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interfere with the retentive power. If the inguinal glands are affected, they must be enucleated, but even if they are removed entirely, the disease cannot be arrested permanently.

13. Lupus, Esthiomène (Huguier); Chronic Inflammation, Infiltration, and Ulceration (R. W. Taylor). The doubtful position of lupus of the vulva in the system of gynecological diseases necessitates an exception from the rule followed in this work not to enter into historical developments. In 1849, Huguier, In 1849, Huguier, a French physician, described a disease of the vulvo-anal region under the name of esthiomène, which was claimed to be identical with lupus as found especially on the face. The name "lupus" has prevailed, and a certain number of cases have been reported in different countries.'

The pathology of lupus itself is not yet settled, and so much the less can we decide whether the disease attacks the external female genitals or not. According to Koch's great authority, lupus is simply tuberculosis of the skin, and only that affection which is caused by the presence of his bacillus tuberculosis deserves the name; but this microbe has so far been looked for in vain in lupus vulvæ. Others claim that an infiltration with small round cells, clustering together in Dodules, especially around the capillary vessels of the skin, or a diffuse infiltration of the papillary layer or around the glands and hair-follicles of the skin, constitutes lupus. Still others lay particular stress on the presence of giant cells in the clusters of small round cells. Others, again, contend that all this is not characteristic of lupus, but may be found in any inflammation with formation of granulation tissue and proliferation of the cells of the connective tissue.2 R. W. Taylor denies altogether the existence of lupus in the female genitals. Based on his large experience in Charity Hospital, he includes all the inflammations and infiltrations of the vulva of non-malignant origin in the following categories:

I. Small hyperplasia, caruncles, and papillary growths;

2. Large hyperplasia.

3. Hyperplasia resulting from acute and chronic chancroids;

4. Indurating edema of syphilis;

5. Hyperplasia resulting from chronic ulcers, so-called chancroids, in intermediary and old syphilis;

6. Hyperplasia in old syphilitics, presenting no specific character and occurring soon or long after the period of gummy infiltration, in some cases being coexistent with specific lesions elsewhere.

The cases of formation of tumors, combined with ulceration, con

Grace Peckham, in an excellent paper fortified by microscopical examinations by H. C. Coe (Amer. Jour. Obst., 1887, vol. xx. p. 785), has collected 48 cases, of which she eliminates some as tubercular, carcinomatous, or not ulcerative, and retains 33, inclusive of her own.

2 Coe, l. Ira Van Gieson in R. W. Taylor's paper.

C.,

R. W. Taylor, N. Y. Med. Jour., Jan. 4, 1890.

P.S. BRU

stituting the condition commonly called lupus vulvæ, that have come under my own observation, were all developed on a foundation of recent or old syphilis.

What has been called lupus vulvæ (Fig. 203) consists in ulcerative lesions of the vulva characterized by their slow development,

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absence of pain, a violaceous color, thickening, induration, and formation of detached tumors. Hyperplasia and destruction go hand in hand, but the hyperplastic process preponderates. The deformity extends often to the perineum and the anus. The inguinal glands may become swollen, but are oftener not affected. The general health stays good for years, and those who are not cured succumb usually to constriction of the intestine and peritonitis. Locally, great destruction takes place. Fistulous tracts may burrow into the labia

and around the rectum, and fistula may open into the urethra, the bladder, or the rectum. Fortunately, this destructive hyperplastic affection of the vulva is a rare disease.

Etiology.-Those who do not look upon the ulcerative hyperplasia of the vulva as a disease sui generis, attribute it to the large vascular and nervous supply of the genitals, to the injuries they are frequently exposed to, to their dependent position between the thighs, to lack of cleanliness and care, and the irritation caused by uterine or vaginal discharges.

Diagnosis.-Epithelioma is usually more localized, of much greater density-even to stoniness-is productive of a large warty or papillamatous and ulcerated surface, and is very soon accompanied by enlargement of the inguinal lymphatic glands. The ulcerations of epithelioma are upon the surface, while those in so-called lupus are mostly found in interstices, fissures, and at the base of tumors. Epithelioma gives rise to lancinating pain; lupus is painless or causes only smarting or pruritus, especially after micturition. The discharge that emanates from the ulcers in lupus has little or no odor. An ulcerated part may heal spontaneously or in consequence of treatment, but the cicatrice is liable to be affected by a new growth of lupus. The microscope settles the question with certainty by showing the epithelioma to contain cancer-nests of concentrically arranged cells of the epithelial type.

Prognosis. We have already stated that the disease is a very tedious one, extending over years. It does not in itself undermine the constitution, but may lead to intestinal obstruction and peritonitis. or general exhaustion. In patients over forty any vulvar tumor, even a caruncle or a papilloma, may degenerate and become cancerous. If not checked, the disease may cause great destruction, and give rise to much annoyance by perforating the partitions between the different hollow pelvic viscera and the external genitals.

