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| {{Ref-Gellhorn1904}}
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| PAPERS
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| PRESENTED TO THE COUNCIL BT THE
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| CANDIDATES ELECTED TO FELLOWSHIP
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| TWENTY-NINTH ANNUAL MEETING.
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| ANATOMY, PATHOLOGY AND DEVELOPMENT OF THE HYMEN.
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| By George Gellhorn, M.D.,
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| St. Louis, Mo.
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| In a discussion of the female genital organs the hymen
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| must be given separate consideration. An exact knowledge
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| of the anatomy and pathology of the hymen is important
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| not only from a practical point of \'iew, but also because it
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| affords valuable evidence concerning the development of the
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| female genitaha. Systematic investigations of the nature of
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| the hJ^nen, however, meet with some difficulty inasmuch as
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| suitable post-mortem material is not easily obtained and
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| portions of tissue excised during life are not often at our
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| disposal. The observations imderlying this article are based
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| upon the microscopic examination of fifteen specimens of
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| hymen, as follows:
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| 1. From a fetus 8 inches long.
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| 2. From a fetus 9^ inches long.
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| 3. From a fetus lOf inches long.
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| 4. From a fetus of 25 weeks.
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| 5. From a fetus of 7 months.
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| 6. From a fetus of 8 months.
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| 7. From a newborn (macerated).
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| 8. From a girl of 3 days.
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| 9. From a deflorated girl of 19 years.
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| 10. From a virgin of 20 years.
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| 11. From a virgin of 20 years.
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| 12. From a deflorated girl of 30 years.
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| 13. From a virgin of 62 years.
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| 14. Caruncle from a woman of 49 years.
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| 15. Caruncle from a woman of 76 years.
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| Anatomy. — The hymen is a membrane situated at the
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| junction of the vulva and vagina, partially closing the entrance
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| of the latter. Older reports speak of the site of the hymen
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| as being sometimes higher up in the vagina. Cumston/ in
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| a medicolegal essay, refers to a trial for rape, in 1777, at
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| which trial it was admitted by the medical authorities that
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| the hymen was in some cases situated an inch or an inch and
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| a half "beyond the vagina." Krimer^ found, in a woman of
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| twenty years, the hymen high up, 2 cm. above the vaginal
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| entrance, the vulvar orifice seeming at first sight to lack the
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| membrane altogether. Turnipseed' and Fort* stated that
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| the hymen in the negress is situated from one and a half to
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| two inches above the entrance of the vagina and is of greater
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| density than that of the white woman. These statements
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| were at once contradicted by Hyatt^ and Smythe;° and
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| inasmuch as no similar observations have since been recorded,
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| we are safe in attributing them to inaccurate examination or
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| erroneous diagnosis.
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| Aside from the human female, the hymen, according to
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| Hirst,' is formed in the ape, bitch, bear, donkey, hyena, and
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| giraffe; and according to Nagel,* also in the horse, cow, and
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| pig. Bischoff," on the other hand, states that the hymen is
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| lacking in the anthropomorphic apes.
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|
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| The macroscopic appearance of the hymen is in the
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| majority of cases that of a semilunar fold. Next to the
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| crescentic form in frequency is the annular variety, in which
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| the hymeneal opening is circular in shape. Less frequently
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| other forms of hymen are found. The septate hymen has
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| two openings separated by a bridge of tissue. The cribriform
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| hymen shows a number of small openings resembling a sieve.
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| The fimbriated hymen has small papillary excrescences upon
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| its free edge. In the imperforate hymen, the membrane is
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| completely occluded. INIost modern text-books give instructive illustrations of these and other even more unusual
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| varieties, and a glance at these pictures explains the macroscopic differences better than words.
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| Hymen of a Iftus of twenty-five weeks (Case 4). (ieneml survey : h, hymen ;
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| c. epithelial mantle; c eomieetive-tissue stroma: va. \asina with papjlL-e; vu,
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| vvilva: ^ laljiuni minus; /.m, labium majus.
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| % Ir
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| Hymea of a fetus ol eight mouths (Case 6) : /, fibrous band connecting
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| the slender basal papillEe (p) with the hymen proper (h) and shutting off a
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| mass of epithelial cells (e); rti, vulva; m, vagina.
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| Fig. 3.
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| Hymen of a fetus of seven months (Case 5): ni, vulva; h.vu, vulvar side of
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| hymen; h.va, vaginal side of hymen.
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| The color of the hymen is white or hght pink. In the
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| fetus it is, Hke the vagina, distinctly white and in marked
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| contrast to the pinkish color of the vestibule. I shall refer
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| later to this decided difference in color. The thickness and
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| consistence of the hymen vary widely from a structure
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| delicate as a spider's web to a dense, ligamentous, even
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| cartilaginous or "bony" membrane.
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|
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| In its position and relation to the vulva the hynaen in the
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| fetus projects forward into the cleft between the labia in the
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| form of two apposed longitudinal lips. (This condition exists
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| also in the newborn and in the young child, while in the
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| virgin the membrane is generally supposed to be stretched in
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| a more or less vertical plane when the indi\'idual is Ijang in
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| dorsal posture. Cullingworth,'" however, pointed out that
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| on separating the labia minora in such a manner as not to
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| disturb the situs of the structures lying behind them, the
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| hymen can be seen in the same position as in the fetus and
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| infant — i. e., eversion of closely apposed longitudinal lips.
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|
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| In the hymen we distinguish, first, the base, the point at
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| which it rises from the underlining tissue; second, the edge,
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| which is differently shaped according to the individual case;
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| and third, two sides or surfaces, the inner (upper, vaginal)
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| and outer (lower, vulvar) surface. \Miile, according to
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| Dohrn," one week after the first appearance of the h^nnen
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| it is as fully developed as is usual in the newborn, the microscopic picture varies with the age of the bearer. The h_\Tnen
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| is composed of a dense connective tissue covered on either
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| side with epitheUum. In the fetus it projects in the form of
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| a long slender fold exhibiting on either surface numerous
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| filiform and conical papillfe. Kolliker,'^ Dohrn" and others
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| describe these papillae only upon the inner surface, but
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| Schaffer'^ had already pointed out that they are almost invariably found also on the vulvar side. Among the papillje which
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| in their turn frequently possess smaller secondary papillae,
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| there is one of conspicuous length found with great frequency
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| upon the vaginal side springing from the base of the hymen or immeiiiatelT below it and extendio^ more or less panDd to
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| tbe hTmen itself. This foki of tissue is oonsadered bj SdaSet
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| &s tbe inDer, vaginal lameila (see p. 171 1; while Kkin" sees
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| in it tbe rPTnna.nt of tbe septum betB-eec tbe Mulknais ducts.
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| Tbe epitbelium is of tbe usual multilaTered pavement Qpe.
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| Tbe cells of the faoLsal la^^er are cubsooqrliQdiic, dien
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| follows a layer of lower cabk: cells and several la^cts of
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| polrbedral cells -wfaidi beoome graduallj Sattened tomrd dbe
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| surface. ik» outensost layers oonsistJng of tfain, plate-Iike
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| cells. KeratiiiizatioQ does sot occur in this earir stage, the
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| nucki tbrougbout taking tbe stain readily. UsoaDy the
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| epitbelium is slightly higher upon tbe Taginal sui&oe. TTie
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| epitbeHmn iiprai tbe vul-rar ade in these cases has a someirhat compressed appearance; the layeis fo&oving the basal
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| layers are not poJyhedraJ bat mariEfidlr flattenpd. This condition is -risible in tbe hymens of the sixdi and serentfa fetal
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| months (Tigs. 2 and 3).
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| Tbe hymen of the Deirbom is of omsdcEaUy greater size.
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| A very long papilla was in one of my spedmess foimd upon
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| tbe vulTar sde Case S. Fig. 4i. From the time betveea
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| birth and nineteen years no specimens were at my
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| Case 9 ''nineteien years; and Case 10 ftwenty years ; ]
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| witbin tbe rather compact hymen nnmeroas sixst and a few
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| longer slender papilla which peneizated deep into the qiitheJial mantle, without, hcwerer, altenmg ifae smoodi outer
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| surface- On the other hand, in a seoond case of twenty yea*%
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| (Case 11), the smfaoe of tbe hymen dxfw&A indentations,
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| corresponding with the large jajslte there present. The
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| latter possessed ntimerous secondary japills (Tig. 5j. The
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| same appearance was present in the hymen of thirty years
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| {Qzse 12 ). Tbe process from the inner surface of vhidi we
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| hare spoken abore was in this case maiiedly increased in
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| H2e- The epihelial mantle in all of these eases was Toy
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| tiiick but nowhere comiSed. The comaectiTe tissne m the
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| hymen of the fetus, newborn and adult,!? dense widmnnaeioas
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| nadei. Only in the papllke is the stroctore somewfaat looser.
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| The bundles of connective tissue seem to be directly continuous with the vaginal connective-tissue fibres. In the
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| amount of nuclei as well as in the density of the fibres, the
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| hymen is readily distinguished from the vulva. The blood
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| supply is rather rich. Numerous bloodvessels and capillaries
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| are seen even in the tips of the finest papillae, and in the
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| hymen of the adult wide lumina are visible (Fig. 5).
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| In the last specimen, that of a virgin of sixt\-two years
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| (Case 13), the rather short hymen presents, on cross-section, a
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| somewhat tongue-shaped appearance and is covered with a few
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| layers of cells with scanty protoplasma, but well-staining
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| nuclei. The connective tissue shows no papillar}- elevations
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| except a few low ones on the vulvar side. It is greatly
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| increased, especially near the base, and its fibers form large
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| bundles, with markedly diminished blood supply.
