constituting a hydrocele or cyst, is of rare occurrence. It is to be
found in the upper part of the vulva. Owing to the rarity of this
affection the greatest caution should be exercised in its diagnosis.
The absence of inflammatory symptoms, of resonance when percussed, and
the ordinary signs of hernia, together with a gradual growth of the
tumor without constitutional disturbance, would by the exclusive mode
of diagnosis leave but little room for doubt as to its character. If,
however, the physician still feels uncertain, the means which are used
for the cure of this disorder will also aid in diagnosis--namely,
aspiration with a fine needle about the size of those used on a
hypodermic syringe. Even where hernia exists no harm will be done, for
this is not an uncommon practice for the reduction of hernia in this
locality.
{398} TREATMENT.--Frequently nothing further is required in the way of
treatment than the reduction of the tumor by aspiration. If, however,
additional treatment seems to be necessary, it is best to inject
tincture of iodine by reversing the action of the syringe. The use of
iodine in this manner is for the purpose of obliterating the sac by
inducing adhesive inflammation, as is done in the treatment of
hydrocele in the male.
Pudendal Hernia.
DEFINITION.--If the process of peritoneum surrounding the round
ligaments as they emerge from the inguinal canal to become lost in the
dartos-like tissue of the labia is not obliterated at birth, the
channel thus formed is known as the canal of Nuck, and furnishes a path
for hernia. Besides a loop of intestine or portion of mesentery the
ovary or bladder may descend through this canal and constitute an
inguinal or labial hernia. The uterus has even been said to have
descended by this route. The infrequency of pudendal hernia makes it
all the more important to recognize it when it does occur, that serious
injury may be avoided when operating on supposed cases of labial
abscesses or cysts.
ETIOLOGY.--Pudendal hernia may be produced by blows, falls, coughing,
or sneezing, and by violent muscular exertions, as in the male.
SYMPTOMS.--The presence of a part of the intestine can be
diagnosticated by the peculiar crackling feeling, the impulse
communicated on coughing, and sometimes the disappearance of the tumor
on taxis. Occasionally reduction is very difficult, and exceptionally
it may become strangulated.
TREATMENT.--The patient being placed on her back with her hips
elevated, a gentle taxis will usually suffice to cause reduction. The
physician should be positive that the tumor has been returned to the
abdomen. After this is accomplished a truss should be adjusted so as to
press on the inguinal canal. Usually a perineal band will be necessary
to keep the truss sufficiently low to accomplish the purpose for which
it was adjusted.
If taxis has proved inefficacious, and strangulation has occurred, a
surgical operation will be necessary.
Hypertrophy of the Vulva.
Hypertrophy of the vulva occurs among certain peoples, as the Bushmen
and Hottentots, so commonly as to constitute a race-peculiarity, and on
account of size and form has been designated as the Hottentot apron.
There is also said to be a peculiar deposit of fat in the nates of
Hottentot women, but this should not be confounded with the vulvar
peculiarity of the same race. Occasionally in our own country
hypertrophy of one or more labia will be met with. Sometimes the nymphæ
are hypertrophied, so that they hang down much lower than the greater
lips; owing to this dependency and their usual pigmentation of a
brownish color they bear some resemblance to elephantiasis. In simple
hypertrophy the progress is gradual, and there is an entire absence of
the inflammatory attacks to {399} which a labium affected with
elephantiasis is subject, nor are there any superficial abscesses as in
the latter affection. Although there is usually the brown color on the
surface in simple hypertrophy, the color is not the same as in
elephantiasis. In the latter there is the peculiar pigmentation, also
roughness and deep crevices in the skin, so closely resembling in
appearance an elephant's skin that there need be no difficulty in the
differential diagnosis of simple hypertrophy and elephantiasis of the
vulva.
Hypertrophy of the clitoris sometimes occurs as a congenital deformity,
and sometimes it is acquired. There has seemed to be quite a general
belief that masturbation is one of its most common causes, but there
are no substantial grounds for such belief. On the contrary, it has
been frequently observed where women were known to have indulged in
this habit that no increase in the size of the normal clitoris could be
perceived.
