TUMORS OF THE VULVA.
So common are varices in women who have borne many children that they are considered by the laity ample evidence of child-bearing. They appear to a greater degree on the limbs than on the labia, although in the latter locality they may attain enormous dimensions. Holden reports the case of a woman who, in the fifth month of her fourth pregnancy, had on the legs varicose veins the size of an in testine, and on the labia the size of a child's head. This distension was only so marked in the erect position. Premature labor was induced, but the woman died a few weeks afterwards of phlebitis.
In general, varices of fair size give rise to no symptoms. Those of the limbs cause edema; on the labia they are exposed to injury from rubbing, and excite scratching.
Distension of the veins during pregnancy is frequent. Congestion is more excessive, the varices increase in size, and often rupture. There are on record many instances where a varix ruptured during pregnancy or in the course of labor, so that the patient died before the physician could reach her. The chances of rupture are, of course, greater when a woman under such conditions is unfortunate to fall. There are two re corded instances where women, in consequence of injury so received, bled to death in from forty to seventy-five minutes. (Hyde and Roche.) As causes of rupture may be instanced rubbing of the skin of the labium against the thigh, and strong muscular effort. Hildebrandt mentions a case of hemorrhage towards the end of labor in a multipara from rupture of a varix induced by effort in carrying a waiter full of dishes from the kitchen into the dining-room. The hemorrhage was so profuse that the woman would have succumbed had she not fortunately lived near the Maternity hospital.
The rupture site in the wall of the vein is often so small as not to be discernible on autopsy.
The prognosis of varices depends on the size of the tumor. Smaller ones have less tendency to rupture, and hence the prognosis is more favorable. The treatment aims at controlling the hemorrhage, which may be accomplished for the moment by compression, and, as soon as the necessary preparations have been made, by careful suture. That the patient should at once be placed in the horizontal position and receive stimulants is self-evident. In case of large varices we should use com pression as a prophylactic measure. This may be readily accomplished
on the legs by bandages, but it is difficult to apply it to the labia. The T-bandage is a good means, associated with rest in bed.
liematoma or Thrombus of the Vulva.—Rupture of varicose veins into the sub-cutaneous cellular tissue of the labia may lead to the formation of a hematoma. Usually this forms without the varices having been previously noted, either from undiluted veins or small arteries or else from rupture of the corpora cavernosa. Von Weckbecker-Sternefeld, blucher, Stocker, and others, have stated that in the instances they observed varices were not present. The cause of rupture lies almost always in labor, or in injuries of the genitals from blows against sharp objects. During labor the cause is seldom direct injury, but precipitate birth of the head, which induces excessive traction and rupture of the blood-vessels. The forceps is certainly rarely to blame, but by means of them, when rightly used, the formation of the hematoma will be prevented.
Aside from pregnancy and labor, hematoma of the vulva occurs only as the result of great mechanical injury, as by falls; still von Franque re ports an instance where the only apparent cause was great abdominal effort.
In labor, pressure and congestion in the vascular system are greater than under other conditions, and therefore hematomata are more frequent and of larger size. During labor there are a number of instances on record where in a short time tumors the size of a child's head formed. Aside from the puerperal state they are almost never met with larger than a hen's egg. Schneider mentions a case where, in the presence of such a tumor, version was performed with the result of its rupture. In another case the forceps was used, and a hematoma afterwards formed in an otherwise healthy multipara. The tumor ruptured and gave exit to two pounds of blood. It has often, further, been noted that soon after the formation of the tumor hemorrhage has occurred. llematomata may also first form after the termination of labor. As explanatory causes we must look to the stretching of the genitals, and the distension of the walls of the genital tract as the primary, and to labor itself as an immediate cause, even though the overfilling with blood of the sub-cutaneous cellular tissue only follows secondarily.