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|
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| To study the distribution of elastic fibers in the h\-men,
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| Weigert's stain was used. Broadly speaking, a gradual
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| increase both in number and thickness of the elastic fibres
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| takes place throughout the e.xistence of the membrane. In
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| the fetal hymen elastic fibers are present as soon as the membrane is formed, but they are very delicate and can be seen
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| only with the oil-immersion lens. Running along the base
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| of the epithelium can be seen a fine elastic fiber. This fiber
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| closely follows the contours of the hymen and seems to form
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| an uninterrupted elastic membrane. Only in some of the
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| finer papillse is the continuity lacking in the earher stages,
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| but in the fetal h\-men of eight months the elastic membrane
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| has reached even these points. This membrane does not send
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| any processes into the adjoining tissues, and nowhere do
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| elastic fibers penetrate into the epithehal mantle. In the
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| connective-tissue stroma there are but a few thin, short
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| elastic fibers which run in a longitudinal direction, parallel
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| to the connective-tissue fibers. The capillaries near the tip
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| of the hymen have no elastic fibers. Only the larger vessels
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| near the base have a very fine, internal elastic membrane.
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| An outer circular laver of elastic fibers in the adventitia of arteries is visible only in a few instances in the eight months'
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| hymen. From this external membrane a few very delicate
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| fibers emerge into the adjacent bundles of connective-tissue
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| fibers and there assume a longitudinal direction. ■
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|
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| In the hjTnen at full term the elastic fibers are readily seen
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| with the oil immersion. In the papillte they appear in long
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| bundles which enter into the finest ramifications of the
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| papillae. They surround the capillaries in the papillje and
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| near the free edge, without, however, entering into closer
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| union with them. In the vessels of the deeper layers, the
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| deUcate internal elastic membrane, upon which lies the
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| endothehum, can be readily distinguished from the outer
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| elastic membrane in the adventitia. The two membranes are
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| connected by a very few elastic fibrils. in the transverse
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| sections of larger arteries of the base such anastomotic fibers
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| in the circular muscular layer between the two membranes
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| are numerous. iThe elastic fibers emanating from the adventitia are hkewise increased in number. The fibers in the
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| connective tissue run both longitudinally and transversely,
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| and increase in quantity but not in size nearer the base.
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|
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| In the adult, the elastic fibers in general are thinner and
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| less nimierous in the higher portions near the edge than
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| toward the base. In the latter the field of vision is almost
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| entirely filled with a network of dehcate fibers surrounding
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| the connective-tissue bundles. In the hymen of a girl of
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| nineteen (Case 9), a few months after defloration, the newformation of elastic fibers at the torn edge is excessive. The
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| elastic membrane at the base of the epithelium, which consisted of but a single fiber in the fetus, is composed of a
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| complex arrangement of delicate fibers which are wound
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| about themselves. In general, the elastic fibers may be
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| divided into two groups, one more or less circular around the
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| hymeneal opening, the other extending radially towards the
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| base.
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| Fin. 4.
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| Hyiucii (if (he iirwliorii (Case 8): (i. loiifr. slender papilla on vulvar surl'ac
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| Ximicrous lil()i)(lvc's«-l.s in coniicetive-tissup struma.
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| Fig. .5.
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| Hymen nf the adult (I'asc 11. Iweiil\ years). Larsje i)apilla-. Hieh Mood
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| supply. .\uNierous lymph s|)aees and \ cs.sels.
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| Fig. e,.
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| Sensory nerve-endings in hymen excised on account of vaginismus (from
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| Amann): p, pavement epithelium surrounding a papilla, which is almost
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| entireh- filled by an enlarged end-bulb of Krause.
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| fl.B.Streedain del
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| Genitals of a fetus of twenty-five weeks (Case 4). The longitudinal folds
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| (/) of the lowest portion of the vagina (ji) turn inward at the vaginal
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| entrance and run parallel to the hymen (/i), thus simulating l)ilamellation;
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| h, bladder.
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|
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|
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| With growing age the elastic fibers perceptibly increase in
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| quantity and size and take the stain very readily. In the hymen of sixty-two years (Case 13), the elastic tissue is
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| stained ad maximum after being exposed to the stain but
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| five minutes. The network at the base of the epithehum consists of a thick, entangled mass. The elastic fibers throughout the hymen are shorter and in some places seem to have
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| nodular swellings.
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|
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| Smooth muscle fibers have repeatedly been found in the
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| normal hymen (Savage,'^ Budin," Hirst'). Their presence,
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| however, is not the rule. In my specimens I found them but
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| once, in the hymen of nineteen. In this case in. the deeper
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| layer near the vulvar side could be seen a few fibers that
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| took the yellow color of the picric acid in Van Gieson's stain,
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| though rather diffusely. This hymen was well formed but
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| not unusually thick. On the other hand, the very fleshy
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| hymen of a girl of twenty (Case 11, Fig. 5) did not contain
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| any muscular elements. The fleshy appearance in this case
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| was produced by an increase of connective tissue and the
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| very rich blood supply. In certain pathologic conditions,
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| such as atresia — congenital or acquired — smooth muscle
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| fibers have been found with greater uniformity. Henkel"
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| and V. Tussenbroeck'* found numerous smooth muscle fibers
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| in their cases of hymeneal atresia. In the wall of h}Tneneal
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| cysts Palm'' and Ziegenspeck^" detected traces of smooth
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| muscle fibers.
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|
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| In order to demonstrate nerves and nerve endings in the
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| hymen the methods of INIarchi and Azoulay and the nigrosin
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| and uran carmine methods were employed. Numerous
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| attempts to find the structures in question proved unsuccessful. The great difficulties of staining the peripheral nervous
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| system are well known, and failure in demonstrating the
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| nerves should, in the first place, be referred to faulty technic.
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| The nature of my material made it impossible for me to
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| employ the methylene-blue method, which is supposed to
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| give the best result. The possibility of a fault on my part,
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| therefore, prevents me from passing a definite judgment on
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| the question of the nerve supply of the hymen. The literature on the subject, moreover, is extremely meager. Only
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| older reports (E. Klein,^' Budin'°) speak in a somewhat
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| sweeping way of "the highly vascular and nervous mucous
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| membrane." On the other hand, authors who have studied
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| the nerve supply of both the internal and external genital
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| organs since the introduction of more perfected laboratory
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| methods (v. Gawronsky," Koestlin"^) do not mention the
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| hymen at all, though their researches are very exhaustive
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| otherwise. Wechsberg*' stained an excised portion of an
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| atresic hymen with hemalaun and eosin and found "here and
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| there nerves in transverse and longitudinal sections." The
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| only author who gives a detailed description of nerves in the
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| hymen is Amann.^^ He found in two hymens excised for
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| vaginismus Krause's terminal bulbs well developed in the
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| papillse (Fig. 6).
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|
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| In this connection I may be permitted to speak of a number
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| of clinical observations which I have made during the last
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| year or two. I am aware that the value of such observations
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| with regard to the question in hand is very limited, but I
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| think that these investigations possess a certain interest.
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|
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| As is well knovra, fear or anticipation of being hurt produces, in a great many women, to a certain extent, the
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| sensation of pain. If we succeed in eliminating this psychic
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| factor, we obtain a more objective criterion as to the presence
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| of pain. Thus I have tried to determine the sensitiveness of
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| the hymen w^th regard to mechanical and thermic irritations.
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| If the attention of the patient be diverted, I find that one
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| can exert pressure and even sHght traction upon the intact
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| hymen by means of a dressing forceps ■n'ithout causing any
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| pain. In women after defloration in whom the hymen is well
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| preserved aside from one or two lateral lacerations, the
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| hymeneal lips may be pressed or pierced without pain.
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| Neither is there any thermic sensitiveness. If the vestibule
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| is carefully avoided, the patient cannot state whether she is
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| touched with a hot or cold instrument. Following the experiments of Calmann,^^ who examined the sensibilitj' of the vagina and uterus, by means of small test tubes filled with
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| hot and cold water, I arrived at the same results as far as
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| the hymen was concerned. In two instances pain was caused
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| by the slightest touch. One of these was a girl of eighteen,
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| with an intact hymen, who suffered from pruritus vulvae;
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| the other was a prostitute of twenty-seven, with myrtiform
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| caruncles, who w^as recently infected with gonorrhea. In
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| these cases the sensitiveness may have been due to the pathologic condition of the genitals. From the above observations
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| I am inclined to believe that the pain in defloration is due
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| to the psychic condition of the indi\-idual and to the forcible
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| dilatation of the vaginal entrance. Especially the latter seems
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| to play an important role. In a nulhparous woman of thirtytwo whose hjTneneal lobes were not sensitive to touch or
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| pressure, coition was extremely painful until a gradual dilatation of the vaginal entrance by means of tubular specula was
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| effected. The normal dilatation by coition had not taken
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| place on account of some anomaly on the part of the husband.
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|
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| I have digressed somewhat from my subject not because
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| I am able to bring any positive proofs about the presence or
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| absence of nerves in the hymen, but because I think that
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| these clinical notes make the existence of a very rich nerve
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| supply rather improbable. Possibly future attempts to
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| decide the question liistologically may be more successful.
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|
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| According to Kollmann,"^ in the newborn mucous glands
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| are found in the fold between the hjTnen and labia minora.
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| These glands, which are in great number in the labia minora
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| and surround the entire vaginal entrance, are found also in
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| the fossa navicularis in immediate proximity to the h'STuen,
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| and represent simple or ramified tubules 0.3 to 0.7 mm. in
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| length. In the hymen itself distinctly glandular structures
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| were found by Ruge^' and RinchevaP" upon the inner surface
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| in a case of atresia. Klein," in the hymen of a fetus 27 cm.
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| in length (five months), observed glandular invaginations of
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| the epithelium of the outer surface. Such invaginations have
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| been described by Schatfer as crypts. Similar blind ducts were also found by Fleischmann.^ In his case there was one,
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| 13 mm. in length in the left side of the iiymen, another in
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| the right side 6 mm. long. The epithelium of these ducts
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| was directly connected with that of the surface. In.Piering's^
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| case, small, well-filled vesicles with thin walls were found
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| near the free edge almost completely surrounding the
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| hymeneal orifice. Upon histologic examination these vesicles
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| were found to be lymphectasias.