TREATMENT.--If a subject of hypertrophy of the vulva suffers any degree
of inconvenience therefrom, the affected parts should be removed. A
surgical operation for this purpose is an exceedingly simple one and
demands no special description.
An operation for the removal of an hypertrophied clitoris is more
bloody than one for the removal of the labia; still, with ordinary
precautions it need be neither a severe nor dangerous one.
Clitoridectomy for the purpose of curing masturbation or various
neurotic affections is happily not of as frequent occurrence as
formerly. The author is firmly of the opinion that neither in cases of
masturbation, epilepsy, nor hystero-epilepsy is the removal of the
normal clitoris beneficial or even justifiable.
Elephantiasis of the Vulva.
DEFINITION.--The vulva is sometimes the site of neoplasms known as
elephantiasis arabum. The labia may become so hypertrophied that they
hang down to the middle of the thighs in the form of tumors; the
clitoris and perineum may also be affected. The skin is generally of
the peculiar brownish color of an elephant's skin, and hence the name
of the disease. The surface of the skin will present many tuberosities
due to hypertrophy of the cutaneous papillæ. Superficial abscesses and
ulcerations often occur, causing discomfort and pain.
ETIOLOGY.--It is said that elephantiasis of the nymphæ sometimes
results from onanism; it is also congenital. Scrofula, malaria,
syphilis, and filth are generally considered as among the direct causes
of elephantiasis arabum in the countries where it is the most common.
Occasionally it is produced by a blow or contusion. Although this
disease is not very common in this country, yet a sufficient number of
cases have been seen from time to time to call forth a number of
articles in the medical periodicals of our country.
PATHOLOGY.--The pathological changes, according to Mayer, consist in a
dilatation of the lymphatic spaces and ducts with secondary formation
of connective tissue and thickening of the layers of the cutis vera;
sometimes the papillæ are specially enlarged, producing swellings which
resemble condylomata in form. The labia majora are most frequently
affected, next in frequency the clitoris; more rarely are the labia
minora {400} hypertrophied. This affection is developed during that
period of life when sexual activity is the greatest.
[Illustration: FIG. 30. L, Right labium majus, healthy; A, upper part
of pachydermatous tumor, covering a part of the mons veneris; B, lower
portion of the tumor, occupying the perineum. This tumor measured from
anterior to posterior margins nearly nine inches. In its widest portion
it measured three inches.]
TREATMENT.--The treatment of elephantiasis of the vulva must
necessarily be surgical, and therefore will be omitted here, excepting
that which is embodied in the following report of cases by the author
in the Detroit _Review of Medicine_ in December, 1875, and are briefly
reproduced here:
Case No. 1.--Fig. 30 shows the condition of Mrs. ----, aged thirty, the
mother of several children and four months advanced in pregnancy at the
time she came to my clinic. She walked with difficulty and complained
of pain on the left side of the genitalia. She had been troubled with
the tumor hereafter described for more than two years, and during her
last pregnancy, because of its becoming larger and more painful, it
proved a serious impediment to childbirth. For these reasons she wished
it removed before being further advanced in pregnancy. The contiguous
parts were irritated by fluid discharged from small integumentary
abscesses. I removed the tumor by a surgical operation, and the patient
made a perfect recovery without any return of the growth. A feature of
the case observed during the operation was that an incision made in any
portion of the tumor caused a serous discharge to exude, so that at
{401} all times it was possible to tell whether I was cutting beyond
the diseased tissue or not.
[Illustration: FIG. 31. FF, Folds of anterior portion of labia majora,
the remaining portion of the great lips being hidden from view; L,
anterior part of the left labium minus; R. middle part of the right
labium minus; M, enlarged left labium minus; N, enlarged right labium
minus. A B, the light line between these letters, is designed to
indicate the introitus vaginæ, but the actual opening to the canal had
its anterior boundary immediately backward of the nodule seen near the
letter B. The urine was voided just above the nodular point, near the
letter C. The figure does not well exhibit the elongated clitoris,
which was fully an inch and a half long, and could be felt in the mass
like a hard cord. The tumor seemed to begin at the clitoris and the
anterior portions of the labiæ minora, and as it increased in size the
introitus was filled by it anteriorly.]
