The first incision was made with the knife, and then the finger alone was sufficient to complete the canal. Specular examination revealed a mucous membrane slightly moist and covered with epithelium.
Epithelial adhesion of the external genitals occasionally gives rise to no symptoms during youth, and passes unperceived. Other children are affected on account of the deviation of the stream of urine upwards towards the abdomen, whereby it is extensively eroded and irritated. When the anomaly exists at puberty, symptoms from the side of menstru ation supervene, and the girl is unfit for marriage. Then to the physical are added psychical symptoms. Conception is not absolutely impossible, as is probable from a number of recorded cases, and as is certain from Mfiller's case, where the woman became pregnant.
Where for one or another reason the clitoris is especially developed, (possibly from irritation by the upward projected stream of urine,) or where this organ is hypertrophied, then it may be a difficult matter to give an opinion in regard to the sex, especially when, as in Debout's case, there exists hernia of the ovary into the adherent labia, thus simulating the scrotum and a testicle. Debout's patient had from youth up played with girls, had MUM11183 and menstruated, but later on was pronounced to be a man on account of the clitoris, which was about three and a half inches long, and she was considered affected with hypospadias and to be cryptorchid. Later still, on separation of the adherent surfaces, she was proved to be a woman, since the internal genitals were found normal, and there existed only an enlarged clitoris with ovarian hernia. Eschricht re ports a similar case.
The recognition of adhesions of this nature depends on careful sound ing of the meatus urinarius, when the sound may be pushed backwards towards the anus and against the skin. When the sound thus entered, in case to one side of the united labia we find a body like the testicle, incision would be indicated in order to clear the diagnosis The treatment, obviously, consists in free separation, and in taking steps to prevent reunion.
Very likely atresia of the hymen is not an anomaly of development. Breisky has already expressed it as his opinion, that even atresia of the vagina is rather to be explained on the supposition of the secondary obli teration of a previously formed canal than on that of an anomaly in de velopment, due to the fact of insufficiency of formation. All the more
probable is this the case in instances of impermeability of the hymen. The hymen is nothing else than the sharply projecting border of the lower extremity of the posterior vaginal wall, which forms, according to Dohrn, about the nineteenth week of the life of the embryo. The formation occurs, however, only after the union of the rectum and the genital fur row has taken place. The two opposed and fusing lamina must therefore have united before the recto-vaginal wall can have begun to form. The position is not tenable that a membranous layer can remain as such be tween the inwardly projecting genital furrow and the rectum growing up from below. Therefore it is that the expression imperforate hymen is not scientific, since it carries with it a false meaning. A non-oommittal term, like atresia of the hymen, or impermeability of the hymen, is preferable.
We have already seen how in the latter part of extra-uterine life, and in the early part of childhood, through defective hornification of the superficial epithelium, adhesions and more or less solid union may result. Breisky has even seen and described direct epithelial union as the cause of retro-hymeneal, thin, obstructing membrane, and we have ourselves wit nessed an instance of atresia hymenalis in a young girl, where at the same time the entire vagina was affected by this epithelial adhesion.
It is probable then that both general atresia and that of the hymen are dependent on the same adhesive cause and secondary union, even as Bokai has proved is the case, in instances of atresia of the labia majora and nymphte in the new-born. It follows then that such an atresia is likely to result in early youth, and that the condition may later rectify itself. If it does not the condition may result in retention of menstrual blood. The Indians are therefore not far wrong in their custom of never neglecting to test the permeability of the hymen by the insertion of the little finger.