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|
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| The latest and most exhaustive researches have been by
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| R. jNIeyer.^" He found six different varieties of glands or
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| gland-like structures in the h\Tnen of the fetus and newborn;
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| viz.: (1) glands of the vaginal type upon the inner, vaginal
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| side; (2) remnants of the Wolffian ducts; (3) glands or glandular tubules situated about the base of the hymen in the
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| sulcus nymphohymenalis and in the fossa navicularis and at
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| times extending into the base of the hymen; (4) real glands
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| of the outer, vnilvar surface; (5) invaginations of the epithelium of the outer surfaces; (6) genuine pavement cell cysts
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| underneath the outer surface. I myself found glands in one
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| instance. The hymen of the eight months' fetus (Case 6)
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| had at its base a few transverse lumina of glands lined with
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| a cuboidal epithelium. These were at some distance from
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| the surface and showed, in several sections, no communication with the latter. No serial sections, however, were made.
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|
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| Henle^' found exceptionally "erectile tissue" in the hymen.
| |
| So far as I know this observation has not yet been corroborated by others.
| |
|
| |
| The elasticity of the hymen is under rare circumstances
| |
| so great that it remains unruptured even at childbirth. As
| |
| a rule, however, the first coition or accidents such as falling
| |
| astride of an object or violent exercise will rupture the delicate
| |
| membrane. The number of tears which divide the hymen
| |
| into "lobes" varies in the individual case. Heahng takes
| |
| place with considerable new-formation of elastic and connective tissue. Very rarely such tears unite; if such should
| |
| happen a cicatrix may remain.
| |
|
| |
|
| |
| Parturition definitely destroys the form of the hymen.
| |
| Only small rests — carunculse myrtiformes — resembling warts,
| |
| are left. ^Microscopically, the caruncle represents a compact
| |
| tissue of rather conical shape and set wdth a few short papillae.
| |
| The caruncle of long standing (Case 15, seven ty-si.x years)
| |
| appears merely as a dome-shaped elevation whose papillae
| |
| have disappeared. The blood supply of the younger caruncle
| |
| (Case 14, forty-nine years) is very rich; that of the older very
| |
| scanty. The superficial layers of the epithelium are cornified
| |
| and the keratinization extends into the deeper laye'rs between
| |
| the papilla^. The process of cornification is present only
| |
| about the hymen and, in a very few places, in the adjoining
| |
| vaginal mucosa, but not in the adjacent portion of the
| |
| vestibule. The elastic tissue is greatly increased both in
| |
| quantity and in the size of the individual elastic fiber, and
| |
| fills almost the entire field of vision.
| |
|
| |
| As to the formation of caruncles, Schroder " holds that the
| |
| hymeneal lobes during childbirth are compressed and undergo
| |
| gangrene, while Bellien'^ believes that the lacerations of the
| |
| hymen, during labor, extend through the base of the membrane into the perivaginal connective tissue; cicatrization and
| |
| consequent shrinking of these tears produce caruncles.
| |
|
| |
| I am inclined to ascribe to the elastic tissue a certain role
| |
| in the formation of caruncles. As described above, the
| |
| elastic fibers are unequally distributed within the hymen, the
| |
| portions nearer the base containing more and thicker fibers
| |
| than the periphery. So long as the hymen is preserved in
| |
| its entirety, or only torn into a few large lobes which but
| |
| little alter the form of the hymen, the upper more delicate
| |
| fibers encircling the hymeneal opening exert an action counter
| |
| to that of the radial fibers which tend to retract toward the
| |
| base. If, however, the hymen, in childbirth, is torn into a
| |
| number of small pieces, each piece retracts owing to the
| |
| more powerful action of the radial fibers. For some time
| |
| after, one is able to pull each caruncle to its original length,
| |
| but after long standing the retraction results in an atrophy of the entire caruncle to a great extent through insufficient
| |
| circulation. Regarding the retraction of elastic fibers, we
| |
| know from numerous examinations that only the fibers of
| |
| thin or medium size are really elastic. Thick fibers, such as
| |
| are found in old age, are unyielding, and only such were
| |
| observed in the caruncle referred to above.
| |
|
| |
| Pathology. The pathology of the hj-men may be divided
| |
| into: (1) inflammations; (2) malformations; (3) neoplasms.
| |
|
| |
| Inflammation of the hymen may start primarily in this
| |
| membrane itself or may originate in adjacent organs and
| |
| tissues. As to the latter or secondary form, it is to be expected
| |
| that the hymen, as a part of the vagina, may be affected by
| |
| inflammatory processes which originate in the vagina and
| |
| descend toward the vaginal entrance. Thus the different
| |
| varieties of colpitis, including those that are produced by
| |
| affections of the uterus, may lead to inflammation of the
| |
| hjTnen. Acute infectious diseases such as cholera, variola,
| |
| scarlatina, measles, etc., not infrequently produce secondary
| |
| inflammations of the entire vaginal tract and, as we shall
| |
| later see, play an important role in the origin of acquired
| |
| atresia. On the other hand, the inflammatory process may
| |
| ascend from the vulva. Gonorrheal infection here deserves
| |
| the first place. Contamination with the colon bacillus, or
| |
| ascarides emigrating from the neighboring anus may cause
| |
| inflammation, and irritation from lack of cleanliness produces
| |
| a similar effect. The inflamed hjTnen has a markedly
| |
| reddened appearance and bleeds easily. Occasionally small
| |
| excoriations are seen. The surrounding tissues have in
| |
| general the same appearance. The microscopic changes in
| |
| the inflamed hymen have not as yet been studied in detail,
| |
| but in analogy with similar processes in the vagina we may
| |
| expect to find round-cell infiltration in the connective tissue
| |
| and a desquamation of epithelium so that this layer is either
| |
| very much thinner or, in places, is altogether absent.
| |
|
| |
| The same pathologic conditions may, after defloration,
| |
| affect the hymeneal lobes and, after childbirth, the mjTtiform caruncles. Thus, in a case of recent gonorrhea, I found the
| |
| mjTtiform caruncles considerably thickened, deep red in
| |
| color and extremely sensitive.
| |
|
| |
| Primary inflammation of the hymen is due either to
| |
| masturbation or coitus. In two girls who admitted masturbation, I found the otherwise intact hymen considerably thickened, grayish-white and edematous. Gosselin^' describes
| |
| cases in which onanism led to pathologic sensitiveness of the
| |
| hymen.
| |
|
| |
| In some cases the hymen, though normal, is particularly
| |
| rigid; in others its orifice is large enough for the introduction
| |
| of the penis without laceration. In any of these cases where
| |
| there is a pushing back or dilatation of the membrane, it
| |
| thickens, inflames, and becomes very sensitive (Pozzi'*).
| |
| Fritsch^'^ considers this rigidity of the hymen as secondary
| |
| The impotent husband with a non-erectile penis or suffering
| |
| from precocious ejaculation does not succeed in perforating
| |
| or lacerating the membrane. The continuous insults lead to
| |
| inflammation of the introitus vaginje and hjinen, and even
| |
| to a purulent discharge. Inflammation of the hjTnen is the
| |
| foremost factor in vaginismus.
| |
|
| |
| It might be supposed that the specific lesions of syphihs
| |
| and chancroid would occasionally be found upon the hjTuen.
| |
| The text-books on venereal diseases, however, which I consulted, make no special mention of such an occurrence; only
| |
| Veit'' pictures a hymen whose posterior margin is destroyed
| |
| by a hard chancre.
| |
|
| |
| As to dermatologic affections of the hjTnen, recent Hterature contains the report of Carriere.^* This auther observed
| |
| three cases of vuhdtis impetiginosa in children. In these
| |
| eases the major and minor lips and the hymen were, at first,
| |
| reddened and swollen. After a few days, the affected parts
| |
| showed an eruption of miliary vesicles which afterward
| |
| opened and gave rise to small ulcerations, the latter containing
| |
| staphylococci.
| |
|
| |
| Traumatisms of the hymen have been extensively dealt with by Veit.*' The majority of injuries occur in the first cohabitation and in childbirth, and as such traumatisms must be
| |
| considered physiologic, they have been spoken of in the first
| |
| part of this paper on the normal anatomy of the hymen.
| |
| Veit is quite right in distinguishing this class of hymeneal
| |
| injuries from the severer ones produced by violent or abnormal coition. In such cases a profuse hemorrhage from the
| |
| torn hymen may occur which demands medical interference.
| |
| The literature on this subject is rather extensive and has been
| |
| thoroughly considered by Veit. I agree with this writer that
| |
| in cases of copious hymeneal hemorrhage other adjacent parts
| |
| must have been injured. In one case in my recollection the
| |
| young, newly married woman was brought into the clinic
| |
| almost pulseless. Upon examination a deep tear of the
| |
| hymen was found which commenced in the left upper
| |
| quadrant and extended through the paraurethral tissue into
| |
| the base of the clitoris.
| |
|
| |
| Malformations of the hjTiien are either congenital or
| |
| acquired. Total absence of hymen, reports of which are
| |
| found in older literature, has not been observed by modern
| |
| authors, and such authorities as Breisky" and Schaifer,"
| |
| while not denying the possibihty, consider this phenomenon
| |
| exceedingly rare. It can, however, occur only simultaneously
| |
| with total absence of the entire genital tract, which in its turn
| |
| is found only in embryos incapable of surviving. In this
| |
| connection I might mention as a curiosity the intentional
| |
| destruction of the hymen practised in several parts of India
| |
| and throughout China. Ploss^' relates that the native nurses
| |
| employ digital cleansing of the vagina in earhest childhood
| |
| so thoroughly that the hymen in time disappears altogether.
