LETTER X.

LABIA AND NYMPHE-COHERENT.

GENTLEMEN:-In my 8th letter, I laid before you some observations upon the accidents that happen to the nymphæ, after having spoken of their physiological nature. In the present communication, I have to offer further remarks upon those tissues.

They are frequently found to cohere in very young children; so as to cover up the small triangular superficies lying in front of the symphysis, and which you studied at the dissection, under the denomination of Vestibulum. This triangular space, you remember, is bounded above by the clitoris, on each side by the nymphæ, and below, by the crown of the pubic arch; or in other words, by the upper semi-circumference of the os magnum:-near its lower edge is the meatus urinæ.

A young baby is usually clouted, or to use a gentler phrase, diaper'd. In case its mamma is not scrupulously nice, the diaper is often left too long unchanged, and the irritating salts of the urine come at last to irritate and vex, and finally to inflame the mucous surfaces that are too continually bathed with it.

A very gentle inflammatory diathesis being in this way acquired by the mucous tissue, whose opposing surfaces are kept in contact, union or fusion of surfaces is likely to take place; and at length, the mother makes the discovery.

When this gentle adhesive inflammation sets in, as to the nymphæ, it is also almost sure to be established as to the labia majora; of which, after all, the nymphæ are but folds, or rugæ of the labia. I have many times found the labia coherent, without cohesion of the nymphæ. Indeed, the latter are much less likely to become glued than the former, because, when the lower sections of the labia become fused or soldered together, there is nothing to tear them asunder-whereas, at their upper section, there is the repeated issue of a stream of urine, which is of sufficient force to break up a commencing process of the sort; and so it happens that, we do not find cohesion of the labia to extend above the level of the meatus urinarius as a common occurrence.

M. Colombat speaks of a case in which the nymphæ cohered in such a fashion as to cover up the orifice of the meatus and compel the urine to ascend behind the cohering apron, in order to escape, with difficulty, and dribbling, over the genital surfaces. They were separated by an incision, which relieved the child of her dysury.

Dr. Dugés, also, in the introduction to a Pract. Treat. on the Dis. of the Uterus and Appendages, p. 30, gives you the account of a little girl, whose urine escaped by a narrow orifice near the clitoris. The catheter could not be introduced into the bladder from this orifice, but went into the vagina, because the labia were also coherent. Pray do not, however, believe what M. Dugés asserts in the same place; viz., that cohesion of the nymphæ necessarily accompanies that of the labia externa; I am sure you will find, in practice, it is not the case, except very rarely.

It is to be readily concluded that, if a child, suffering from an occlusion, by this cause, of the genital fissure, should by neglect, or from excess of fastidiousness, be suffered to grow up, the fusion of the surfaces might become complete, and thus effectually prevent the fulfilment of her sexual destiny as a parturient creature-for, the longer the union continues, the more complete will it become, and the more absolute the loss or extinction of the mucous structure, whose opposing faces first came into soldering contact.

Whenever the fault is discovered-say up to the sixth or eighth year, and I have known it not to be detected earlier than the tenth year the mucous membranes are not lost, but only coherent. and they may be pulled apart, leaving the newly uncovered superficies true mucous superficies, and not fleshy ones.

The same sort of cohesion I have observed in the glans and preputium of a little boy.

In all the cases that have fallen under my care, I have adopted the following method of cure.

The child is held down on its back, on the nurse's lap; who abducts the left knee with her left hand, while I abduct the right one with my right arm. Then, separating and stretching asunder, as far as I can, the labia with my left thumb on the right labium, and my index finger upon the left one, I draw the bulb of a common probe dipped in oil along the raphe, which it always opens and separates without bleeding; or at least, without the loss of

five drops of blood. The pressure of the probe appears to me to have the effect of pulling out a sort of villi, like a cylindrical epithelium, which had interlocked their floating extremities and become hypertrophied, like placentules in the sheep.

M. Colombat advises, as a measure of precaution, after the division, to touch one of the surfaces, either the right or the left one, with the nitrate of silver; not to touch both of them. His notion is, that by touching one surface only with the nitrate, we institute in that surface a stage or a rate of vital action different from that going on in the one left untouched; and as there is then no parity of vital movement in the two superficies, they will not cohere when they are brought into contact.

