CHAPTER XXVIII
THE DIAGNOSIS OF THE GYNECOLOGICAL AFFECTIONS OF INFANCY AND CHILDHOOD
Importance of examining the-genitals, p. 555. The examination, p. 556.
Anomalies, p. 557: Adherent prepuce, p. 557. Labial hernia, p. 558. Hydrocele of the labium majus, p. 559. Imperforate hymen, p. 500. Im- perforate rectum and anus, p. 561. Prolapse of the uterus, p. 562. Erosion of the cervix, p. 563. Precocious menstruation and precocious maturity, p. 564.
Diseases of the vulva and vagina, p. 566: Vulvo-vaginitis, p. 566; Simple vulvo-vaginitis, p. 566; Gonorrheal vulvo-vaginitis, p. 5G(>, Symptoms, p. 568, Diagnosis, p. 568; Tuberculosis of the vulva, p. 568; Diphtheritic vulvitis, p. 569. Gangrene of the vulva, or noma, p. 569. Sarcoma of the vagina, p. 570.
Genital hemorrhages, p. 571 : Hemorrhage from the vulva in the new- born, p. 572. Hemorrhage from the vulva in little girls, p. 572. Metrorrhagia of puberty, p. 573.
Masturbation, p. 574.
Malignant disease of the uterus, p. 576.
Diseases of the ovaries and tubes, p. 576: Diagnosis, p. 576.
Diseases of the bladder, p. 578 : How to collect the urine in infants, p. 578. Peculiarities of urination, p. 578. Enuresis, p. 578. Bacterinria. p. 579. Cystitis and stone in the bladder, p. 581. Primary tumor of the bladder. |>. 582. Hematuria, p. 583.
Diseases of the rectum, p. 584 : Prolapse of the rectum, p. 584. Proctitis, p. 585. Fissure in ano, p. 585. Incontinence of feces, p. 585.
With the march of progress the gynecological affections of chil- dren that were formerly thought to be so infrequent as to merit little attention, are now known to be not only not rare, but of con- siderable importance from the standpoint of prophylaxis, if from no other. Practically all the diseases found in tin1 adult have now- been observed in children. It IS a well-known fact thai the genitals of the female infant are n< »1 so carefully looked after by the physician and nurse as are those of the male child. Abnormalities of the prepuce in the latter are almosl always noted, while Hie vulva ol
the little girl is not systematically inspected. Neglecl of abnor- malities and disease in the female infant -such, for instance, asaD insufficient opening in the hymen, adhesions of the aymph©, or vulvo-vaginitis— provide in later years for retained menses, or in-
556 INFANCY AND CHILDHOOD
fection of the genital tract, enuresis, masturbation, or salpingitis, — or for uterine malpositions, which are the result of previous pelvic peritonitis. The relatively frequent occurrence of sarcoma of the vagina in infants, its rapid and fatal course, make delay in diagnosis especially dangerous. Also, diseases of the urinary organs are by no means rare and deserve prompt attention.
EXAMINATION
The examination of the genital organs in children varies from that in adults in that the anatomical parts are very much smaller and the little patient's attention has to be distracted and her good- will obtained in greater measure before the investigation can be carried through. The use of an anesthetic becomes neces- ! sary more often in the case of children than in adults, in order to secure the essential relaxation. A digital examina- tion of the vagina should seldom be at- tempted in children. If the vagina is | to be examined it must be inspected through a Kelly cystoscope of the largest size that will enter the vagina without rupturing the hymen ; artificial light and _^___A a head mirror being employed as de-
Fig. 203. -The Infantile scribed in the chapter on the investiga- Vulva. (Williams.) tion of the bladder (Chapter VIII., page
110). The knee-chest position is the best posture for the examination. (See Fig. 205.)
The recto-abdominal touch (see Chapter V., page 53) is the one to be employed in palpating the pelvic organs in children. For this an anesthetic is generally necessary in the case of very young children, but in older children, if their confidence can be gained, ether may not be required. The utmost gentleness and delicacy of touch must be employed in making palpation because of the relatively small size of the sphincter ani and the friable nature of the rectal wall in infants and children. The sad accident has occurred of the examining finger making a rent through the
ANOMALIES 557
rectum into the peritoneal cavity because too much force was used. Because of the relatively greater length of the examining finger and the small size of the pelvis and the close proximity of the abdominal organs, it is possible in little children to palpate the iliac, hypogastric, and umbilical regions through the rectum, and, in addition to the pelvic organs, in this manner to feel a diseased appendix or enlarged mesenteric glands. Be on the lookout for a full bladder, which is an abdominal organ in the child, and may simulate a cystic ovarian tumor or a collection of pus.