| |
| Thus not even the native physicians in Cliina know anything
| |
| about the existence of a hymen. Ploss himself examined a
| |
| girl of European descent, but born in China, and found no
| |
| trace of this structure. Similar customs resulting in the total
| |
| demohtion of the hymen exist among several Indian tribes
| |
| in South America and certain savage nations of the Malay Archipelago. These manipulations, however, are not dictated
| |
| by a desire for cleanliness, but rather by immoral reasons.
| |
|
| |
| The existence of a true double hymen— one behind the
| |
| other — has not been proved. Breiskj^' saw, in two newborn
| |
| females, a very thin membrane closing the lower portion of
| |
| the vagina, close behind a well-formed hymen, and, furthermore, a firm septum retrohymenale in a \irgin fifty-four
| |
| years old. Both he and Dohrn" consider these septa due to
| |
| a coalescence of folds of the vaginal mucous membrane
| |
| immediately behind the hjTnen. Such a formation is facihtated, as Dohrn points out, by the fact that at this point the
| |
| lumen of the vagina is narrow even pre\'ious to the appearance of the hymen. ]Moreover, Piana and Bassi^' found that
| |
| in this area epithelial conglutinations in the human fetus are
| |
| "physiologic." We shall speak later of the h\Tiien bilamellatus of Schaffer in reference to double hymen.
| |
|
| |
| A double hymen — one beside the other — has repeatedly
| |
| been found in cases of double vagina and is easily explained
| |
| in the light of embryologic studies of the development of the
| |
| genital tract.
| |
|
| |
| In connection with these cases of hymen duplex cum
| |
| vagina septa it must be emphasized that congenital malformations of the hjTnen are impossible without anomalous
| |
| development of the rest of the internal genitals. This holds
| |
| true especially of the most frequent form of malformation of
| |
| the hymen, viz., atresia.
| |
|
| |
| Nagel' and Veit'° forcibly declare that only a minority of
| |
| atresias of the female genitals can be considered as of congenital origin. Those of the hjTnen, hymen imperforatus, are
| |
| found only where other parts of the Miillerian ducts are
| |
| malformed. That form of hjTneneal atresia which is caused
| |
| by a conglutination of the h^nneneal folds in utero, the rest
| |
| of the genitals being normal, cannot be classified as a congenital atresia, a "\4tium primos formationis." All other
| |
| cases of atresia which show a normal formation of the
| |
| internal genitals — and these form the great majority — must be considered as acquired. C. v. Tussenbroeck,'" through
| |
| the microscopic study of a case of "hymeneal" atresia,
| |
| opposes this theory of Nagel and Veit. Her original publication in the Dutch language was not at my disposal, so that
| |
| I had to rely on a short abstract in the ZenfralblaU fiir Gyndkologie and on one of her drawings reproduced in an article
| |
| by Stratz.^' v. Tussenbroeck points out that while the
| |
| normal hymen consists only of vulvar and vaginal epithelium
| |
| and connective tissue between the two epithelia, her case of
| |
| hymeneal atresia contained in the intermediary tissue also
| |
| smooth muscle fibers and bloodvessels but showed no signs
| |
| of a previous inflammation. She takes the stand that in this
| |
| case no hymen has been formed and that the septum consisted, in the first place, of the lower ends of the atresic
| |
| jNIiillerian ducts with their surrounding secondary layer of
| |
| smooth muscle fibers, and, secondly, of the floor of the imperforate sinus urogenitalis. The patient, a girl of twenty-four
| |
| years, possessed otherwise perfectly normal internal and
| |
| external genitals.
| |
|
| |
| While Stratz, Treub and Bolk expressed their agreement
| |
| in the discussion following this demonstration of v. Tussenbroeck, Pincus,^^ who strongly seconds the \'iews of Nagel,
| |
| points out that the absence of signs of pre\'ious inflammation
| |
| is no positive proof against the supposition of an acquired
| |
| atresia, and Henkel," in a similar case of hymeneal atresia,
| |
| was able to show microscopically the presence of a chronic
| |
| inflammatory condition and to demonstrate numerous mast
| |
| cells and leukocytic wander cells.
| |
|
| |
| A critical review of the numerous cases reported as congenital atresias convinces one of the strength of Nagel's
| |
| theory. In the light of this theory, cases of pregnancy and
| |
| childbirth with imperforate hymen are readily understood.
| |
| V. Gu^rard*^ compiled about fifty instances of this sort from
| |
| literature and added five observations of his own. This goes
| |
| to prove that atresia may occur at any time in the adult.
| |
| Even repeated atresias may take place. In this respect the third case of v. Gu^rard is unique. The patient in the
| |
| seventh month of her first pregnancy complained of intense
| |
| pain in the genitals. Although she had pre\-iously been
| |
| operated upon twice for atresia h\-menalis, the vagina was
| |
| now fomid completely occluded by a firm and extremely
| |
| sensitive membrane. After total excision of this membrane
| |
| all symptoms promptly ceased, and normal delivery took
| |
| place at term.
| |
|
| |
| In the majority of instances, however, the formation of
| |
| atresia dates back to earlier years of life. A careful anamnesis
| |
| in such cases will often reveal its cause. Neugebauer," with
| |
| his well-known assiduity and admirable thoroughness, has
| |
| gathered almost 1000 cases of gynatresias from Uterature.
| |
| In 479 of these cases the atresia was undoubtedly acquired.
| |
| In almost 300 the anamnesis was negative. Neugebauer
| |
| himself says that it would be a mistake to interpret the lack
| |
| of data in the history in favor of the congenital origin of the
| |
| malformation. He refers to atresias in general, and it is clear
| |
| that the same reasons must pertain to hjTiieneal atresias.
| |
| The etiologic factor is furnished either by acute infectious
| |
| diseases such as were enumerated above, which lead to
| |
| inflammatory processes in the genital system, or by vulvovaginitis due to gonorrhea or other causes. The inflammation subsequent to an acute infectious disease may make
| |
| itself manifest at once or may remain unnoticed, as for
| |
| instance in the case reported by Thienhaus.*^ In the latter
| |
| event the result of the inflammation, viz., more or less firm
| |
| coalescence of the hymeneal folds, will not be noticed until
| |
| at puberty the menstrual flow is obstructed. Even if, at that
| |
| time, signs of pre\'ious inflammation should not be found in
| |
| the imperforate hymen, this would not speak against the
| |
| atresia being acquired. ]\Ieyer" has proved from literature the
| |
| acquired origin of atresia even in the absence of any scars,
| |
| and Odebrecht" points out that cicatrices acquired in infancy
| |
| completely disappear within a few years on account of increased cellular vitality. If several sisters present hymeneal atresia, the inference is justified that the children were simultaneously affected by the same acute infectious disease.
| |
| Pincus cites a very interesting case reported by Madge."
| |
| Four sisters, two to ten years old, had hymeneal atresia; the
| |
| fifth child, a boy, had phimosis. Pincus rejected the supposition of heredity in this case and is inclined to ascribe this
| |
| coincidence to the action of some obnoxious factor common
| |
| to the five children, such as baths, sponges, or towels.
| |
|
| |
| This somewhat lengthy consideration may be thus summarized : In all cases of hymeneal atresia with normal functionating genital system, the condition is acquired. Here the
| |
| occluding membrane causes the retention of menstrual blood
| |
| and leads to hematocolpos, hematometra, etc.
| |
|
| |
| The hterature on the histology of hjTiieneal atresia is not
| |
| very great. The reports of v. Tussenbroeck'' and Henkel"
| |
| have been recorded above. A recent contribution to this subject was furnished by Wechsberg.'^ The patient, a girl aged
| |
| fourteen years, had had measles, chicken-pox and whooping cough. She came to the hospital with the symptoms of
| |
| hematocolpos, which an examination revealed to have been
| |
| caused by an imperforate hymen. Wechsberg excised a small
| |
| portion of the membrane. Upon microscopic examination
| |
| both surfaces of the specimen showed papillae, those upon
| |
| the vaginal side being the larger. The vulvar surface was
| |
| covered by pavement epithelium, the vaginal side by a single
| |
| layer of high cylindric cells. On the vaginal side, however,
| |
| there were at one point, on the outer surface of a conspicuously
| |
| large papilla, ex'idences of keratinization. On the vulvar
| |
| side, cornification was seen throughout the uppermost layers
| |
| of the epithelium. Within the connective-tissue stroma there
| |
| were smooth muscle fibers, numerous lymph spaces and
| |
| vessels, and a few nerves. There was no round-cell infiltration
| |
| nor other signs of previous inflammation such as cicatricial
| |
| tissue.
| |
|
| |
| Wechsberg refers to a similar case reported by Rincheval"
| |
| in which there was found multilayered pavement epithelium upon the outer surface, while the inner surface was lined with
| |
| cylindric epithelium which in places presented glandular
| |
| invaginations into the dense connective tissue.
| |
|
| |
| In the observation of Kochenburger" the excised hjTnen
| |
| had multilayered epithelium on its outer surface and cuboidal
| |
| epithelium on its inner side. Kochenburger considered the
| |
| latter to be the basal layer of the epithelium after the upper
| |
| layers had been macerated by the accumulated blood in the
| |
| occluded vagina and had been cast off. This epithelium
| |
| resembled that found upon erosions of the portig vaginalis
| |
| uteri. In corroboration of this \'iew the upper layers of the
| |
| pavement epithelium were seen to persist in some places
| |
| while in others they had undergone degenerative processes,
| |
| but were still in connection with the basal layers. From his
| |
| findings Kochenburger deduced that in hymeneal atresia the
| |
| origin of epithelial cells resembling cylindric epithelium is
| |
| due to pressure, infiltration, imbibition, atrophy, and necrosis.
| |
| Wechsberg, however, maintains that in his and Rincheval's
| |
| cases the cylindric epithelium is primary inasmuch as no
| |
| signs of cell degeneration could be detected; staining for
| |
| mucous degeneration resulted negatively, and the cylindric
| |
| cells themselves were high and took the ordinary stains
| |
| readily. In his opinion, the differentiation of the cylindric
| |
| epithelium primarily present in the vagina of the embryo
| |
| into pavement epithelium had not taken place in the small
| |
| portion excised. Upon the rest of the hymen and on the
| |
| walls of the vagina multilayered pavement epithelium was
| |
| found.
