenty yea*% (Case 11), the smfaoe of tbe hymen dxfw&A indentations, corresponding with the large jajslte there present. The latter possessed ntimerous secondary japills (Tig. 5j. The same appearance was present in the hymen of thirty years {Qzse 12 ). Tbe process from the inner surface of vhidi we hare spoken abore was in this case maiiedly increased in H2e- The epihelial mantle in all of these eases was Toy tiiick but nowhere comiSed. The comaectiTe tissne m the hymen of the fetus, newborn and adult,!? dense widmnnaeioas nadei. Only in the papllke is the stroctore somewfaat looser.


The bundles of connective tissue seem to be directly continuous with the vaginal connective-tissue fibres. In the amount of nuclei as well as in the density of the fibres, the hymen is readily distinguished from the vulva. The blood supply is rather rich. Numerous bloodvessels and capillaries are seen even in the tips of the finest papillae, and in the hymen of the adult wide lumina are visible (Fig. 5).

In the last specimen, that of a virgin of sixt\-two years (Case 13), the rather short hymen presents, on cross-section, a somewhat tongue-shaped appearance and is covered with a few layers of cells with scanty protoplasma, but well-staining nuclei. The connective tissue shows no papillar}- elevations except a few low ones on the vulvar side. It is greatly increased, especially near the base, and its fibers form large bundles, with markedly diminished blood supply.

To study the distribution of elastic fibers in the h\-men, Weigert's stain was used. Broadly speaking, a gradual increase both in number and thickness of the elastic fibres takes place throughout the e.xistence of the membrane. In the fetal hymen elastic fibers are present as soon as the membrane is formed, but they are very delicate and can be seen only with the oil-immersion lens. Running along the base of the epithelium can be seen a fine elastic fiber. This fiber closely follows the contours of the hymen and seems to form an uninterrupted elastic membrane. Only in some of the finer papillse is the continuity lacking in the earher stages, but in the fetal h\-men of eight months the elastic membrane has reached even these points. This membrane does not send any processes into the adjoining tissues, and nowhere do elastic fibers penetrate into the epithehal mantle. In the connective-tissue stroma there are but a few thin, short elastic fibers which run in a longitudinal direction, parallel to the connective-tissue fibers. The capillaries near the tip of the hymen have no elastic fibers. Only the larger vessels near the base have a very fine, internal elastic membrane. An outer circular laver of elastic fibers in the adventitia of arteries is visible only in a few instances in the eight months' hymen. From this external membrane a few very delicate fibers emerge into the adjacent bundles of connective-tissue fibers and there assume a longitudinal direction.

In the hymen at full term the elastic fibers are readily seen with the oil immersion. In the papillte they appear in long bundles which enter into the finest ramifications of the papillae. They surround the capillaries in the papillje and near the free edge, without, however, entering into closer union with them. In the vessels of the deeper layers, the deUcate internal elastic membrane, upon which lies the endothehum, can be readily distinguished from the outer elastic membrane in the adventitia. The two membranes are connected by a very few elastic fibrils. in the transverse sections of larger arteries of the base such anastomotic fibers in the circular muscular layer between the two membranes are numerous. The elastic fibers emanating from the adventitia are hkewise increased in number. The fibers in the connective tissue run both longitudinally and transversely, and increase in quantity but not in size nearer the base.

In the adult, the elastic fibers in general are thinner and less nimierous in the higher portions near the edge than toward the base. In the latter the field of vision is almost entirely filled with a network of dehcate fibers surrounding the connective-tissue bundles. In the hymen of a girl of nineteen (Case 9), a few months after defloration, the newformation of elastic fibers at the torn edge is excessive. The elastic membrane at the base of the epithelium, which consisted of but a single fiber in the fetus, is composed of a complex arrangement of delicate fibers which are wound about themselves. In general, the elastic fibers may be divided into two groups, one more or less circular around the hymeneal opening, the other extending radially towards the base.


Fig. 4. Hymen(if (he iirwliorii (Case 8): (i. loiifr. slender papilla on vulvar surl'ac Ximicrous lil()i)(lvc's«-l.s in coniicetive-tissup struma.


Fig. .5. Hymen of the adult (I'asc 11. Iweiil\ years). Larsje i)apilla-. Hieh Mood supply. .\uNierous lymph s|)aees and \ cs.sels.


Fig. 6. Sensory nerve-endings in hymen excised on account of vaginismus (from Amann): p, pavement epithelium surrounding a papilla, which is almost entireh- filled by an enlarged end-bulb of Krause. fl.B.Streedain del


Fig. 7. Genitals of a fetus of twenty-five weeks (Case 4). The longitudinal folds (/) of the lowest portion of the vagina (ji) turn inward at the vaginal entrance and run parallel to the hymen (/i), thus simulating l)ilamellation; h, bladder.


With growing age the elastic fibers perceptibly increase in quantity and size and take the stain very readily. In the hymen of sixty-two years (Case 13), the elastic tissue is stained ad maximum after being exposed to the stain but five minutes. The network at the base of the epithehum consists of a thick, entangled mass. The elastic fibers throughout the hymen are shorter and in some places seem to have nodular swellings.

Smooth muscle fibers have repeatedly been found in the normal hymen (Savage,'^ Budin," Hirst'). Their presence, however, is not the rule. In my specimens I found them but once, in the hymen of nineteen. In this case in. the deeper layer near the vulvar side could be seen a few fibers that took the yellow color of the picric acid in Van Gieson's stain, though rather diffusely. This hymen was well formed but not unusually thick. On the other hand, the very fleshy hymen of a girl of twenty (Case 11, Fig. 5) did not contain any muscular elements. The fleshy appearance in this case was produced by an increase of connective tissue and the very rich blood supply. In certain pathologic conditions, such as atresia — congenital or acquired — smooth muscle fibers have been found with greater uniformity. Henkel" and V. Tussenbroeck'* found numerous smooth muscle fibers in their cases of hymeneal atresia. In the wall of h}Tneneal cysts Palm and Ziegenspeck^" detected traces of smooth muscle fibers.