ANOMALIES
The development of the external genital organs is described in the chapter on the diseases of the vulva (Chapter XXI., page 392) and the reader is advised to consult this description and Figs. 158 to 162, page 395, also Fig. 71 (from Kollmann), page 198, show- ing the development of the ovaries, tubes, uterus, and vagina, before taking up the congenital affections seen in children. Fig. 204, page 558, after Webster, shows the anatomy of the pelvic organs in the new-born child. Note that the vagina is relatively long, the cervix is long compared with the body of the uterus, and the uterus is in a position of retroposition with anteflexion, besides being high in the false pelvis.
The congenital anomalies of the vulva, vagina, uterus, tubes, ovaries, — also of the bladder and rectum, are treated at length in the chapters devoted to these subjects. In the present chapter we will consider only those defects of the generative organs that cause symptoms during childhood and with which the practitioner must be familiar.
Adherent Prepuce. — Adhesion of the prepuce to the clitoris with retained smegma is a not uncommon condition in female infants and children. Some; authors consider that the prepuce is adherent normally. W. A. Edwards (supplement to Keating's "Cyclopedia of Diseases of Children," p. 872) noted adhesions of the labia minora nine times in his private records of the births of two hundred and fifty female children. He says further thai he has been accus- tomed to see several cases of adherent prepuce in children every year. It is doubtful whether adherent prepuce is often a cause of
558
INFANCY AND CHILDHOOD
grave nervous disease, but this acts sometimes as a cause of local irritation and of enuresis in children. In cases of wetting of the bed the genitals should be inspected carefully to rule out this abnormality. The irritation caused by the adhesion of the prepuce is thought to be a cause of masturbation, — at any rate the prepuce is often found adherent in masturbators.
Labial Hernia. — An inguinal hernia sometimes passes along the round ligament and appears in the labium ma jus. This condition
Fig. 204. — Longitudinal Median Section of the Pelvis of a New-born Child. (After Webster.) Showing relatively long cervix and vagina, retroposition with anteflexion, straight sacrum and cartilaginous coccyx.
is seen in late childhood occasionally, and not rarely in infants. The hernial sac may contain omentum, intestine, or ovary and tube. Hernia of the ovary, sometimes accompanied by its tube, has been met fairly often in female infants under eighteen months of age, it being due apparently to the normal position of the ovaries and tubes in infancy close to the internal openings of the inguinal canals (sec Fig. 206), to a patent canal of Nuck, or a shortened round ligament. ,,The protrusion can be traced to the external abdominal ring above, and is limited to the upper portion of the
ANOMALIES 559
labium. If it contains omentum it is irregular to the feel and flat to percussion, and if intestine it is smooth and has a tympanitic note. The sac is generally reducible by taxis if the patient is re- cumbent unless it contains an ovary, when it is firmer, flat on per- cussion, tender, and can not be returned to the abdominal cavity. Labial hernia is to be distinguished from hydrocele of the labium majus and tumor of the labium.
Hydrocele of the Labium Majus. — Should the peritoneal invest-
Fig. 205.— Examination of the Infantile Vagina and Cervix with a Kelly Blad- der Speculum. (Kelly.)
ment of the round ligament extend downward nearly to the end of the ligament in the labium instead of terminating as normally in the inguinal canal, this sac of peritoneum (the canal of Nuck) may become filled with serum, thus forming a hydrocele. In this case there is a firm ovoid tumor in the labium with its smaller end upward. It can not be reduced, it is Hat on percussion, and its up- per pole Is generally separated by an appreciable distance from the external abdominal ring. If the hydrocele is of large size, fluctua-
560 INFANCY AND CHILDHOOD
tion may be made out. The condition is a rare one and is dis- tinguished from labial hernia in not being reducible and in presenting a flat percussion and fluctuation. The differentiation from a tumor of the labium may be impossible. Tumors are apt to be in the lower part of the labia and they are of even rarer oc- currence.
Imperforate Hymen. — Imperforate hymen, as pointed out in