| |
|
| |
| These arguments of Wechsberg in favor of an embryonal
| |
| origin of the atresia in his case are not convincing. It would
| |
| be strained to suppose that only the very small portion which
| |
| was excised should have remained in an embrj'onal state. Nor
| |
| is the absence of degenerative signs sufficient proof. I believe
| |
| Kochenburger is right in comparing this condition with the
| |
| erosion of the portio vaginalis uteri. In this affection, after
| |
| the upper layers have been destroyed by the pathologic process and have entirely disappeared, only the basal layer
| |
| remains, the cells of which under the irritating influence may
| |
| be stimulated to more excessive growth of size and length.
| |
| They even invade the underlying tissue, forming the so-called
| |
| glands of erosion, and I am inclined to ascribe a similar
| |
| origin to the glandular formations mentioned in Rinchcval's
| |
| case.
| |
|
| |
| Neoplasms of the hymen are very rare. To this group
| |
| belong the cysts. I found in literature a total of 17 cases of
| |
| hymeneal cysts reported by Bastelberger,^° Doderlein,^"
| |
| Piering,^' Ziegenspeck," ■" Miiller," Goerl,^^ Ulesko-Stroganowa,'* Palm," ^° Marchesi," Lannelongue and Achard,"
| |
| Theilhaber,^* and Ricci.^' These cysts occur on either side
| |
| of the hymen, but more frequently on the outer surface.
| |
| They may attain the size of a cherry and are occasionally
| |
| multiple. Ulesko-Stroganowa's case presented one cyst on
| |
| either side. In the case of Ricci, there was a small cyst in
| |
| the wall of the larger cyst. In Ziegenspeck's third case two
| |
| smaller cysts were found at the base of the main -cyst. Piering
| |
| observed a number of very small transparent cysts around
| |
| the edge of the hjinen. Microscopically, the hymeneal cysts
| |
| have been carefully studied. On the outside they are covered
| |
| with the hymeneal epithelium. Beneath this lie layers of
| |
| more or less dense connective tissue with well-developed
| |
| papillae and numerous capillaries, in some cases combined
| |
| with smooth muscle fibers. The inner surface is lined with
| |
| epithelium, usually of the pavement variety, varying in
| |
| thickness. In other cysts the epithelium has a more cuboidal
| |
| or even cylindric character (iSIarchesi). This variation
| |
| depends upon the source of origin, which we shall presently
| |
| consider. The cysts may contain detritus and epithelium, or
| |
| a homogeneous, yellowish-brown, jelly-like substance, or else
| |
| a watery fluid. The latter may consist of lymph fluid
| |
| (Piering), or may contain blood corpuscles (Ulesko-Stroganowa). Ricci's cyst, the size of a cherry, which he so carefully examined, contained 1 c.c. of a thick, dark-brown liquid, the microscopic examination of which revealed
| |
| epithelial cells in large number, detritus of blood corpuscles,
| |
| fat droplets, glossy masses of amber color apparently consisting of red corpuscles and fat drops, and a small amount of
| |
| hematic pigment.
| |
|
| |
| Cysts of the hymen may develop in four different ways,
| |
| viz. :
| |
|
| |
| 1. By invagination and separation ("Abschniirung") of
| |
| hymeneal epithelium (cases of Bastelberger, Ziegenspeck,
| |
| Goerl).
| |
|
| |
| 2. From rests of embryonal tissue within the substance of
| |
| the hymen. This mode of origin is claimed by Ricci for his
| |
| case. He cites the observation of Pestalozza,^ who found
| |
| ectodermal embryonal rests within the stroma of a hjTnen.
| |
|
| |
| 3. By conglutination or coalescence of converging hymeneal
| |
| folds. This mode was first suggested by Dotlerlcin, who
| |
| observed a pronounced development of folds upon the outer
| |
| side which in places approximate. When the tips of these
| |
| folds become completely conglutinated, a space is shut off,
| |
| which at first is filled with epithelial cells. By gradual
| |
| necrosis and liquefaction of the central cells a lumen is
| |
| formed and a cyst produced. Doderlein's view is strongly
| |
| supported by Schaffer." According to this writer, the folds
| |
| of the embryonal hymen are usually obliterated by the
| |
| upward growth of the connective tissue. In many instances,
| |
| however, these folds coalesce at the end of the papilla, thus
| |
| leaving a pocket of epithelium. One of my own specimens
| |
| shows that fibrous bands may extend from any point of the
| |
| papilla to the hymen and separate a mass of epithelium
| |
| which may eventually give rise to a cystic cavity (Fig. 2).
| |
|
| |
| 4. By retention of contents : (a) In lymph spaces (Piering) ;
| |
| (6) in portions of the ^YolfBan ducts within the hymen. In
| |
| the report of Ulesko-Stroganowa and in one of Alarchesi's
| |
| cases, the cysts were lined with cylindric epithelium similar
| |
| to that of the Wolffian ducts; (c) of a sebaceous gland. Palm
| |
| considers his two cysts as true atheromata. This author bases his views upon the macroscopic and microscopic
| |
| similarity to genuine atheromata found in other parts of the
| |
| body, mainly the labia minora, and upon the supposition that
| |
| the few true glands which have been found upon the inner
| |
| and outer side of the hjTnen (Ruge, Klein) are of a sebaceous character.
| |
|
| |
| Of other benign neoplasms of the hymen I have found two
| |
| observations of polypus" and one case of angioma.'^ The
| |
| original articles, however, I could not obtain.
| |
|
| |
| Of malignant diseases of the hymen there exists in literature but one case of sarcoma reported by Sanger.^' A child
| |
| of three years had a profuse foul vaginal discharge, and
| |
| occasionally a tumor of the size of half a finger appeared at
| |
| the entrance of the vagina. From the vulva hung two bodies
| |
| like mucous polypi, pediculated from the posterior hymeneal
| |
| border. There was a still larger tumor with ulcerated surface,
| |
| distending the vagina and sessile on the anterior wall. There
| |
| existed, in addition, a number of polypoid excrescences, like
| |
| hydatids, occupying various portions of the vaginal membrane, and numerous metastases in the broad ligaments and
| |
| the rectovaginal septum. INIicroscopically the tumor proved
| |
| to be a typical round-cell sarcoma.
| |
|
| |
| Development. Four theories of the development of the
| |
| hymen have been advanced which may be briefly characterized as follows:
| |
|
| |
| 1. The hymen is the product of the INIullerian ducts
| |
| (KoUiker, Dohrn, Nagel, Klein).
| |
|
| |
| 2. The hymen is the product of the sinus urogenitalis
| |
| (Pozzi).
| |
|
| |
| 3. The hymen is the product of both the Miillerian ducts
| |
| and the sinus urogenitalis (Schaffer).
| |
|
| |
| 4. The hj-men is the product of the Wolfiian ducts (Hart).
| |
| I begin vnth the last and chronologically latest theory which
| |
|
| |
| is advanced by D. Berry Hart,'^ °^ but was in somewhat
| |
| similar form pubUshed by v. Hoffmann^" in 1878. Hart
| |
| formulates his theory as follows: The hymen is formed by a special bulbous development of the lower ends of the two
| |
| Wolffian ducts aided by an epithelial involution from below
| |
| of the cells lining the urogenital sinus. The terminal parts
| |
| of the Miillerian ducts are at first solid epithelial cords, the
| |
| epithelial mass being derived from the bulbous termination
| |
| of the Wolffian ducts. These Wolffian bulbs after having
| |
| mapped out the vaginal portion of the uterus and the fornices
| |
| of the vagina, coalesce, break down in the center and form
| |
| the lumen of the vagina. The coalesced Wolffian bulbs, then
| |
| protrude into the urogenital sinus and thus form the hymen.
| |
| The epoophoron, the paroophoron, and the Wolffian ducts
| |
| near the uterus and upper part of the vagina are all useless
| |
| and dangerous relics to women, giving rise to many pathologic conditions simple as well as malignant. Only at the
| |
| lower end of the Wolffian ducts do we get an actual normal
| |
| utilization in the development of the hymen, the relining of
| |
| the vagina and cervix with an ectodermic multilayered
| |
| epithelium and the opening up of the imperforate eminence
| |
| of Miiller where the IMiillerian ducts end blindly.
| |
|
| |
| This theory was accepted by Keith" and Garrigues" and
| |
| seems to be supported by a case of persistence of the urogenital sinus recorded by Purslow." This case is interesting
| |
| enough to be quoted more in detail. A well-developed girl
| |
| aged twenty-three years sought medical aid for dysmenorrhea.
| |
| Micturition was always normal. The pubic hair was well
| |
| developed. On separating the labia, there was seen an
| |
| unusually well-marked hymen having a crescentic opening
| |
| in front, which would admit the index finger. Immediately
| |
| within the hymen, but quite distinct from it, was a firm
| |
| fibrous ring contracting the opening into the vagina, and just
| |
| admitting the tip of the little finger; but the finger could not
| |
| be forced through this narrowed part of the canal, which gave
| |
| the impression of being about 1 cm. in length. A catheter
| |
| passed through the hymeneal opening readily into the bladder,
| |
| and urine was v^dthdrawn. The clitoris was not enlarged.
| |
| The constriction, together with the hymen, was divided by deep incision wdth a bistoury, and the orifice was well
| |
| stretched until it would admit three fingers. It was then
| |
| ascertained that the constricted portion communicated at its
| |
| upper end wth a capacious vagina, and that at the junction
| |
| the bladder opened by an aperture which admitted the tip
| |
| of the finger and appeared to have very Uttle sphincter power.