In order to demonstrate nerves and nerve endings in the hymen the methods of INIarchi and Azoulay and the nigrosin and uran carmine methods were employed. Numerous attempts to find the structures in question proved unsuccessful. The great difficulties of staining the peripheral nervous system are well known, and failure in demonstrating the nerves should, in the first place, be referred to faulty technic. The nature of my material made it impossible for me to employ the methylene-blue method, which is supposed to give the best result. The possibility of a fault on my part, therefore, prevents me from passing a definite judgment on the question of the nerve supply of the hymen. The literature on the subject, moreover, is extremely meager. Only older reports (E. Klein,^' Budin'°) speak in a somewhat sweeping way of "the highly vascular and nervous mucous membrane." On the other hand, authors who have studied the nerve supply of both the internal and external genital organs since the introduction of more perfected laboratory methods (v. Gawronsky," Koestlin"^) do not mention the hymen at all, though their researches are very exhaustive otherwise. Wechsberg*' stained an excised portion of an atresic hymen with hemalaun and eosin and found "here and there nerves in transverse and longitudinal sections." The only author who gives a detailed description of nerves in the hymen is Amann.^^ He found in two hymens excised for vaginismus Krause's terminal bulbs well developed in the papillse (Fig. 6).

In this connection I may be permitted to speak of a number of clinical observations which I have made during the last year or two. I am aware that the value of such observations with regard to the question in hand is very limited, but I think that these investigations possess a certain interest.

As is well knovra, fear or anticipation of being hurt produces, in a great many women, to a certain extent, the sensation of pain. If we succeed in eliminating this psychic factor, we obtain a more objective criterion as to the presence of pain. Thus I have tried to determine the sensitiveness of the hymen w^th regard to mechanical and thermic irritations. If the attention of the patient be diverted, I find that one can exert pressure and even sHght traction upon the intact hymen by means of a dressing forceps without causing any pain. In women after defloration in whom the hymen is well preserved aside from one or two lateral lacerations, the hymeneal lips may be pressed or pierced without pain. Neither is there any thermic sensitiveness. If the vestibule is carefully avoided, the patient cannot state whether she is touched with a hot or cold instrument. Following the experiments of Calmann,^^ who examined the sensibilitj' of the vagina and uterus, by means of small test tubes filled with hot and cold water, I arrived at the same results as far as the hymen was concerned. In two instances pain was caused by the slightest touch. One of these was a girl of eighteen, with an intact hymen, who suffered from pruritus vulvae; the other was a prostitute of twenty-seven, with myrtiform caruncles, who w^as recently infected with gonorrhea. In these cases the sensitiveness may have been due to the pathologic condition of the genitals. From the above observations I am inclined to believe that the pain in defloration is due to the psychic condition of the indi\-idual and to the forcible dilatation of the vaginal entrance. Especially the latter seems to play an important role. In a nulhparous woman of thirtytwo whose hjTneneal lobes were not sensitive to touch or pressure, coition was extremely painful until a gradual dilatation of the vaginal entrance by means of tubular specula was effected. The normal dilatation by coition had not taken place on account of some anomaly on the part of the husband.

I have digressed somewhat from my subject not because I am able to bring any positive proofs about the presence or absence of nerves in the hymen, but because I think that these clinical notes make the existence of a very rich nerve supply rather improbable. Possibly future attempts to decide the question liistologically may be more successful.

According to Kollmann," in the newborn mucous glands are found in the fold between the hjTnen and labia minora. These glands, which are in great number in the labia minora and surround the entire vaginal entrance, are found also in the fossa navicularis in immediate proximity to the h'STuen, and represent simple or ramified tubules 0.3 to 0.7 mm. in length. In the hymen itself distinctly glandular structures were found by Ruge^' and RinchevaP" upon the inner surface in a case of atresia. Klein," in the hymen of a fetus 27 cm. in length (five months), observed glandular invaginations of the epithelium of the outer surface. Such invaginations have been described by Schatfer as crypts. Similar blind ducts were also found by Fleischmann.^ In his case there was one, 13 mm. in length in the left side of the iiymen, another in the right side 6 mm. long. The epithelium of these ducts was directly connected with that of the surface. In.Piering's^ case, small, well-filled vesicles with thin walls were found near the free edge almost completely surrounding the hymeneal orifice. Upon histologic examination these vesicles were found to be lymphectasias.

The latest and most exhaustive researches have been by R. jNIeyer.^" He found six different varieties of glands or gland-like structures in the h\Tnen of the fetus and newborn; viz.: (1) glands of the vaginal type upon the inner, vaginal side; (2) remnants of the Wolffian ducts; (3) glands or glandular tubules situated about the base of the hymen in the sulcus nymphohymenalis and in the fossa navicularis and at times extending into the base of the hymen; (4) real glands of the outer, vnilvar surface; (5) invaginations of the epithelium of the outer surfaces; (6) genuine pavement cell cysts underneath the outer surface. I myself found glands in one instance. The hymen of the eight months' fetus (Case 6) had at its base a few transverse lumina of glands lined with a cuboidal epithelium. These were at some distance from the surface and showed, in several sections, no communication with the latter. No serial sections, however, were made.

Henle found exceptionally "erectile tissue" in the hymen. So far as I know this observation has not yet been corroborated by others.

The elasticity of the hymen is under rare circumstances so great that it remains unruptured even at childbirth. As a rule, however, the first coition or accidents such as falling astride of an object or violent exercise will rupture the delicate membrane. The number of tears which divide the hymen into "lobes" varies in the individual case. Heahng takes place with considerable new-formation of elastic and connective tissue. Very rarely such tears unite; if such should happen a cicatrix may remain.


Parturition definitely destroys the form of the hymen. Only small rests — carunculse myrtiformes — resembling warts, are left. ^Microscopically, the caruncle represents a compact tissue of rather conical shape and set wdth a few short papillae. The caruncle of long standing (Case 15, seven ty-si.x years) appears merely as a dome-shaped elevation whose papillae have disappeared. The blood supply of the younger caruncle (Case 14, forty-nine years) is very rich; that of the older very scanty. The superficial layers of the epithelium are cornified and the keratinization extends into the deeper laye'rs between the papilla^. The process of cornification is present only about the hymen and, in a very few places, in the adjoining vaginal mucosa, but not in the adjacent portion of the vestibule. The elastic tissue is greatly increased both in quantity and in the size of the individual elastic fiber, and fills almost the entire field of vision.

As to the formation of caruncles, Schroder " holds that the hymeneal lobes during childbirth are compressed and undergo gangrene, while Bellien'^ believes that the lacerations of the hymen, during labor, extend through the base of the membrane into the perivaginal connective tissue; cicatrization and consequent shrinking of these tears produce caruncles.

