sequent on protracted labour. Fistulous
cloacae are also commonly formed in advanced
stages of cancer (fig. 479.).
Inflammation of the vagina. Vaginitis.
This occurs both in the acute and chronic
form. It may present the character of be-
nignant catarrh, or of a specific blenorrhoea
(gonorrhoea}. In the more acute form the
mucous membrane is highly vascular, and is
sometimes excoriated, from excessive shed-
ding of epithelium. The discharge presents
variable characters, from the viscid yellow
puriform mucus, to the creamy, milk-hke, or
thin, nearly watery, fluid (leucorrhcea).
Croupous exudations occasionally form upon
the vaginal mucous membrane, chiefly in con-
nexion with typhoid exanthematous or puer-
peral processes.
Epithelial desquamaiion. Occasionally
the entire epithelial coat of the vagina is
thrown off, forming a membranous cast of
that canal. Several of these casts may be
found, one contained within another. Their
discharge may be accompanied by symptoms
resembling those of dysmenorrhoea ; but more
particularly by an intolerable itching or sensa-
tion of crawling in the vagina. They are
composed entirely of dense vaginal tessel-
lated epithelium.*
Serous and sanguineous infiltration into the
mucous and fibrous coats of the vagina takes
place occasionally during protracted labour,
producing considerable tumefaction, and con-
sequent narrowing of the canal. In this state
* 1 have given a description, with several illus-
trative figures, of these epithelial casts of the vagina,
some of which include also the epithelium of the
vaginal portion of the cervix uteri, in Beale's Ar-
chives of Medicine, for April, 1858. I suspect that
the nature of these has been overlooked, and that
they, have been confounded with the true dysmenor-
rhoeal membranes which consist of the lining mem-
brane of the uterus. See^fy. 443.
z z 2
708
UTERUS AND ITS APPENDAGES.
the vaginal walls are easily lacerable, or if
subjected to continued pressure pass readily
into gangrene.
Abscess forms occasionally in the vaginal
walls, but many of the abscesses which burst
into that canal have their origin in pelvic
cellulitis, or in inflammation of other struc-
tures external to the vagina.
Ulceration. The minute aphthous ulcers
which are dotted over the surface of the va-
gina originate in follicular inflammation. The
more extensive and irregular ulcers, except
those which form upon the more exposed
parts when the vagina is inverted, as in proci-
dentia uteri, are usually either syphilitic or
cancerous.
Gangrene of the vagina occurs in conjunc-
tion with gangrene of the vulva in septic puer-
peral processes ; or it results from pressure
in protracted labour. Spontaneous gangrene
occurs also occasionally in infants and young
children.
Cysts and tumours. The former, if of small
size, may result from obstructed mucous fol-
licles ; but more often the larger cysts arise
in situations external to the vagina, and pro-
trude into its canal. In the same way, fibrous
or osseous tumours growing from the perios-
teum or ligaments of the pelvis, ovarian, or
even uterine tumours may, by pushing before
them the walls of the vagina, protrude into the
canal. Vaginal cystocele and rectocele occur
in a similar manner. The tumours which lie
free within the vagina are chiefly uterine polypi,
or cancerous tumours of the cervix or of the
vagina itself. The uterus, when partly in-
verted, also forms a tumour occupying the
vagina.
Cancer may originate in the vagina, although
it more often constitutes an extension of the
same disease from the uterus. In either case
it appears most commonly as medullary can-
cer, taking the form of tuberculated masses or
ridges, which narrow or obstruct the passage,
and quickly pass through the stages that cha-
racterise the ordinary progress of uterine can-
cer. The surrounding parts become infiltrated
with cancer matter, and the vagina is fixed in
the pelvis, ulceration of the walls and fistulae
resulting. Occasionally, at the commencement,
this disease appears in the form of soft, rapidly-
growing papillary structures, springing from
the upper and posterior wall of the vagina
(villous cancer).
EXTERNAL ORGANS OF GENERATION.
SYN. Vulva. Pudendum. These parts per-
form subordinate offices in the act of repro-
duction. They are in no way concerned in
gestation, and only slightly in menstruation
and parturition. They are associated with
the vagina in the act of copulation, which
has for its object insemination, or the con-
veyance of the seminal fluid to the internal
or formative organs. The parts which serve
to establish this relation between the sexes,
with the exception of the vagina, are placed
external to the body, and are attached to
the front of the pelvis. They are included
under the general term vulva or pudendum,
which extends from the mons veneris to the
perineum. The vulva consists of the follow-
ing parts, viz. labia, clitoris, nymphae, vesti-
bule, vaginal orifice, and hymen.
