Chapter XXI., page 396, is a misnomer, the condition being gener- (Part 1)

Chapter XXI., page 396, is a misnomer, the condition being gener- ally one of atresia of the lower part of the vagina. It is rare and generally causes no symptoms until menstruation is established. The results of not recognizing it until puberty are so deleterious to the patient that the obstetrician should satisfy himself by a careful examination of the genitals of every new-born girl, not only that the hymeneal opening is not closed, but that it is of suffi- cient size to afford proper drainage to the vagina. For, if it is not, infections and inflammations are more likely to occur in later years. This point can be determined easily by passing a catheter into the vagina. If the catheter will not pass, a proper opening into the vagina should be established by operation. The physician will do well to bear in mind that atresia of the vulva and vagina arises in many cases from the infectious diseases and is not, as formerly taught, "congenital." An apparent trifling infection of the genitals in childhood, accompanied by minor symp- toms, may result in closure of the vaginal opening or a gluing together of the nymphse. Therefore, the physician should watch his female infants and girls who are suffering from typhoid fever, smallpox, scarlatina, and diphtheria, with great care, having this possibility in mind. As pointed out by Nagel in 1896, it is rare to find true congenital atresia of the vagina except in cases where there is also present some arrest of development of the uterus or ovaries. L. Pincus (Monatsschr. fur Geb. und Gyn., 1903, XVII., p. 751) has maintained that a majority of cases of primary absence of the menses, supposed to be due to congenital obstruction of the vagina, are really caused by atresia of the vagina accompanying or follow- ing the infectious diseases, and he has reported cases which bear out his contention. According to him and contrary to common belief, typhoid fever is the most frequent cause of atresia, and H. A. Kelly (" Medical Gynecology," page 248) has collected nine ANOMALIES 561 cases from the literature in which typhoid fever was the cause of vaginal atresia. Smallpox, as we might expect from the nature of the disease, comes next in frequency, and cases are reported of atresia following dysentery, pneumonia, erysipelas, cholera, scar- latina, and diphtheria. Attention has been called to this subject only in recent years so that the number of reported cases is not as yet large. To overlook atresia in a child is an easy matter, therefore the importance of instituting a minute inquiry as to the presence of vulvar irritation or discharge in a female child suffering from an infectious disease is apparent, and in the presence of atresia in children of more mature years the mother should be questioned as to whether these symptoms had existed during or following infectious disease in the child in the past. Imperforate Rectum and Anus. — Starr (" American Text-Book of Diseases of Children") has estimated that malformation of the rectum and anus occurs about once in ten thousand births and is more common in girls than in boys, — if we include anus vaginalis. As has been pointed out elsewhere (see Chapter XXVI., page 495) the rectum and anus are developed from entirely different struc- tures of the blastoderm — the former from the hind-gut, the latter from the proctodeum — therefore malformation of one does not necessarily imply abnormality of the other, and observations show that where the rectum is malformed or displaced the anus is com- monly normal, and vice versa. Imperforate Rectum. — Imperforate rectum is comparatively common, the rectum ending in an open tube on a level with the reflection of the peritoneum on the rectum, due presumably to the failure of the hind-gut to send out a bud (the post-allantoic gut) to meet the proctodeum. The imperforate rectum may open into the vagina, and in this case, unless imperforate hymen is present also, there is an escape of meconium or feces by the vagina. Imperforate Anus. — Imperforate anus, due to failure of develop- ment of the proctodeum, is a not uncommon anomaly. There may be no trace of the anus, or its situation may be marked by a slight depression or by a wart-like prominence. Imperforate anus with anal canal ending in the vulva is common and is confounded with imperforate rectum having a vaginal outlet. Incontinence of feces is generally present in these cases. 562 INFANCY AND CHILDHOOD Anus well formed and the anal canal ending above in a cul-de-sac is not uncommon. In this anomaly the child on straining causes the septum dividing the rectum from the anal canal to protrude from the anus. The obstetrician should examine the anus of every new-born child with a view to discovering the abnormalities just described. His little finger well anointed and introduced through the sphincter ani will go a long way toward finding an anomaly before it has caused serious symptoms. A thorough examination must be Fig. 206.