I am inclined to ascribe to the elastic tissue a certain role in the formation of caruncles. As described above, the elastic fibers are unequally distributed within the hymen, the portions nearer the base containing more and thicker fibers than the periphery. So long as the hymen is preserved in its entirety, or only torn into a few large lobes which but little alter the form of the hymen, the upper more delicate fibers encircling the hymeneal opening exert an action counter to that of the radial fibers which tend to retract toward the base. If, however, the hymen, in childbirth, is torn into a number of small pieces, each piece retracts owing to the more powerful action of the radial fibers. For some time after, one is able to pull each caruncle to its original length, but after long standing the retraction results in an atrophy of the entire caruncle to a great extent through insufficient circulation. Regarding the retraction of elastic fibers, we know from numerous examinations that only the fibers of thin or medium size are really elastic. Thick fibers, such as are found in old age, are unyielding, and only such were observed in the caruncle referred to above.

Pathology

The pathology of the hymen may be divided into: (1) inflammations; (2) malformations; (3) neoplasms.

Inflammation of the hymen may start primarily in this membrane itself or may originate in adjacent organs and tissues. As to the latter or secondary form, it is to be expected that the hymen, as a part of the vagina, may be affected by inflammatory processes which originate in the vagina and descend toward the vaginal entrance. Thus the different varieties of colpitis, including those that are produced by affections of the uterus, may lead to inflammation of the hjTnen. Acute infectious diseases such as cholera, variola, scarlatina, measles, etc., not infrequently produce secondary inflammations of the entire vaginal tract and, as we shall later see, play an important role in the origin of acquired atresia. On the other hand, the inflammatory process may ascend from the vulva. Gonorrheal infection here deserves the first place. Contamination with the colon bacillus, or ascarides emigrating from the neighboring anus may cause inflammation, and irritation from lack of cleanliness produces a similar effect. The inflamed hjTnen has a markedly reddened appearance and bleeds easily. Occasionally small excoriations are seen. The surrounding tissues have in general the same appearance. The microscopic changes in the inflamed hymen have not as yet been studied in detail, but in analogy with similar processes in the vagina we may expect to find round-cell infiltration in the connective tissue and a desquamation of epithelium so that this layer is either very much thinner or, in places, is altogether absent.

The same pathologic conditions may, after defloration, affect the hymeneal lobes and, after childbirth, the mjTtiform caruncles. Thus, in a case of recent gonorrhea, I found the multiform caruncles considerably thickened, deep red in color and extremely sensitive.

Primary inflammation of the hymen is due either to masturbation or coitus. In two girls who admitted masturbation, I found the otherwise intact hymen considerably thickened, grayish-white and edematous. Gosselin^' describes cases in which onanism led to pathologic sensitiveness of the hymen.

In some cases the hymen, though normal, is particularly rigid; in others its orifice is large enough for the introduction of the penis without laceration. In any of these cases where there is a pushing back or dilatation of the membrane, it thickens, inflames, and becomes very sensitive (Pozzi'*). Fritsch^'^ considers this rigidity of the hymen as secondary The impotent husband with a non-erectile penis or suffering from precocious ejaculation does not succeed in perforating or lacerating the membrane. The continuous insults lead to inflammation of the introitus vaginje and hjinen, and even to a purulent discharge. Inflammation of the hjTnen is the foremost factor in vaginismus.

It might be supposed that the specific lesions of syphihs and chancroid would occasionally be found upon the hjTuen. The text-books on venereal diseases, however, which I consulted, make no special mention of such an occurrence; only Veit pictures a hymen whose posterior margin is destroyed by a hard chancre.

As to dermatologic affections of the hjTnen, recent Hterature contains the report of Carriere.^* This auther observed three cases of vuhdtis impetiginosa in children. In these eases the major and minor lips and the hymen were, at first, reddened and swollen. After a few days, the affected parts showed an eruption of miliary vesicles which afterward opened and gave rise to small ulcerations, the latter containing staphylococci.

Traumatisms of the hymen have been extensively dealt with by Veit.*' The majority of injuries occur in the first cohabitation and in childbirth, and as such traumatisms must be considered physiologic, they have been spoken of in the first part of this paper on the normal anatomy of the hymen. Veit is quite right in distinguishing this class of hymeneal injuries from the severer ones produced by violent or abnormal coition. In such cases a profuse hemorrhage from the torn hymen may occur which demands medical interference. The literature on this subject is rather extensive and has been thoroughly considered by Veit. I agree with this writer that in cases of copious hymeneal hemorrhage other adjacent parts must have been injured. In one case in my recollection the young, newly married woman was brought into the clinic almost pulseless. Upon examination a deep tear of the hymen was found which commenced in the left upper quadrant and extended through the paraurethral tissue into the base of the clitoris.

Malformations of the hymen are either congenital or acquired. Total absence of hymen, reports of which are found in older literature, has not been observed by modern authors, and such authorities as Breisky" and Schaifer," while not denying the possibihty, consider this phenomenon exceedingly rare. It can, however, occur only simultaneously with total absence of the entire genital tract, which in its turn is found only in embryos incapable of surviving. In this connection I might mention as a curiosity the intentional destruction of the hymen practised in several parts of India and throughout China. Ploss^' relates that the native nurses employ digital cleansing of the vagina in earhest childhood so thoroughly that the hymen in time disappears altogether. Thus not even the native physicians in Cliina know anything about the existence of a hymen. Ploss himself examined a girl of European descent, but born in China, and found no trace of this structure. Similar customs resulting in the total demohtion of the hymen exist among several Indian tribes in South America and certain savage nations of the Malay Archipelago. These manipulations, however, are not dictated by a desire for cleanliness, but rather by immoral reasons.

The existence of a true double hymen— one behind the other — has not been proved. Breiskj^' saw, in two newborn females, a very thin membrane closing the lower portion of the vagina, close behind a well-formed hymen, and, furthermore, a firm septum retrohymenale in a \irgin fifty-four years old. Both he and Dohrn" consider these septa due to a coalescence of folds of the vaginal mucous membrane immediately behind the hjTnen. Such a formation is facihtated, as Dohrn points out, by the fact that at this point the lumen of the vagina is narrow even pre\'ious to the appearance of the hymen. ]Moreover, Piana and Bassi^' found that in this area epithelial conglutinations in the human fetus are "physiologic." We shall speak later of the h\Tiien bilamellatus of Schaffer in reference to double hymen.

