THE LABIA AND THE VESTIBULE. 2021 



Recto-vesical fistula in a woman has followed ischio-rectal abscess, after the dis- 

 charge of which the patient passed gas and fsecal matter through the urethra (Noble). 



Vesico-vaginal fistulae are usually due to sloughing consequent upon the impac- 

 tion of the head in a difficult labor ; they are not due, as erroneously believed, to the 

 use of forceps, but to too long delay in using them (Emmet). 



Urethro-vaginal fistulae following labor are rare. More frequently the com- 

 munication between the vagina and the upper part of the urethra is part of a larger 

 opening into the bladder. It is in reality a vesico-urethro-vaginal fistula. 



Vesico-uterme fistulae are usually due to a tear extending forward through the 

 anterior vaginal fornix into the bladder, and upward along the cervical canal. The 

 lower part of the tear heals, leaving an opening between the bladder and cervical 

 canal, the urine dribbling outward from the bladder into the cervical canal and thence 

 into the vagina. If the lower part of the tear does not heal, we then have a vesico- 

 utero-vaginal fistula. 



Recto-vagi?ial fistulae are found usually at the upper or lower end of the vagina. 

 At the upper end they are most frequently due to extension of an epithelioma of the 

 cervix into the rectum, and in the lower end to incomplete closure of a torn perineum 

 extending into the rectum. They are very rarely due to labor itself. 



THE FEMALE EXTERNAL GENITAL ORGANS. 



The external generative organs of the female include those parts of the repro- 

 ductive apparatus that lie below the triangular ligament and in front of and below the 

 pubic arch. They are the labia majora, with the mo7is pubis above and the urogen- 

 ital cleft between them, the labia minora or nymphce, and the enclosed vestibule, the 

 clitoris and the bulbus vestibuli, together with the glands of Bartholin ; within the 

 vestibule are the orifices of the urethra and of the vagina. Of these structures, col- 

 lectively termed \}i\Q pudendum (pudendum muliebre), or vulva,- in the upright posture 

 usually little more than the mons pubis and the labia majora are \isible, although 

 exceptionally the labia minora and the clitoris may be seen within the genital fissure. 



THE LABIA AND THE VESTIBULE. 



The labia majora (labia majora pudendi) are two prominent rounded cutaneous 

 folds, the homologue of the scrotum, about 7.5 cm. (3 in.) long and 2.5 cm. thick, 

 that extend backward from the mons pubis and enclose between their medial surfaces 

 the Jirogcnital cleft (rima pudendi ). Above, their inner margins are continuous ( com- 

 missura labiorura anterior) over the ridge formed by the body of the clitoris ; behind, 

 where their tapering ends blend with the perineum, they are connected by a trans- 

 verse fold (commissura labioruni posterior), often only slightly marked and sometimes 

 wanting, that crosses the mid-line in advance of the anus. Their outer surface is 

 covered with thick, dark-hued integument and beset with hairs, in varying profusion, 

 that encroach for a limited zone on the inner surface of the labia and may extend as 

 far as the anus. The medial surface, on which the hairs are few and minute, is 

 clothed with skin of much more delicate texture, that at the bottom of the nympho- 

 labial furrow passes onto the outer surface of the nymphae. In addition to the skin, 

 each labium consists of a layer of subcutaneous fat, between which and the integu- 

 ment in the posterior half, a thin stratum of involuntary muscle (tunica darto- 

 labialis) is continued forward from the dartos of the perineum and represents the 

 similar but better developed sheet in the scrotum. The centre of the labium is occu- 

 pied by a fairly well defined mass of fat (corpus adiposum) that is connected with the 

 adipose tissue within the inguinal canal continuous with the subperitoneal tissue and 

 is, therefore, of different derivation than that of the subcutaneous fat, from which it 

 is separated by a delicate fascia. Into the latter are inserted some of the fibres of 

 the round ligament of the uterus that ends within the labium majus. Sweat and 

 sebaceous glands are numerous within the integument of the labia. 



The mons pubis or Veneris, as the triangular rounded eminence above the 

 genital cleft is called, consists of a cushion of fat, enclosed by dense skin and thickly 

 covered with hair. The subcutaneous fatty layer, usually from 2-3 cm. thick, but 



