blood vessels and loops of nerves. They are a morbid development of existing tissues instead of a growth of abnormal substance. These tumors are often observed, particularly the more dense and lightcolored varieties, without giving origin to any symptom that would lead to their detection; on the other hand, in many instances, they often produce the most excruciating suffering. The kind of caruncle. that has seemed to me to be the important one is the blood-red tumor projecting from the mouth of the urethra and attached by a small neck. A few weeks since I met with one of these of crescentic shape, attached by a neck that arose from the concave margin, and had its other attachment inside the urethral orifice. It would not have weighed two grains, but it caused agonizing symptoms. It must not be supposed that all of the varieties will not occasionally cause great pain. The symptoms of their presence are almost always connected with the evacuation of the bladder and attempts to handle the part. The passage of urine causes the most excruciating suffering from pain and tenesmus, the patient often straining for several minutes after the complete discharge of the urine. The slightest touch, also, is the cause of great pain. The diagnosis cannot be clear without an ocular examination. If the parts are exposed to a good strong light, and the labia separated, the excrescence will be at once discovered, unless it be quite inside the urethra. If any doubt exists, we should introduce the finger into the vagina, and press the urethra forward. It is difficult to say, with truthfulness, what are the causes of these carunculæ. My cases have been in patients obviously deficient in cleanliThis seems to have been the cause in that which came under Dr. West's observation.

ness.

The treatment is simple, and consists in two main objects: 1st, the thorough removal of them; and 2d, the production of a profound impression upon the point of origin. In fact, the tissues from which they spring should be destroyed to a slight depth. The first object may be most readily gained by snipping off deeply with scissors; and the second by holding nitric acid, or applying the actual cautery, to the place until the nidus is destroyed.

Vascular Urethra.

Analogous to the caruncle is the vascular urethra. It gives rise to the same train of symptoms, though not so intensely distressing, and is very persistent. It occurs more frequently in patients near the climacteric period, although I have seen it in much younger persons. When the labia are separated, and the parts exposed to a good light, the urethra is seen to be patent, and the tissues around the orifice swollen and of deeper hue than usual. The mucous membrane of the urethra is of an intensely scarlet color, and, upon minute inspection,

the vessels may be seen enlarged; it is very tender and sensitive to the touch, slight contact producing exquisite pain. There is great burning and sense of cutting when urine is voided, and all the symptoms, even the sympathetic nervous derangements, attendant upon caruncle. This condition is not incipient caruncle, for there is no elevation, no protrusion, and the condition lasts for years without material change of substance. The treatment I have found most effective is dilatation and the use of strong nitric acid, applied cautiously to the membrane inside the urethra. The passage of a large urethral sound twice a week sometimes exerts a beneficial alterative influence.

Hypertrophy of the Clitoris and Nympha.

It is very rare that we meet with hypertrophy of these organs without morbid change in the tissues. There is either cystic development in their substance or degeneration of the membranous tissues. The two diseases that seem to contribute most frequently to this enlargement are syphilis and elephantiasis.

Treatment.

Removal by the thermocautery.

CHAPTER VII.

LACERATION OF THE PERINEUM AND PELVIC FLOOR.

THE structure of the perineum and pelvic floor, and their relation to each other and to the uterus, have been briefly considered in the first and third chapters. A few preliminary observations about their relation to labor will also be necessary to prepare the way for a discussion of the treatment of injuries of these parts.

Preliminary Observations upon the Conditions leading to Injuries of the Parturient Canal.

At the beginning of normal labor the occiput projects into the pelvic cavity below the level of the pubic arch. As the external os uteri dilates and is drawn up over the head, elevating with it the pubo-uterine, sacro-uterine and broad ligaments, the bag of waters presses down against the pelvic floor, dilates the vagina, fills the pelvis, and in some cases protrudes at the vulval orifice. The fetal head, following the bag, dilates the more rigid parts, and is directed by the conformation of the pelvic cavity over the folded and retracted perineal raphé into the dilating vaginal and vulval orifices.