A double hymen — one beside the other — has repeatedly been found in cases of double vagina and is easily explained in the light of embryologic studies of the development of the genital tract.

In connection with these cases of hymen duplex cum vagina septa it must be emphasized that congenital malformations of the hjTnen are impossible without anomalous development of the rest of the internal genitals. This holds true especially of the most frequent form of malformation of the hymen, viz., atresia.

Nagel' and Veit' forcibly declare that only a minority of atresias of the female genitals can be considered as of congenital origin. Those of the hjTnen, hymen imperforatus, are found only where other parts of the Miillerian ducts are malformed. That form of hjTneneal atresia which is caused by a conglutination of the h^nneneal folds in utero, the rest of the genitals being normal, cannot be classified as a congenital atresia, a "\4tium primos formationis." All other cases of atresia which show a normal formation of the internal genitals — and these form the great majority — must be considered as acquired. C. v. Tussenbroeck,'" through the microscopic study of a case of "hymeneal" atresia, opposes this theory of Nagel and Veit. Her original publication in the Dutch language was not at my disposal, so that I had to rely on a short abstract in the ZenfralblaU fiir Gyndkologie and on one of her drawings reproduced in an article by Stratz.^' v. Tussenbroeck points out that while the normal hymen consists only of vulvar and vaginal epithelium and connective tissue between the two epithelia, her case of hymeneal atresia contained in the intermediary tissue also smooth muscle fibers and bloodvessels but showed no signs of a previous inflammation. She takes the stand that in this case no hymen has been formed and that the septum consisted, in the first place, of the lower ends of the atresic jNIiillerian ducts with their surrounding secondary layer of smooth muscle fibers, and, secondly, of the floor of the imperforate sinus urogenitalis. The patient, a girl of twenty-four years, possessed otherwise perfectly normal internal and external genitals.

While Stratz, Treub and Bolk expressed their agreement in the discussion following this demonstration of v. Tussenbroeck, Pincus,^^ who strongly seconds the \'iews of Nagel, points out that the absence of signs of pre\'ious inflammation is no positive proof against the supposition of an acquired atresia, and Henkel," in a similar case of hymeneal atresia, was able to show microscopically the presence of a chronic inflammatory condition and to demonstrate numerous mast cells and leukocytic wander cells.

A critical review of the numerous cases reported as congenital atresias convinces one of the strength of Nagel's theory. In the light of this theory, cases of pregnancy and childbirth with imperforate hymen are readily understood. V. Gu^rard*^ compiled about fifty instances of this sort from literature and added five observations of his own. This goes to prove that atresia may occur at any time in the adult. Even repeated atresias may take place. In this respect the third case of v. Gu^rard is unique. The patient in the seventh month of her first pregnancy complained of intense pain in the genitals. Although she had pre\-iously been operated upon twice for atresia h\-menalis, the vagina was now fomid completely occluded by a firm and extremely sensitive membrane. After total excision of this membrane all symptoms promptly ceased, and normal delivery took place at term.

In the majority of instances, however, the formation of atresia dates back to earlier years of life. A careful anamnesis in such cases will often reveal its cause. Neugebauer," with his well-known assiduity and admirable thoroughness, has gathered almost 1000 cases of gynatresias from Uterature. In 479 of these cases the atresia was undoubtedly acquired. In almost 300 the anamnesis was negative. Neugebauer himself says that it would be a mistake to interpret the lack of data in the history in favor of the congenital origin of the malformation. He refers to atresias in general, and it is clear that the same reasons must pertain to hjTiieneal atresias. The etiologic factor is furnished either by acute infectious diseases such as were enumerated above, which lead to inflammatory processes in the genital system, or by vulvovaginitis due to gonorrhea or other causes. The inflammation subsequent to an acute infectious disease may make itself manifest at once or may remain unnoticed, as for instance in the case reported by Thienhaus.*^ In the latter event the result of the inflammation, viz., more or less firm coalescence of the hymeneal folds, will not be noticed until at puberty the menstrual flow is obstructed. Even if, at that time, signs of pre\'ious inflammation should not be found in the imperforate hymen, this would not speak against the atresia being acquired. ]\Ieyer" has proved from literature the acquired origin of atresia even in the absence of any scars, and Odebrecht" points out that cicatrices acquired in infancy completely disappear within a few years on account of increased cellular vitality. If several sisters present hymeneal atresia, the inference is justified that the children were simultaneously affected by the same acute infectious disease. Pincus cites a very interesting case reported by Madge." Four sisters, two to ten years old, had hymeneal atresia; the fifth child, a boy, had phimosis. Pincus rejected the supposition of heredity in this case and is inclined to ascribe this coincidence to the action of some obnoxious factor common to the five children, such as baths, sponges, or towels.

This somewhat lengthy consideration may be thus summarized : In all cases of hymeneal atresia with normal functionating genital system, the condition is acquired. Here the occluding membrane causes the retention of menstrual blood and leads to hematocolpos, hematometra, etc.

The literature on the histology of hymeneal atresia is not very great. The reports of v. Tussenbroeck and Henkel" have been recorded above. A recent contribution to this subject was furnished by Wechsberg.'^ The patient, a girl aged fourteen years, had had measles, chicken-pox and whooping cough. She came to the hospital with the symptoms of hematocolpos, which an examination revealed to have been caused by an imperforate hymen. Wechsberg excised a small portion of the membrane. Upon microscopic examination both surfaces of the specimen showed papillae, those upon the vaginal side being the larger. The vulvar surface was covered by pavement epithelium, the vaginal side by a single layer of high cylindric cells. On the vaginal side, however, there were at one point, on the outer surface of a conspicuously large papilla, ex'idences of keratinization. On the vulvar side, cornification was seen throughout the uppermost layers of the epithelium. Within the connective-tissue stroma there were smooth muscle fibers, numerous lymph spaces and vessels, and a few nerves. There was no round-cell infiltration nor other signs of previous inflammation such as cicatricial tissue.

Wechsberg refers to a similar case reported by Rincheval" in which there was found multilayered pavement epithelium upon the outer surface, while the inner surface was lined with cylindric epithelium which in places presented glandular invaginations into the dense connective tissue.

