CHAPTER XLV.

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 fœtal 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 depression 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 uro-genital sinus, into which the ducts of Müller open) and a posterior part (the anus); thus the perineum is formed (Figs. 313 and 314). 4. The uro-genital sinus contracts in its upper portion to form the urethra, while the lower part persists as the vestibule (Fig. 315); the ducts of Müller coalesce to form the vagina (v. Vol. I., p. 74).

The parts round the vulva develop, therefore, as follows: the clitoris from the genital eminence, the labia minora from the margins of the genital cleft, the vestibule from the uro-genital sinus.

Fig. 314.

The perineum is completely formed (Schroe

der).

Fig. 315.

The upper part of the uro-genital sinus has contracted into the urethra; the lower portion persists as the vestibule, Su (Schroeder).

The following malformations have been described. 1. Complete atresia of the vulva through the non-formation of the depression of the skin (Fig. 311); the allantois and rectum either communicate as in Fig. 311 or have become separated. This condition has only been found in fœtal monstrosities. 2. Persistence of a cloaca so that the rectum, vagina, and urethra have a common orifice (Fig. 312); such cases are sometimes spoken of as atresia of the anus, but are really due to non-formation of, the recto-vaginal septum. 3. Persistence of the uro-genital sinus into which the bladder opens directly as the urethra has not formed (Fig. 314); in such cases the vulvar orifice is contracted and opens into a long, narrow vestibule, which, at its farther end, communicates with the bladder and vagina. This condition is sometimes described as hypospadias.

HERMAPHRODITISM.

For a detailed description of this condition, with illustrative cases, the student should consult Sir J. Y. Simpson's exhaustive article on Hermaphroditism (Collected Works, Vol. II., p. 407).

Of hermaphroditism ('Epuns and 'Appoòírn) there are two varieties, true and spurious.

By true hermaphroditism, we understand that from the Wolffian bodies both ovary and testicles have developed, so that both forms of gland coexist in the same individual. This is an extremely rare occurrence; when it has occurred, there is a tendency towards the better development of one form of organ (determining the sex) while the other is rudimentary. According to Hildebrandt (loc. cit., S. 6), only two authentic cases of bilateral hermaphroditism (ovary and testicle present on each side) have been recorded; of unilateral hermaphroditism (ovary and testicle present on one side, the other side having only one form of gland), a case has been recorded by Bannon; lateral hermaphroditism (ovary on one side and tes

Fig. 316.

Spurious Hermaphroditism (Sir J. Y. Simpson). Pelvis of a female infant in which the external organs simulated those of a male. c, uterus and appendages; b, hypertrophied clitoris with a sulcus, a, at its extremity, which ended blindly and did not communicate with the urethra.

ticle on the other) has been more frequently met with, and cases, confirmed by microscopic examination, have been recorded by Berthold, Barkow, and Meyer.

By false or pseudo-hermaphroditism is understood a malformation of the external organs so that they simulate those of the opposite sex. This occurs in two forms. 1. The external organs in the female may simulate those of the male. This is due to a hypertrophy of the clitoris and its prepuce, with approximation of the labia majora (simulating a scrotum) and contraction or occlusion of the ostium vaginæ; in very rare cases is the clitoris perforated by the urethral canal. This condition is seen at Fig. 316, which represents the pelvis and external organs of an in

fant christened as a boy; a post-mortem dissection showed that the sex was female.'

2. The external organs in the male may simulate those of the female; the non-closure of the lower surface of the urethra and perineum, which constitutes hypospadias, produces an appearance resembling the external organs in the female. Numerous cases are on record in which the sex of males has been mistaken, even by medical experts, and the persons have entered married life as belonging to the female sex. The penis may be

Spurious Hermaphroditism (Sir J. Y. Simpson). Case of hypospadias in the male, making the external organs simulate those of the female. a, a, lobes of scrotum; b, imperforate penis, 1 inch long; e, perineal fissures 1 inch deep, lined with mucous membrane. at bottom of which the urethral orifice, d, is seen; c, the split urethra with openings, f, of glands beside it-supposed to be orifices of prostatic ducts, of Cowper's glands, and of seminal canals.

small and imperforate, the urethra opening at its base; the perineal fissure, lined by mucous membrane, may closely resemble the vagina; and the halves of the scrotum may appear like labia. This condition is seen at Fig. 317 the case is reported by Otto; the person lived in a state of wedlock with three husbands before the true sex was ascertained by medical examination.

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portion of the penis) is exposed along with a portion of the bladder, would only on hasty examination be mistaken for the external female organs. The exposed vesical mucous membrane with its skin margins resembles the vagina with the labia, but it is situated above the pubis; further, below the penis we find the normal scrotum and testicles.

Diagnosis. In examining a case, proceed as follows: Palpate the supposed labia carefully to ascertain whether testicles are present in them; the possibility of hernia of the ovaries into the labia and of non-descent of the testicle into the scrotum, must be kept in view. 2. Examine per rectum for traces of uterus or ovaries. 3. After puberty watch for the menstrual molimina or hemorrhage in the female, and for development of sexual powers in the male. 4. Note secondary sexual characters: development of breasts, appearance of face, tone of voice, and inclination toward one or other sex.

Hermaphroditism, like malformation in general, lies beyond treatment.

INFLAMMATION OF THE VULVA (VULVITIS).

Pathology. In the acute stage, the mucous membrane round the ostium vaginæ and urethra is red, swollen, and painful. Sometimes the mucous glands are obstructed, and a form of acne develops; the glands of Bartholini may inflame and suppurate, producing an abscess about the size of a pigeon's egg; the sebaceous glands at the roots of the hair on the labia majora are sometimes specially affected, producing the "Folliculite vulvaire" of Huguier. In the chronic stage, there is abundant secretion of creamy purulent matter; when due to gonorrhoea, condylomata form round the vaginal orifice.

Etiology. It is often secondary to vaginitis, and accompanies urinary fistula and carcinoma. Want of cleanliness and protracted exercise, specially in hot weather, produce it, and that most readily in patients with much adipose tissue. It is sometimes occasioned by awkward coitus and by masturbation. In children, it is not uncommon; it is important to remember this, as the inflamed appearance of the vulva and the profuse discharge make the parents suspect that the child has been attacked and has contracted specific disease. It is caused by irritation of urine, want of cleanliness, and the strumous diathesis; sometimes it takes an epidemic form in the children of a family or district (Sir J. Y. Simpson).

The Symptoms and Physical Signs will be apparent from what has been said under pathology.