The primary seat is most frequently on one of the labia majors, and next on the clitoris. Mayer's two instances of scirrhus, developed from the clitoris or its prepuce, and his two cases of sarcoma, one from the nymphre, and the other from a labium majus. Of Hildebrandt's two cases of scirrhus, one developed from the right labium majus, and thence extended to the labium minus and to the clitoris. The glands on both 'sides were much swollen, more so to the left than to the right; the other grew from the prepuce of the clitoris.
Scirrhus cancer begins ordinarily with deeper-seated nodules than the cancroids. In case it ulcerates, this occurs after extensive spreading. All the reported cases belong to women advanced in life. Mayer's and Hildebrandt's cases ranged between sixty and seventy years of age.
There are only a few cases of sarcoma of the vulva on record. The first of the instances recorded by L. Mayer concerned a woman in her sixtieth year, who had on both labia, the nymphs) and their neighbor hood, eight to ten red, sponge-like excrescences springing from the cutis and varying in size from that of a pin's head to a hazel nut. These growths bled most readily, and this rapidly weakened the woman. In the second case there also existed profuse hemorrhage. The tumors when first seen were the size of a cherry, pediculated, and excoriated on the surface. On the opposite side of the vulva were dark pigmented markings. The growths were removed, and the base was cauterized with the red-hot iron. The patient remained healthy for five months. Then the growth recurred and death soon followed.
Hildebrandt's case was rather an instance of sarcoma of the meatus urinarius, a few instances of which are on record. The sarcoma de veloped in an old woman from carbuncles of the urethra, which had fre quently been treated by the scissors and the cautery, and it spread to other portions of the external genitals. G. Simon, Bleeberg, and Winckel have also recorded instances. Winckel's first case had been diagnosti eated lipoma of the clitoris, but microscopical examination proved it to be made up of round cells. The second tumor, springing from near the urethra, was a myxo-sarcoma, and the greater portion consisted of spin dle cells.
Rhabdomyomata, such as are found developing from the vaginal wall, are not met with on the vulva.
The symptoms and the course of these varieties of cancer, are more severe than in case of cancroid. The nodules under the skin, in these cases as well, either give rise to no symptoms or else only to pruritus. There is also more profuse vaginal discharge. When once the parts ulcerate, however, there is more pain than in case of cancroids. The tissue, which is greatly infiltrated, breaks down extensively, and there is greater tendency to hemorrhage, even as in case of similar growths of the uterus. The lymphatic glands are earlier affected, and these degenerate and ulcerate speedily. The patients die relatively soon of cachexia and metastases.
The treatment consists in the removal of all the diseased tissue. In case of the rapidly spreading forms, however, where the glands are speedily affected, nothing but palliation is to be expected. Recurrence sets in in the cicatrix, and the laity are accustomed to say that operative interference has simply resulted in increase in the disease. Cures have been recorded, but we are always skeptical in case of reported cures, and are in doubt as to the real nature of the tumor. Hildebrandt says that he has operated in the early stage of scirrhus and medullary sarcoma without lasting effect. We are not dealing indeed with disease of the superficies, but with a carcinomatous infiltration of the entire wound.
The symptomatic treatment consists in allaying pain by narcotics, and overcoming the pus formation and the hemorrhage by antiseptic powder, iodoform, naphthalin, salicylic acid, etc., and by painting with iodine (diluted) or occasionally with the sub-sulphate of iron.
Tuberculosis of the external genitals, if we exclude lupus, I cannot find a single instance of. This is noteworthy, since Jarisch and Chiari have recorded a case of tuberculosis of the skin. It is, however, probable that lupus is a localized tuberculosis of the skin. In Caylds recorded in stance of tubercular ulceration of the external genitals, there were tuber cles in the apices of the lungs and ulceration of the labia and vestibule. Many nodules were on the affected parts, which under the microscope pre sented the characteristics of lupus. ( Vide Gehle, Dissertation on Primary Tuberculosis of the Internal Female Genitals, Heidelberg, 1881.)