In the observation of Kochenburger" the excised hjTnen had multilayered epithelium on its outer surface and cuboidal epithelium on its inner side. Kochenburger considered the latter to be the basal layer of the epithelium after the upper layers had been macerated by the accumulated blood in the occluded vagina and had been cast off. This epithelium resembled that found upon erosions of the portig vaginalis uteri. In corroboration of this \'iew the upper layers of the pavement epithelium were seen to persist in some places while in others they had undergone degenerative processes, but were still in connection with the basal layers. From his findings Kochenburger deduced that in hymeneal atresia the origin of epithelial cells resembling cylindric epithelium is due to pressure, infiltration, imbibition, atrophy, and necrosis. Wechsberg, however, maintains that in his and Rincheval's cases the cylindric epithelium is primary inasmuch as no signs of cell degeneration could be detected; staining for mucous degeneration resulted negatively, and the cylindric cells themselves were high and took the ordinary stains readily. In his opinion, the differentiation of the cylindric epithelium primarily present in the vagina of the embryo into pavement epithelium had not taken place in the small portion excised. Upon the rest of the hymen and on the walls of the vagina multilayered pavement epithelium was found.

These arguments of Wechsberg in favor of an embryonal origin of the atresia in his case are not convincing. It would be strained to suppose that only the very small portion which was excised should have remained in an embrj'onal state. Nor is the absence of degenerative signs sufficient proof. I believe Kochenburger is right in comparing this condition with the erosion of the portio vaginalis uteri. In this affection, after the upper layers have been destroyed by the pathologic process and have entirely disappeared, only the basal layer remains, the cells of which under the irritating influence may be stimulated to more excessive growth of size and length. They even invade the underlying tissue, forming the so-called glands of erosion, and I am inclined to ascribe a similar origin to the glandular formations mentioned in Rinchcval's case.

Neoplasms of the hymen are very rare. To this group belong the cysts. I found in literature a total of 17 cases of hymeneal cysts reported by Bastelberger,^° Doderlein,^" Piering,^' Ziegenspeck," Miiller," Goerl,^^ Ulesko-Stroganowa,'* Palm," ^° Marchesi," Lannelongue and Achard," Theilhaber,^* and Ricci.^' These cysts occur on either side of the hymen, but more frequently on the outer surface. They may attain the size of a cherry and are occasionally multiple. Ulesko-Stroganowa's case presented one cyst on either side. In the case of Ricci, there was a small cyst in the wall of the larger cyst. In Ziegenspeck's third case two smaller cysts were found at the base of the main -cyst. Piering observed a number of very small transparent cysts around the edge of the hjinen. Microscopically, the hymeneal cysts have been carefully studied. On the outside they are covered with the hymeneal epithelium. Beneath this lie layers of more or less dense connective tissue with well-developed papillae and numerous capillaries, in some cases combined with smooth muscle fibers. The inner surface is lined with epithelium, usually of the pavement variety, varying in thickness. In other cysts the epithelium has a more cuboidal or even cylindric character (iSIarchesi). This variation depends upon the source of origin, which we shall presently consider. The cysts may contain detritus and epithelium, or a homogeneous, yellowish-brown, jelly-like substance, or else a watery fluid. The latter may consist of lymph fluid (Piering), or may contain blood corpuscles (Ulesko-Stroganowa). Ricci's cyst, the size of a cherry, which he so carefully examined, contained 1 c.c. of a thick, dark-brown liquid, the microscopic examination of which revealed epithelial cells in large number, detritus of blood corpuscles, fat droplets, glossy masses of amber color apparently consisting of red corpuscles and fat drops, and a small amount of hematic pigment.

Cysts of the hymen may develop in four different ways, viz. :

  1. By invagination and separation ("Abschniirung") of hymeneal epithelium (cases of Bastelberger, Ziegenspeck, Goerl).
  2. From rests of embryonal tissue within the substance of the hymen. This mode of origin is claimed by Ricci for his case. He cites the observation of Pestalozza,^ who found ectodermal embryonal rests within the stroma of a hjTnen.
  3. By conglutination or coalescence of converging hymeneal folds. This mode was first suggested by Dotlerlcin, who observed a pronounced development of folds upon the outer side which in places approximate. When the tips of these folds become completely conglutinated, a space is shut off, which at first is filled with epithelial cells. By gradual necrosis and liquefaction of the central cells a lumen is formed and a cyst produced. Doderlein's view is strongly supported by Schaffer." According to this writer, the folds of the embryonal hymen are usually obliterated by the upward growth of the connective tissue. In many instances, however, these folds coalesce at the end of the papilla, thus leaving a pocket of epithelium. One of my own specimens shows that fibrous bands may extend from any point of the papilla to the hymen and separate a mass of epithelium which may eventually give rise to a cystic cavity (Fig. 2).
  4. By retention of contents : (a) In lymph spaces (Piering) ; (6) in portions of the Wolffian ducts within the hymen. In the report of Ulesko-Stroganowa and in one of Alarchesi's cases, the cysts were lined with cylindric epithelium similar to that of the Wolffian ducts; (c) of a sebaceous gland. Palm considers his two cysts as true atheromata. This author bases his views upon the macroscopic and microscopic similarity to genuine atheromata found in other parts of the body, mainly the labia minora, and upon the supposition that the few true glands which have been found upon the inner and outer side of the hjTnen (Ruge, Klein) are of a sebaceous character.

Of other benign neoplasms of the hymen I have found two observations of polypus" and one case of angioma.'^ The original articles, however, I could not obtain.

Of malignant diseases of the hymen there exists in literature but one case of sarcoma reported by Sanger.^' A child of three years had a profuse foul vaginal discharge, and occasionally a tumor of the size of half a finger appeared at the entrance of the vagina. From the vulva hung two bodies like mucous polypi, pediculated from the posterior hymeneal border. There was a still larger tumor with ulcerated surface, distending the vagina and sessile on the anterior wall. There existed, in addition, a number of polypoid excrescences, like hydatids, occupying various portions of the vaginal membrane, and numerous metastases in the broad ligaments and the rectovaginal septum. INIicroscopically the tumor proved to be a typical round-cell sarcoma.

Development

Four theories of the development of the hymen have been advanced which may be briefly characterized as follows:

  1. The hymen is the product of the Mullerian ducts (Kolliker, Dohrn, Nagel, Klein).
  2. The hymen is the product of the sinus urogenitalis (Pozzi).
  3. The hymen is the product of both the Mullerian ducts and the sinus urogenitalis (Schaffer).
  4. The hymen is the product of the Wolfiian ducts (Hart). I begin vnth the last and chronologically latest theory which s advanced by D. Berry Hart, but was in somewhat similar form published by v. Hoffmann" in 1878.