THE MONS VENERIS forms a slightly
rounded or flattened eminence, of triangular
outline, covering the symphysis and horizon-
tal rami of the pubes. In fat subjects it is
separated from the abdomen by a transverse
furrow. It is composed of adipose and fibrous
tissue, covered by integument. The latter
contains many sebaceous and hair follicles.
The hair is not developed until the age of
puberty.
Fig. 480.
External organs of generation, and commencement of
vagina. (After Huguier.}
I, labium of left side (that of the right side is
divided and partly removed to expose the vagina
and vulvo-vaginal gland) ; n, nympha ; c, glans
clitoridis ; p c, preputium clitoridis ; v, vestibule ; u,
orifice of urethra; va, vagina; g, vulvo-vaginal
gland, or gland of Bartholin and Duvernay ; d,
duct of the same.
THE LABIA, termed also labia majora, to
distinguish them from the lesser labia or
nymphae, are two symmetrical tegumental
folds(j6g. 480. //), placed one on either side of
the rhna or fissure which leads to the vagina.
The labia vary considerably in size and form in
different subjects. In stout adults they are full
and fleshy, closing the vulvar orifice, and con-
cealing the rest of the generative organs,
which they serve to protect. In the aged the
labia become shrivelled and the nymphae pro-
trude between them, as they also commonly
do in infants and young subjects. The outer
surface of each labium is composed of com-
mon integument, which at the age of puberty
EXTERNAL ORGANS OF GENERATION.
709
becomes covered with hair. Along the line
of apposition of the two labia, where the rima
is formed, the hair and integument cease, and
the mucous membrane common to the rest of
the generative canal commences. From this
point inwards the surface of the labium is
smooth, of a reddish or pink colour, and is
here furnished with numerous muciparous and
sebaceous follicles, which bedew the parts
with an odorous secretion, and preserve their
constant moisture. The labia are united
above by a slight fremdum, termed the ante*
rior commissure, while below they are con-
nected, at the anterior margin of the perineum,
by a broader posterior commissure. When the
parts are here drawn asunder, a second fold
appears within the former, just below the
entrance of the vagina. The transverse boat-
shaped furrow between these constitutes the
fossa naviculnris. Beneath the cutaneous and
mucous covering of the labia is found a layer
of dartoid tissue, the rest of their substance
being formed of loose fibrous and adipose tissue.
The labia represent the scrotum, which in
the early foetus is divided into two halves. A
raphe indicates in the male the line of their
subsequent confluence. In the female the
two halves remain permanently separate.
The normal descent of the testis into the
scrotum in the male, about the seventh month
of intra-uterine life, is represented by the ab-
normal descent of the ovary into the labia of
the female which constitutes ovarian ingui-
nal hernia. (See p. 574.)
When the labia are drawn asunder, the
clitoris, the vestibule, nymphae, and vaginal
orifice are brought into view.
THE CLITORIS (Jigs. 481. and 482.), in
general form and composition, resembles, on
a diminutive scale, the penis, but it is deficient
in some of the parts which compose the latter
organ. The clitoris lies in the upper part of
the vulvar fissure, concealed between the
labia, and encased in a fold of mucous mem-
brane, the lower border of which forms a hood
or prepuce (preputium clitoridis) (Jig. 480. pc),
that terminates just above the superior com-
missure of the nymphae, and allows the ex-
tremity only of the organ to appear. When
this covering is removed, the clitoris is seen
to consist of the following parts : viz. a
small imperforate glans (fig. 481. c), com-
posed of spongy erectile tissue, and covered
by a highly senwtive mucous membrane,
which is abundantly supplied with nerves ;
this terminates the free extremity of the organ :
a body (fig. 481. b), consisting of two cor-
pora cavernosa, united along the median
line, and invested by a fibrous tunic. The
body extends upwards and backwards to
a point a little above the centre of the pubic
arch. Here it makes a sudden downward curve,
and, after dividing into two crura, is attached
by these beneath the iscio-pubic rami of either
side. Opposite the point of curvature, a flat-
tened suspensory ligament attaches the body
of the clitoris to the pubic symphysis. Two
ischio-cavernous muscles (erectores clitorides),
composed of striped muscular fibre, are in-
serted into the crura. They have the same
relations, and, according to Kobelt, are fully
as long as in the male (fig. 483. n).
