and more or less pain in the affected parts, followed by a profuse flow
of yellow pus. There is also tumefaction, hypersensitiveness, and often
pruritus. Follicular vulvitis is the term employed to indicate an
inflammation of the mucous or sebaceous glands and of the
hair-follicles of the vulva. This disease may be the result of any of
the causes of purulent vulvitis, as alluded to in the preceding clause.
The subjective symptoms are common also to the purulent form.
Objectively, the mucous membrane will appear to be very red in spots,
resembling in this respect the raised papillæ of the tongue. These
spots frequently bleed on slight provocation. The internal surface of
the nymphæ and vestibule is the seat of the disease when the mucous
glands are involved, but where the sebaceous glands are mainly affected
the inflamed papillæ will be found on the surface of the labia and at
their juncture anteriorly. In the course of the inflammation a drop of
pus will exude from the papules, and they then gradually {390}
disappear. Occasionally, collections of exudate from the diseased
glands accumulate beneath the labia minora, concealing the diseased
surfaces and becoming quickly very offensive. The disorder, though
sometimes persistent, is seldom chronic. The acute affection may be the
cause of urethritis in the male closely resembling gonorrhoea if
coition occurs during its existence, and thus not infrequently giving
rise to suspicion of infidelity.
TREATMENT.--In the matter of treatment, touching the inflamed points
with carbolic acid or caustic sometimes favorably influences the course
of the disease. Cleanliness is the most important item in the treatment
of the two forms of the disease, for without it the application of
remedies will be of little avail. Strict attention to this, with
perfect rest of the parts, will not infrequently be all that is
requisite to effect a cure, but in cases that do not yield to this
treatment sedative, astringent, or alterative applications are
indicated. These should be applied after bathing. In the purulent
variety such remedies as the lead-and-opium wash after the following
formula will prove serviceable:
Rx. Tinct. opii, fluidounce j;
Plumbi acetat. drachm j;
Aquam ad fluidounce viij.
Lint may be saturated with this lotion and applied between the labia.
If the disease does not yield to the treatment already mentioned in the
course of two or three days, a solution of argentic nitrate (gr. x to
ounce j) should be brushed upon the parts, and between the intervals of
its application bismuth or starch may be kept constantly on the parts.
In cases associated with vaginitis a much stronger solution is
sometimes required. (Vide chapter on Vaginitis.) The author has used
powdered iodoform in some cases with very good results.
[Illustration: FIG 28. Follicular Vulvitis (Huginer).]
In the follicular variety the disease is more severe and usually of
longer duration than the purulent, although the principles of treatment
are essentially the same. In this as in the other variety cleanliness
is of paramount importance, frequent washing being very essential. To
the inflamed follicles such applications as nitrate of silver,
persulphate of iron, and carbolic acid are the more frequent remedies
used in this disease. After the application of any of these remedies
the parts should be rendered dry, and then a piece of soft linen or a
roll of absorbent cotton should be smeared with vaseline or soaked with
carbolized glycerin and inserted within the vulva in a way to keep the
labia apart. Occasionally the practitioner will meet with a chronic
form of vulvitis, and the rareness of its occurrence is fortunate, for
the reason {391} that it is a very obstinate and intractable variety of
the disease. Vulvitis is very frequently associated with vaginitis,
owing to the fact that the mucous membrane is continuous in both vulva
and vagina. On this account the principle of treatment of inflammation
of either locality is essentially the same. To avoid repetition, the
reader is therefore referred to the section on Vaginitis for a more
detailed description of treatment.
There is a form of this disease described by Vinay[17] as ulcerous or
aphthous vulvitis. This is an affection peculiar to childhood,
occurring only when the general health is much impaired. It is often a
sequel of fevers, and may even become epidemic. It attacks children of
any age, but is of more common occurrence in infancy. The disease
appears first upon the mucous membrane in the form of small and round
patches of a white or grayish-white color, which soon ulcerate, and at
a more advanced stage are liable to become gangrenous. This variety of
vulvitis has long been known, and is mentioned in the works of
Hippocrates. This disease is rarely met with in this country.
[Footnote 17: _Nouveau Dict. de Méd._, tome xxxiii., 1885.]
Phlegmonous Inflammation of the Labia Majora.
