When the clitoris is enlarged, but retains its normal shape, then may it imperfectly subserve the purpose of a penis as an agent of coition. In the older works are recorded instances, which prove that in immoral times it was not uncommon for females thus to have connection one with an other. The name applied to this habit was "Lesbian love." Although in olden times the clitoris was so hypertrophied as to frequently serve for copulation, are we justified as physicians in believing that it may increase in size as the result of irritation ? To-day hypertrophy of the clitoris is rarely met with in Europe, and yet two thousand years ago, it would seem to have been common. According to Parent-Duchatelet the clitoris in the prostitutes of Paris is usually, certainly in the majority, hypertrophied.
All the above-described hypertrophies of the labia majora, labia minora, and the clitoris, may be present without symptoms. Complaint is usu ally made on account of deviation of the stream of urine, or interference with intercourse. They may, however, through fusion of the labia, lead to concealment of the true sex. This is the explanation of the interest ing case recorded by Casp. Baulieu, where a monk first became aware of his correct sex on the supervention of gravidity. There are many in stances on record of irritation by the urine or the clothing, although such need not necessarily result any more than irritation of the glans penis does from the same causes.
In every case of great hypertrophy which causes symptoms, extirpation is the correct measure, and where such hypertrophy is noted in early childhood, the same procedure is indicated. It is apparent, however, from what W3 have stated, that resort to the knife is only necessary in the presence of great hypertrophy, seeing that in the slighter degrees there are not apt to be symptoms.
These anomalies, which as a rule affect more or less both the external and internal genitals, are to be sharply differentiated from those arising later in life, the result of fusion. As we have said, Foville's case may be explained on the supposition of such fusion having taken place. Here the genitals in the embryo have developed normally from the start, and later during intra- or extra-uterine life have become fused. The cause of fusion is the ulceration of two skin or mucous surfaces,which lie in contact. It is a surgical principle that two surfaces deprived of their epithelial layer will grow together. Where then wounds, abrasions, etc., have oc curred, we need seek no further explanation for fusion.
We must next.consider union the result of wounds or extensive abra sion during parturition. The so-called diphtheria of the vagina,. gan grene of the mucous membrane, is a common cause and many instances of the kind are recorded. The cicatrization ordinarily affects the vagina, although exceptionally the labia are the site. (Cases of Seggel, Turn bull, Hastings, Hamilton, Kiwisch.) Two cases are on record
union followed on attacks of cholera. Hildebrandt mentions an instance where it occurred after small-pox. We propose, however, to leave en tirely out of consideration instances of atresia vagina, seeing that they have been treated of by Breisky at length. A curious case, as regards its unique etiology, has been reported by Dr. Burdach. It concerns a three year old child who was left by her parents in a field, and while they were occupied with their work, the child fell on an ant-hill. The disturbed inaects invaded the entire body of the infant, and many crawled into the genitals, and acted as such irritants that intense inflammation resulted. Medical aid was not sought until the labia and nymphse had united. The child was ultimately cured by incision of the fused parts.
In the majority of instances of union between the external genitals of little girls, however, a very different explanation exists. Exactly as in boys, slight adhesion exists between the prepuce and the glans which or dinarily breaks loose spontaneously, so is the same condition frequently present in girls between the nymphse. Bokai explains the occurrence on the assumption of arrested hornification of the superficial epithelial layer of the skin.
The superficial epithelium consists of flattened horny cells. There are a number of layers, and the entire thickness has received the name of the horny layer. Underneath the horny layer are the cells of the rate mal pighi. It is apparent now that if the horny layer is arrested in develop ment, the chances of fusion of the two surfaces are great. Hornification later on can lead to spontaneous separation of the surfaces, so that the only exceptionally lasting. Bokai noted thirty-nine instances of such union. In one little girl there existed retention of urine, on account of the adhesive process having extended above the meatus. Huebner believes that this epithelial adhesion may occur also in extra-uterine life. He found it in a girl nine months old. In the same category belong the two cases of Zimmer, one of five and the other of two years, also the case of Zeiss, and possibly that of P. Muller, where, notwithstanding apparently complete adhesion, conception ensued. A very similar instance is recorded by Biwisch. We have seen one case of epithelial adhesion in a little girl a number of months old. She passed water readily, and on examination a small opening was detected anteriorly by which the urine escaped, but otherwise the genitals were adherent. A sound was passed through the above opening downwards, and on exerting considerable pressure the united skin flaps yielded without the slightest blood. I am also of the opinion that a similar adhesive process existed in a young girl who consulted me on account of absence of the vagina. There existed only a blind cul-de sac. Since the young girl complained of dysmenorrhoea, we proceeded to open the vagina.