Blood-vessels. Two dorsal arteries (fig.
481. K), running along the upper surface of the
Fig. 481.
The clitoris (enlarged 4 diameters.) (After Kobelt.)
a, body ; b, angle or curvature ; c, glans ; d, vena
dorsalis; e, superficial veins emerging from the
root of the glans, and fg, veins of deeper origin.
These transmit the blood to the vena dorsalis ; h,
dorsal artery; Hi, dorsal nerves ; k, the venous
plexus, termed pars intermedia (shown also at d,
Jig. 482., and e,fig. 483.); /, communicating venous
branch between the glans clitoridis and pars inter-
media ; m, ascending venous canals proceeding from
the pars intermedia (k) to the under surface of the
body of the clitoris ; n n and o, lateral branches of
communication between the vessels last named and
the vena dorsalis ; p, veins from the labia, and r,
from the nymphae and frenulum clitoridis, which
enter the pars intermedia ; 7, arterial branches cor-
responding with the pars intermedia and commu-
nicating veins ; s, frenulum clitoridis.
clitoris, supply the glans, from which the blood
is again collected by superficial veins, emerging
from the root of the glans at e, and by others
having a deeper origin at f. These transmit
the blood to the vena dorsalis, d. From the
cavernous bodies the blood is also collected
by a series of vascular canals, of which an
account will be presently given.
Nerves. The clitoris is richly endowed
with nerves, i i, which are relatively three or
four times larger than those of the penis.
They pass along the sides of the clitoris, each
dividing usually into three branches, the ulti-
mate ramifications of which lose themselves
z z 3
710
UTERUS AND ITS APPENDAGES.
partly in intricate plexuses within the glans,
and partly in terminal loops upon its mucous
covering.
Development. In the foetus of three to
four months, the clitoris is scarcely distin-
guishable from the penis. But about the
latter period the proportionate retrocession of
the one organ, and the increased development
of the other begin to be apparent. In the
male, the groove along the under surface of
the penis is closed in, and at the same time
the raphe of the scrotum is formed ; while in
the female, the parts corresponding with the
bulb and corpus spongiosum urethras remain
open, and constitute a portion of the rima.
These lie in two halves on either side of the
entrance of the vagina, while the urethra is
developed independently of them.
NYMPHS. Labia minora v. internet, These
consist of two thin and slightly fleshy folds of
mucous membrane (fig. 480. 72), somewhat re-
sembling a cock's comb, which lie on either side
of the entrance to the vagina, extending from
the clitoris downwards, as far as the middle or
lower border of that orifice. The nymphae
commence above by two roots. The inner one,
thin and membranous, is inserted beneath the
glans clitoridis, and forms with its fellow a
kind of frenum. The outer one, more fleshy,
passes round the glans, and by its junction with
the corresponding portion of the opposite side
constitutes the preputium clitoridis (fig. 480.
p c) already described. From these two roots
or origins each nympha extends downwards
and outwards, forming a thin prominence, of
variable extent in different subjects, until it
becomes merged in the labium of the corre-
sponding side, near its posterior extremity.
The nymphae are composed almost entirely
of mucous membrane, which on their outer
side is continuous with that of the labia, and
upon their inner surface with the lining mem-
brane of the vagina.
Various uses have been assigned to the
nymphae. One of these is that they serve to
direct the stream of urine issuing from the
nrethral orifice, as suggested in the classic
allusion to the sea nymphs pouring water
from a vase which is implied in their name.
Another supposition is that the nymphae aid
the enlargement of the vaginal orifice, by be-
coming unfolded at the time of labour, although
no such unfolding can be absolutely observed.
It is more probable that their office is that of
extending the secreting and sensitive surfaces
at the entrance of the vagina.
The nymphas correspond with that part in
the male which forms the tegurnental covering
of the urethra, but which remains ununited
in the female along the median line.
THE VESTIBULE. This term has been
employed in two senses. In its widest sense it
includes all the parts which immediately sur-
round the vaginal orifice. In a more restricted
meaning, it is limited to that triangular patch
of mucous membrane (Jig. 480. v) which fills
up the summit of the pubic arch. In the latter
sense the apex of this triangle is formed by the
clitoris, the sides by the upper halves of the
nymphae, and the base by the roof of the vaginal
orifice. In the centre of the base is situated
the mcatus urinarius, which forms here a slight
prominence (fig. 480. u), at a distance of
one inch behind the clitoris. Immediately
below this point the anterior column of the
vagina terminates in a prominent bulb or
tubercle, marked usually by numerous trans-
verse folds.