One of the most frequent deviations from this method is a premature rupture of the membranes. In a much larger percentage than has been supposed they rupture at or before the beginning of labor,* and allow the amniotic fluid to drain off. As soon as it has escaped active labor pains come on, drawing the cervix rapidly over the head, and often producing a laceration of the cervix that may extend into the vagina, and thus inaugurate a series of lesions. Having neither its normal protection, the pouch of membranes, nor an oozing amniotic fluid to lubricate it, the vagina is dragged down toward the vulva, and, if the upper part be thus lacerated or the head be proportionately too large, may be torn loose from the receding uterine ligaments and their surrounding connective tissue. As the head descends the mucous membrane may be loosened from its intimate fascial connection with the levator vaginæ and pubic arch, and perhaps torn asunder along with the weaker perineal tissues. The rectum may also be dragged loose

*

According to G. W. H. Kemper (Am. Journ. Med. Science, April, 1885, p. 412) and J. C. Bliss they occur in from seven to ten per cent. before the onset of labor. In my private obstetrical practice, which is mostly among delicate or sickly primipara, and multipara who have uterine disease, the percentage of such premature ruptures has been during the past year as high as forty per cent.

from its naturally firm and unyielding sacral attachments, behind and below the sacro-uterine ligaments. If the membranes rupture later, at any time before reaching the vulva, a similar unfavorable change occurs in labor, but it involves chiefly the parts lower down. Other things being equal, the greater the amount of perineal dilatation at the time of the rupture of the membranes, the more will any injuries that may occur be confined to the lower and superficial structures.

When the head remains at the pelvic brim during the first stage of labor, the upward traction upon the cervix, vaginal fornices, and contiguous structures separates and attenuates them, and deprives both the cervix and vagina of their connective-tissue support. This lengthening of the parturient tube from the internal os down diminishes also its transverse distensibility and predisposes to laceration.

Expulsive efforts during the first stage are very commonly employed by multipara, and occasionally by misdirected primipara. This forces the foetus down before the maternal parts have had time to retract, and unduly hastens dilatation while interfering with retraction.

A rapid instrumental delivery, by affording too little time for moulding of the head and the dilatation and adjustment of the maternal tissues, must lead to a.laceration in all but the previously lacerated or abnormally relaxed outlet. The greater number of forceps are so constructed that one or both blades press or cut into the vaginal levator vaginæ and constrictor cunni of one or both sides and, by the irritation they produce, tend to bring on disastrous expulsive efforts.

Imperfect development of the pelvis, vagina and perineum, pelvic deformity, cicatrices, rigidity from age, fetal abnormalities, etc., constitute conditions that must also be understood by the gynecologist, and which should be earefully studied in treatises on obstetrics.

The Mechanism of Laceration and Injuries of the Perineum and
Pelvic Floor.

Whether it be admitted or not that the bag of waters can as a rule be preserved to dilate the vaginal and vulval outlets,* a reference to Figs. 111 and 112 will show the advantage the perineum gained by such preservation.

The Sciatic and Coccygeal Surface.

The curved lines (Fig. 111), marked to represent the anterior edges of the smaller sacro-sciatic ligament and coccygeus muscle, run from

* In nine-tenths of my private obstetric cases during the past year in which the membranes remained intact until complete dilatation of the external os uteri, they protruded from the vulva before rupturing. In one third of these cases the head was born with the membranes intact.

the ischial spines to the coccyx. They may be felt, at the beginning or subsidence of a pain, as the anterior edge of the flat surfaces upon which the frontal region rests while the perineum is being dilated. It will be noticed that the vulval orifice is larger in Fig. 111 than in Fig. 112, while the frontal region is still completely supported upon

Folding of the Perineal Body in Normal Labor when Dilated by means of the Bag of Waters or

The dots on the perineal body indicate connective tissue containing fat.

p. c., post. commissure; e. c. c., edge constrictor cunni or vulval sphincter; e. l. v., edge levator vaginæ or vaginal sphincter; a., anus; e. l. a., edge levator ani; e. l. c., edge levator coccygei; e. c., edge coccygeus; s. 8. l., smaller sacro-sciatic ligament.

these planes. This part of the pelvic floor is dilated but little, and is seldom injured except by contusion. Schatz diagnosticated one laceration extending by the side of the coccyx.*

Plane of Obturato-Coccygeus.

From this plane to the curve marked in the figure as the edge of the levator coccygei, and which can often be traced as a ring around the head extending from the pubic bone on either side to the tip of the

* Archiv für Gynecologie, vol. xxii., p. 302.