I have not adopted his idea. But the idea is a very philosophical one, or rather a truly physiological one, founded on what is well known to be a fixed law in teratology. You would do well to study that beautiful law as it is laid down by M. Serres in his remarkable work, "The Anatomie Transcendantale," a volume which contains the richest stores of fact and reasoning on the nature and operation of the development forces in man. But to return to my subject:

When I have completely destroyed the cohesion, Í dip the minimus finger in oil, and draw it downwards to the fourchette, effectually separating the labia, and I then explain to the nurse the necessity of repeating this method once a week at least; as the mere separation of the cohering surfaces does not cure the cohesive tendency; which, being in full force, will soon unite the surfaces again, and give other trouble, besides that of feeing the surgeon. The last motive is an ægis for the baby: if you do not set it fairly before her, you may soon be called again to make it cry; whereupon I advise you not to forget such a prophylactic charm. The last thing the sick think of is the doctor's fee; tell them of it and they sometimes take care of their health.

While I was writing to you about the labia, I did not say anything as to their cohesion, because I wished to make my remarks on it in coincidence with those I should have to make on the same accident as to the nymphæ, and now I have nothing more to offer on the subject worthy of your attention.

The nymphæ are occasionally the seats of a very rebellious sort of ulceration. I have found them at times very difficult to cure. In one example, the nymphæ near their summit or angle, were

deeply eroded, and the ulcerated surfaces were hard from the induration of the base of ulceration. The young person, about sixteen years of age, was not uncleanly in her person; nor was her health positively bad, as being affected by any sort of constitutional vice, that I could discover.

In this case I succeeded in effecting a cure by repeated contacts with strong solutions of sulphate of copper; which, next to the nitrate of silver, appears to me to possess a great power to overcome ulcerative tendencies of the mucous membranes. It is reasonably to be suspected, in such cases as are not clearly to be traced to some constitutioual depravation, that the local irritation is maintained by vicious propensities to excite the parts by friction. On this head I would gladly refer you to the monstrous proceedings of a scoundrel under the garb of a physician, in a case related by the late David D. Davis, the able Professor of Midwifery in the London University College: you will find it at page 58, vol. 1, of his magnificent quarto on obstetric medicine. It ought not to be reprinted in this book.

Should you encounter any cases that will not readily yield to contacts of your nitrate pencil or to a sharpened crystal of sulphate of copper, you will scarcely fail to obtain healthy and healing granulations, if you should carefully, very carefully and delicately touch the ulcerated points with a small camelhair-pencil, whose point shall have been dipped in some acid nitrate of mercury. This escharotic cuts everything down like a knife; and is not very painful,-but it is so powerful that you ought not to let it touch anything but the very points you design to affect. A jet of solution of soda, or salt of tartar, or of limewater, upon the part after the contact, will neutralize all the excess of the acid that you may have incautiously left, and save the patient from the cauterization of other parts which you desire not to burn. A sponge filled with soap suds answers the same end, by neutralizing the excess of the acid.

An enlargement of the nymphæ to such an extent as to prove troublesome and offensive to the individual herself, might be safely diminished by the excision of a portion of the hypertrophied mass. You will please to observe, however, as the tablier des Hottentottes is an ethnographical peculiarity, it does not necessarily follow that an unusual development of the organ must be the occasion of great trouble. The chief annoyance resulting

from its great protrusion is likely to be an ulcerative tendency, obtained from the constant friction of it in walking, and against the dress of the female. Such a source of disorder is, however, not likely to prove lasting, since the mucous surfaces, when brought out and kept constantly exposed to the air and to attrition, become covered with a real cuticle, and gradually acquire the properties of the true dermal tissues.

As the nympha is a very vascular structure, it might be expected that the vessels would bleed freely upon an excision; yet no difficulty could arise as to the suppression of hemorrhage from a part which, like this, could be readily compressed, as lying close to the top of the pubal ramus.

Mauriceau gives, in his 174th case, an account of an operation on the nympha as follows:

"July 25, 1676, I operated for the excision of the nympha, on a woman who begged me to do it for her; because, as she was obliged to be much on horseback, she was put in pain by the friction of the organs, and also because such an indecence was displeasing to herself as well as to her husband."

After cutting off both of the nymphæ with his scissors, Mauriceau remained near her for an hour, in order to observe whether hemorrhage might follow; during all which time she lost only about four ounces. Finding her doing so well he left her, but was much surprised on returning in the evening to find that she had had repeated faintings; and that she had lost between forty and fifty ounces of blood in the course of only five or six hours.

Mauriceau says she soon recovered, and was subsequently confined under his care. The labor was with a shoulder presentation, for which he turned. No inconvenience attended it, as relative to the absence of the nymphæ, which, says he, "n'étoit utile que pour la décoration." What a curious old Frenchman! In my next letter I propose to speak with you of the organ called clitoris, as the subject of disease, and am very truly your friend and servant. C. D. M.

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