Hart formulates his theory as follows: The hymen is formed by a special bulbous development of the lower ends of the two Wolffian ducts aided by an epithelial involution from below of the cells lining the urogenital sinus. The terminal parts of the Miillerian ducts are at first solid epithelial cords, the epithelial mass being derived from the bulbous termination of the Wolffian ducts. These Wolffian bulbs after having mapped out the vaginal portion of the uterus and the fornices of the vagina, coalesce, break down in the center and form the lumen of the vagina. The coalesced Wolffian bulbs, then protrude into the urogenital sinus and thus form the hymen. The epoophoron, the paroophoron, and the Wolffian ducts near the uterus and upper part of the vagina are all useless and dangerous relics to women, giving rise to many pathologic conditions simple as well as malignant. Only at the lower end of the Wolffian ducts do we get an actual normal utilization in the development of the hymen, the relining of the vagina and cervix with an ectodermic multilayered epithelium and the opening up of the imperforate eminence of Miiller where the IMiillerian ducts end blindly.

This theory was accepted by Keith" and Garrigues" and seems to be supported by a case of persistence of the urogenital sinus recorded by Purslow." This case is interesting enough to be quoted more in detail. A well-developed girl aged twenty-three years sought medical aid for dysmenorrhea. Micturition was always normal. The pubic hair was well developed. On separating the labia, there was seen an unusually well-marked hymen having a crescentic opening in front, which would admit the index finger. Immediately within the hymen, but quite distinct from it, was a firm fibrous ring contracting the opening into the vagina, and just admitting the tip of the little finger; but the finger could not be forced through this narrowed part of the canal, which gave the impression of being about 1 cm. in length. A catheter passed through the hymeneal opening readily into the bladder, and urine was v^dthdrawn. The clitoris was not enlarged. The constriction, together with the hymen, was divided by deep incision wdth a bistoury, and the orifice was well stretched until it would admit three fingers. It was then ascertained that the constricted portion communicated at its upper end wth a capacious vagina, and that at the junction the bladder opened by an aperture which admitted the tip of the finger and appeared to have very Uttle sphincter power. There was no trace of a urethra. In this report there are several important points of information lacking. From the history we do not know whether the patient in her childhood had suffered from any acute infectious disease which might have led to inflammation and consequent stricture of the vagina. WTiat was the condition of the uterus and appendages? Was the dysmenorrhea due to a malformation of the internal genitals, or did it cease after the operation?

In Hart's theory there are several weak points. In the first place, it is difficult to understand that an organ should form an intrinsic part of the human economy only at its lower end while the rest forms a dangerous anomaly. Secondly, systematic researches of other investigators result in an altogether different conception of the course of the WolflBan ducts. Until recently the majority of observers believed that the Wolffian ducts terminated at or near the cer\nx uteri in the upper part of the vagina. This view can no longer be held. Beigel, Dohrn, and v. Ackeren first described rests of the Wolffian ducts along the entire length of the vagina, and Klein,'" in 1897, demonstrated in serial sections the course of the Wolffian ducts at either side of the vagina and the termination of these ducts in the hymen. These sections were taken from the genitals of the newborn and of a girl, aged four and one-half years. The findings of Klein were confirmed by many observations of Meyer^° in the fetus and newborn. He found in seventeen cases larger remnants of the Wolffian ducts in the vagina and especially within the hymen. Here the ducts entering the base of the hjTnen from the posterior wall of the vagina run upward within the hymeneal tissue and usually open at the outer side near the free edge. It must be noted that v. Ackeren, Meyer, Klein, and Groschuff, Seitz and Hengge, the last three working with Klein, actually found the Wolffian ducts within the hymen. Nagel suggests that the ducts of Bartholin's glands might be mistaken for the Wolffian ducts and I feel inclined thus to interpret the pictures given by Hart.

While Hart holds that the vagina is derived only in its upper two-thirds from the Miillerian ducts and in its lower third from the sinus urogenitalis, all other theories have as their premise that the vagina in its entirety is of Miillerian origin.

According to the next theory, that of Pozzi,'* the origin of the hymen is intimately connected with that of the vulva. On either side of the sinus urogenitalis and below the urethra lie two corpora spongiosa which, after surrounding the meatus urinarius, extend upward to the base of the clitoris. From the superficial portion of these spongious organs which remain in the fetal state, the hymen develops. I'ozzi bases his theory upon the aspect of the external genitals and the analogy with the frenulum in masculine hypospadias, and upon the following clinical observations: (1) the existence of the hymen in total absence of the vagina; (2) the presence of a single hymen in cases of double vagina; (3) the existence of a urethral hymen— r. e., a prolongation of the ring around the meatus, partly or even entirely covering this orifice, which goes to prove the close relationship between the different parts of the hymen and the ring which surrounds the meatus.

Cases of hymen existing in the absence of the vagina are occasionally found. In addition to those cited by Pozzi himself and by Neugebauer,** I have seen in recent literature reports by Loefqist" (ten cases), Krevet,'^ and Strauss. On the other hand, in the majority of cases of total absence of the vagina, no trace of a hjTnen can be found. Loefqist himself does not consider his cases as supporting the theory of Pozzi who, as he points out, ignores the results of embryologic studies altogether and thus denies facts verified by the microscope. In my opinion the microscopic examination of the atresic vagina or rather of the tissues behind the hymen will possibly throw light upon this point. The vagina must either have been normal and become obliterated afterward or have been atrophic from the beginning. At any rate, the INIiillerian ducts must have reached the sinus, for otherwise the origin of a hjTnen is inexplicable. In corroboration of this, absence of the hymen in absence of the vagina is the more frequent occurrence. An example is to be seen in the case recorded by Veit" in which there was a uterus bipartitns, but no trace of the vagina nor of the hymen could be found. Even according to Pozzi's theory, the hymen is only then formed from the vulva when there exists an opening which the corpora spongiosa can surround. Pozzi's second argument of the presence of one hymen in double vagina is balanced by observations of double hymen in double vagina. Only last year two further cases were observed by Benno MuUer" and ^Marchand."