DEFINITION.--The adipose and areolar tissue which compose the greater
bulk of the labia majora often become the seat of acute inflammation,
in consequence of direct injury, excessive or awkward coition, exposure
to cold, from irritating discharges, scratching in pruritus, vulvitis,
or that peculiar blood-state which predisposes to the formation of
boils or carbuncles.
SYMPTOMATOLOGY AND DIAGNOSIS.--The patient will first complain of heat
and pain, increased by standing or walking, and later throbbing and
shooting pains in the affected parts. In the outset the part is
congested, followed by induration from effusion in the loose tissues,
and next suppuration ensues. An examination in the last-named stage
will reveal the existence of an abscess in one labium. The diagnosis is
by no means difficult, but the physician, however, should bear in mind
that this same locality may be the site for pudendal hernia, a
dislocated ovary, hæmatocele, or vulvitis.
TREATMENT.--In the outset the inflammation may be caused to disappear
by resolution, by means of cold and sedative lotions, such as the
lead-and-opium wash, saline laxatives, non-stimulating diet, and
perfect rest. In the majority of cases the disease proceeds to
suppuration. When it is found that resolution is unattainable, then
means should be taken to promote and hasten suppuration. This is best
effected by the frequent application of hot poultices. The mistake is
often committed of permitting too long intervals to elapse between the
application of poultices, and allowing the one applied to become cold
before another one takes its place. The patient can be saved many hours
of suffering by keeping hot applications constantly on the inflamed
labium. As soon as suppuration is detected the abscess should be
opened, for two reasons aside from the one of affording relief: First,
the tissue resists early natural evacuation; second, owing to the
laxity of the tissues, pus will sometimes force itself upward toward
and through the abdominal ring.
{392} Furuncles of the Labia.
DEFINITION.--Closely resembling phlegmonous inflammation are the
furuncles or boils which are quite common on the labia. They occasion
much pain and distress, for the reason that they are very obstinate and
apt to recur, one forming as soon as its predecessor has apparently
healed. In many instances these boils seem to be consequent upon
inflammation of sebaceous glands. They differ in size, some being no
larger than a pea, while others are the size of a filbert.
TREATMENT.--This should be constitutional and local. Quinine, arsenic,
cod-liver oil, and other remedies of a tonic character should be
administered. The bromide of arsenic has been used by the author in a
few cases with quite satisfactory results. As soon as one of these
furuncles shows that it contains pus, it should be freely opened and a
crucial incision made to prevent immediate healing; after which
poultices should be applied. These small boils are extremely painful,
and are very troublesome, owing, as previously stated, to their
liability of recurrence. To prevent their recurrence is one of the
reasons why immediate healing of the incisions should be prevented. If
contraction of the sacs of the abscesses does not occur, pus will
continue to be formed and the tissues in their immediate neighborhood
will become indurated. In this way the furuncles may become of a
chronic character. To further facilitate healing and aiding their
contraction the sacs should have applied to them some stimulating
remedy, such as carbolic acid or nitrate of silver. Edis says that
painting the surface of the affected labium with tincture of iodine is
beneficial in some instances.
One of the most important requisites in treatment is perfect
cleanliness.
Pruritus Vulvæ.
DEFINITION.--Pruritus vulvæ, although merely a symptom of disease,
characterized by itching of the vulva and contiguous neighborhood at
times wellnigh intolerable, has, because of its occasional obscure
etiology and severity, always been considered by medical authors as a
disease of itself, instead of a symptom of other disorders, in
treatises on diseases of women.
ETIOLOGY.--Predisposing and Exciting Causes.--It frequently occurs from
external irritation, as animal parasites, or such as may be produced by
acrid discharges, particularly in gonorrhoea and uterine cancer,
changes in the normal composition of the urine, especially diabetic,
and not infrequently during the menstrual flow. Pruritus may occur in
connection with inflammation of the uterus and vagina without any
irritating discharge; likewise it occurs in diseases of the urethra,
bladder, and kidneys. Sometimes masturbation may be the cause as well
as the effect of pruritus. Secondarily, there may be an insufferable
itching in consequence of the continued titillation or irritation of
the parts, although masturbation by no means invariably leads to
pruritus. The habitual use of opium or alcoholic drinks often causes
intractable forms of this disorder. Edis states "that the custom of
immoderate tea-drinking is a by no means infrequent cause of pruritus."
