with the douche; after this, iodoform is dusted over the vestibule or, if the patient is recumbent, lint soaked in acetate of lead and opium lotion is laid between the separated labia. In some cases, chloroform and almond oil have given relief (Scanzoni).

Sig. Apply externally as directed.

Preparations of mercury give benefit in other cases.

Schroeder has seen very good results from the application of carbolic acid of varying strength-1 to 40 up to 1 to 10. Where milder measures have failed, solid nitrate of silver well rubbed into the irritated parts and followed by cold water dressing has given relief. To procure rest at night, morphia and chloral may be necessary; Hildebrandt has found tinct. cannabis indicæ (m. 10-20) even more effective than these.

ERUPTIONS ON THE VULVA.

The skin round the vulvar orifice may be affected with any of the eruptions found on other parts of the body. Of these the most important are erysipelas, eczema, prurigo, herpes, acne. These eruptions have the same character as when they occur in other situations and their treatment is the same. Condylomata will be referred to under syphilis.

TUMOURS OF THE VULVA.

Under these we shall notice briefly

Cysts of the Bartholinian glands,
Elephantiasis,

Neuromata,

Fibroma,

Lipoma,

Carcinoma.

This is also the most convenient place to refer to

Pudendal hernia,

Varix, hæmatoma and hæmorrhage.

Cysts of the Bartholinian glands.

The Bartholinian or vulvo-vaginal

glands, which are the analogue of Cowper's glands in the male, are situated at each side of the ostium vaginæ (see fig. 7); their ducts (about 2 c.m. long and wide enough to admit a fine probe) run upwards

to about the middle of the ostium vaginæ, where their mouths may be seen just in front of the hymen.

A cyst may form by dilatation of the ducts or of the glands themselves. When due to distension of the duct, it has at first an elongated oval form; when the gland itself is affected, there may be multiple cysts or a lobulated swelling. The contents are thick mucus which is clear or of a brownish tinge. Suppuration may occur and abscess form (v. fig. 318).

The symptoms are due to the discomfort of the swelling, which is most felt on walking. The diagnosis is easy, from the position of the swelling and its fluctuating character; when it has developed during the puerperium, we must differentiate it from hæmatoma (which after a time becomes firm from coagulation) and inflammation after injury.

The treatment consists in complete evacuation of the cyst and destruction of its walls. It is not sufficient to open it and allow the fluid to escape; we must cut out a portion of the wall and then plug the cyst with carbolised lint. By far the best instrument is the thermo-cautery: we first puncture the cyst with it; when the fluid has escaped, we pick up the outer cyst wall with forceps and lay it fairly open with the cautery; we then cauterise the inner wall also. A piece of carbolised lint is laid over the wound.

Elephantiasis. This is a common condition in tropical countries, but is comparatively rare in Europe and America although a minor degree of it is occasionally met with.

The pathological changes 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 hypertrophied (Mayer).

It developes, according to Mayer, most frequently at ages of from 20 to 30 years that is in the period of sexual activity. It has been traced to direct injury, but the most fruitful cause of minor degrees of hypertrophy is syphilis.

The symptoms are due to the weight and discomfort of the tumour which may reach to the knees.

The treatment of the larger growths is removal with the thermocautery.

Neuromata, or exquisitely sensitive red papules which resemble a urethral caruncle, have been described by Sir J. Y. Simpson (see the figure of urethral caruncle); their occurrence, except at the urethral orifice, is extremely rare.

Fibromata. These spring from the labia majora, resemble in structure fibroid tumours of the uterus and, like them, are embedded in cellular tissue or hang down by a pedicle.

Lipomata may arise from the fatty tissue of the mons veneris or labia majora. Emmet* describes a case in which the tumour hung down to the patient's knees and was supported in a bag round the waist; Stiegelet removed one which weighed 10 lbs.

Carcinoma of the vulva is rare in comparison with its frequency in the uterus. The most frequent form is the cancroid (West). It begins, usually on the inner surface of the labia majora, as small round nodules which elevate the skin; they may remain for a long time unnoticed, as their growth is at first slow and painless (Hildebrandt). After ulceration they spread more rapidly, and extend forwards and backwards but rarely into the vagina (Mayer). The inguinal glands are early involved.

