At the outset the symptoms of the disease are practically nil. The slightly enlarged labia may cause deviation of the stream of urine, and discomfort on sitting. Marked symptoms, however, only appear when the tumor has become large enough to cause inconvenience in walking. standing, or in working. The large tumors cause retention of secretion, and interfere with the stream of urine, thus leading to abrasion of the skin. There is present a disagreeable smell which robs the patient of appetite. After a short time there occur superficial inflammations and tumor formation. Frequently the tendency to ulceration is increased by the outflow of sticky serum. Those patients are in the worst condition who suffer from incontinence of urine through pressure of the tumor on the urethra, for here large surfaces of the skin are ulcerated and irritated by the constant flow of urine. These circumstances render the disease a chronic one, and the affected individuals die after a longer or a shorter interval.
The prognosis as regards life is, in general, good. Aside from causes due to the size of the tumors and the loss of strength from the exudation, death from elephantiasis of the vulva has never been noted. Klebs records an instance where a woman aborted, and where fatal peritonitis set in, the result of absorption probably from the open and abraded sur faces. Still, cure of this disease is not to be expected either spontaneously or from medication. We may not even hope to lessen the growth of the tumors by means of caustics. The most certain way of effecting cure is by surgical interference. The operation cannot be called a difficult one.
Speedy cure as the result of ablation has often been noted, frequently at the end of five days.
The differential diagnosis lies between fibroids of the labia, condylo matous tumors, cases of deep-spreading ulceration accompanied by loss of substance, carcinoma, lupus, and finally disease of the Bartholinian glands, abscesses, etc.
The differential diagnosis between fibroid and elephantiasis may ex ceptionally be difficult. Many of the reported cases of elephantiasis un questionably belong in the category of fibroid. Where tumors springing from the skin and readily movable under it exist, which have the peculiar fibrous feel, the certainty is in favor of fibroids. Elephantiasis is a disease of the skin and of the sub-cutaneous cellular tissue. When the tumor consists of greitly thickened skin and of extensive infiltration of the cellular tissue, then it is elephantiasis. Even here, however, as the result of unequal hyperplasia of the cellular tissue, distinct nodules, hard and soft in places, may be detected.
In the beginning, certainly, elephantiasis of the vulva does not present the acute inflammatory symptoms and the erysipelatous eruption which characterize the disease of the lower extremities. The inguinal buboes are also often lacking (Mayer), so that here also there exists no point for differential diagnosis from fibroids.
Careful examination will differentiate condylomata. They possess a soft, not an indurated surface. The condylomatoid papillary excrescences of elephantiasis spring from a thickened hypertrophic skin.
Malignant tumors are differentiated by their sharp outline, by deep isolated infiltration of the skin, and by their speedy progress. Lupus,
also, extends much more deeply than does elephantiasis. With or abscess, both of which are products of inflammation, and are accom panied by pain and fever, elephantiasis ought never to be mistaken.
In the beginning of the disease the treatment aims at checking its progress, but the results are not marked, since we do not know the causes at work. Antiphlogistics have been resorted to, as well as venesection, but elephantiasis has not thus been checked. In case of elephantiasis cruris Hebra has used a bandage with success, but this treatment is not applicable for any length of time to the vulva. In case of large tumors removal, as in other growths, is the best treatment. Surgical treatment is the simpler on the vulva, because there are no included organs, as in the scrotum, to beware of injury. Large tumors reaching even to the knee have been removed by Petit, Rogers, Tansini, Mason, Ronbais, Louis Mayer, Leteuneux, Wassink, Dittel, and others. Hildebrandt found only two deaths recorded; one case of Green's, 1835, where a tumor springing from the mons veneris and reaching to the knee was removed by a cre scentic incision. The wound did not heal, and the woman died; a case of Bourguet's, 1867, where a large tumor of the right labium drew down by its weight the anterior vaginal wall and the bladder and urethra. The operation was of long duration and was accompanied by much hemorrhage. Finally the one inch thick pedicle was removed by the icraseur and the bladder wounded. The patient died of peritonitis.
The operative methods are: The ligature, the ocraseur, the galvano cautery wire, the knife and scissors. The complicated methods, by crushing and burning, aim at little hemorrhage, but they do not certainly fulfill this aim, and they are not so valuable as the operation with a knife and scissors. The ligature has the disadvantage of being followed by long-continued J3uppuration. and it should be rejected. The leaves a wounded surface which will not heal by first intention. The same remark applies to the galvano-cautery wire. The great objection, however, to all these methods is that there is no certainty of removing all the diseased mass, as there is by the knife. Only after such an opera. tion is it possible to restore the genitals to their proper shape and appear ance. Finally the ligature, kraseur and the galvano-cautery are only applicable to more or less pediculated tumors. Extirpation has frequently been performed without special loss of blood, by inserting needles through the base of the mass, throwing an elastic ligature around them, thus constricting the tumor, and then operating above the needles. This method is simple, does not require special instruments, and is followed by union by first intention. Schroeder operates after a different fashion. He also aims at little loss of blood, and therefore a better plastic result.. The tumor is pulled forward, and the incision made under it. As the incision is made deep sutures are passed, thus bringing the surfaces together as fast as ho cuts.