As to Pozzi's third point, the existence of a membrane partly or totally occluding the urethra may be admitted as of vulvar origin but need not necessarily be associated with the formation of the hymen. According to a recent article by Dickinson,*^ this "urethral hj-men" is a pathologic structure due to repeated traction and found only in company with hypertrophied nymphse. In addition to these remarks, a case of persistent sinus urogenitalis reported by Kelly'^ is worthy of note. The patient, a nuUipara, aged forty-six years, had normal external genitals as far as the introitus of the vagina, where the only opening between the rectum and clitoris was found. There was no hymen, and the smooth orifice beneath the pubic arch had the form of a transverse sUt. From this orifice a short muscular canal led directly into the bladder. Into this canal behind the orifice a double vagina opened. It is at this point, at the opening of the Miillerian ducts into the sinus, that a hymen should be looked for, though Kelly does not make mention of it. The absence of an external hymen speaks strongly against Pozzi's supposition. In conclusion, Pozzi does not bring sufficient e\ndence to prove the fact that the hymen is independent of the ]\Iullerian ducts.

Schaffer," upon a careful study of an unusually large material, propounds the following theorj-: In the fifth month of fetal life every hjinen makes its appearance more or less distinctly in the form of two lamellte (hymen bilamellatus) in such a way that the inner lamella is formed by the vagina, the outer by the vulva. Schaffer found this mode of origin 53 times in 190 specimens. In many instances the two lamellae unite either at once or later; in more than one-fourth of his cases, they persisted more or less until full term, but rarely after birth. p]ach lamella is covered with mucous membrane on both sides so that the h}'men bilamellatus, properly speaking, consists of four layers. Schaffer supports his theory with the following observations: (1) frequency of a distinctly bilamellate form (28.8 per cent.); (2) unity of the outer lamella with a layer of vulvar mucosa around the urethral orifice and upward to the cHtoris; (3) different stages of the coalescence of the two lamellce by means of transverse processes or papilla?; (4) folds or ridges of mucosa which spring from the frenulum labiorum, the njonphse, and the "frenulum masculinum," and end in the outer lamella, usually at or near the free edge; (5) relation of the urethral orifice to the outer lamella; (6) difference in the form of the free edge of the outer and inner lamellae; (7) difference in color and epitheHal covering of both lamellae; (8) possibility of dissecting the outer lamellae from the inner; (9) analogy with the portio vaginalis uteri, the growth of which is, to a great extent, due to material furnished by the vagina; (10) cases of single hvmen in double vagina; (11) cases of persistence of both lamellae (hjTnen duplex); (12) cases of presence of hymen (outer lamella) in absence of vagina.

The painstaking researches of Schaffer deserve earnest consideration. A number of his observations coincide with those of Pozzi. The extension of the hymen beyond the urethral orifice, in SchaflFer's description, corresponds to Pozzi's "bride mascuHne" or "frenuhim mascuUnum." The relation of the meatus urethrte, the folds from the surrounding vulva stretching to the outer surface of the li}'men and the possibility of dissecting the superficial layer of the vulvar mucosa 'hi toto, including the outer surface of the hymen, are observations common to both authors. Only the interpretation of these facts and the conclusions drawn therefrom are different. This is most noticeable in the arguments classified under 10 and 12.

There are several objections, however, to Schaffer's theory :

1. Schaffer states that in the first series of 103 fetuses, 42 had abnormal genitals. In a second series of 87 cases he gives no detailed data; altogether he found hymen bilamellatus 53 times in these 190 specimens. The large percentage of cases with abnormal sexual organs in addition to the comparatively small percentage of bilameljate hymens actually found, to a certain extent detracts from the value of these observations.

2. While a number of text-books (Gebhard," Chrobak and Rosthorn'*) reproduce Schaffer's statements without commenting upon them, later workers in the same field emphasize that they have not yet seen the bilamellate form in a single instance. I refer to Klein" and Hart." Nor have I been able to observe this formation in the seven fetal hymens of my collection. Since Schaffer found the bilamellate hymen in 28.8 per cent., one would expect to find it at least once in the dozen or more cases examined by Klein, Hart and myself. In only one instance, that of a girl, aged twenty years, I thought at first sight to have noted a case of hymen duplex (persistence of the two lamellae). The hymen was well developed and of annular shape. Immediately behind the hymen there was a second, well-marked, fleshy fold springing from the left side of the vaginal entrance and running parallel to the left half of the hymen. At about the median line this fold began to converge slightly toward the h}Tnen and ended in its posterior surface a little to the right of the median line. This fold was as high as the hymen itself and exactly like it in appearance. After cautiously pushing aside the h>Tneneal membrane it was Seen that this fold was but the continuation of a longitudinal vaginal ruga which ran directly below the juncture of the posterior and left walls of the vagina. These longitudinal folds or rugse are of ordinary occurrence in the lowest inch of the vagina. Fig. 7 (Case 4) shows this condition in an embryo of twenty-five weeks. Hart** also notes that the rug£e or columns of the lowest inch of the vagina run for the most part longitudinally; above this the vagina has its rugffi transverse. These longitudinal folds (Fig. 7) turn inward at the vaginal entrance and run parallel or but slightly converging to the posterior surface of the hjTnen and fuse with the latter at irregular points, but, as a rule, below the free edge,

3. As the first formation of the h}Tnen takes place in the nineteenth week, and as the lamell.ie, according to Schaffer, persist more or less distinctly until term, the bilamellate form should be \-isible, at least remnants of it, in microscopic sections through hymens of a later fetal period. None of my sections, however, present this form. INIoreover, the hjTiien of twenty-five weeks, pictured in Fig. 7, which simulates bilamellation, does not, microscopically, show two lamella?, though the section comprises Aiilvar and vaginal portions adjoining the hjTnen. With Klein I consider the high fold usually found at the vaginal side as one of the numerous papillae of the vagina and without importance in regard to the development of the hjTnen.

4. Schaffer mentions the difference in color and epithehal covering of the two surfaces. While I shall speak later of the epithelial coverings of the two sides of the hjTnen, I may say as to the difference in color that in the fetus I observed the entire hymen, both inside and outside, as white, exactly like the vagina, and contrasting markedly with the grayish red appearance of the \'ulva. I observed a similar condition in the h\Ti>en of a \argin of twenty-five.

