CHAPTER IV.

INJURIES.

THE vulva may be the seat of bruises or wounds in consequence of a fall on some sharp object, for instance the back of a chair or the edge of a table, or of blows and kicks. The injury in such cases is mostly found on the labia majora. On account of the sharp edge of the ascending ramus of the ischium and the descending ramus of the pubes, even contact with a blunt object may cause a clear cut.

Coition seldom gives rise to traumatism of the vulva except in cases of rape. The fossa navicularis may, however, be penetrated, resulting in the formation of a permanent vulvo-rectal fistula.1

Children and old women are more liable to injury during sexual connection, on account of the lack of development in the former, and senile involution, with loss of elasticity, in the latter.

Parturition is the most frequent cause of injuries to the vulva. Lacerations of the perineum will be considered later. Superficial tears of the labia majora are quite common, but need no special attention if my antiseptic occlusion dressing is used. Sometimes a tear occurs in the vestibule, near the clitoris, which gives rise to dangerous or fatal hemorrhage.3

The symptoms vary according to the cause and the degree of the violence. If the skin remains unbroken, there are pain, soreness, swelling, discoloration, or perhaps subcutaneous extravasation of blood (pudendal hematoma). If the skin is broken, the hemorrhage is often alarming (p. 41).

Treatment. If the skin is unbroken, the pain is often best relieved by hot-water fomentations, to which may be added tinct. of arnica (3j to 3j). After that lead-and-opium stupes (tinct. opii, liq. plumbi subacetat., āā 3j; aquæ, 3viij) may be applied with advantage. If the hematoma is of so large a size that complete resorption is not to be expected, the best treatment is to apply Braun's colpeurynter filled with ice-water in the vagina, and compression on the skin for three or four days. When, then, the danger of hemor rhage is passed, a free incision is made on the internal surface of the labium majus, parallel and near to its lower edge. The blood-clots are turned out, and the cavity washed out with antiseptic fluid, preferably creolin, on account of its hemostatic properties. If any vessels are seen bleeding, they should be tied with catgut, or if there is oozing the surface should be seared with the thermo-cautery. Next the sac

3

Joseph Price, Amer. Jour. Obst., 1886, vol. xix. p. 832.

Garrigues, Practical Guide to Antiseptic Midwifery, Detroit, Michigan, 1886, p. 27. Mundé, Amer. Jour. Obst., 1875, vol. viii. p. 537.

is packed with iodoform gauze. The dressing should be renewed every day, and the cavity washed out with antiseptic fluid.

If an abscess is formed, the pus should be given a free outlet by incision, and the wound treated antiseptically. A slight tear is dressed with iodoform ointment (p. 178). If there is any hemorrhage, a careful examination should be made for its source. Spurting arteries are twisted or tied. Bleeding surfaces are brought into contact and united by deep sutures. If this does not check the hemorrhage, the wound should be covered with styptic cotton (p. 182), the vagina tamponed (p. 179), and the external genitals covered with compresses or a folded towel tightly fastened with a T-bandage. A fistula is treated by paring the edges and uniting them with silkworm sutures. If the contusion has been considerable enough to cause the death of the tissue, the wound should be kept clean with an antiseptic solution, the dead tissue cut away as soon as feasible after a line of demarkation has formed, and the wound dressed with iodoform ointment.

CHAPTER V.

VULVITIS.

VULVITIS is inflammation of the vulva. It appears under five different forms: the catarrhal, the follicular, the phlegmonous, the venereal, and the diphtheritic inflammation.

Etiology. The causes of catarrhal and follicular vulvitis are lack of cleanliness, irritation produced by discharges from the uterus or vagina, or from the bladder if the patient is afflicted with a vesicovaginal fistula; masturbation, excess in coition, rape; friction produced by physical exercise in fat women; pin-worms that find their way from the anus to the vulva, and ants that creep in from the skin. The scrofulous diathesis predisposes to the disease, especially

in children.

The phlegmonous form may result from the catarrhal or be caused by violence. It is mostly found in prostitutes. The venereal is due to infection with one of the three venereal diseases, gonorrhea, chancroid, or syphilis. The diphtheritic occurs in childbed and in grave fevers, such as scarlet fever, small-pox, and typhoid fever.

Symptoms.-The catarrhal vulvitis is either acute or chronic. The acute is more common. The mucous membrane is red, swollen, and covered with a muco-purulent secretion. There is a sensation of heat and pain, especially smarting during micturition. In the chronic form the mucous membrane is of a less bright red color, and often the seat of abrasions or superficial ulcers. On the denuded places

the papillæ are hypertrophied and bleed easily. Redness and excoriations are often found in the groin and on the inside of the thighs. Intolerable itching drives the patient mad, prevents sleep, and may easily lead to masturbation. Sometimes the glands of the groins swell, the lymphatics leading to them from the excoriated patches becoming inflamed.