But instances of pruritus occur where all {393} of the causes mentioned
are lacking, and they are instead purely of a reflex character, such as
are met with in women about the time of the change of life and during
the latter months of pregnancy, or from the presence of worms in the
rectum. If the worms migrate to the vulva, as they sometimes do, the
irritation then becomes direct. Interference with the circulation of
the vulva by pregnancy and tumors may cause pruritus: unquestionably,
certain varieties of the disorder are idiopathic or neurotic.
SYMPTOMATOLOGY AND COURSE.--When the complaint has existed for some
time, the itching will be pretty well diffused from the pubis backward,
but in more recent cases it may be localized at the perineum, nymphæ,
clitoris, or portions of labia. The itching is not always constant, but
subject to exacerbations. It is usually much worse when the patient
becomes heated from exercise or is warm in bed, thus preventing comfort
or sleep, and thereby adding an additional complication to treatment.
The sufferer naturally seeks relief by scratching the involved tissues,
and for this very transient satisfaction spreads the disease by
increasing the irritability of the parts and inducing a condition
closely resembling eczema.
TREATMENT.--Inasmuch as the etiology of the complaint is often
uncertain, as heretofore stated, it is highly important that the
physician should ascertain if possible the cause of the disease, and
thereby be better enabled to treat the complaint intelligently. In case
the itching can be traced to the animal parasites most common in this
region, such remedies as the black or yellow wash, mercurial ointment,
or the oleate of mercury will usually prove sufficient; but if it be
found that the Acarus scabei is the cause of the itching, the
application of the ordinary sulphur ointment will destroy this parasite
and the itching will consequently cease. If due to uterine catarrh or
any vaginal affection, attention should be directed to the removal of
the primary disorder by appropriate means, for it cannot be expected
that itching of the vulva can be relieved so long as there is any
irritating discharge constantly exciting it. The most important measure
of all is perfect cleanliness. This can be secured by sitz-baths,
sometimes several being necessary daily. At the same time, the vagina
should be syringed with warm water or water with the addition to it of
such remedies as are used for the relief of leucorrhoea. The irritated
surfaces of the vulva should be prevented from coming in contact by
vaseline spread upon absorbent cotton or lint, or by powders, such as
bismuth, starch, etc.
In case there is an unmistakable acrid discharge from the uterus
causing pruritus, proper topical applications should be made to as much
of the endometrium as is diseased; the vagina should be thoroughly
douched night and morning, and then there should be placed against or
around the neck of the womb one or more tampons of cotton saturated
with the boro-glyceride or with glycerin, in which has been dissolved
borax or acetate of lead in the proportion of ounce ss of one of these
salts to ounce ij of glycerin.
In some instances, where there is a profuse discharge, simply packing
the vagina with dry salicylated or borated cotton will suffice. This
should never be allowed to remain longer than twelve hours without
removal. In those cases where the discharge is less acrid a single
tampon saturated with one of the remedies named or glycerin alone, and
placed {394} against the cervix daily, will suffice, as it will prevent
the discharge from coming in contact with the vulva. In severer forms
of this affection a number of tampons saturated in the same manner will
be more efficacious, and still permit the patient to move about. When
several tampons are used they should be loosely rolled, and each one
should have a string attached for convenient removal. In the mean time,
topical applications can be made to the vulva, and washing of the parts
will not interfere with the tampons. The author has found the following
prescription of Thomas very efficacious as a vaginal injection and wash
for the vulva:
Rx. Plumbi acetatis, drachm ij;
Acidi carbolici, scruple ij;
Tr. opii, fluidounce j;
Aquæ, pint iv. M.
Another prescription which has demonstrated its value is:
Rx. Bismuthi subnitratis,
Acaciæ pulv. aa drachm ij. M.
Sig. Add water to the consistency of cream and apply frequently with a
brush.
A somewhat similar prescription, to be applied in the same way, is the
following:
Rx. Pulv. acaciæ, drachm ij;
Bals. Peru, drachm j;
Ol. amygdalæ, drachm iss;
Aquæ rosæ, fluidounce j; M.;
or,
Rx. Acidi carbolici, drachm ij;
Glycerinæ, fluidounce j;
Aq. rosæ, q. s. fluidounce viij. M. Ft. lotio.