Klein, '^ in his studies of the development of the h}Tnen, advances the following theory: The hymen is that part of the pelvic floor which is thinned out by the ampuUary enlargement of the lower portion of the vagina. The anlage of the hj-men is present at the beginning of the third month when the IMlillerian ducts break through into the sinus urogenitalis. From the third to the fifth month, the vagina undergoes an ampullary enlargement in its terminal portion, which in its turn leads to a stretching and thinning out of the surrounding pelvic floor. I might suggest that this theory does not explain the formation of the annular hymen. It is only the posterior wall of the vagina which undergoes a dilatation thus producing the ampulla vaginse; the anterior wall remains unaffected and, consequently, a sj-mmetric structure hke the annular hymen is impossible.

Klein ascribes to the Miillerian ducts an active part in the formation of the hjTiien. In this respect, Klein's \dews coincide with the most generally accepted theory, that advanced by v. KoUiker,'" v. Mihalkovicz, Budin, Dohrn, and especially Nagel.' According to these writers the development of the hymen is inseparable from the development of the vagina. In the human embryo of 8 to 10 mm., the INIiillerian duct on either side may be divided into a proximal and a distal part characterized by different kinds of epithehum. The proximal portion, which later becomes uterus and tube, is hollow and has cylindric epithelium. The distal part, which becomes the vagina, has, in the beginning, no lumen, but is filled with large protoplasmic cells of a more cubic form. At about the third month, the lower ends of the Miillerian ducts in their downward growth reach the sinus urogenitalis and by the protrusion of their blind ends form the Miillerian eminence. From this eminence the hj-men is formed. The finer details of this process may, to my mind, be conceived as follows. When the united Miillerian ducts reach the sinus urogenitalis they push the thin layer of epitheUum Uning the sinus forward, and by so doing they make this epithelium even thinner than before. This condition is clearly seen in Nagel's picture (Fig. 8). In this stage the lower ends of the Mtillerian ducts represent a somewhat cone-shaped solid epithehal cord. The formation of a lumen proceeds from above downward, and this canalization corresponds with the curve of the ducts themselves with its concavity anterior. Therefore the point where the lumen of the ducts breaks through the solid end is, as a rule, nearer the upper border of the conus, and so is responsible for the production of the semilunar form of the hymen which is by far the most common. The concave course of the Miilleriart ducts is due to the curved abdomen of the embryo. Thereby every organ in the lower part of the body, the sacrum, rectum, genital tract, and sinus urogenitalis, acquires a curved axis. The extremity of the conus (]\liillerian eminence) with a more or less eccentric lumen protruding into the sinus, consists, at first, only of the epitheUum of the Miillerian eminence covered on the outer surface with a very thin layer of sinus epithelium. Only secondarily is this mass of epithehum invaded by connective tissue. According to Nagel the Miillerian ducts originally are composed of large protoplasmic cells of an epithelial character. Around this mass of cells which gradually becomes a tube, the mesodermal formative cells are grouped in a circular arrangement, thus forming the first anlage of the connective tissue and muscular layer of the Miillerian ducts. In other words, the connective tissue appears after the ducts are established and grows in proportion to, and together with, the downward growth of the ducts. Thus, when the ends of the ducts protrude into the sinus in the form of an epithelial protuberance, their connective tissue comes down with them, grows into the terminal conus and forms the inner or central layer of the protuberance.


Fig -Sagittal section through the lower third of the Mullcriau duct in a fetus 4 cm. in length (from Xagel) : 1, Miillerian duet; 2, lower end of the same (anlage of the vagina); 3, cylindric epithelium of the anlage of the uterus; 4. canalis urogenitalis.


If this be the true mode of origin, the hymen is a product of the Miillerian ducts exclusively. The epithelium of the sinus urogenitalis does not play any active part, but only covers the outer layers of the epithelium of the ^lullerian ducts in the form of a very thin cuticle. Thus it is readily understood why the epithelium of the vulva can be dissected from the hymen as recorded above in connection with the theories of Pozzi and ScKaffer.

The ]\Iiillerian theory is further supported by the following observation. It is asserted by a number of authors (Winckel,"* Dohrn," Pozzi,'* Roze" and others) that the outer surface of the h}Tnen is different from the inner and resembles the structure of the vestibule in that it has, like the latter, no papillse and that its epithelium is like that of the vestibule. My sections, however, described above, show that the vulvar surface has papillse as well as the vaginal surface, and I infer the same from SchafTer's remarks on this subject. In my sections, the papillse, it is true, are not quite as numerous nor are they as high and richly ramified as those on the inner side, but this difference is but comparative, and can be explained by physical reasons. The hymen in the embryo and in the infant, as all observers agree, protrudes into the vulva. It thus hes in close juxtaposition to the vestibule and its papillae are subjected to a certain degree of pressure atrophy while the vaginal surface does not suffer any pressure from the yielding epitheHum which at that time fills the vaginal lumen.

The vestibule itself has no papillae at all; its surface in the vicinity of the hymen is perfectly smooth. It is covered with but a few layers of flattened epithelium while the vulvar surface of the hymen is lined with many layers of epithelium. The slight difference in the number of epithelial layers between the vulvar and vaginal surfaces of the hymen is, again, explained by the same physical reasons. These conditions are strikingly ob\aous in the section through the vulva, hymen, and vagina, of an embryo of twenty-five weeks (Fig. 1), detailed above. In another section through the hymen of a seven months' fetus the epithelium on the vaginal side is very thick; that on the vulvar side is only about half as thick. This latter epithelium appears compressed; the cells adjoining the germinative basal layers are markedly flattened instead of being polygonal, as is usually the case in multilayered pavement epithelium.

I am well aware that the form of epithelium, because of its changeability, cannot establish a theory, but it can support \'iews which are otherwise well founded. Embryologic studies and macroscopic or clinical observations alone cannot decide the question. It must be supported by histologic examination, the value of which has thus far been underestimated. Under this heading I should Hke to call attention to certain features of the connective-tissue structure which to my knowledge have not heretofore been pointed out. In all sections examined the fibers of connective tissue are distinctly seen to run in a straight line from the vagina into the hymen. Account of this was given in the first part of this paper. It may here suffice to reiterfite this observation. The great mass of the hymen appears as a direct continuation of the connective tissue of the vagina, and only at the base a few semicircular fibers connect the hjniien with the stratum of the vulva. The latter can by its looser structure be differentiated from the more compact vaginal and hymeneal connective tissue and so clearly shows the hymen to be of


vaginal origin.

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