SPECIAL DIVISION.

PART I.

DISEASES OF THE VULVA.

CHAPTER I.

MALFORMATIONS.1

1. Absence of Vulva.-By an arrest of development in the first month of fetal life the external genitals and the anus may be absent, the skin covering the region uninterruptedly. (See p. 32.) This condition is almost always combined with arrest of development in other organs, and is only found in non-viable fetuses.

If the anus is formed, life may be continued without external genitals, the urine being evacuated through the navel. Such a case is on record, and was cured by the formation of an artificial urethra and closure of the opening of the urachus at the umbilicus.

2. Hypospadias.-In consequence of an insufficient closure in the median line the lower wall of the urethra may be split more or less deeply (Fig. 199). If the defect extends very deeply, so as to divide the different sphincters of the urethra (p. 76), the patient cannot retain her urine. A small degree of hypospadias is, by far, not so important in woman as in man, and will hardly call for treatment. The complete congenital hypospadias has been successfully treated by paring and uniting the surrounding mucous membrane to such an extent as to form an artificial urethra, the relations of which to the bladder were much like those of a spout to a teapot.2

In this chapter I have to some extent used my article on this subject in American System of Gynecology, edited by Mann, Philadelphia, 1887, vol. i. pp. 235-282. For details the reader is referred to T. A. Emmet's Gynecology, 2d ed., pp. 649-654.

3. Epispadias.-Epispadias (Fig. 200) is the name for the condition characterized by a lack of union of the upper wall of the urethra. It is generally combined with a similar defect in the anterior wall of the bladder (extroversion). The clitoris and the symphysis pubis may be cleft or not. These defects are due to the intracorporeal part

Hypospadias (Mosengeil): a, open canal, formed by the anterior wall of the urethra; b, posterior, closed part of the urethra; c, entrance to vagina; d, hymen.

of the allantois being pulled abnormally forward, becoming overfilled, and finally bursting.

Epispadias, like hypospadias, has been cured by different plastic operations. One way is to form a transverse flap of the mucous membrane of the vestibule and stitch it to the meatus. Another is to denude two lateral surfaces and unite them in front of the open urethra.

4. Abnormalities of the Clitoris.-Sometimes the clitoris is split in two lateral halves, without any cleavage of the urethra or bladder, but in connection with a non-united symphysis and an opening in the abdominal wall above the bladder. Such cases are exceedingly rare. The cleavage of the clitoris is of no importance. The defect in the abdominal wall may be closed according to the general rules of plastic surgery.

The clitoris may be absent or very small, or, on the other hand, as large as a medium-sized penis.

This hypertrophy of the clitoris may be inconvenient, and can then

be remedied by amputation with the galvano-caustic wire (p. 235), with the écraseur, or with Paquelin's thermo-cautery (p. 282).

The prepuce is very frequently adherent to the glans, and in many cases this condition gives rise to reflex neuroses, even epilepsy and nymphomania.

Treatment.-The vulva should be washed with bichloride-of-mercury solution. A couple of drops of cocaine solution are thrown

Epispadias (Kleinwächter): a, fissure in the bladder; b, labium majus; c, clitoris; d, labium minus; e, hymen ; f, vaginal entrance.

into the glans clitoridis with a hypodermic syringe, and four or five drops more are thrown into the prepuce. If one margin of the prepuce is then seized with a fixation-forceps, the thumb-nail will easily complete the work of clearing the glans. Raw surfaces are sprinkled with aristol and the prepuce packed with a little ball of corrosivesublimate gauze. As there is a marked tendency to recurrence of the

adhesions, and the consequent nervous reflexes, this packing must be repeated every two or three days until the appearance of normal smegma shows that the mucous surfaces have developed sufficiently to take care of themselves.1

5. Abnormalities of the Labia Minora.-The labia minora may be absent. They may be multiple, each being split lengthwise in two or three flaps. They are sometimes too long, which is found physiologically in whole tribes. (See, for instance, Hottentot apron, p. 37).