— Pelvic Organs of a Female Infant at Birth. (After Bland- Sutton.) Showing elongated ovaries and the Fallopian tubes in close relation with the internal abdominal rings. instituted in case a baby has not had a movement of the bowels within twenty-four hours after birth and in case there is incontinence of feces. Prolapse of the Uterus. — Prolapse of the uterus in a new-born child is a rare condition. Ballantyne and Thompson (Amer. Journ. Obstet.j 1897, Vol. II., p. 35) reported eight cases from the literature and their own experience. The anomaly seems to be associated with lumbo-sacral spina bifida and rectal prolapse, — often with club-foot and sometimes with hydrocephalus, so that it may be ANOMALIES 563 regarded as one of those congenital malformations that occur in children destined to have a short life. Two cases are on record of prolapse in girls of thirteen, due in one case to a persistent cough and in the other to carrying heavy burdens. I have myself seen a case of prolapse in a stout full-grown virgin due to a chronic diarrhea with tenesmus. Erosion of the Cervix. — Congenital erosion of the cervix is a con- dition that would hardly excite the attention of the general prac- titioner unless it were accompanied by a persistent vaginal discharge. In such an event it may be recognized by speculum examination of the vagina. Leopold first called attention to the occurrence of erosions in babies and children in 1872. Fischel (Arckiv. filr Gynaekol, 1880, Bd. XVI., S. 192) found cervical erosions which he examined microscopically in four fetuses still-born at term, in two infants a few days old, in an infant fourteen days old, and in three infants three, four, and five weeks old, respectively. As a rule, the external os in these cases is found in the form of a narrow transverse opening amounting often to a split in the crown of the cervix. The opening is surrounded by a reddened, velvety area from three to four millimeters wide. Sometimes the eroded area extends higher up on the lateral surfaces of the cervix than on the anterior and posterior aspects, and in other cases the erosion is limited to the crown of the cervix where the cervix comes in contact with the posterior wall of the vagina. These observations of Fischel have been confirmed by later observers, notably, in our own country, by C. B. Penrose. He says (" Diseases of Women," sixth edition, p. 174): — " Erosion of this character has been found in a more or less marked degree in thirty-six per cent of new-born in- fants." It predisposes to erosion in the adult virgin and appeals to be due to lack of proper development of the external os, so thai the sharp line of demarcation between the squamous epithelium of the vagina] portion of the cervix and the cylindrical epithelium of the mucosa of the cervical canal is not formed, and the cervical mucosa appears on the crown of the cervix. The affection has no characteristic symptoms. In the girl of more mature years congen- ital erosion may cause a mucoid vaginal discharge, a sense of weight in the pelvis and perhaps backache. In this event the vagina should be inspected will) a small Sims speculum, or a large Kelly cystoscopy. 564 INFANCY AND CHILDHOOD Precocious Menstruation and Precocious Maturity. — Genital hem- orrhage in the new-born does not constitute precocious menstrua- tion. A flow of one to five days' duration must recur at regular intervals and be attended by various feelings of discomfort anal- ogous to those experienced by women at the catamenia, in order to be classed as premature menstruation. V. Gautier (Rev. meal, de la Suisse romande, 1884, IV., p. 501) reported twenty-four cases of this affection and Dr. John Lovett Morse (Archives of Pediatrics, 1897) had brought the number of reported cases up to thirty-five in 1897. In this series the first flow began all the way from one week after birth to the seventh year, and regular menstruation persisted from three months to five and a half years. Numerous cases have been reported since. Precocious maturity involves a rapid growth of the whole body in height and weight, also changes in the size and shape of the genital organs and mammary glands, the growth of hair about the genitals and in the axillae, and regular menstruation. In older children who are instances of precocious maturity there is generally noted by the parents a marked pre- dilection of the child for the opposite sex. Menstruation is rarely the first symptom observed, in precocious maturity, but follows the changes in body development already noted. Gautier and Morse (loc. cit.) collected together fifty-seven cases of tins condition and the literature has shown many instances since. Here is a case reported by C. Wischmann, of Norway (ab- stract in Zentralbl. fur Kinderheilk., 1904, 9, p. 46). The child was born September 4, 1899, and a discharge of blood from the genitals was first noted February 24, 1901. In the succeeding sixteen months twelve menstrual periods were observed. The child was large, the breasts were full, and the mammary glands well developed. There was hair on the mons veneris and in the axillae. There were no evidences of rickets and there was no his- tory of similar abnormalities in the family. Dr. Morse, (loc. cit.) reported a case which I saw and examined for him on November 9, 1896, when the child was fourteen and a half months old. The facts in the case were briefly these:— The child was born August 29, 1895, and was said to have weighed fourteen poundsat birth. At that time her breasts were large and the baby was very fat in the neck. There was no history of early menstruation in the family except that the mother began to men- ANOMALIES 565 struate at twelve. One previous child, a boy three years old, was normal in every respect. When two months old the mother noticed that the baby had the " whites" and that there was a little coarse hair on the vulva. On May 29, 1896, when exactly nine months old, a bloody vaginal discharge was noted. Weight then was twenty-eight and a half pounds, — breasts large, mons veneris prominent, and external genital organs well developed. A flow of three clays, recurring each month, occurred regularly until she was examined November 9, 1896, and a leucorrhea was noted Fig. 207. — A Case of Precocious Maturity. months old. Child fourteen and a half during the intermenstrual period. There were no evidences of immodesty or sexual feelings. Then her appearance was that of a child of three, — weight thirty-six pounds, height thirty-two and a half inches, two teeth, intelligence above the average, and could say several words distinctly and walked well, — a moderate growth of hair in the axillae and on the back, breasts prominent and each contained a mass of gland tissue as large as