HERNIAS.
distinguished English surgeon Astley Cooper first called atten tion to the occurrence of hernia of the external female genitals, and Scarps reported two personally observed cases.
Hernia of the intestines at the external genitals may occur in three Localities: 1. The intestine descends through the inguinal ring into the labia majora. Scrotal hernia, then, has its analogue in inguino-labial hernia.
2. The intestine may either appear above or below the broad ligaments. In front of the ligaments they fall into the vesico-uterine pouch, between the bladder and the uterus, and below the lateral vaginal wall, extending, at times, to the labia. These are the vagino-labial hernias.
3. Below the broad ligaments, the intestines lie between the rectum and vagina, and result in vagino-labial hernias, similarly, by dissecting down between the rectum and the vagina. In the male the analogue is perineal hernia.
When in the last two instances intestine or omentum appears beneath the skin, necessarily the pelvic fascia and the muscles of the pelvic walls must have been loosened at one or another portion. In either case the peritoneum forms the sac.
Still other organs may lie in these hernial sacs. The occurrence of ovarian hernia at the inguinal ring is not at all uncommon. There is a vast difference, however, between inguinal ovarian hernia and labial ovarian. One case has been recorded by Billard, and we have already referred to Debout's case, as well as to an instance of utero-labial hernia seen by Barkow.
Inguino-labial herniae, analogous to scrotal in the male and occurring under similar conditions, occur less frequently than in the male, and are not so large. Still, instances have been recorded where the labium majus was distended down to the middle of the thigh. Since these hernias occupy rather the upper portion of the labia, they are called hernia; labia' majoris anterioris, in contra-distinction to the vagino-labial, which are termed hernia labii majoris posterioris.
Vagino-labial hernim are very rare. Stoltz describes an instance in a woman six months pregnant with her third child. The right side of the vulva was enlarged, as also the inguinal ring. On cough the intestines
descended. On repositing them, Stoltz was able to feel the opening be tween the fasciae and the levator ani.
An interesting instance of this nature has recently been reported by Winckel, where the case was complicated by prolapse of an ovary. In con nection with perineal hernia Hager's reported case is of interest on account of its size. The vertical diameter was sixteen inches, the transverse at the base was eight inches, and at the apex three inches. Another in stance has been reported where a vagino•labial hernia was mistaken for a prolapse of the uterus, and was cut off, resulting in the woman's death.
As causes of these labial and perincal hernife may be mentioned severe labors, great abdominal pressure, frequent and great distension of the bladder, tumors in the abdominal cavity, prolapse of the rectum and of the vagina.
The diagnosis is not difficult. There exists a tumor in the labia and the percussion note will be tympanitic. In Winckel's observation, how ever, such was not the case. Abscesses of Barth°lin's glands, and various new growths must be differentiated. In the latter instance the percussion note is dull, and in the former the formation is painful and the skin over the abscess presents signs of inflammation. Certainty in diagnosis is, however, afforded by the fact that the hernia may be replaced and the hernial opening felt. Symptoms of strangulation have been noted, but impossibility of reduction has not. We cannot theoretically state how an operation for the relief of incarceration must be performed Treatment by trusses is indicated and is effectual in inguino-labial hernias, even as in other inguinal hernias. In cases of vagino-labial hernia pessaries are of assistance. Winckel endeavored to unite the edges of the hernial opening, but failed, and resorted to the bandage recommended by Scarpa. This consists of an abdominal bandage to which is attached a crescentic bar, at the extremity of which is a cushion. It is similar in appearance to loser's uterine supporter.