Case No. 2.--Miss ----, æt. twenty-two, a brunette of French parentage,
came to the clinic for the purpose of having removed from the vagina a
tumor of a year's growth, which she said was still rapidly growing,
making it difficult and painful for her to walk or engage in any
pursuit. The tumor of which she spoke is the one represented by Fig.
31. The operation for the removal of the tumor simply consisted in
excising the entire mass and putting a ligature around the base of the
hypertrophied clitoris. Three days after a hard-rubber vaginal dilator
was inserted, and ordered to be worn most of the time until the parts
were healed.
In the first case here reported there was no evidence of any syphilitic
taint, but the woman lived in a markedly malarial district. In the last
one there were indications of a syphilitic taint. A microscopic
examination of the tumor of each case plainly showed its pachydermatous
character. Both women were very dark brunettes, each having a coarse,
tawny skin, and neither was over-cleanly in her habits.
An important indication relating to operative treatment in this
locality is the use of the galvano- or thermo-cautery, particularly the
latter, owing to the great vascularity of the parts and the lack of
points upon which to exercise counter-pressure to control hemorrhage.
Hæmatoma.
DEFINITION.--Hæmatoma of the vulva is also designated as thrombus or
pudendal hæmatocele. This affection consists of an effusion of blood in
subcutaneous or submucous cellular tissue of the vulvo-vaginal region;
the effusion occurs usually in one labium or in the cellular tissue
surrounding the vaginal walls, and, later becoming coagulated, forms a
tumor which may vary in size. The tumors sometimes attain the size of a
foetal head.
ETIOLOGY.--Hæmatoma generally occurs during pregnancy or during labor,
usually from some injury, but rarely spontaneously or in the
non-pregnant. Muscular effort during childbirth, blows, kicks, falls,
the passage of the foetal head, or anything which can obstruct the
return of venous blood or produce rupture of the veins, may be a cause.
SYMPTOMATOLOGY.--The patient will have a feeling of discomfort, later
pain of a throbbing character, and often difficult urination on account
of the tumor encroaching upon the urethra. If the tumor is very large
she will experience some degree of faintness.
DIAGNOSIS.--The sudden appearance of the tumor with the symptoms
alluded to usually renders diagnosis an easy task. The affections which
may possibly be confounded with this are abscess of the labia,
inflammation or cysts of the glands of Bartholini, and pudendal hernia.
TREATMENT.--If the effusion should be small and the symptoms light, but
little is demanded except quiet and cooling lotions, like the
lead-and-opium wash. If there is effusion in the labia and there are
indications of suppuration, it should be treated as phlegmonous
inflammation by hot poultices, etc.[20]
[Footnote 20: Vide Phlegmonous Inflammation of the Labia, p. 391.]
{402} It is sometimes necessary during labor, in order to complete it,
that a free incision is made in the tumor and the clot turned out with
the fingers. This same treatment is often requisite when the tumor is
very large and there are good reasons for believing that it will not
undergo absorption. It is generally advisable to pursue the same course
if a thrombus has existed for some time and there are no signs of
absorption or suppuration, by reason of the continued discomfort and
pain to which the patient is subject.
After the clot is removed there is often a renewal of the bleeding, in
which case the cavity should be plugged with lint or surgical cotton
and pressure applied by means of vaginal tampons and external bandages.
Sometimes it is requisite to saturate lint or cotton with liquid
persulphate of iron, and finally pack the cavity with it in order to
check the bleeding. If there is no hemorrhage after the evacuation of
one of these tumors, then there is no need of packing or making use of
styptics, but it is necessary to prevent phlegmonous inflammation or
septicæmia. For this purpose iodoform or carbolic acid should be used
and a free outlet provided for the discharge of pus. Washing out the
cavity with a weak solution of the permanganate of potassium[21] also
serves a good purpose.
[Footnote 21: The author usually directs that from 4 to 8 grains of
this salt shall be added to each pint of warm water when it is to be
used as an injection or wash.]
Cancer of the Vulva.
Cancer is not a common disease of the vulva, yet as a primary affection
it attacks this locality more frequently than the vagina.
Epithelioma is the most common form, and generally appears in the
outset near the clitoris or on one labium as a small hard and warty
growth, which at first itches and later smarts, but is not painful.