In all cases of pruritus, except from parasites, much benefit can be
derived from washing the parts two or three times daily in a weak
solution of bicarbonate of sodium (half a tablespoonful in a quart of
water, with a tablespoonful of eau de Cologne).
In pruritus from diabetes some relief may be afforded by the
administration of alkaline mineral waters or salicylate of sodium. In
pruritus associated with chronic cystitis the last-named remedy is very
useful.
In pruritus of a neurotic character a solution of the muriate of
cocoaine of the strength of 4 per cent., sprayed upon the parts or
applied with a camel's-hair brush, has often in the author's hands
afforded relief when every other application has failed.
One of the latest publications relating to the treatment of pruritus
vulvæ is a paper by Kustner,[18] agreeing with Schroeder that the
results of operative treatment for pruritus vulvæ are encouraging. This
author publishes several cases resulting successfully. A synopsis of
one will suffice to show his mode of treatment. A patient, unmarried,
suffered for a long time from uterine catarrh and pruritus vulvæ: the
former was relieved after prolonged treatment, but there still remained
two symmetrical spots between the hymen and labia minora which were the
seats of most troublesome itching and were exceedingly sensitive to
touch. These portions of the mucous membrane were rich in sebaceous
glands, and were also studded with small retention-cysts. The author
dissected off {395} the two elliptical portions of mucous membrane,
each 1 cm. broad and 3 or 4 cm. long, and containing the small
retention-cysts, and then united each wound with interrupted sutures.
The pruritus entirely disappeared, and did not again return, though
some years after the patient again suffered with uterine catarrh. Other
cases are related by the same author, notably one case of pruritus
where there was a lacerated perineum. The operation for repair of this
perineum was performed, with the result of the permanent disappearance
of the pruritus. The author does not give any definite rule as to how
and in what cases he should have recourse to operative treatment, but,
admitting that pruritus may arise from causes heretofore mentioned in
this article, he asks whether those cases where secondary pathological
changes have occurred in the vulvar mucous membrane cannot be
definitely cured by excision of the affected portion. Not enough cases
of cure of pruritus by surgical treatment have been reported to fully
establish the theory of Kustner, yet it is a matter of sufficient
importance to merit our attention and warrant further investigation.
[Footnote 18: _Centralbl. f. Gyn._, No. 12, 1885.]
Hyperæsthesia of the Vulva.
DEFINITION.--This is a disorder first described by Thomas under the
above caption.[19] It consists of a hypersensitiveness of the nerves
supplying some portion of the mucous membrane of the vulva. Sometimes
the area of tenderness will be confined to one of the lesser lips or it
will be limited to the vestibule, and in other cases a number of parts
may be simultaneously affected. "It is a condition of the vulva closely
resembling that hyperæsthetic state of the remains of the hymen which
constitutes one form of vaginismus," and doubtless is often confounded
with the latter.
[Footnote 19: _Op. cit._, p. 145.]
ETIOLOGY.--It is more common about the time of change of life, and
occurs more frequently among women of hysterical diathesis where there
exists a morbid mental condition with a tendency to melancholia. In
some instances the disease seems to be excited by vulvitis or vascular
growths in the urethra.
SYMPTOMATOLOGY.--The slightest friction causes intense pain and
nervousness, and even a current of cold air produces very great
discomfort. Coition causes such severe pain that for this cause the
subject usually consults her physician. As in vaginismus, the mental
distress is often of an exaggerated character, in some instances
bordering upon monomania.
PATHOLOGY.--In this disorder there are no indications of inflammation
except occasional spots of erythematous redness. It is not a neuralgia
in a true sense of the term, but an abnormal sensitiveness of diseased
nerves supplying the vulva.
DIAGNOSIS.--The affections most liable to be confounded with this are
vascular growths (or irritable caruncles) of the urethra and
vaginismus, but ocular inspection and digital examination will enable
the physician to determine the character of the disease.
TREATMENT.--This is far from satisfactory in many cases. Thomas speaks
most discouragingly concerning it, and states that "the treatment of
this condition is most unsatisfactory."
