With regard to marriage, we may learn much from a case reported by Magitot. The individual referred to had a penis five centimeters (nearly two inches) in length, but having been married to a man for twelve years, upon the death of the husband, decided, for the sake of variety, to play the man, and supplied himself with a mistress. CHAPTER II. HYPERPLASIA AND HYPERTROPHY OF THE VULVA. 1. WE seldom see hypertrophy of the labia majora to such an extent that they hang down in heavy folds to the anus. I once found what appeared to indicate a reduplication of the labia majora.* 2. Supernumerary nymphæ are oftener met with, an illustration being shown in my Atlas.† I have seen only one other beside this. On the other hand, we more frequently observe that one or both nymphæ have two or even several peduncles which lose themselves in the mons veneris, or originate by two just above the clitoris. 3. Hypertrophy of the nymphæ is far more frequently observed, one generally being larger than the other, or both may be enlarged and hang down below the labia majora. This condition, known as the Hottentot apron, from its frequency in that race of people, is quite common amongst the European races, e.g., I once measured nymphæ 11.5 centim. (4.6 inches) and 9.5 centim. (3.7 inches) in length. Nineteen per cent. of pregnant women have one of the nymphæ more developed than the other. In 3000 lying-in-women I found one or the other nympha wing-shaped and elongated in 108 cases. The prepuce may also be elongated and project over the clitoris. Hypertrophied nymphæ may cause great inconvenience; it is, therefore, interesting to note that H. Carrard has very recently been able to show that the cause is an increase of their nerve * Entlassungsbefund 94 der Wöchner. † Plate id., fig. 3, p. 265. fibres in the form of Meissner's tactile bodies, also in the form of club-shaped terminations and peculiar tactile bodies having an aggregation of adenoid tissue.* 4. Hypertrophy of the clitoris, which may reach the usual length of the male organ, was found by Parent-Duchatelet 3 times among 6000 prostitutes. Bainbridge and Appin removed tumors 3" to 4" in length and 2" to 4" thick; Mason extirpated one 4" long, having a periphery of 4 inches. The greatest enlargement of the clitoris which I have seen, excepting tumors, occurred in the glans, which was the size of a bean. Hyrtl states that the clitoris is larger in the tropics than in the northern and temperate latitudes. The clitoris is also enlarged among the Abyssinians, Suzees, Mandingos, the androgynous and lascivious women, and to such an extent among the first-named races as to sanction the custom of removing it with the knife. John Matthews§ states that the extremity of the clitoris is removed with special ceremonies. I myself have never heard of attaching the hypertrophied clitoris by rings to the perineum as a protection to virginity, a custom mentioned by Hyrtl and Hildebrandt, but I succeeded, with the help of my colleague Dr. Wildt, in examining three Arabian girls in Cairo in 1880, and I really found, in the place of the glans, a radiating scar in regard to which they could tell me nothing. Salem Pacha, director of the medical faculty in Cairo, believed that such scars were not universal, but found only in Fellah girls. Blumenbach portrays the vulva of a girl eighteen years old, whose nymphæ alone were cut off, the clitoris remaining intact. It has been asserted that the clitoris becomes hypertrophied in consequence of masturbation, but this is a mistake; males do not have hypertrophy of the penis from the same practice. I have often been unable to see a trace of any change in the clitoris in patients who have confessed they masturbated, yet two decades * Zeitschrift für Geburtsh. von K. Schroeder, x., 62. + Virchow-Hirsch f. 1868, ii., 607. Nr. 1554, d. W. Bef. ? Journey to Sierra Leone, 1785-87. || Stark's Archiv, 1792, iv., 188. ¶ De gen. human. var. not., Gott., 1781, p. 100, plate ii. ago great numbers of patients, victims of this vice, were supposed to be cured by performing clitoridectomy. Baker Brown in 1866 recommended the operation for certain forms of insanity, epilepsy, catalepsy, and hysteria, and many Germans followed his example, although G. Braun could find no pathological changes in the clitorides amputated by him.