After an indefinite length of time the growth, which has increased
somewhat in size, becomes painful, ulcerated, and there is more or less
of an offensive ichorous discharge. If the disease pursues its natural
course, the ulceration will rapidly extend until neighboring tissue
becomes involved; the inguinal glands become affected, and after the
characteristic cachexia becomes apparent there is no known remedy or
means of treatment that can prevent the progress of the disease to a
fatal termination.
If the clitoris becomes affected with this form of malignant disease,
it can be detected earlier than epithelioma of any other portion of the
organs of generation on account of its more external position, its
greater sensitiveness, and the increasing pain which the affection and
its enlargement produce.
TREATMENT.--If the disease is detected sufficiently early, an entire
removal of all the affected parts, including a wide margin of healthy
tissue, will generally effect a cure; but postponement until
neighboring parts, more particularly the lymphatic glands, are
implicated leaves little or no hope of cure through any mode of
treatment. Carcinoma of the vulva is generally an extension of the same
disease from the uterus or the inguinal glands, and rarely occurs as a
primary affection.
{403} Urethral Caruncle.
This painful affection, commonly included by medical authors as among
diseases of the vulva, will be very briefly considered.
DEFINITION.--The most common neoplasm to which the urethra is subject
is known as urethral caruncle, vascular tumor, or irritable vascular
excrescence of the urethra. These growths consist of all excrescences
located at the mouth of the urethra, and sometimes extending within the
canal for a short distance. They are of a deep-red color, soft and
friable, sometimes regular in shape, but more frequently irregular, and
then resemble a small cockscomb. They vary in size from the head of a
pin to a raspberry, occasionally attaining that of a walnut.
ETIOLOGY.--No definite cause can be given for the development of
urethral caruncle. These growths occur among married and single, old
and young.
SYMPTOMS.--The first symptom generally is that the patient experiences
a severe smarting pain during or immediately after voiding urine. Pain
is also caused by walking, pressure, friction, or even the slightest
contact of clothing. Also sleep is frequently disturbed in consequence
of slight movements of the body. Coition not only causes a severe pain,
but, owing to the friable and vascular character of the growth, it
often causes a flow of blood, which leads the subject to believe she
has cancer or some other serious disorder. In addition to the foregoing
symptoms the patient usually becomes fretful, nervous, hysterical, and
melancholy. The severity of one's suffering when thus affected is very
much out of proportion to the size of the growths giving rise to it.
Occasionally there will be a feeling of weight and pain in the pelvic
region, extending down the thighs. There will also be a muco-purulent
discharge from the urethra.
PATHOLOGY.--Urethral caruncles may be briefly defined as consisting of
"dilated capillaries in connective tissue, the whole being covered with
squamous epithelium."[22]
[Footnote 22: Hart and Barbour.]
DIAGNOSIS.--(This has been given in part under head of Symptoms.) If
there is protrusion of any portion of the caruncle the diagnosis is
easy. Yet a prolapse of the urethral mucous membrane or of the urethra
may be mistaken for a vascular tumor, but there will not be the
characteristic pain attending either of these conditions that
invariably accompanies caruncle of the urethra.
Syphilitic growths are sometimes located here, but they are wart-like
and painless, and generally have companions in the same neighborhood.
By placing the patient on her back in the lithotomy position and
carefully inspecting the parts a diagnosis is by no means difficult.
When the growths are within the meatus slight dilatation may be
requisite to see them, for which purpose a pair of ordinary
dressing-forceps will usually suffice.
TREATMENT.--Owing to the liability of the recurrence of caruncles their
simple removal by a cutting instrument will not, as a rule, suffice.
Various modes of treatment have been recommended, but the most
efficacious can be very briefly stated as follows: The patient being
anæsthetized and placed on her back, the growths are then removed and
their bases {404} thoroughly cauterized by Paquelin's thermo-cautery at
a dull heat; if of a large size it is a better plan to first remove
them by scissors and then apply the cautery. If a thermo- or galvanic
cautery is not at hand, a knitting-needle heated in the flame of a
spirit-lamp will serve a good purpose.
Atresia.