Treatment. On account of the dangers lurking in the background treatment ought to be quite active. The indication is to remove tumors and heal ulcers. Simon's sharp spoon, strong caustics-e. g. nitric acid, the thermo-cautery, the galvano-cautery, the galvanocaustic wire-may all be used to advantage, but, if possible, it is preferable to cut away all diseased tissue and unite the edges with sutures. Fistulous tracts may be laid open by means of the elastic ligature. It goes without saying that the utmost cleanliness should be practised by means of baths, fomentations, and injections. Often a tonic treatment with iron, quinine, cod-liver oil, etc., or local or general antisyphilitic treatment, may be called for in combination with the mechanical local treatment.

CHAPTER XIII.

TUBERCULOSIS.

TUBERCULOSIS of the vulva is an exceedingly rare affection; which is strange, since one would think that occasions of direct inoculation, either from the same or another individual, by means of fingers, handkerchiefs, towels, or the sexual act, would present themselves frequently. But the fact is that the more we approach the surface of the body the rarer becomes tuberculosis in the genital system.

It forms ulcers with sharp edges, sinuous contour, and a depressed grayish-yellow bottom covered with a cheesy detritus. Around the ulcers are often found small opaque, yellow nodules. In the discharge of the ulcers and in the tissue forming them and the nodules. are found tubercle bacilli. In the mucous membrane are found clusters of polygonal cells surrounded by a zone of small round cells, and containing giant cells, in the interior of which may be found tubercle. bacilli. As a rule, similar affections will be found in other parts of the genitals and in the lungs.

Treatment. The general treatment is the same as for tuberculosis in other parts-nutritious diet, tonics, sunshine, and fresh air. The local treatment consists in application of tincture of iodine or iodoform. If this does not suffice to eradicate the disease, removal with the knife or destruction with caustics or cautery is indicated in the early stages. If the patient is far gone, more palliative treatment with the curette and iodoform or aristol is all that should be attempted.

CHAPTER XIV.

PROGRESSIVE ATROPHY OF THE NYMPHE (L. TAIT), KRAUROSIS VULVE (BREISKY).

AT or after the menopause, and quite exceptionally in younger years, is sometimes found a peculiar atrophy of the mucous membrane of the inner side of the labia minora. It begins as small red spots, depressed under the level of the surrounding mucous membrane, tender and prone to bleed, transitory or spreading. They may disappear in one place and reappear in another, or spread serpiginously. Later, the mucous membrane contracts, so as to cause considerable coarctation of the vestibule. The stenosis may be so great that hardly a finger can be introduced into the vagina. Coition becomes painful, and childbirth is accompanied by tears of the tissues. When the disease is fully developed, the labia minora seem to be absent. The

mucous membrane appears dry, smooth, and cicatricial. Sometimes there is a slight yellow discharge. In many cases itching or burning is complained of.

The cause of the disease is unknown. Its course is very slow.

Pathological Anatomy.-Microscopical examination of the red spots shows dilated capillaries, with thinned walls, and nerve-fibers. All over the affected part of the mucous membrane the rete mucosum is thin, so that in many places the horny epidermis-cells lie directly on the papillæ. These are of uneven length, mostly short; the papillary body is composed of straight fibers like a cicatrice, and the sebaceous and sudoriferous glands disappear.

Treatment.-Kraurosis vulvæ is a very intractable disease. Cocaine is said to increase the sufferings. Applications of strong carbolic acid and a pledget steeped in a saturated solution of acetate of lead are recommended. A cure has been obtained by cutting the affected part of the mucous membrane away and uniting by sutures. be destroyed with the thermo- or galvano-cautery.

It may also

CHAPTER XV.

DISEASES OF THE VULVO-VAGINAL GLANDS.

THE vulvo-vaginal glands may be the seat of catarrh, cystic degeneration and abscess.

1. Catarrh of the gland is rare. It is characterized by hypersecretion of mucus and redness of the mucous membrane surrounding the opening. The duct may become dilated, so that a uterine sound may be passed through it, or it may become closed, and then a retention cyst is formed. Sometimes the accumulated secretion may be thrown off in paroxysms, constituting a kind of nocturnal emission.

The treatment is not satisfactory. The duct should be dilated with probes, and astringent antiseptic fluids injected. On account of the emissions, it has been recommended to extirpate the glands.

entrance.

2. Cysts.-There may be a superficial or a deep cyst. The former is supposed to be formed by the duct. It forms a small round tumor immediately under the mucous membrane, just outside the vaginal It may vary in size from that of a hazelnut to that of a hen's egg. The deep cyst is situated in the gland itself, and may be unilocular or multilocular. It forms a large tumor which is situated in the posterior part of the labium majus. Both form well-defined globular or oval, elastic tumors. The contents are ordinarily like the raw white of an egg, but may be chocolate-colored from admixed blood or purulent when inflammation has taken place. As a rule, the duct is closed, but by increased pressure it sometimes opens again. If

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