The Practice of medicine and surgery

DISEASES AND INJURIES OF THE LABIA AND PERINEUM-ADHESION OF LABIA -DURING INFANCY-CAUSES AND CURE-IN ADULTS-WOUNDS OF THE LABIA-BY ACCIDENT-THROMBUS OF LABIA-CEDEMA OF LABIA-ABSCESS OF THE LABIA-RUPTURE OF THE LABIA DURING LABOR-TREATMENT-RUPTURE OF THE PERINEUM DURING LABOR-EFFECTS IN DIFFERENT DEGREES-PREVENTION-CURE WITHOUT OPERATION-OPERATION FOR RESTORATION OF PERINEUM.

ADHESION of the labia, and consequent occlusion of the vagina, sometimes occurs in infancy, or early childhood, as well as in adult life. The adhesions of infancy are so feeble and easily broken up, that it may be considered a trifling affair. Upon examining the parts, it will be found that there is no development of adhesive tissue, but the mucous membrane of the two sides is merely in strong coaptation. It probably is caused by the adhesive influence of dried mucus accumulating and drying between the parts, when in close contact, from want of cleanliness. The vaginal orifice is closed up to the urethra above, and down to the fourchette below. The treatment consists in separating the labia, by forcibly pressing each in opposite directions, until the adhesion gives way, washing and oiling them once every day, and afterwards to keep them from adhering again. Should we not be able to separate them in this way, the point of a silver catheter may be passed down so as to interrupt it. There will be no need of any other instruments in the case.

On one or two occasions I have seen firm tissual cohesions of the labia in childhood as the effect of ulcerative vulvar inflammation. In this form of adhesions it may be so firm as to require the use of the knife. They are, however, always superficial, and we may generally introduce behind the adhesions from above a bent probe or director. When this is the case, it is, I believe, the best plan to separate them, by driving the bent director through the adherent part. The same care as in the infant will prevent them from adhering again.

The most grave sort of adhesions with which we meet is in the adult, as the effect of neglected inflammation of the vulva after childbirth. These adhesions are sufficient to entirely close the vaginal orifice by the coaptation and firm accretion of the entire inner surfaces of the labia. I have met with more than one instance in which the hairy margins of the labia were so nicely adjusted to each other, that you could not distinguish the point of original separation, from the perineum to the urethral orifice, and the finest probe would not enter the vagina anywhere. The depth of the adhesion may be very great, involving much of the vaginal cavity.

These cases are very embarrassing, and are seldom perfectly remedied. It is decidedly the best plan not to interfere with them, until the menstrual accumulation fills up all the vaginal cavity remaining open, and then our object should be to reach the accumulation with a small trochar as near the middle of the adherent parts as possible. Placing our patient in the lithotomy position, the catheter should be introduced into the urethra, the urine all drawn off, and the urethra held as near the symphysis pubis, or as far from the middle line of the vagina, as practicable. The catheter should be thus held by an assistant, while the fore-finger of the left hand should be placed in the rectum. With this preparation, we may safely introduce the trochar into the collection of fluid as felt by the finger. The fluid being drawn off, the outer extremity of the perforation may be increased by the knife as far as may be desired, and as deeply as the surgeon may consider it safe. The opening may be increased as much as necessary by wax bougies, introduced and allowed to remain for twelve hours. The whole should be thoroughly cleansed by a syringe, with soap and water, as often as every twelve hours. The size of the bougies should be increased as often as once in twenty-four hours. If the opening is superficial, the treatment will not be protracted; but if it is deep, it will be tedious. It should be continued until all danger of closure is past, and it will be best to keep the patient under our supervision for some time after this appears to be the case.

Wounds. The labia are sometimes wounded by accidents of some kind extraneous to the patient, and they are sometimes torn during labor. When the wound is deep enough to reach the bulb of the clitoris, alarming and sometimes fatal hemorrhage is the

result. Professor Meigs gives an instance of great hemorrhage from these parts in a woman who had fallen upon a chair so as to cut through one of the labia. A case of fatal hemorrhage was caused in this city about four years since, in the following manner, as well as it could be learned from a legal investigation. A drunken husband returned home late at night, and, as was his wont under such circumstances, beat and kicked his wife, who was, probably, also inebriated. He kicked her with great violence in the genitals, and the square-toed heavy boot, in penetrating the pelvis, had cut off one labium and deeply wounded the other. In six or eight hours after the occurrence, the woman was found dead, with such copious effusion of blood from the wounds as, in the opinion of the examining jury, to account for the fatal result. I saw a case many years ago, where the patient was wounded by a knife in one labium so as to cause very profuse hemorrhage.

The hemorrhage being the important effect of these wounds, our efforts should be directed to its suppression, and this may, in most cases, be easily done. The bleeding part should be pressed by the hand firmly against the pubic ramus of the side upon which it is situated until temporarily arrested, when an elastic air-bag, or plug of oiled cotton or lint, may be introduced to fill up the vagina, and a hard compress placed and held firmly by bandages, so as to press the wounded part between the two. When wounds of the labia are large and gaping, the hair should be removed, and the wound treated according to ordinary rules for external wounds. The rents occurring in labor do not, in the great majority of cases, require any special treatment, cleanliness and quiet being all that is required.

Sanguineous Infiltration.-During labor, when the parts are stretched to their utmost extent, some of the arterial twigs give way and extravasate the blood in the loose structure of one labium. The infiltration usually shows itself after the child has been delivered, but sometimes, before the head has passed, the swelling becomes very great, and proves an obstacle to the expulsion of the head. When this last is the case, the blood is effused from a large branch of the pudic artery, and the forcible injection into the tissues is so great as to urge the blood so far in every direction as to fill a large part of the space between the vagina and the pelvic walls. This is a very serious state of

affairs, and calls for prompt and judicious interference. I once saw, in consultation, a case of this kind, so extensive as to arrest labor for several hours. These effusions, however, do not always call for surgical treatment, but when, as in the case here alluded to, the effusion is extensive, we must make a free incision in the inner surface of the labium, and allow the blood to escape; if it is coagulated, we should introduce the fingers and dislodge it. When the blood is thus evacuated, if hemorrhage continue, the bleeding artery must be compressed by the fingers until it ceases. The artery may be felt by the finger, where it crosses the plane of the ischium, just above its tuberosity, and as it runs along the ramus of the ischium and pubis. As it occurs after the expulsion of the foetus, the branch of the artery is smaller, and, as a general thing, the effusion not very extensive. Water-dressing, some evaporating lotion, or cooling discutient, will be sufficient, and absorption will be effected in from one to four weeks. Suppuration occasionally, I think not frequently, is excited by a small amount of effusion. This should be treated as an abscess. If the amount of blood is great, and the parts are tensely distended even after the child is expelled, it is better to liberate it by incision, for fear of sloughing or extensive suppuration and serious damage.

Edema. The distensible nature of the structure of the labia renders them liable to great oedematous infiltration in cases of general dropsy. Ordinarily, such distension is a matter of trifling importance, but the supervention of labor at a time when they are very largely swollen, is often a very embarrassing condition. They are sometimes so swollen as to occlude the vaginal entrance, and to yield only after protracted efforts, and even then, sometimes only after one of them has been more or less torn. When this excessive oedema is discovered before the head is pressing upon the external parts, or even when this is the case, no time should be lost before taking measures to lessen their size. This may be best done by everting first one and then the other, and making from ten to twenty small punctures through the mucous membrane only. A very sharp-pointed knife, taken between the thumb and finger of the right hand, so as to show only about the eighth of an inch, is the best instrument. Several quick, smart strokes with the instrument thus held suffice for the operation. The serum begins to

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