* This is a dark page in the history of our progress, and the operation has not yet been abandoned. A short time ago I examined a young girl whose clitoris had been partially removed, and the cicatrix afterwards cauterized because the irritation had returned. What was the result? The irritation is more severe than ever, and manifests itself even when the patient looks at naked figures in galleries, etc. Westt has protested against the operation, and at this time the majority of gynecologists are firmly convinced that it is quite useless in epilepsy, hysteria, or masturbation. Treatment. When the hypertrophy causes chafing of the parts, burning, itching, oedema, general irritation, interferes with coition or with walking and standing, the symptoms may be temporarily removed by the application of lead-water dressings, of salicylic acid, vaseline with boric acid, or iodoform, and by frequent bathing, or sitz-baths containing a decoction of oakbark, etc. If, however, the symptoms persistently return, it is best to partially remove the hypertrophied tissue with scissors, the knife, Paquelin's cautery, or the galvano-caustic loop; then the patient is not made imperfect or deprived of important organs, but simply restored to a normal condition. CHAPTER III. HERNIÆ OF THE VULVA. THE hernia which alter the shape and position of the external sexual organs are of three varieties. 1. Inguinal labial hernia, so named because the hernia passes along the round ligament and appears in one or both labia * Wiener Med. Wochenschrift, 1866. † British Medical Journal, 1866. majora. The contents of the sac may be omentum, intestine, ovary, Fallopian tube, and even the pregnant uterus. In 5600 private patients I found inguinal labial, or anterior labial hernia only 6 times; in one case an ovary was found in the left side; in a second, each ovary in a hernial sac; in a third, the uterus, and in the fourth the pregnant uterus. 2. The second variety, vagino-labial hernia, or posterior labial hernia, is much less common. The hernia passes down in front of the broad ligament into an opening or rent in the pelvic fascia and levator ani, and appears at the posterior extremity of one of the labia majora. Stoltz, Veit, and Koenig have each seen but one case of this kind.* represented in the atlas. I have met with two. The first is in it I could also feel the ovary. Upon the external surface there was an appendage as large as a walnut (Fig. 3, a), which must have been an inverted gland of Bartholin. I removed this by an operation, then secured the retention of the hernia by using Scarpa's pad and a pelvic band with a semicircular spring to which the pad is attached. This hernia, which was the size of a man's fist, could not be * Gaz. Méd. de Strasbourg, 20, i., 1845, and Lehrbuch, 1867; Lehrbuch der Chirurgie, 1877, Bd. ii., p. 201. † Plate iii., p. 282. retained with the largest round pessaries. The patient was a multipara with wide, dilated pelvic organs. The second case was an unmarried primigravida, 27 years of age, in the ninth week of pregnancy, and with a history of previous good health. She discovered this tumor, which was elastic and reducible, in the posterior extremity of the left labium majus, shortly after she became pregnant. Upon coughing and bearing down after the hernia had been reduced, it passed along the vagina and out of the pelvis. The fundus of the uterus could be felt just above the symphysis. The hernia was easily reduced, and retained by a round pessary. I 3. With regard to the third variety, named perineal hernia,* agree with Klobt for anatomical reasons I consider such herniæ improbable, and have not been able to find a single authenticated case in literature. The diagnosis of labial hernia ought to be readily made. The variable size, increasing upon bearing down, the reduction attended by gurgling sounds, the disappearance of the fluid contents upon pressure, palpation of the abdominal ring, the sudden reappearance of the hernia when the pressure is removed, are all so easily demonstrable that errors in diagnosis can hardly occur. A case reported by Michelson and Lukin seems to belong here, though it was not very exactly described, and may have been a vaginal enterocele. The tumor, three inches long and two and a half wide, protruding between the labia majora, was thought to be a polyp and was cut off; the woman died from the hemorrhage, and when the tumor was examined it was found to consist of 24 centimeters (9 inches) of omentum and 10 centimeters (nearly 4 inches) of the colon. I have been unable to confirm the statement of Bardeleben, that in inguinal labial hernia the tumor is in two parts, because the tense anterior inguinal ring retains part of the tumor in the canal. This view is, of course, wholly inapplicable to posterior labial hernia. The treatment of anterior labial hernia is the same as that of all inguinal hernia. Retention is to be secured in vagino-labial * Straatmann, Ueber den perinaealbruch, Griefswald, b. Kunike, 1867. † Vide Path. d. w. Sex. Org., p. 285. Centralblatt f. Gynaec., 1879, p. 203. |