Although the subject is referred to here in its regular order, yet for
the greater convenience of the reader vulvar atresia has been included
by the author in the preceding section on Diseases of the Vagina (see
p. 373).
Eruptions.
The skin and mucous membrane of the vulva may develop eruptions common
to such tissues in other parts of the body. Those most often found are
eczema, erythema, herpes, and acne. They are not distinguished from
eruptions located elsewhere, except it may be their greater obstinacy
in responding to treatment.
{405}
DISORDERS OF PREGNANCY.
BY W. W. JAGGARD, A.M., M.D.
"Gestation," says Mauriceau, "is a disease of nine months' duration."
Robert Barnes[1] more truthfully remarks: "Since in pregnancy every
organ and the whole organism are specially weighted, undergoing
extraordinary developmental and functional activity, so any defect or
fault inherited or acquired, however latent, will be liable to be
evolved or intensified under the trial. Hence pregnancy is the great
test of bodily soundness." The pregnant woman is liable to many
disorders which can be distinctly traced to the existence of pregnancy.
The study of the natural history of gestation renders it highly
probable that these disorders are merely pathological exaggerations of
physiological functions. Then, pregnancy confers upon the individual no
immunity from the diseases to which the non-pregnant woman is liable.
But certain acute and chronic diseases, sustaining the relation of
accidental complications, are variously modified in their course and
effects by pregnancy, and accordingly are of interest to the general
practitioner.
[Footnote 1: _Obstetric Medicine and Surgery_, 1884, London, p. 205.]
For convenience of discussion the disorders of pregnancy may be
classified under two headings: I. The Pathological Exaggerations of
Physiological Processes; and II. The Peculiarities of Certain
Accidental Acute and Chronic Diseases occurring in the Course of
Pregnancy.
* * * * *
I. THE PATHOLOGICAL EXAGGERATIONS OF PHYSIOLOGICAL PROCESSES.
It is always difficult, frequently impossible, to draw the
boundary-line at which normal functional activity becomes pathological.
As remarked by Spiegelberg, all the diagnostic penetration of the
physician is demanded to recognize this transition. Then, a high
exercise of judgment is necessary to determine when to preserve a wise
and masterly inactivity, when to adopt measures of active interference.
Alterations in the Constitution of the Blood.
CHLOROSIS AND HYDRÆMIA.
Recent investigations show that qualitative and quantitative changes
occur in the constitution of the blood of the normal pregnant woman.
The {406} red corpuscles, albumen, and iron diminish, while the white
corpuscles, fibrin, and aqueous elements increase. Virchow describes
this increase in the number of white corpuscles as a physiological
leucocytosis dependent upon the growth of the lymph-vessels and
corresponding hypertrophic changes in the pelvic and lumbar lymphatic
glands. The total blood-mass is also increased--a change especially
notable in the second half of pregnancy. When the number of red
blood-corpuscles is abnormally diminished the woman becomes chlorotic.
If, in addition, the albumen is abnormally diminished, hydræmia
results. Chlorosis and hydræmia can only be regarded as independent
affections in the absence of cardiac and renal lesions. They are seldom
traceable to pregnancy in the absence of individual predisposition.
Effusions into the subcutaneous connective tissue, pleural and
peritoneal cavities, are liable to occur. Sudden exudations into the
pleural cavity are particularly dangerous, while effusions into the
subcutaneous tissue of the abdomen, vulva, and lower extremities are
annoying and may interrupt pregnancy.
TREATMENT.--The indications for treatment are obvious. The quality of
the blood must be improved, elimination of the aqueous elements
attempted, and local disturbances alleviated. Nutritious food, iron in
combination with non-irritant diuretics, fulfil the first two
indications. Blaud's pill, which Niemeyer and Spiegelberg extol so
highly, is an excellent tonic preparation. Basham's iron mixture is
admirable in its effects.
PROGRESSIVE PERNICIOUS ANÆMIA.
Gusserow[2] was the first to observe and describe a peculiar form of
progressive pernicious anæmia occurring during gestation. The disease
is of rare occurrence, and nothing is known as to its etiology.
Chlorosis and hydræmia, however, may be mentioned as predisposing
causes.
[Footnote 2: _Arch. f. Gyn._, ii. p. 218.]