This condition may interfere with coition, and may then be remedied by cutting away the superfluous tissue and uniting the edges of the wound, which will heal by first intention.

6. Abnormalities of the Labia Majora.-These may likewise be split by longitudinal clefts, so as to become double or triple.

Alone or together with the labia minora they may extend so far back as to reach behind the anus, so that there is no perineum.

7. Epithelial Coalescence.-During the second half of fetal development the large and small labia may grow superficially together from behind forward. It is rare that the coalescence goes so far as to prevent micturition in the new-born child. Sometimes it may, however, give an inconvenient direction to the jet of urine. Menstruation may become difficult, and the small dimensions of the vulvar opening may oppose a serious obstacle to coition or childbirth.

If the coalescence is combined with hypertrophy of the clitoris, the sex may become doubtful.

Treatment. The parts ought to be cut open in the median line on a director introduced through the existing opening, and kept separated during the healing process, or, if the cut surface is large, the edges of each side may be brought separately together by stitches.

It is not rare that the urethra alone is agglutinated, so that the child cannot pass its urine. All that is needed in such cases is to introduce a silver probe into the bladder. Once opened, the canal

stays open.

8. Hermaphrodism.-Hermaphrodism, or hermaphroditism, is the condition in which the characteristics of the two sexes become more or less blended in one individual.

From the history of the development of the genitals we know that they are composed of three parts, each of which has its independent embryonal foundation-namely, the sexual glands, the two sets of ducts (Wolffian and Müllerian), and, finally, the external genitals (pp. 20, 22, 30, and 33). It is, therefore, not so difficult to understand how one of these parts may be developed according to a sexual type differing from that of the others.

1

Robert T. Morris of New York, Trans. Amer. Obstetricians and Gynecologists,

It is more difficult to understand how there can be more than one set of reproductive glands, for we have seen (p. 22) that it is one and the same body that, identical in the beginning, later becomes either an ovary or a testicle. But while the connective-tissue part is identical in the two kinds of glands, ovary and testicle, it is not unlikely that the epithelial part of them has a different origin in the two sexes. Some anatomists claim, indeed, that the seminal canals in the testicle are formed as invaginations from the Wolffian duct, while we know that the follicles in the ovaries are derived from the germepithelium (p. 28).

We know, furthermore, that we may have supernumerary ovaries (p. 120), and the same is claimed in regard to testicles, although it is infinitely rarer with them than with ovaries.

Hermaphrodism is true or spurious. True hermaphrodism is that in which at least one ovary and one testicle are found in the same person. There may be found a complete double set of sexual glandsi. e. two ovaries and two testicles (true bilateral hermaphrodism); or there might be found one sexual gland on one side, be it a testicle or an ovary, and on the other both a testicle and an ovary (true unilateral hermaphrodism), but it is somewhat doubtful if such a case actually has been observed or not; or, finally, there may be one ovary on one side and one testicle on the other (true lateral hermaphrodism).

True hermaphrodism is at best exceedingly rare, and its existence is not even universally admitted.

Spurious hermaphrodism, or pseudo-hermaphrodism, is that condition in which the sexual glands belong to one sex, either masculine or feminine, and the passages leading from them, as well as the external parts, approach more or less the other. Spurious hermaphrodism is subdivided into male or female according to the nature of the sexual gland. Each of these classes comprises three groups: the first is formed by those cases in which the ducts alone belong to the opposite sex (internal male or female pseudo-hermaphrodism); the second, by those in which the external parts alone represent the opposite sex (external male or female pseudo-hermaphrodism); and the third, those in which both the ducts and the external parts approach the type of the other sex (internal and external-or complete-male or female pseudo-hermaphrodism).

Pseudo-hermaphrodism, as well as true hermaphrodism, is a malformation that dates from the earliest periods of fetal development. It is much more frequently found in the male than in the female sex, and reaches also a much higher degree in the former, so that a vagina, uterus, and tubes may be found more or less developed in an individual with testicles, vasa deferentia, seminal vesicles, and male external genitals. The presence of menstruation does not settle the sex, since a periodical bloody discharge has even been observed to