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transposition of skin from the buttocks. Such treatment is usually unsatisfactory, as a patulous canal cannot be maintained. It may be necessary to remove the uterus

and appendages.

Sometimes the vagina is absent in only part of its

Vagina

Septum

Hymen

FIG. 175.-Transverse septum of the vagina (Heyder).

course, being open below and represented above by a fibrous cord; or the upper and lower portions may be developed, while the middle portion is imperforate.

These conditions are more amenable to operative treatment than in the case of complete absence of the vagina. The intervening septum should be incised, and the patulous condition maintained by the

passage of bougies if necessary.

Sometimes the lumen of the vagina is obstructed by the presence of transverse bands or crescentic folds, which have been described as supplementary hymens (Fig. 175).

A hematocolpos is produced when the vagina becomes distended with menstrual blood above such an obstruction.

Hermaphroditism.—A true hermaphrodite is an individual who possesses the organs of both sexes in a condition of perfect function. The existence of true hermaphroditism is denied by many authorities of the present day, though the older writers firmly believed in it. It is doubtful if there are any cases, recorded as true hermaphrodites, in which the demonstration of the condition. is not open to serious criticism; such individuals are in reality pseudo-hermaphrodites.

A pseudo-hermaphrodite is possessed of a distinct sex, and has either ovaries or testicles, though the external genitals and other secondary sexual characteristics may present the appearance of a double sex.

In male pseudo-hermaphroditism the individual has

testicles, and the external genital organs simulate those of the female.

In female pseudo-hermaphroditism the individual has ovaries, and the external genital organs simulate those of the male.

In male pseudo-hermaphroditism the condition of hypospadias is usually present, the lower surface of the urethra and the perineum being split. The penis may be very small and imperforate, the urethra opening at its base. The fissure of the perineum closely resembles the vagina, and the split scrotum may be mistaken for the labia. Cases of this kind are on record in which the individuals, ignorant of their true sex, have for years indulged in sexual connection with men.

In female pseudo-hermaphroditism there is hypertrophy of the clitoris and the prepuce, with approximation of the labia majora and contraction or occlusion of the ostium vaginæ, giving the genitals the appearance of the masculine type.

The secondary sexual characteristics of both varieties. of pseudo-hermaphrodites-the distribution of hair, mammary development, shape, voice, etc.—are usually of the feminine type.

It is often exceedingly difficult to determine during life the true sex of the individual in cases of hermaphroditism.

The labia should be carefully palpated to determine whether or not testicles are present. Rectal examination should be made to determine the existence of uterus or ovaries. The sexual inclinations of the individual should be observed. The discharge from the genitals during sexual excitement should be examined for spermatozoa.

If conception occurs, of course all doubt is removed. If the sex cannot be definitely determined by such examination, it is best to consider the case one of male pseudohermaphroditism, which is the usual form, and to treat the individual as a male.

CHAPTER XXXIV.

DISORDERS OF MENSTRUATION.

MENSTRUATION, or the regular periodical discharge of blood from the uterus, is a phenomenon that occurs only. in the human race and in some monkeys. The anatomical changes that accompany menstruation have not yet been definitely determined. Nothing is known with any degree of certainty regarding its cause and significance. There is much diversity of opinion in regard to the coincidence of ovulation and menstruation. Ovulation and conception may occur when menstruation is absent, and it seems probable that menstruation may take place independently of ovulation.

The process of menstruation is in many respects different from the rut of other animals.

Menstruation usually begins in this country at the fourteenth year. The time of the first appearance of the process is influenced by race, climate, and environment. As a rule, it begins earlier in warm climates and later in cold climates. It is earlier in girls who lead luxurious, indolent lives than in girls of the working classes.

Precocious menstruation rarely occurs at a very early age. It has been known to begin, and to recur with regularity, from the time of birth. In such cases there is a corresponding premature development of the sexual

organs.

The menstrual fluid consists of blood, inucous secretion from the uterus and vagina, and epithelial cells from the endometrium.

The normal duration of the flow is from two days to a week. The amount of fluid discharged is from 2 to 9 ounces. Menstruation occurs every twenty-eight days,

counting from the beginning of one period to the beginning of another. The menstrual interval is subject to considerable individual variations, which appear to be within the limits of health. It sometimes occurs with regularity every two, three, or five weeks. When it occurs every two weeks, the alternate flows are often but small in amount. The occurrence of, or the attempt at, menstruation every two weeks, in a woman who had previously menstruated monthly, is sometimes a symptom of beginning uterine disease.

Menstruation commonly ceases at about the forty-fifth year, when the menopause appears.

Most of the disorders of menstruation have already been considered as symptoms of the various lesions of the genital organs that have been described in the previous pages.

There are some disorders of menstruation, however, often unaccompanied by discoverable lesions, which now demand consideration.

Amenorrhea.-Amenorrhea is the absence of menstruation. Failure of the menstrual blood to be discharged from the vagina, such as occurs in cases of atresia, is not necessarily amenorrhea; menstruation may have taken place, though the most marked phenomenon of this process, the discharge of blood, is concealed.

The term primary amenorrhea, or emansio mensium, is applied to those cases in which menstruation has never appeared. Secondary amenorrhea, or suppressio mensium, is applied to those cases in which menstruation has ceased after having once been established.

Amenorrhea is due to defective development of the organs of generation; to premature atrophy, such as occurs in superinvolution of the uterus; to lesions, pathological and traumatic; to acute and chronic general diseases; and to psychical disturbances.

Menstruation is often absent during the acute diseases, such as typhoid fever, and it may remain suppressed until the general health is fully restored.

Amenorrhea may also occur in any chronic debilitating condition. It is common in chlorosis, anemia, phthisis, and malaria.

It frequently results from changes of climate and surroundings, and continues until the person becomes adapted to the new environment. It is seen in emigrants from other countries, and in women who move from the country to large cities. It is often caused by overwork, physical and mental, and by insufficient food. It is not uncommon in studious school-girls.

Amenorrhea is sometimes due to the excessive general development of fat, even in young woman who are apparently in good general health.

Amenorrhea is frequently associated with insanity. It may be caused by fright, grief, or anxiety. The fear of pregnancy after illicit coitus sometimes produces it.

In some unusual cases amenorrhea is present without any discoverable cause. The woman may be in perfect general health, and the sexual organs may be well developed, at least so far as can be determined by physical examination.

In amenorrhea there is often a general periodical disturbance that marks the times at which the menstrual bleeding should occur. There may be headache, flashes of heat, nervousness, nausea and vomiting, and a feeling of fulness and pain in the pelvis. Various cutaneous eruptions may occur as the result of amenorrhea, as in other diseases of the genital apparatus.

The poor health, mental and physical, that usually accompanies amenorrhea is often thought by the patient and her friends to be the result, rather than the causeas it really is-of the arrested bleeding.

Treatment-The treatment of amenorrhea depends upon the cause of the condition. Little, if any, benefit is to be expected in those cases due to defective development of the uterus or the ovaries. If an attempt at menstruation is made, as shown by periodical local pain and general disturbance, and the uterus is found to be small

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