Complete removal before the glands are affected, is the only treatment. As the growth is accessible, there seems a prospect of cure ; during the last few years cases are reported by Schroeder and others of extirpation without recurrence, but the time elapsed is too short to justify definite conclusions.

Pudendal hernia. This corresponds to scrotal hernia in the male. The round ligaments are the analogues of the spermatic cord, and after emerging from the inguinal canal pass into the substance of the labia

*

Op. cit., p. 601.

+ Zeits. f. Chir. u. Geb., Bd. IX., S. 243.

majora which correspond to the scrotum; if the process of peritoneum surrounding the round ligaments-known as the canal of Nuck-does not become obliterated at birth, it forms a track for the hernia.

Though it be very rare, the possibility of a hernia must be kept in mind on examining a tumour of the labia; the crackling feeling, the impulse communicated on coughing, and disappearance on taxis, indicate hernia. The serious consequences of cutting into such a hernia by mistake for an abscess, are self-evident.

Varix. The plexus of veins which forms the erectile tissue of the bulbi vagina has been already referred to (v. p. 10 and fig. 7). A varicose condition of the veins sometimes occurs in pregnancy and with pelvic tumours. In a case described by Holden,* they formed, when the patient was erect, a tumour of the size of a child's head. When these vessels rupture and the blood is effused into the cellular tissue, a hæmatoma is formed.

Hæmatoma.

This condition is also called "Thrombus" and "Hæmatocele of the vulva; the former term should be limited to a coagulum within a vessel, and the latter to blood effusion into the peritoneal cavity. It arises most frequently during labour, from injury produced by the child's head; the effusion may appear rapidly, as a tumour from the size of a walnut to an orange or larger, or may take place gradually. It has also been known to occur independent of labour or pregnancy, as the result of a blow or violent muscular effort.

is

The treatment consists in the application of ice to the vulva, and regular evacuation of the bladder and rectum without the patient's being allowed to strain. With this treatment, the mass may be absorbed. Should inflammation occur, poultices are applied and pus evacuated with the knife; if this occurs in the puerperal condition, special care is required to keep the wound aseptic by repeated washing with carbolic solution and dressing with carbolised lint.

The

External hæmorrhage from ruptured veins sometimes occurs. rupture may be caused by muscular straining, or by a blow or wound of the vulva. The dilated state of the veins makes such an injury serious during pregnancy, and several cases of a fatal result from a blow or kick have been the subject of criminal prosecution (Sir J. Y. Simpson). In a case recorded by Hyde,+ hæmorrhage from a vein ruptured by a fall proved fatal in forty minutes. Those who suffer from varicose veins should be recumbent for some hours during each day; should a vein rupture, the patient must lie down at once and apply pressure to the bleeding point. * Immense vulvar and vaginal Varix: N. Y. Med. Record, July 1868. + Lond. Obst. Trans., Vol. XI.

CHAPTER XLVI.

RUPTURE OF THE PERINEUM AND ITS OPERATIVE TREATMENT.

LITERATURE.

Bantock, G.-On the Treatment of Rupture of the Female Perineum, Immediate and Remote: London 1878. Duncan, Matthews-Papers on the Female Perineum : Churchhill, London 1879. Goodell-Lessons in Gynecology: Philadelphia 1880. Hart, D. B. -Op. cit. Hildebrandt-Die Krankheiten der äusseren weiblichen Genitalien: Stuttgart, 1877. Schroeder-Op. cit., s. 512. Simpson, Sir J. Y.-Diseases of Women, p. 644. Thomas-Op. cit., p. 165. See Duncan and Hildebrandt for literature.

Nomenclature. It will be most convenient to retain the nomenclature already used in the section on anatomy. The pelvic floor is made up of

The sacral or supporting segment of the pelvic floor (Hart). e symphysis pubis; perineum or inferior angle of sacral segment; g anus.

pubic and sacral segments, as already defined; in labour, each of these behaves characteristically-the pubic segment is drawn up, the sacral one driven down.