a pigeon's egg, nipples well developed and surrounded by a dark areola and a little hair. Local examination showed: (I quote from my notes made at the time) "the labia majora well developed and meeting in the median line, a spare growth of light brown coarse hair on the 566 INFANCY AND CHILDHOOD mons veneris and outer surfaces of the labia majora, labia majora well developed and of moderate size, clitoris normal, hymen with central opening dilatable, easily admitting my little finger, which is nine-sixteenths of an inch in diameter, for a distance of one and a half inches in the vagina, ruga? of vagina normal and cervix well formed, and of normal density. Vagina as large as that of a girl of six years." DISEASES OF THE VULVA AND VAGINA Vulvo- Vaginitis. — In discussing imperforate hymen and atresia of the vagina, vulvo-vaginal inflammation — more particularly the kinds of inflammation that attend the infectious diseases — has been referred to as a cause of atresia. Simple Vulvo-Vaginitis. — Epstein has described a form of vulvo- vaginitis that is present in fetal life and continues after birth. It is characterized by an abundant, glairy mucoid and muco-purulent vaginal discharge, and by redness and excoriation of the genitals. In the secretion are found much epithelium, leucocytes, and many forms of bacteria, — notably the streptococcus and frequently the bacillus coli communis, but never the gonococcus. By the bacte- riological examination this rare affection is distinguished from the common gonorrheal vulvo- vaginitis. Many authors have described a non-gonorrheal vulvo-vaginitis occurring in infants and children of all ages. It is due in some cases to masturbation. In these cases the discharge is more apt to be mucoid or muco-purulent than purulent — unlike the gonorrheal form — and the disease is not so rebellious to treatment as in the case of gonococcus infection. Mendes de Leon (abstr. in Jahrb. fur KinderheilL, 1908, Vol. 67, p. 253) thinks that the staphylococcus plays a role in the etiology of a simple vulvo-vaginitis in children and that this form of inflamma- tion is contagious, as in the case of the gonococcus form. Gonorrheal Vulvo-Vaginitis.— Of late years, since the discharge coming from the genitals of children who are affected with inflam- i mm lion in that region has been examined microscopically, the fact lias become painfully apparent that a majority of the cases of vulvitis are caused by the gonococcus. Of course the gonorrheal Form is met more often in dispensaries and in hospital clinics than i" private practice. Epidemics of the disease have occurred where DISEASES OF THE VULVA AND VAGINA 567 all cases started from one child, such as that in the Babies' Hospital in New York in 1902 reported by L. Emmett Holt (New York Medical Journal, 1905, Vol. 81, p. 521). Another evidence of indirect and accidental infection is an epidemic which occurred in the city of Posen, Germany, in 1890, when two hundred and thirty-six school girls aged from six to fourteen years, were taken ill with vulvo-vaginitis in from eight to fourteen days after using the same public bath-house, where, on account of limited accommodations, the children were required to bathe in the same tub. Sometimes the infection is intentional, due to the superstition prevalent among some of the ignorant classes, that a man may rid himself of gonorrhea by giving it to a virgin. According to the published statistics of dispensary services, the disease is most frequent in the new-born and during the first five years of life, — then it is frequent again just before puberty. There is reason to believe that in a good many cases the infection has been transmitted to the child intentionally. To show the frequency of vulvo-vaginitis among the children seen in out-patient clinics, we may cite those of the Mount Sinai Hospital in New York, as given by Sara Welt-Kakels (New York Medical Journal, 1904, Vol. 80, p. 689). During the ten years from 1893 to 1903 she saw 190 cases of vulvo-vaginitis, forming one and six-tenths per cent of all the children seen. In the Women's Venereal Department of the Johns Hopkins Hospital Dispensary, 139 cases of vulvo-vaginitis were seen among 1,366 patients, or ten and two-tenths per cent (" Medical Gynecology," p. 365). These, of course, were in venereal cases only. Most authors regard the frequency of vulvo-vaginitis among sick children as about one per cent. The disease may be acquired from the mother during birth, and O. Heubner ("Lehrbuch der Kinderheilkunde," 1906, p. 502) has observed a case where an infant infected with gonorrheal ophthalmia subsequently became infected in the vulva, because of the carelessness of the nurse, and had a vulvo-vaginitis and a ure- thritis. This author thinks that in cases of vulvo-vaginitis in the child investigation will show that in many instances the mother will be found to have had a chronic leucorrhea. The use of the same towels, linen, and sponges by several members of a family may be the means of spreading the infection and of course the soiled fingers of the nurse or the mother are accountable in many cases. INFANCY AND CHILDHOOD Symptoms of Vulvo-Vaginitis.— The symptoms of vulvo-vaginitis may excite little attention. In the case of a baby it may cry on passing water and an older child may complain of smarting on micturition. There may be itching or burning at the vulva so that the child scratches. In a few cases Bartholin's glands are swollen, but they do not suppurate. The inguinal glands may be swollen, but a bubo is not formed. If attention is called to the disease in its initial stage the body temperature will be found to be elevated. Often the mother brings the child to the physician because its linen is stained with yellow spots. In cases of long standing the child becomes pale and its general health suffers. The disease most often gets into the chronic stage