ORIFICE or THE VAGINA, AND HYMEN.
Immediately below the vestibule, and between
the nymphse, is the orifice of the vagina (fig,
480. va), which, in its undistended state, has
the form of a vertical fissure, especially in
women who have borne children, but in virgins
it is more constricted and circular, and is
further narrowed by a fold of the vaginal mu-
cous membrane, the hymen, which either en-
circles or semi-encircles the orifice. As some
important questions in obstetric and forensic
medicine relate to this membrane it will
receive here a more particular examination.
The hymen, regarded in an anatomical point
of view, possesses no peculiarity or speciality
by which it is essentially distinguished from
many like structures in other parts. It belongs
to the same class of formations as the valvulae
conniventes of the intestines, and the frill-like
folds of mucous membrane which not infre-
quently surround the terminal orifices of mu-
cous tubes. In the foetus such folds are seen
with various degrees of distinctness at the ter-
mination of the urethra, vagina, and often of
the rectum. The lower end of the vagina, in
the foetus invariably terminates in a marked
projection outwards of the mucous lining of
the tube. It takes the form of a laterally
compressed conical fold, the base of which is
continuous all round with the vaginal walls,
but the apex is directed forwards. Its centre
exhibits a vertical slit-like orifice, the direction
of which is apparently due to the lateral com-
pression of the nymphae and labia, between
which it lies. This is the hymen. In ad-
vanced foetuses it is scarcely distinguishable in
form, and only to a certain extent in size, from
the similar conical termination of the cervix
uteri, which projects into the vagina, as the
hymen does between the nymphae. The vaginal
portion of the cervix uteri and the hymen both
constitute invaginations or intussusceptions at
two different points of the same mucous tube,
the one marking the division between the
uterus and the vagina, the^ther between the
latter and the external parts. The chief dif-
ference between them is that the direction of
the orifice in the former is transverse, and in
the latter vertical.
Such is the condition of the hymen during
foetal and infantile life. But as growth
advances the posterior half becomes much
more developed than the anterior, just as
the posterior half of the uterus, the poste-
rior lip of the cervix, and the posterior wall
of the vagina, are commonly larger and more
developed than the corresponding anterior
halves. Thus it happens that in adults the
hymen presents usually theformof acrescentic
or seinilunar fold, the concave border of which
EXTERNAL ORGANS OF GENERATION.
71
is directed upwards or forwards, while that
which had been in the fetus, the upper half,
has now become unfolded or lost among the
plaits of mucous membrane, situated at the
upper part of the vaginal entrance. This,
because it is the most constant, has been
usually regarded as the typical form of the
hymen. But the foetal form is also often re-
tained, namely, the circular fold of mucous
membrane, which, as the parts become more
expanded, acquires a round rather than a slit-
like aperture. If, however, the folds of the
mucous membrane lining the vagina are pro-
fusely developed, then the hymen also exhi-
bits the form not so much of a distinct
membrane as of an irregularly constricted ori-
fice, the sides of which are puckered or
gathered into plaits, so as nearly to close the
vaginal entrance. And this also is a very
common condition of the part, especially in
young subjects.
The varieties, therefore, in the hymen which
anatomists recognise, such as the crescentic,
circular, cribriform, and the like, become easily
explicable. They all proceed apparently from
a common starting point, but differences in
the degree of development, or accident, may
determine the permanent form. The half-
circle and crescent result from a normal deve-
lopment of the posterior, and a corresponding
retrocession of the anterior, moiety of that
conically projecting mucous fold which is
more or less distinct in every fcetus. The
hymen with a central or nearly central circu
Jar orifice, results from a flattening down and
retiring within the vaginal orifice of the cone ;
the retiring naturally following upon an expan-
sion of the vaginal walls as growth advances.
The appearance of a notched margin to the cen-
tral aperture is produced by the prominent
edges of the terminal vaginal folds, which are
in some subjects more profusely developed
than in others. The cribriform hymen pro-
bably results from an abnormal cohesion of
these notched edges, in such a manner, that
small apertures are left between them, and
the completely imperforate hymen by an en-
tire adhesion of the margins of the orifice,
the result sometimes of inflammation in in-
fancy.