| |
| There was no trace of a urethra. In this report there are
| |
| several important points of information lacking. From the
| |
| history we do not know whether the patient in her childhood
| |
| had suffered from any acute infectious disease which might
| |
| have led to inflammation and consequent stricture of the
| |
| vagina. WTiat was the condition of the uterus and appendages? Was the dysmenorrhea due to a malformation of the
| |
| internal genitals, or did it cease after the operation?
| |
|
| |
| In Hart's theory there are several weak points. In the
| |
| first place, it is difficult to understand that an organ should
| |
| form an intrinsic part of the human economy only at its lower
| |
| end while the rest forms a dangerous anomaly. Secondly,
| |
| systematic researches of other investigators result in an
| |
| altogether different conception of the course of the WolflBan
| |
| ducts. Until recently the majority of observers believed that
| |
| the Wolffian ducts terminated at or near the cer\nx uteri in
| |
| the upper part of the vagina. This view can no longer be
| |
| held. Beigel, Dohrn, and v. Ackeren first described rests of
| |
| the Wolffian ducts along the entire length of the vagina, and
| |
| Klein,'" in 1897, demonstrated in serial sections the course
| |
| of the Wolffian ducts at either side of the vagina and the
| |
| termination of these ducts in the hymen. These sections
| |
| were taken from the genitals of the newborn and of a girl,
| |
| aged four and one-half years. The findings of Klein were
| |
| confirmed by many observations of Meyer^° in the fetus and
| |
| newborn. He found in seventeen cases larger remnants of
| |
| the Wolffian ducts in the vagina and especially within the
| |
| hymen. Here the ducts entering the base of the hjTnen from
| |
| the posterior wall of the vagina run upward within the
| |
| hymeneal tissue and usually open at the outer side near the free edge. It must be noted that v. Ackeren, Meyer, Klein,
| |
| and Groschuff, Seitz and Hengge, the last three working with
| |
| Klein, actually found the Wolffian ducts within the hymen.
| |
| Nagel suggests that the ducts of Bartholin's glands might be
| |
| mistaken for the Wolffian ducts and I feel inclined thus to
| |
| interpret the pictures given by Hart.
| |
|
| |
| While Hart holds that the vagina is derived only in its
| |
| upper two-thirds from the Miillerian ducts and in its lower
| |
| third from the sinus urogenitalis, all other theories have as
| |
| their premise that the vagina in its entirety is of Miillerian
| |
| origin.
| |
|
| |
| According to the next theory, that of Pozzi,'* the origin of
| |
| the hymen is intimately connected with that of the vulva.
| |
| On either side of the sinus urogenitalis and below the urethra
| |
| lie two corpora spongiosa which, after surrounding the
| |
| meatus urinarius, extend upward to the base of the clitoris.
| |
| From the superficial portion of these spongious organs which
| |
| remain in the fetal state, the hymen develops. I'ozzi bases
| |
| his theory upon the aspect of the external genitals and the
| |
| analogy with the frenulum in masculine hypospadias, and
| |
| upon the following clinical observations: (1) the existence
| |
| of the hymen in total absence of the vagina; (2) the presence
| |
| of a single hymen in cases of double vagina; (3) the existence
| |
| of a urethral hymen— r. e., a prolongation of the ring around
| |
| the meatus, partly or even entirely covering this orifice, which
| |
| goes to prove the close relationship between the different
| |
| parts of the hymen and the ring which surrounds the meatus.
| |
|
| |
| Cases of hymen existing in the absence of the vagina are
| |
| occasionally found. In addition to those cited by Pozzi
| |
| himself and by Neugebauer,** I have seen in recent literature
| |
| reports by Loefqist" (ten cases), Krevet,'^ and Strauss.''
| |
| On the other hand, in the majority of cases of total absence
| |
| of the vagina, no trace of a hjTnen can be found. Loefqist
| |
| himself does not consider his cases as supporting the theory
| |
| of Pozzi who, as he points out, ignores the results of embryologic studies altogether and thus denies facts verified by the microscope. In my opinion the microscopic examination of
| |
| the atresic vagina or rather of the tissues behind the hymen
| |
| will possibly throw light upon this point. The vagina must
| |
| either have been normal and become obliterated afterward or
| |
| have been atrophic from the beginning. At any rate, the
| |
| INIiillerian ducts must have reached the sinus, for otherwise
| |
| the origin of a hjTnen is inexplicable. In corroboration of
| |
| this, absence of the hymen in absence of the vagina is the
| |
| more frequent occurrence. An example is to be seen in the
| |
| case recorded by Veit" in which there was a uterus bipartitns,
| |
| but no trace of the vagina nor of the hymen could be found.
| |
| Even according to Pozzi's theory, the hymen is only then
| |
| formed from the vulva when there exists an opening which
| |
| the corpora spongiosa can surround. Pozzi's second argument of the presence of one hymen in double vagina is
| |
| balanced by observations of double hymen in double vagina.
| |
| Only last year two further cases were observed by Benno
| |
| MuUer" and ^Marchand."
| |
|
| |
| As to Pozzi's third point, the existence of a membrane
| |
| partly or totally occluding the urethra may be admitted as
| |
| of vulvar origin but need not necessarily be associated with
| |
| the formation of the hymen. According to a recent article by
| |
| Dickinson,*^ this "urethral hj-men" is a pathologic structure
| |
| due to repeated traction and found only in company with
| |
| hypertrophied nymphse. In addition to these remarks, a case
| |
| of persistent sinus urogenitalis reported by Kelly'^ is worthy
| |
| of note. The patient, a nuUipara, aged forty-six years, had
| |
| normal external genitals as far as the introitus of the vagina,
| |
| where the only opening between the rectum and clitoris was
| |
| found. There was no hymen, and the smooth orifice beneath
| |
| the pubic arch had the form of a transverse sUt. From this
| |
| orifice a short muscular canal led directly into the bladder.
| |
| Into this canal behind the orifice a double vagina opened.
| |
| It is at this point, at the opening of the Miillerian ducts into
| |
| the sinus, that a hymen should be looked for, though Kelly
| |
| does not make mention of it. The absence of an external
| |
| hymen speaks strongly against Pozzi's supposition. In conclusion, Pozzi does not bring sufficient e\ndence to prove
| |
| the fact that the hymen is independent of the ]\Iullerian
| |
| ducts.
| |
|
| |
| Schaffer," upon a careful study of an unusually large
| |
| material, propounds the following theorj-: In the fifth month
| |
| of fetal life every hjinen makes its appearance more or less
| |
| distinctly in the form of two lamellte (hymen bilamellatus) in
| |
| such a way that the inner lamella is formed by the vagina,
| |
| the outer by the vulva. Schaffer found this mode of origin
| |
| 53 times in 190 specimens. In many instances the two
| |
| lamellae unite either at once or later; in more than one-fourth
| |
| of his cases, they persisted more or less until full term, but
| |
| rarely after birth. p]ach lamella is covered with mucous
| |
| membrane on both sides so that the h}'men bilamellatus,
| |
| properly speaking, consists of four layers. Schaffer supports
| |
| his theory with the following observations: (1) frequency of
| |
| a distinctly bilamellate form (28.8 per cent.); (2) unity of
| |
| the outer lamella with a layer of vulvar mucosa around the
| |
| urethral orifice and upward to the cHtoris; (3) different stages
| |
| of the coalescence of the two lamellce by means of transverse
| |
| processes or papilla?; (4) folds or ridges of mucosa which
| |
| spring from the frenulum labiorum, the njonphse, and the
| |
| "frenulum masculinum," and end in the outer lamella,
| |
| usually at or near the free edge; (5) relation of the urethral
| |
| orifice to the outer lamella; (6) difference in the form of the
| |
| free edge of the outer and inner lamellae; (7) difference in
| |
| color and epitheHal covering of both lamellae; (8) possibility
| |
| of dissecting the outer lamellae from the inner; (9) analogy
| |
| with the portio vaginalis uteri, the growth of which is, to a
| |
| great extent, due to material furnished by the vagina; (10)
| |
| cases of single hvmen in double vagina; (11) cases of persistence of both lamellae (hjTnen duplex); (12) cases of presence
| |
| of hymen (outer lamella) in absence of vagina.
| |
|
| |
| The painstaking researches of Schaffer deserve earnest
| |
| consideration. A number of his observations coincide with those of Pozzi. The extension of the hymen beyond the
| |
| urethral orifice, in SchaflFer's description, corresponds to
| |
| Pozzi's "bride mascuHne" or "frenuhim mascuUnum." The
| |
| relation of the meatus urethrte, the folds from the surrounding vulva stretching to the outer surface of the li}'men and
| |
| the possibility of dissecting the superficial layer of the vulvar
| |
| mucosa 'hi toto, including the outer surface of the hymen, are
| |
| observations common to both authors. Only the interpretation of these facts and the conclusions drawn therefrom are
| |
| different. This is most noticeable in the arguments classified
| |
| under 10 and 12.
| |
|
| |
| There are several objections, however, to Schaffer's theory :
| |
|
| |
| 1. Schaffer states that in the first series of 103 fetuses, 42
| |
| had abnormal genitals. In a second series of 87 cases he
| |
| gives no detailed data; altogether he found hymen bilamellatus 53 times in these 190 specimens. The large percentage of cases with abnormal sexual organs in addition to the
| |
| comparatively small percentage of bilameljate hymens
| |
| actually found, to a certain extent detracts from the value
| |
| of these observations.
| |
|
| |
| 2. While a number of text-books (Gebhard," Chrobak and
| |
| Rosthorn'*) reproduce Schaffer's statements without commenting upon them, later workers in the same field emphasize
| |
| that they have not yet seen the bilamellate form in a single
| |
| instance. I refer to Klein" and Hart." Nor have I been
| |
| able to observe this formation in the seven fetal hymens of
| |
| my collection. Since Schaffer found the bilamellate hymen
| |
| in 28.8 per cent., one would expect to find it at least once in
| |
| the dozen or more cases examined by Klein, Hart and myself.
