NORTH AMERICAN JOURNAL OF HOMEOPATHY.

Now

Original Articles in Medicine.

PRURITUS VULVÆ.*

BY THEODORE J. GRAMM, M.D.

Philadelphia.

OW and then articles appear in the journals which seem to exaggerate the difficulties encountered in the treatment of pruritus vulvæ and, as a recent writer has done, refer to it as the bugbear of gynecologists, and point to the long list of remedies suggested for its relief as indicating that we do not understand its pathology nor have any one remedy adequate to its cure. They bewail the failure of some of the newer remedies vaunted as the hoped-for specific for this disease which, of course, follow their predecessors into the limbo of useless and abandoned remedies. It appears that at least some of the ill-success in treating pruritus vulvæ is ascribable to a search for one agent adequate to its cure, and because the judgment of practitioners is permitted to be led astray by the seductive claims of manufacturing pharmacists whose formidable array of publications flood the doctor's desk every morning. It seems to be not yet universally appreciated that the search for a specific for any disease is utterly vain, neither is it possible to evolve a curative remedy from the inner consciousness of even an expert chemist. The use of new remedies, until their efficacy is well assured by repeated trial, must ever be regarded as in the experimental stage, and experiments are notoriously not always successful. If, on the contrary, the treatment of this troublesome affection be viewed from the standpoint suggested by the antiseptic method, and if the latter be applied specifically modified and in accord with the discoveries relating to the bacterial conditions of

* Read before the Homeopathic Medical Society of the State of Pennsyl. vania.

the affected parts, it seems as though there would be cause for a more hopeful view of the treatment of this disease for it has not been my experience heretofore that pruritis vulvæ presents insurmountable obstacles to its cure.

Strictly considered, pruritus vulvæ is not a disease; it is only a condition, or rather only a symptom of several conditions or diseases; but as has been pointed out, it is still treated in the literature as a special subject because of its predominating effect in overshadowing the underlying disease, resembling in that respect diarrhea and metrorrhagia. Pruritis vulvæ is sufficiently well known not to require a more lengthy description than to say that it consists in an itching, associated with burning of the female genitalia, necessitating rubbing and even violent scratching, and is at times. so intense as to make life unendurable, mainly also because of nightly exacerbations interfering materially with sleep, and the general health suffers both in consequence thereof and because of the deleterious effects upon the nervous system. Most cases coming to the specialist are already chronic, both because of hesitancy on the part of the patient to mention the ailment, induced possibly by the unfounded fear that the physician will confuse pruritus with excitement of the sexual passion, and also because most patients have already submitted to a protracted course of treatment consisting mainly in the application of a long list of lotions and ointments which have been "highly recommended." Consequently it is not unusual to find that the vulva, particularly the labia majora, have undergone inflammatory changes, chronic in character. The skin, as pointed out by Veit (Handbuch, vol. 111-1-131), is more opaque, whiter, swollen or thickened, and deficient in elasticity and contractility. Scratch marks of greater or less depth, or even ulcerations, are visible. The pudendal hairs are broken. Microscopically there is an inflammatory parakeratosis presenting the picture of sub-epithelial small-celled infiltration; the keratin formation is deranged and an irregular desquamation of the horny layer takes place. The conditions differ from vaginitis, in that the epidermis is thickened, and especially so in its outer layers, as opposed to the thinning in vaginitis, and that now under the deepest layers of the rete Malpighii there are larger, discrete collections of the small often polynuclear round cells; now and then there are small cysts formed from dilated lymph vessels.

Webster (Centbl. f. Gyn., 1894, No. 7-154), is said to have found a subacute inflammation of the connective tissue papillary bodies and a progressive fibrosis of the nerves and nerve terminals.

Because of the inflammatory changes in the affected parts,

Sanger (Centbl. f. Gyn., 1894-154) has proposed to set aside the old term of pruritus vulvæ and proposes to call it vulvitis prurignosa. This term, admirable as it is, has not been generally adopted, because cases appear in which there is no evidence of vulvitis and yet the pruritus exists. These cases are still looked upon as pure neuroses, and have been the cause for much discussion among observers, largely because their place in an etiological classification is not readily determinable. Such cases, however, are constantly diminishing in number, and promise ultimately to disappear as we learn more fully to look for their cause. In fact, Sanger is already on record as saying that he has never seen a case of persistent pruritus without disease of the skin; even where the naked eye is scarcely able to discover anything abnormal, the corion may yet be and is affected. Schultze (Centbl. f. Gyn. 1894, No. 12), on the other hand, maintains that there are cases in which there is no vulvitis and in which the cause, reflex in character, is elsewhere demonstrable, or cannot be found. The cases he has reported are, however, not conclusive. The first is one where there were labial adhesions interfering with free urination. The second occurred in a case of endometritis which he cured with intrauterine irrigations. In the third case he mentions touching the endometrium with the sound excited pruritus in the vulva, and this case was likewise cured by means of intrauterine irrigations.