{396} The author has at this time a patient with hyperæsthesia of the
vulva who has been treated by him for many months, and up to the time
of this writing has obtained no relief. Thomas recommends sending the
patient "away from home, where, in addition to enjoying changes of air,
scene, and surroundings, she would live absque marito."
In this, as in all disorders which depend on or are associated with the
hysterical diathesis, galvanism and massage are, as a rule, of decided
benefit. In addition, general tonics, such as arsenic, strychnia,
quinia, and iron, should be prescribed. If any local affection exist,
such as vulvitis or urethral vegetations, it should be cured first.
Warm fomentations, the frequent use of warm water, sedative lotions,
and ointments consisting of opium or its salts, carbolic acid,
chloroform, and iodoform, are useful topical remedies. Much benefit may
be derived by the application of a 4 per cent. solution of
hydrochlorate of cocoaine by means of a spray or soft brush. Strong
solutions of alum and tannin have sometimes proved beneficial.
No good results have been derived from the use of the knife or caustics
in cases where they have been used.
Tumors of the Vulva.
Under this head will be included any enlargement, neoplasm, or
adventitious growth which has the vulva for its site. The most common
are the following, which will be considered in the order named: viz.
Cysts, Hydrocele, Hernia, Hypertrophy, Elephantiasis, Hæmatoma, Cancer,
and Urethral Caruncle. There are other growths of the vulva, such as
fibroma, lipoma, sarcoma, lupus, etc., but they are of such rare
occurrence that their discussion is necessarily omitted.
Cysts and Inflammation of the Vulvo-Vaginal Glands.
The frequent concomitance of cysts and abscesses in these glands has
caused the author to consider them here under the same caption.
The most frequent cysts of the vulva are those springing either from
the ducts or glands of Bartholini, or, as more commonly known, the
vulvo-vaginal glands, situated near the lower part of the labia. Cysts
having their origin in the ducts are single and are invariably of an
oval form; such also is the more common shape of those springing from
the gland, yet sometimes they are lobulated, of an irregular form, and
comprise one or more in number. Inasmuch as this same locality is
sometimes the site of hernia, and cysts of the labia often of a similar
form, the physician should be positive that the tumor is a cyst before
having recourse to any active mode of treatment.
If fluid accumulates in a cyst in such quantity as to cause the subject
inconvenience or discomfort, surgical treatment will be required, of
which there are three different modes in common use.
The first mode is to remove by scissors a segment of the sac, allowing
escape of its contents, after which the cavity is filled with marine
lint or carbolized cotton, which is allowed to remain for about
forty-eight hours {397} before renewal. By this plan of treatment the
sac will usually be obliterated. Another method is to freely open the
cyst and apply some caustic, preferably the galvano- or thermo-cautery.
In the absence of either of the last named nitric acid may be used with
good effect. The third and last method has in the author's experience
proven the most efficacious, though objection has been made to it on
account of its being a more bloody operation--namely, complete
extirpation of the gland.
The causes of inflammation of these glands are the same as those that
cause vulvitis; in truth, they are often accompanying disorders. The
symptoms are pain, heat, itching, and an increased redness,
particularly about the opening of the duct. If a finger be pressed over
the location of the gland, it will elicit signs of pain.
[Illustration: FIG. 29. Abscess of Glands of Bartholini.]
In the outset of the inflammation it is felt hard and unyielding, but
two or three days later a fluctuating tumor may be easily discerned. An
abscess of the gland should be easily distinguished and rarely mistaken
for a cyst. There are the history and ordinary signs of inflammation to
aid in diagnosis. If, on the contrary, there is simply a cyst, it can
be rolled about under the finger and no indications of pain produced.
Further, it may exist an indefinite length of time, and unless the
gland from some cause become inflamed no great inconvenience is
experienced. It is not an infrequent occurrence, from some cause, for
inflammation to attack a cyst-wall, in which event the symptoms of
inflammation ensue. Where such is the case the treatment should be the
same as in inflammation of the gland--namely, absolute rest and any
soothing or anodyne lotions which favor restoration. Should indications
of suppuration occur, it should be promoted by the frequent application
of hot poultices. If the pain is not severe, the abscess may be left to
nature; but if it be severe, then the abscess should be emptied by a
free incision at the most prominent point.
Hydrocele, or Cysts of the Canal of Nuck.