| |
| In only one instance, that of a girl, aged twenty years, I
| |
| thought at first sight to have noted a case of hymen duplex
| |
| (persistence of the two lamellae). The hymen was well
| |
| developed and of annular shape. Immediately behind the
| |
| hymen there was a second, well-marked, fleshy fold springing
| |
| from the left side of the vaginal entrance and running parallel
| |
| to the left half of the hymen. At about the median line this fold began to converge slightly toward the h}Tnen and ended
| |
| in its posterior surface a little to the right of the median line.
| |
| This fold was as high as the hymen itself and exactly like it
| |
| in appearance. After cautiously pushing aside the h>Tneneal
| |
| membrane it was Seen that this fold was but the continuation
| |
| of a longitudinal vaginal ruga which ran directly below the
| |
| juncture of the posterior and left walls of the vagina. These
| |
| longitudinal folds or rugse are of ordinary occurrence in the
| |
| lowest inch of the vagina. Fig. 7 (Case 4) shows this condition in an embryo of twenty-five weeks. Hart** also notes
| |
| that the rug£e or columns of the lowest inch of the vagina run
| |
| for the most part longitudinally; above this the vagina has
| |
| its rugffi transverse. These longitudinal folds (Fig. 7) turn
| |
| inward at the vaginal entrance and run parallel or but
| |
| slightly converging to the posterior surface of the hjTnen and
| |
| fuse with the latter at irregular points, but, as a rule, below
| |
| the free edge,
| |
|
| |
| 3. As the first formation of the h}Tnen takes place in the
| |
| nineteenth week, and as the lamell.ie, according to Schaffer,
| |
| persist more or less distinctly until term, the bilamellate form
| |
| should be \-isible, at least remnants of it, in microscopic
| |
| sections through hymens of a later fetal period. None of my
| |
| sections, however, present this form. INIoreover, the hjTiien
| |
| of twenty-five weeks, pictured in Fig. 7, which simulates
| |
| bilamellation, does not, microscopically, show two lamella?,
| |
| though the section comprises Aiilvar and vaginal portions
| |
| adjoining the hjTnen. With Klein I consider the high fold
| |
| usually found at the vaginal side as one of the numerous
| |
| papillae of the vagina and without importance in regard to the
| |
| development of the hjTnen.
| |
|
| |
| 4. Schaffer mentions the difference in color and epithehal
| |
| covering of the two surfaces. While I shall speak later of
| |
| the epithelial coverings of the two sides of the hjTnen, I may
| |
| say as to the difference in color that in the fetus I observed
| |
| the entire hymen, both inside and outside, as white, exactly
| |
| like the vagina, and contrasting markedly with the grayish red appearance of the \'ulva. I observed a similar condition
| |
| in the h\Ti>en of a \argin of twenty-five.
| |
|
| |
| Klein, '^ in his studies of the development of the h}Tnen,
| |
| advances the following theory: The hymen is that part of
| |
| the pelvic floor which is thinned out by the ampuUary
| |
| enlargement of the lower portion of the vagina. The anlage
| |
| of the hj-men is present at the beginning of the third month
| |
| when the IMlillerian ducts break through into the sinus
| |
| urogenitalis. From the third to the fifth month, the vagina
| |
| undergoes an ampullary enlargement in its terminal portion,
| |
| which in its turn leads to a stretching and thinning out of
| |
| the surrounding pelvic floor. I might suggest that this theory
| |
| does not explain the formation of the annular hymen. It is
| |
| only the posterior wall of the vagina which undergoes a
| |
| dilatation thus producing the ampulla vaginse; the anterior
| |
| wall remains unaffected and, consequently, a sj-mmetric
| |
| structure hke the annular hymen is impossible.
| |
|
| |
| Klein ascribes to the Miillerian ducts an active part in the
| |
| formation of the hjTiien. In this respect, Klein's \dews
| |
| coincide with the most generally accepted theory, that
| |
| advanced by v. KoUiker,'" v. Mihalkovicz, Budin, Dohrn, and
| |
| especially Nagel.' According to these writers the development of the hymen is inseparable from the development of the
| |
| vagina. In the human embryo of 8 to 10 mm., the INIiillerian
| |
| duct on either side may be divided into a proximal and a
| |
| distal part characterized by different kinds of epithehum.
| |
| The proximal portion, which later becomes uterus and tube,
| |
| is hollow and has cylindric epithelium. The distal part,
| |
| which becomes the vagina, has, in the beginning, no lumen,
| |
| but is filled with large protoplasmic cells of a more cubic
| |
| form. At about the third month, the lower ends of the
| |
| Miillerian ducts in their downward growth reach the sinus
| |
| urogenitalis and by the protrusion of their blind ends form
| |
| the Miillerian eminence. From this eminence the hj-men is
| |
| formed. The finer details of this process may, to my mind,
| |
| be conceived as follows. When the united Miillerian ducts reach the sinus urogenitalis they push the thin layer of
| |
| epitheUum Uning the sinus forward, and by so doing they
| |
| make this epithelium even thinner than before. This condition is clearly seen in Nagel's picture (Fig. 8). In this stage
| |
| the lower ends of the Mtillerian ducts represent a somewhat
| |
| cone-shaped solid epithehal cord. The formation of a lumen
| |
| proceeds from above downward, and this canalization corresponds with the curve of the ducts themselves with its concavity anterior. Therefore the point where the lumen of the
| |
| ducts breaks through the solid end is, as a rule, nearer the
| |
| upper border of the conus, and so is responsible for the
| |
| production of the semilunar form of the hymen which is by
| |
| far the most common. The concave course of the Miilleriart
| |
| ducts is due to the curved abdomen of the embryo. Thereby
| |
| every organ in the lower part of the body, the sacrum, rectum,
| |
| genital tract, and sinus urogenitalis, acquires a curved axis.
| |
| The extremity of the conus (]\liillerian eminence) with a more
| |
| or less eccentric lumen protruding into the sinus, consists,
| |
| at first, only of the epitheUum of the Miillerian eminence
| |
| covered on the outer surface with a very thin layer of sinus
| |
| epithelium. Only secondarily is this mass of epithehum
| |
| invaded by connective tissue. According to Nagel the
| |
| Miillerian ducts originally are composed of large protoplasmic
| |
| cells of an epithelial character. Around this mass of cells
| |
| which gradually becomes a tube, the mesodermal formative
| |
| cells are grouped in a circular arrangement, thus forming
| |
| the first anlage of the connective tissue and muscular layer of
| |
| the Miillerian ducts. In other words, the connective tissue
| |
| appears after the ducts are established and grows in proportion
| |
| to, and together with, the downward growth of the ducts.
| |
| Thus, when the ends of the ducts protrude into the sinus in
| |
| the form of an epithelial protuberance, their connective tissue
| |
| comes down with them, grows into the terminal conus and
| |
| forms the inner or central layer of the protuberance.
| |
|
| |
|
| |
|
| |
| Fig -Sagittal section through the lower third of the Mullcriau duct in a fetus
| |
| 4 cm. in length (from Xagel) : 1, Miillerian duet; 2, lower end of the same
| |
| (anlage of the vagina); 3, cylindric epithelium of the anlage of the uterus;
| |
| 4. canalis urogenitalis.
| |
|
| |
|
| |
|
| |
|
| |
|
| |
| If this be the true mode of origin, the hymen is a product
| |
| of the Miillerian ducts exclusively. The epithelium of the sinus urogenitalis does not play any active part, but only
| |
| covers the outer layers of the epithelium of the ^lullerian
| |
| ducts in the form of a very thin cuticle. Thus it is readily
| |
| understood why the epithelium of the vulva can be dissected
| |
| from the hymen as recorded above in connection with the
| |
| theories of Pozzi and ScKaffer.
| |
|
| |
| The ]\Iiillerian theory is further supported by the following
| |
| observation. It is asserted by a number of authors (Winckel,"*
| |
| Dohrn," Pozzi,'* Roze" and others) that the outer surface of
| |
| the h}Tnen is different from the inner and resembles the
| |
| structure of the vestibule in that it has, like the latter, no
| |
| papillse and that its epithelium is like that of the vestibule.
| |
| My sections, however, described above, show that the vulvar
| |
| surface has papillse as well as the vaginal surface, and I infer
| |
| the same from SchafTer's remarks on this subject. In my
| |
| sections, the papillse, it is true, are not quite as numerous nor
| |
| are they as high and richly ramified as those on the inner
| |
| side, but this difference is but comparative, and can be
| |
| explained by physical reasons. The hymen in the embryo
| |
| and in the infant, as all observers agree, protrudes into the
| |
| vulva. It thus hes in close juxtaposition to the vestibule and
| |
| its papillae are subjected to a certain degree of pressure
| |
| atrophy while the vaginal surface does not suffer any pressure
| |
| from the yielding epitheHum which at that time fills the
| |
| vaginal lumen.
| |
|
| |
| The vestibule itself has no papillae at all; its surface in the
| |
| vicinity of the hymen is perfectly smooth. It is covered with
| |
| but a few layers of flattened epithelium while the vulvar
| |
| surface of the hymen is lined with many layers of epithelium.
| |
| The slight difference in the number of epithelial layers
| |
| between the vulvar and vaginal surfaces of the hymen is,
| |
| again, explained by the same physical reasons. These conditions are strikingly ob\aous in the section through the vulva,
| |
| hymen, and vagina, of an embryo of twenty-five weeks (Fig. 1),
| |
| detailed above. In another section through the hymen of a
| |
| seven months' fetus the epithelium on the vaginal side is very thick; that on the vulvar side is only about half as thick.
| |
| This latter epithelium appears compressed; the cells adjoining the germinative basal layers are markedly flattened
| |
| instead of being polygonal, as is usually the case in multilayered pavement epithelium.
