tion of the part, which bleeds, whenever an attempt is made to draw it back; and in consequence phymosis is apt to occur.

Paraphymosis is the opposite condition, in which a tight prepuce having been drawn back, constricts the neck of the glans, from having itself become thickened, and thus occasions a distended state of the glans, and even mortification, unless the stricture be removed. Phymosis is apt to give rise to attacks of balanitis, from the accumulation of the secretions of the coronal follicles.

Warty vegetations belonging to the class of epithelial tumors sometimes form on the glans, or on the inside of the prepuce; they are commonly the result of repeated inflammatory excitement, and are capable of being cured effectually by removal.

Fig. 326.

Dr.

Cancer may affect any part of the penis, but is most frequent on the glans and prepuce. Rokitansky says, that it chiefly assumes the encephaloid form; but we think the epithelial is more often met with, at least in the site which has been mentioned as its favorite. Walshe speaks of scirrhus as the species which usually affects the penis, though it may subsequently give rise to encephaloid vegetations. He states that the disease may originate as a warty excrescence, or as a pimple, which discharges an excoriating fluid, scabs, and breaks out afresh, while induration, followed by ulceration, advances at its base; or it may infiltrate the glans, so as to convert that part into an indurated mass; or venereal ulcers may take on cancerous action, and fungate as primary cancer. Secondary cancers, except in the adjacent glands, are not of common occurrence. Phymosis, and the irritation attending upon it, seem to act as exciting causes; advanced age as a predisposing.

THE PATHOLOGICAL ANATOMY OF THE FEMALE ORGANS OF GENERATION.

CHAPTER XXXVII.

THE EXTERNAL ORGANS OF GENERATION.

THE various tissues entering into the composition of the external organs of generation of the female are liable to numerous affections, differing according to the immediate seat of the lesion. In the pudenda, which we shall notice first, we have to deal with the cutaneous covering, the mucous lining, the loose, intervening cellular tissue, and the sebaceous and mucous follicles. The relation of the parts as the organs of copulation, is one, that, in addition to the pathological questions they give rise to, often has a most important bearing upon medico-legal points of vital interest, which it is necessary for the medical man to understand well, as numerous cases are on record of a misappreciation of the circumstances having led to very mischievous results. In the labia, sugillations are frequently met with as a result of external violence, or after parturition; the effusion from a violent injury may give rise to very considerable tumefaction, which must not be confounded with varicose swellings. When the consequence of childbirth, it generally affects the left labium,' and occurs more frequently in primiparæ than multiparæ. The swelling in either case has been known to attain the size of a fist, or a child's head. It presents a tense, smooth surface, with a livid color. Varicose veins of the labia may also acquire a very considerable size; but the slow increase of the tumor, and the vermicular character of its contents, will determine the diagnosis. Varicose swellings, too, occur during the course of pregnancy, and, though sometimes very considerable, do not generally cause any impediment to parturition, as they are external to the vulva. Cases, however, are recorded of their sudden laceration during parturition, and of a consequent fatal issue. The hemorrhagic tumor disappears spontaneously, or in consequence of treatment, but exceptionally the swelling persists, probably becoming encysted, and may then be borne for an indefinite period. A case is related by Mauriceau, in which a tumor, originating in this way, existed for twenty

1 Kilian, die Geburtslehre, &c., vol. ii. p. 517. 1840. Frankfurt.

2 Observations sur la Grossesse et l'Accouchement des Femmes. Paris, 1695. Obs. 29.

five years. Inflammatory affections of the labia may arise from internal and external causes, and exhibit the various forms of inflammation met with in other superficial textures. Eczematous and aphthous inflammation, as a result of derangement of the digestive organs, of pregnancy, of a want of cleanliness, or of sexual over-indulgence, are common. Eczema is characterized by the appearance of a vesicular eruption scattered over the inner or outer surface of the labia. The vesicles break and scab, and they are the source of much of the pruritus to which females are subject.

The loose cellular tissue, occupying the interval between the external and internal lamina, especially favors oedematous swelling, and, when the inflammation bears a phlegmonous character, extensive sloughs form. Instances of this in early life are recorded by Mr. Kinderwood,' who witnessed an epidemic at Manchester, marked by great fatality.

The mucous crypts, especially the aggregation lying on each side of the vestibulum, and termed by Bartholinus the female prostate, are liable to inflammation from catarrhal, herpetic, syphilitic, or other causes, resulting in chronic ulceration or tedious discharges. Even young children are frequently liable to simple or benignant inflammatory affections of these parts, giving rise to much irritation and muco-purulent secretion—a circumstance with which it is necessary to be acquainted, as popular prejudice is only too prone to attribute it to contagion.

The syphilitic taint gives rise to warty excrescences of the dermoid tissues, which may affect the labia and the introitus vaginæ. They consist of groups of small pedunculated tumors, aggregated together in such a manner as to produce a sort of mushroom appearance. These warts are not identical with, though they resemble, the tubercule muceux of French writers on syphilis. Mr. Safford Lee describes these as round, flattened tubercles, raised above the surrounding tissues, sometimes becoming elongated, of a reddish-blue color, and frequently ulcerated on their surface, producing a moisture of the parts.2

Encysted tumors of slow growth affect the labia, and are probably due to an obstruction in the first instance, and subsequent distension of one or more of the follicular structures. They consist of a membranous envelop, containing a transparent, glairy fluid; and only prove a source of inconvenience after they have attained a large size. Other tumors are described as occurring in the pudenda, independently of the hypertrophy resulting from chronic inflammation. Sir Charles Clarke has described a variety under the designation of the oozing tumor of the labium, which is chiefly characterized by a profuse watery discharge, corresponding in appearance with that from the cauliflower excrescence. It is but slightly elevated above the skin, and has an irregularly nodu lated surface. It occurs in persons advanced in life, endowed with general obesity, and in whom the labia are enlarged. Erectile and scirrhoid tumors are also met with in this part of the system. A remarkable specimen of the latter is preserved in the Royal College of Surgeons of England (No. 2715), which was successfully removed by