The hymen, however various its forms may
be, consists of a double layer of mucous mem^
brane, containing between its laminae a small
quantity of fibrous tissue and blood-vessels.
It is of variable degrees of thickness, being in
some subjects very strong and tough, and in
others forming a very slender lamina. Its
situation is at the entrance of the vagina.
Although the depth at which it is placed
within the vulva varies in different subjects,
according to the thickness of the labia, and
the size of the nymphas and vestibule. Occa-
sionally, as already stated, one or more plicae
of the vaginal mucous membrane, more than
usually developed, form constrictions at a
higher point within the canal, but the term
hymen cannot with propriety be applied to
any of these.
The presence of the hymen, although it
raises a strong probability of virginity, jet
affords no certain evidence upon that point,
nor does its absence establish the contrary.
The hymen is commonly said to be ruptured
on the occasion of a first complete intercourse,
but the expression unfolded would probably,
in many instances, more accurately represent
the mode of its disappearance. Whenever
the hymen presents any considerable mem-
branous surface, doubtless a real laceration
occurs, but in the cases in which it takes the
form of a crescentic fold, or of a puckered
rosette, instead of being lacerated, it probably
becomes unfolded or flattened out, and so dis-
appears, just as the ordinary vaginal folds are
obliterated, by frequent intercourse or by
parturition, without any rupture.
Upon the presumption that the hymen is
always lacerated a certain hypothesis has been
raised, namely, that the tittle fleshy bodies
occasionally observed near the orifice of the
vagina, termed carunculce myrtiformes, consti-
tute the remains of that membrane. But,
notwithstanding a great amount of evidence
that has been collected regarding the myrti-
form bodies, it cannot be shown that these are
anything more than accidental and uncertain
formations, having nothing necessarily to do
with the hymen.
The Kymen may be broken by accident, or
may become obliterated by the frequent em-
ployment of vaginal injections, and in other
like modes. Or, from constant leucorrhoea,
the parts may become so relaxed that a dis-
tinct membranous fold can be no longer dis-
cerned at the vaginal orifice, although there
may have been no loss of virginity.
On the other hand, impregnation may take
place without destruction of the hymen, which
has frequently been found entire at the time
of labour, and even in women affected by sy-
philis.*
Sebaceous and Muciparous Glands and Fol-
licles of the Vulva. -^ The sebaceous follicles
correspond with the male preputial follicles.
They are scattered over the nymphae, clitoris,
and inner surface of the labia. Their secretion
contains butyric acid and has a strong and
somewhat ammoniacal odour. This occasion-
ally becomes highly irritating, especially when
cleanliness is neglected.
The muciparous follicles are arranged in
groups, the principal ones being situated
upon the vestibule (vestibidar follicks, fig.
480. v), around and upon the sides of the
meatus urinareus (urethral follicles, fig. 480. &),
and at the sides of the entrance of the vagina
(lateral follicles of the vaginal orifice, fig. 480.
va}.
The muciparous follicles are composed of a
delicate vascular mucous membrane arranged
in the form of short mucous crypts, or con-
sist of simple or branched tubules ending
* In a case of extensive syphilitic periostitis
which came under my notice, in a woman thirty
years of age, who had previously been a prostitute,
a tough membranous circular hymen closed the
orifice of the vagina so completely that the tip of
the fore finger could scarcely be inserted within it.
z z 4
712
UTERUS AND ITS APPENDAGES.
in a cul-de-sac. The vestibular follicles are
of the former kind and the urethral of the
latter.
All these vulvar follicles secrete a viscid
mucus, the quantity of which becomes consi-
derably increased under excitement or irrita-
tion. It serves to lubricate the several parts
of the vulva.
The vidvo-vaginal glands, termed also the
glands of Bartholin and of Duvernay, consist
of two conglomerate glands of the size of a
haricot bean, variable in form, and of a pale
reddish yellow colour, which are placed one
upon each side of the vagina near the entrance
(Jig. 480. g). They are lodged beneath the
superficial perineal fascia, having their inner
side united to the vagina by areolar tissue, and
their outer surface in relation with the con-
strictor muscle of the vagina. The lobules
composing this gland send off tubules which at
its upper and fore part unite to form an excre-
tory duct that proceeds horizontally forwards
as far as the vaginal orifice, upon the side of