| |
|
| |
| I am well aware that the form of epithelium, because of
| |
| its changeability, cannot establish a theory, but it can
| |
| support \'iews which are otherwise well founded. Embryologic studies and macroscopic or clinical observations alone
| |
| cannot decide the question. It must be supported by
| |
| histologic examination, the value of which has thus far been
| |
| underestimated. Under this heading I should Hke to call
| |
| attention to certain features of the connective-tissue structure
| |
| which to my knowledge have not heretofore been pointed
| |
| out. In all sections examined the fibers of connective tissue
| |
| are distinctly seen to run in a straight line from the vagina
| |
| into the hymen. Account of this was given in the first part
| |
| of this paper. It may here suffice to reiterfite this observation.
| |
| The great mass of the hymen appears as a direct continuation
| |
| of the connective tissue of the vagina, and only at the base
| |
| a few semicircular fibers connect the hjniien with the stratum
| |
| of the vulva. The latter can by its looser structure be
| |
| differentiated from the more compact vaginal and hymeneal
| |
| connective tissue and so clearly shows the hymen to be of
| |
|
| |
|
| |
| vaginal origin.
| |
|
| |
| Bibliography.
| |
|
| |
| 1. C. G. Cumston. On the Significance of the Hymen Intactus.
| |
| Annals of Gyn. and Ped., Jan., 1904.
| |
|
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| 2. Krimer. Hufeland's Journal, Sept., 1834; cited by Pozzi.
| |
|
| |
| 3. E. B. Turnipseed. Some Facts in Regard to the Anatomic.
| |
| Differences between the Negro and AATiite Races. Amer. Joum. of
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| Obst., 1877, vol. X, p. 32.
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|
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| 4. C. H. Fort. Some Corroborating Facts, etc. Ibid., p. 258.
| |
|
| |
| 5. H. O. Hyatt. Note on the Normal .\natomy of the Vulvovaginal Orifice. Ibid., p. 253.
| |
|
| |
| 6. A. G. Smythe. The Position of the Hymen in the Negro Race.
| |
| Ibid., p. 638.
| |
|
| |
| 7. B. C. Hirst, in Clinical Gynecology, edited by J. M. Keating and
| |
| H. C. Coe, 1895, p. 244
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|
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|
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|
| |
| 8. W. Nagel. Entwickelung und Entwickelungsfehler der weiblichen Genitalien. Veit's Handbuch der G^vnakologie, 1897, Band 1.
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| |
| 9. Bischoff. Abhandl. der K. Bayr. Akad., 1879; cited by Pozzi.
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|
| |
| 10. C. J. Cullingworth. A Note on the Anatomy of the Hynien, etc.
| |
| Journal of .A.natomy and Ph\'S., 1893, vol. xxvii.
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|
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| 11. F. A. R. Dohrn. Die Bildungsfehler des Hymen. Zeitschr. f.
| |
| Geb. u. Gyn., Bd. 11.
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| 12. A. V. KoUiker. Manual of Human Microsc. Anatom)', 1860,
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| p. 465.
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|
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| 13. O. Schaffer. Bildungsanomalien der weibl. Geschlechtsorgane,
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| etc. Arch. f. Gyn., 1890, Bd. 37.
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| 14. G. Klein. Entstehung des H^nnen. Wien^ 1894.
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| 15. H. Savage. The Female Pelvic Organs, 1876, p. 3.
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| 16. Budin. Recherches sur rh\-nien et rorifice vaginal. Prog. M^d.,
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| 17. Henkel. Tr. Gjti. and Obst. Soc, Berlin. Zeitschr. f. Geb. und
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| 18. C. van Tussenbroeck. Tr. Dutch Gynec. Soc. Zentralbl. f.
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| 20. R. Ziegenspeck. Ueber die Entstehung von Hymenalcj'sten.
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| 21. E. Ivlein, in S. Strieker's Manual of Human and Comparative
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|
| |
| 22. N. V. GawTOnsky. Ueber Verbreitung und Endigung der Nerven
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| in den weibl. Genitalien. Arch. f. Gyn., 1894, Bd. 47.
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|
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| 23. R. Koestlin. Die Nervenendigungen in den weibl. Geschlechtsorganen. Fortschritte der Medicin, 1894, No. 11-12.
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| 24 J. A. Amann, Jr. Lehrbuch der Mikrosk.-Gynak. Diagnostik,
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| 1897, S. 35.
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|
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| 25. A. Calmann. Sensibilitatspruefungen am weibl. Genitale.
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| 26. J. Kollmann. Lehrb. der Entwickelungsgesch. des Menschen,
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| 1898.
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| 27. C. Ruge. Cited by Breisky.
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| 28. Fleischmann. Eine Bildungsanomalie des Hj-men. Zeitschr. f.
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| 29. O. Piering. Zur Kenntniss der Cystenbildung im HjTnen. Prager
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| Med. Wochenschr., 1887, S. 409.
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| 30. R. Meyer. Ueber Driisen der Vagina bei Foten und Neugeborenen. Zeitschr. f. Geb. u. Gyn., 1901, Bd. 46.
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| 31. Henle. Cited by Pozzi.
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| |
| 32. Schroder. Schwangerschaft, Geburt u. Wochenbltt; cited by
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| 33. Bellien. Arch. f. Gyn., Bd. 6, S. 132.
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| |
| 34. S. Pozzi. Medical and Surgical G}aiecology. Amer. Transl.,
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| vol. ii; cited by Pozzi.
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| 37. A. Breisky. Diseases of the Vagina. Cyclopedia of Obst. and
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|
| |
| 38. H. Ploss. Das Weib in der Xatur und Volkerkunde. 1899, Bd.
| |
| 1, S. 197.
| |
|
| |
| 39. Plana and Bassi. Rivista CUnica di Bologna, Nov. 1874; cited
| |
| by Sehaffer.
| |
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| |
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| |
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| |
|
| |
| 41. C. H. Stratz. Blutanhaufungen bei einfachen und doppelten
| |
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|
| |
| 42. L. Pincus. Praktisch wichtige Fragen zur Nagel-Veit'schen
| |
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|
| |
| 43. V. Gu^rard. Schwangerschaft und Geburt bei undurchbohrtem
| |
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|
| |
| 44. F. V. Neugebauer. Zvir Lehre von den angeborenen u. erworbenen Verwachsungen. Berlin, 1895.
| |
|
| |
| 45. O. Thienhaus. Atresia Hymenalis. Joum. Amer. Med. Assoc,
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| July 20, 1901.
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|
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| 46. R. Meyer. Zur Aetiologie der GjTiatre.sien, etc. Zeitschr. f.
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| 47. Odeijrecht. Discussion. Zentralbl. f. Gya., 1894, S. 126.
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|
| |
| 48. Madge. Tr. Obst. Soc, London, vol. xi. p. 213; cited by Pincus.
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|
| |
| 49. Bastelberger. Cyste im Hymen. Archiv. f. G>-n., Bd. 23, S. 427.
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|
| |
| 50. Doderlein. Ein Fall von angeborener Hj-menalcyste. Arch. f.
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| 51. R. Ziegenspeck. Ueber Cysten im Hyemn Neugeborener. Archiv
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| f. Gyn., Bd. 32.
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| 52. Miiller. Ein Fall von angeborener H\'menalcyste. Archiv f.
| |
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| 53. Goerl. Cyste ira Hvmen einer Em-achsenen. Archiv f. GjTj.,
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| Bd. 42.
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| 54. Ulesko-Stroganowa. Zur Pathologie der Hymenal und Vaginalcysten (russ.). Monatsthr. f. Geb. u. Gyn., Bd. 2, S. 269.
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|
| |
| 55. P. Marchesi. SuUe cisti imenali. Arch Ital. di Gin., 1900; cited
| |
| bj- Ricci.
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| 56. R. Palm. Beitrag zur Entstehung der Cysten im Hjinen bei
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| 57. Lannelongue et Achard, cited by M. G. Marion. Les kystes du
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| 58. Theilhaber; cited by Ziegenspeck.
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| 61. D. C. Gunenier. Deux observations de polypes de la membrane
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| vol. xiii, p. 309.
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|
| |
| 62. Vascular Excrescence on the Hymen. New Jersey M. Reporter,
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|
| |
| 63. M. Sanger; cited by Breisky.
| |
|
| |
| 64. D. Berry Hart. Morphology of the Human Urinngenital Tract.
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|
| |
| 65. D. Berry Hart. The Development of the Urinogenital Tract.
| |
| Brit. Med. Journ., Sept. 13, 1902.
| |
|
| |
| 66. V. Hoffman. Tr. Germ. Gyn. Soc, 1878. Transl. in American
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|
| |
| 67. A. Keith. Human Embryology and Morphology, London, 1902.
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| |
| 68. H. J. Garrigues. Diseases of Women, 1900.
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| |
| 69. C. E. Purslow. Persistence of the Urogenital Sinus. Brit. Med.
| |
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| |
|
| |
| 70. G. Klein. Ueber die Bezeihungen der Miiller'schen zu den
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| 1897, vol. ix. S. 163.
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|
| |
| 71. R. Loefqist. Ausgebildeter Hymen bei Defect der Vagina.
| |
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|
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| 72. Krevet. Castration bei fehlender Schiede. Zeitschr. f. Geb. u.
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| |
| 73. Strauss. Miinchener med. Wochenschr., 1904, No. 4, S. 177.
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| |
| 74. B. Miiller. Ein Fall von Vagina duplex und Hymen duplex.
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| 75. F. Marchand. Ueber Verdoppelung der Vagina bei einfachen
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| 76. H. A. Kelly. Operative Gynecology, 1899, vol. i. p. 288.
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| |
| 77. C. Gebhard. Pathol. Anatomic der weibl. Sexualorgane, 1899.
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| 80. F. V. Winckel. Diseases of Women. Amer. Transl., 1887.
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| |
| 82. Robert L. Dickinson. " Urethral Labia" or "Urethral Hymen."
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| |