1 Medico-Chirurg. Trans. vol. vii. p. 84.

2 Safford Lee on Tumors of the Uterus, &c. p. 254. London, 1847.

operation. It weighed upwards of eleven pounds, and is six inches in diameter. It is covered with healthy skin, and consists of a pale and compact, but soft and elastic, tissue, traversed in some parts by irregu lar, shining fibres, and in others having several small oval cavities in it. The patient was thirty years of age, and the tumor had been growing for many years. Under the head of hypertrophy, we must also allude to the liability of the labia being affected by elephantiasis. The nymphæ or labia minora are often abnormally enlarged, and frequently the seat of chronic inflammation, and consequent induration. In new-born infants they normally project beyond the labia majora, and, in some wild tribes, the custom exists of inducing their elongation by artificial means; this is said to be the case among the Bushmen and the Kamschatdales. Among the Arabs and Copts circumcision of females prevails, which consists in removing a portion of the elongated nymphæ. The enlargement of the nymphæ has been set down to an abuse of sexual indulgence; but this is, probably, as incorrect as the same statement has been shown to be with regard to hypertrophy of the clitoris. This rudimentary penis excites no attention, unless enlarged much beyond its normal proportions. It is capable of assuming the most extravagant size. Some of the cases of hermaphrodism that are on record may be explained by a reference to congenital hypertrophy of the clitoris. The largest specimen that we have met with is preserved in the Museum of the University of Bonn. It is fourteen inches in circumference, and weighs eight pounds. Mr. Safford Lee quotes several instances of similar hypertrophic enlargement. Parent Duchâtelet met with enlarged clitoris in only three cases of 6,000 registered prostitutes in Paris. Dr. Ashwell, in his remarks on the subject, expresses his concurrence with the last observer as to there being no necessary connection between an habitual sexual indulgence and the permanent increase of the clitoris. He adds, that he has often been struck with the integrity of the external genitals in prostitutes, while the uterus and ovaries have been bound in all directions by bands of false membrane. The warty growths, already spoken of, also affect the clitoris, and it is occasionally the seat of malignant degeneration, where the parts of generation are generally involved.

In the Pathological Society's Report for 1847-48, Mr. Brooke has recorded a case of malignant disease of the clitoris, which caused an excrescence of the size of a nut, attached by a pedicle, and which, having ulcerated and involved one of the nymphae, was successfully removed by an operation. In this case it does not appear that the system at large was at all affected.

We allude to the urethra at present, only to speak of certain affections of the orifice which opens beneath the clitoris, into the vestibular portion of the vagina. The very large crypts and sebaceous follicles surrounding this sensitive point, are the frequent seat of blennorrhaic and other forms of inflammatory action. The mucous membrane of the part is liable to an hypertrophic development, giving rise to small vascular, generally pediculated tumors. They are exquisitely sensitive during life, and the surface being easily abraded by contact, they frequently exude small quantities of blood, or they are the cause of painful

micturition and protracted leucorrhoea. The mucous membrane surrounding the orifice of the urethra is very apt to become hypertrophied; the affection is described, by Sir C. M. Clarke, as consisting of an inflammatory hardening and thickening of the cellular structure, with an increase in the erectile tissue of the part.

The valvular fold of membrane which protects the virginal vagina, the hymen, which is commonly ruptured when coition is first completely effected, has been a subject of much discussion by medical jurists, as its absence has been regarded as an unequivocal sign of defloration, or its presence as a proof of the unimpaired virginity of the individual. Neither position is absolutely correct; for the best authorities are agreed, that, on the one hand, it may be destroyed by ulcerative absorption; or, on the other, that it may persist, not only after coition, but even after parturition. The latter fact is corroborated by the testimony of Merriman, Nägelé, Ramsbotham, and others. Other deviations from the normal state of the hymen are, the cribriform perforations that it exhibits; or it surrounds the entire introitus vaginæ, leaving a central circular orifice, or it entirely excludes the passage. The latter circumstance is not likely to be discovered, as other atresia of the external orifices are early in life. With the approach of puberty it will induce much inconvenience from the mechanical retention of the menstrual discharge, and, unless discovered and rectified, will be the source of serious disturbance. The hymen is sometimes found much indurated, and of a cartilaginous consistency, and even osseous deposits have been met with in it. The hymen, after it has been ruptured, is partially, if not entirely, absorbed. The carunculæ myrtiformes, which have been generally looked upon as the remains of the hymen, are now regarded by many authorities as normal formations that are not associated with lesion of the hymen.

THE VAGINA.

The vagina presents very considerable varieties of conformation and size within the normal limits of health, differences depending upon the of the individual and the effects of cohabitation or childbirth, or the absence of these influences. A congenital closure of the passage may, independently of an imperforate hymen, or adhesion of the labia, convert the vagina into a cul-de-sac, a lesion which can scarcely be attributed to anything but intra-uterine inflammation, if the uterus be present. A remarkable instance, which appears to have been an arrest of development, is detailed by Dr. Boyd, where, in a female, æt. 72, who had been married, though necessarily without issue, the vagina terminated in a cul-de-sac about half an inch deep, beneath the orifice of the urethra. There was no vestige of a uterus, nor any Fallopian tubes; the right ovary was natural, and attached by a loose ligament to the bladder; the left ovary was abnormal, but similarly connected with the bladder. A multiplication of parts is, perhaps, more frequently met with, and is produced by the formation of a septum, which

1 Medico-Chir. Trans., vol. xxiv. p. 187.