In follicular vulvitis the seat of the inflammation is the hair-follicles, the sebaceous and sudoriparous glands, and, less frequently, the mucous follicles, the intervening mucous membrane remaining healthy.

This gives a peculiar appearance to the vulva, the labia majora and minora being studded with small round red protuberances of the size of a millet-seed to a hemp-seed (Fig. 201). Often a hair comes out from the middle, and a drop of pus may be pressed out through the center. As a rule, the inflamed follicle bursts and shrivels up, but exceptionally the disease may end in induration, when small hard. nodules remain after the inflammation has run its course. In phlegmonous vulvitis the inflammation extends to the submucous and subcutaneous connective tissue. Deep abscesses and sloughs may form, and end in permanent fistulous tracts if not properly treated. Gonorrheal vulvitis is much like the simple acute catarrhal, but redness and swelling are more intense, the discharge is more purulent,

and the inflammation has a tendency to implicate the urethra, and is usually accompanied by gonorrheal vaginitis. Micturition causes burning pain, the urethra is swollen and tender, and a drop of thick, creamy pus may be pressed out from it. In children the veins of the labia majora and minora are congested and varicose. The presence of gonococci may be revealed by the microscope. Valuable as these signs are from a diagnostic standpoint, they are not so pathognomonie that, called as expert in a lawsuit, the physician should not be careful not to be too positive in his assertions. (See below under Vaginitis.) Chancroids and chancres will be considered under Venereal Diseases. Diphtheritic vulvitis is characterized by the formation of a gray diphtheritic membrane on and in the mucous membrane or wounded surfaces. The surrounding parts are edematous, dark red, or otherwise discolored. In this form there is also high fever and general disturbance of the whole system.

Prognosis. The acute catarrhal and follicular forms are of little importance and short duration. The chronic form may be very protracted. The gonorrheal may extend upward, and is then, as we shall see later, a very dangerous disease. The infective agent has also a tendency to remain in Bartholin's glands, and may thus cause infection long after the woman is seemingly cured. The phlegmonous form is rather serious. The diphtheritic form is only found as part of the most severe diseases. Besides endangering the patient's life, it may lead to more or less complete destruction of important parts, coalescence, and atresia of the genital canal.

Treatment. If the patient is feverish, she should be kept in bed, have a saline aperient and aconite; in the diphtheritic form large doses of quinine and alcoholic drinks, and in the later stage tinct. ferri chloridi. The genitals should be carefully cleansed, lukewarm or hot sitz-baths given two or three times daily; vaginal injections with carbolized water (p. 172) should be used as often. If there is any irritating discharge from the uterus or the vagina, it is a good plan to keep it away by means of a cotton ball introduced into the vagina. This ball ought to be wrung out of a weak antiseptic fluid. The genitals should be covered with fomentations of the same description, part of which should be applied between the labia. When the acutest stage is over the lead-and-opium wash may be substituted for the carbolic acid, or both combined. In the gonorrheal form hydrargyrum bichloride is preferable for injections and fomentatious (p. 172).

Later, the mucous membrane of the vulva may be painted several times daily with Monsel's solution of subsulphate of iron or the liq.

1 The reader is referred on this point to the timely warning of so high an authority as Robert W. Taylor, Atlas of Venereal and Skin Diseases, Philadelphia, 1888, pp.

ferri chloridi, each of them diluted with eight parts of glycerin. If this does not effect a cure, the inflamed parts should be painted every other day with a solution of nitrate of silver (gr. x-3j) or tinct. iodinii co., diluted with two parts of water. When the mucous membrane has nearly recovered, dry powders, such as oxide of zinc, subnitrate of bismuth, iodoform, or even inert powders, as lycopodium, taleum, or corn starch, often hasten the process. These same powders are used for the accompanying intertrigo.

If the urine is alkaline, benzoate of ammonium or sodium should be given (gr. x-xx every four hours). When, on the other hand, the urine is too acid, bicarbonate of sodium or liquor potassæ are indicated:

M.

R. Tinct. belladonnæ,

Liq. potass.,
Aquæ,

zij ;

3j; ad 3iv.

Sig. A teaspoonful in a wineglassful of water, t. i. d.).

In gonorrheal urethritis the urethra should be washed out with hot water or flaxseed tea by means of a reflux catheter. When the inflammation subsides somewhat, carbolized water (per cent.) or corrosive sublimate ( gr. to 3j), or nitrate of silver (gr. to 3j), or chloral hydrate (gr. x-3j), should be used. Pain may be relieved by instillation of cocaine with a glass pipette. If necessary, a few drops of a strong solution of nitrate of silver (gr. x to xxx-3j) may be injected or applied with applicator through an endoscope. Antiblennorrhagic medicines (copaiva, cubebs, and sandal oil) should only be given in the subacute or chronic stage. Itching is relieved by chloral hydrate, camphor, or hydrocyanic acid :

When nothing else will help, the whole mucous membrane must be excised.

In the phlegmonous form abscesses should be laid open by free