Varicocele.
Symptoms and Etiology.—This condi tion occurs not infrequently as an ac companiment of pregnancy. It is, in all cases, an evidence of interference with the venous circulation. The venous sup ply of the vulva is extensive; hence any condition which causes an increase of pressure in the pelvis may derange the venous circulation. Fibroid tumors of the uterus, tumors of the ovaries and tubes, pelvic abscess, pelvic peritonitis and cellulitis, and subinvolution of the uterus may all cause interference with the venous circulation and result in en largement in the veins of the vulva. In the later months of pregnancy the en largement of these veins is sometimes enormous, and the danger of rupture is constantly imminent. Occasionally rupt ure does occur, either just before or dur ing labor and hemorrhage, phlebitis, or thrombosis may confront one, with grave possibilities.
Treatment.—The treatment may con sist of rest in bed and the use of a press ure bandage upon the enlarged vessels. A pad of absorbent cotton moistened with an astringent solution (tannic acid, alum, or fluid extract of hydrastis) may be worn until the cause of the pressure can be removed; when this has been done the varicoccle usually disappears.
Tumors of the Vulva.
Mention has already been made of tumors of the vulvo-vaginal glands (re tention cysts, abscesses, etc.; venereal tumors. hypertrophy of the labia, and in flammatory enlargement in general).
The vulva may also be the seat of furuneles, ervsipelatous inflammation, hernia, hirmatoma, and enlargement from various benign and malignant growths. Furuncles should be incised as early as possible, even before suppura tion occurs, the incision being repeated should tension become troublesome. Antisepsis and cleanliness need hardly be mentioned as indispensable. For erysipelas rest in bed and the constant use of the ordinary lead-and-opium lo tion are indicated. The application of pure carbolic acid at the border of the swelling has been highly recommended as a check to the progress of the disease. The destruction of tissue which is likely to result from the use of this powerful substance must not be forgotten.
Hernial tumor of the vulva may re sult from prolapse of an ovary or from descent of the intestine through the in guinal or femoral canal into the labium majus. The differentiation of the causes of hernia is not always possible, and when operating for this condition it is well to remember the desirability of re turning a healthy ovary to the pelvic cavity. The prolonged ovarian ligament may be shortened by looping it upon itself to prevent recurrence of the pro lapse. The Bassini operation offers good prospect of radical cure for hernia in women. Hydrocele of the round ment will, in some eases, simulate in testinal hernia, and must be distin guished from it in the plan of treatment.
The contents of such a tumor are, of course, to be evacuated and a portion of the tumor-wall removed to prevent sible recurrence of the condition. Mem atoma of the vulva may occur apart from that which occurs with varicocele.
It consists in a swelling of one or both labia majora, and is almost invariably the result of traumatism. Rest, pressure, and the application of soothing lotions form the principal means of treatment. Should abscess occur, it must be treated by suitable surgical measures.
Other benign tumors of the vulva which also are of rare occurrence are fibroma of the round ligament, dermoid. and lipoma. These are to be treated surgically as would be the ease should they occur in other parts of the body.
Among 420 primary neoplasms of the external genitals in women, Williams found only 17 fibromas, or only about 1 in 600 of all the new growths in women he tabulated. The fibrous and fibromy omatous tumors that are seen in this re gion may have their origin in two main sources: (1) the subcutaneous connect ive tissue, and (2) the connective tissue and terminal muscular fibres of the round ligament, and possibly in mus cular fibres in the skin, while, as curi osities, may be mentioned tumors arising in [0] the pelvic fascia and periosteum of the bony pelvis, [b] the recto-vaginal septum, and [Cl the uterus. Malcolm Storer (Boston Med. and Surg. Jour., Dee. 15, '98).
Malignant disease of the vulva may be either carcinoma or sarcoma, the former being the more frequent. Their clinical differentiation is difficult and sometimes impossible. They present an indurated mass, which is usually very painful and may have numerous ulcerating and charging areas. The mass develops rapidly, and in a short time the inguina] glands become enlarged and painful.
The diagnosis is not difficult, syphilis being excluded.
Epithelionm of the vulva is liable to be confounded: (1) with simple vegeta tions; (2) with lupus of the vulva; and (3) with syphilitic affections; but the first, the simple vegetations, secrete a virulent liquid unlike the iehor of cancer, they readily yield to an energetic caus tic which prevents their reproduction, and they have no hardened base, being remarkable for their softness. In the ease of lupus, the vulva is red and presents scattered fungous ulcerations which are without any indurated base; while the syphilitic chancre is more lim ited and has a little circle of character istic induration. Wilmer Krusen (Phila. Med. Jour., Sept. 2, '99).
Treatment.—The tumor should be re moved as thoroughly and as promptly as possible, and my preference is for the cautery-knife for such operations. The haemorrhage may be very profuse, but it can usually be checked by firm press ure. The tumor is likely to return quickly and should be removed as often as the conditions will warrant it.