Sanger has defined pruritus vulvæ as a localized disease of the vulva in consequence of certain internal but especially external injurious influences. Among the causes of pruritus he has mentioned icterus, nephritis, diabetes, the abuse of morphine and alcohol, impaired circulation in the pudendal veins, retroflexion, tumors, diseases of the skin as urticaria, eczema, hyperidrosis, seborrhea, incontinence of urine, secretions from the vulva, vagina and uterus, as also from the bowel; parasites, masturbation and thermic causes. To these many other causes have been added, but I wish to refer to one more mentioned by Veit, namely, wearing a pessary too long.

Of these causes those depending upon well recognized dermatoses need not further detain us, for their explanation and treatment are the same as those of the skin diseases of which the vulvar pruritus is but a part. The same is true of jaundice. In diabetes, pruritus vulvæ is a common and indeed an early symptom. It is most likely induced by the frequent and excessive urination characteristic of the disease, in consequence of which the parts are so frequently bathed by the urine and the underclothing soiled far more than ordinarily. The changed character of the urine also so readily affected by fermentative changes, is an important factor.

urinary alterations in nephritis explain the symptom in that disease. The compulsory uncleanliness in incontinence of urine is to be included here. Certain animal parasites are a well-known cause of itching. The changed secretion of the sweat glands from general systemic conditions, under which also the action of morphia and alcohol are probably to be included, and the action of heat, should be classed along with the diseases of the skin.

Pruritus vulvæ is often associated with discharges from the vulva, vagina and uterus, and to this I desire to call special attention. Where the discharge is corrosive in character as in carcinoma and in consequence of acute venereal infections, the symptom is clearly dependent upon the localized and general vulvitis commonly associated with these diseases, and the case would hardly be classed under pruritus vulvæ. But there is a large class of cases in which the cause is not so manifest, and while in some of them as, for instance, in endometritis, in cervical catarrh and vaginitis from many causes, there is more or less leucorrheal discharge, there are many cases having these internal pathological lesions who tell us that they do not have leucorrhea, and a vaginal examination will show that the secretions are not excessive, and indeed may be diminished. It is these latter which may tempt to classify them. under the second group suggested by Olshausen, who has spoken. of pruritus vulvæ as symptomatic as in diabetes, leucorrhea, etc., and as essential depending upon a true neurosis.

Now what shall we do when a case of pruritus presents and the patient says that there is no leucorrhea? I believe that in no case should we accept this statement as indicating that no distinctly recognizable departures from the normal conditions exist; but we should institute a systematic examination. This should comprisean exact determination of the conditions of the skin surface; of the vulvo-vaginal glands; of the meatus urinarius and urethra, and of the urethral glands. These are the localities which long retain evidences of previous inflammation, and treatment specially directed to the conditions found is indicated. The vagina and cervix are to be examined by the aid of a speculum, and then the bimanual examination is to be made. I want to emphasize that the lesions. found in these cases are not gross, are not pronounced, and do not at once attract attention. They are of such a character that one might be tempted to underrate their importance because of their frequent occurrence in women, and particularly in patients who do not suffer from pruritus, but I am convinced that appropriate treatment is followed by satisfactory results.

Personally, I always make a microscopic examination of the:

vaginal secretion taken from some part of the vulva, from the upper part of the vagina, and sometimes from the cervical canal. This secretion is removed in such a manner as not to become contaminated by secretions found in any other part of the tract. Unfortunately, other professional duties have not permitted culture examinations to be made in all of these cases, but of the cover-glass preparations I can say that invariably they have shown the bacteria present to be cocci, and not bacilli. I have also used every opportunity to make cover-glass preparations from normal cases, and these examinations have shown that in all normal cases, both virginal and others, the micro-organisms present are bacilli; no case has shown cocci. The preparations made from secretion taken from about the fourchette or vulva may contain several forms of bacteria, both bacilli and cocci in both normal and abnormal cases, but that taken from high up in the vagina has shown the distinct results as just stated. As the case has improved from treatment the cocci have gradually disappeared and have been replaced by the large bacilli. It is very interesting to observe this change in a given case. I am well aware that these results are far removed from scientific completeness by reason of insufficient culture experiments; but then the cases were not examined for this purpose nor even with a view to their publication, but only in order to obtain working clinical evidence. These results are in accord with the experiments of Doederlein (Das Scheidensekret), as also are my observations of the reaction of the vaginal secretion.

This entire subject of the vaginal flora has received considerable attention, but satisfactory, oft-confirmed results are not yet at hand. Still Doederlien's results, apparently made with reliable accuracy, and being attractively consistent, seem to merit acceptance as a working basis, to be modified by other results subsequently to be obtained. They should surely not be cast aside in toto by another investigator who has failed to confirm even his elementary observations. Doederlein has shown that the vaginal secretion of healthy puerpera is acid in reaction, and the same is true of that of the non-pregnant and virgins. This acidity is due to lactic acid and is produced by a large bacillus which has received the name of the vaginal bacillus of Doederlein. This acidity, produced by the life activity of this bacillus, in addition to certain other qualities of the vaginal secretion, exerts a certain inhibitory action upon the growth and infective qualities of other, especially pathogenic micro-organisms. This has been proven by the inoculation experiments in which pure cultures of pathogenic micro-organisms introduced into the vagina have not been able to develop there, but on the con