uterus, they consist chiefly of fibrous tissue with some unstriped muscular fibre; they are usually situated in the anterior wall, in 17 out of 27 cases (A. R. Simpson); they are pediculated (forming so-called fibrous polypi) or sessile.

Symptoms. These are produced only when the tumour is large. In the case described by A. R. Simpson, in which the tumour was the size of two fists, it interfered with micturition and the escape of the uterine discharges.

Diagnosis. This is easy, except in the case of large tumours when the pedicle is difficult to reach. The relation of the bladder should always be carefully ascertained.

Treatment consists in division of the capsule and enucleation of the tumour when it is sessile, or ligature and division of the pedicle when it is pediculated.

CARCINOMA OF THE VAGINA.

LITERATURE. Breisky-Op. cit., S. 151. Bruckner-Der primäre Scheidenkrebs und seine Behandlung, Zeitschrift für Geburtshülfe und Gynäk., B. VI., Hft. 1., S. 110. Goodell-Boston Gyn. Jour., vol. VI., p. 383. Küstner-Archiv. f. Gynäk., Bd. IX., S. 279. Parry-Amer. Jour. of Obstet., vol. V., p. 163: and Philad. Med. Jour., Feb. 1, 1873. Simpson, A. R.—Op. cit., p. 205.

Pathology. Primary carcinoma occurs very rarely in the vagina-in 14 out of 8287 cases (Beigel); in the paper cited above, Küstner has collected but 28 cases out of the whole literature. This is the more surprising when we remember how very frequently it affects the cervix., It occurs in two forms, either as a localised broad-based papillary swelling seated most frequently in the posterior wall or as a diffuse infiltration which often constricts the canal in a ring-like manner. The inguinal glands are generally enlarged by carcinomatous infiltration.

Symptoms and Diagnosis. As in carcinoma of the cervix, there is hæmorrhage and fætid discharge; the pain is slight in the early stage. The diagnosis that there is primary carcinoma of the vagina is often doubtful, because it is difficult to ascertain the condition of the cervix and uterus; in the specimen represented at fig. 275, it was supposed to be primary until the post-mortem showed that it was secondary to carcinoma of the cervix. The examination per rectum is useful in these

cases.

Treatment. This consists in the removal of as much as possible of the diseased tissue with the cautery, spoon, or knife. Bruckner recommends that, where possible, the wound produced by extirpation of the carcinomatous mass be closed by deeply placed sutures.

SARCOMA VAGINE.

LITERATURE. Breisky-Op. cit., S. 150. Man-Amer. Jour. of Obst., vol. VIII., p. 541. Meadows-Lond. Obst. Trans., vol. X., p. 141. p. 204. Smith-Amer. Jour. of Obst., vol. III., p. 671. Bd. IV., S. 348.

Simpson A. R.-Op. cit.,
Spiegelberg-Arch. f. Gyn.,

Sarcoma of the vagina has only recently been described, and is still rarer than sarcoma uteri. As in the uterus, it is either diffuse or in circumscribed nodules. The symptoms are the same as in sarcoma uteri; and the treatment consists in removal (more easily effected in the circumscribed form), which in a case reported by Spiegelberg effected a permanent cure.

SECTION VII.

AFFECTIONS OF THE VULVA AND PELVIC FLOOR.

CHAPTER XLV. The Vulva: Malformations; Inflammation; Tumours.

XLVI. Rupture of the Perineum and its operative treatment.

XLVII. Displacements of the Pelvic Floor: Prolapsus Uteri;
Enterocele.

CHAPTER X L V.

THE VULVA: MALFORMATIONS; INFLAMMATION; TUMOURS.

LITERATURE.

MALFORMATIONS. Hildebrandt-Die Krankheiten der äusseren weiblichen Genitalien : Stuttgart, 1877, S. 2. Meyer-Virchow's Archiv., XI., p. 420. Schroeder-Op. cit., S. 497. Simpson, Sir J. Y.-Hermaphroditism: Collected Works, Vol. II. p. 407. Tait; Lawson-Am. Gyn. Trans., Vol. I., p. 318.

INFLAMMATION. Hildebrandt-Op. cit., S. 17 and 64. Simpson, Sir J. Y.-Diseases of Women, p. 286. Thomas-Op. cit., p. 122.

TUMOURS. Hildebrandt-Op. cit. Chap. VII., where the student will find the literature of the various forms of tumour fully given.

MALFORMATIONS.

THESE are easily understood when we remember the normal development of the external organs of generation. 1. At the sixth week of foetal life, the genital eminence appears externally; at this period the rectum, allantois and ducts of Müller communicate with one another but not with the exterior (fig. 311). 2. At the tenth week, a depres

sion of the skin (known as the genital cleft) occurs; this extends inwards till it meets the conjoined allantois and rectum, and thus the cloaca is formed (fig. 312). 3. The tissue between the rectum and the allantois grows downwards, and divides the cloaca into an anterior part (the urogmital sinus, into which the ducts of Müller open) and a posterior part