hernia by applying either Scarpa's pad, or a firm, hollow, hard rubber ring, which should as far as possible fill up the pelvic cavity.

CHAPTER IV.

NEOPLASMS OF THE VULVA.

TUMORS appearing as neoplasms on separate parts or on all parts of the vulva are far less frequent than on other organs, e. g., the uterus and ovaries. They are characterized by their great diversity, even exceeding in variety those of the ovary.

In 11,140 cases of women with benign and malignant tumors, Gurlt* found the following relative frequency of tumors involving the sexual organs: vulva, 89; vagina, 114; uterus and vagina, 604; uterus alone, 2845; ovaries, 71. Gurlt found only 106 cases of this character recorded in the Vienna hospitals during a period of many years, while the author met with 58 cases in 10,218 female patients

The hard papillomata of the skin, or warts, are very similar to the papillomata of the vulva as they are shown in my Atlas, plate ii., fig. 1, 2, and iii., fig. 4. They are hypertrophied papillæ, the epithelium often being more exuberant than the stroma. All sizes are met with, from those which scarcely project beyond the

* Langenbeck's Archiv, xxv.

mucous membrane, appearing like small points the size of a millet seed, to those the size of a cherry, or larger. Hundreds of the first variety may be found on the same patient (compare fig. 4). They are simple, not divided. Klob found in one case which he examined, that the larger part of the nodule consisted of an enormous development of nuclei similar to a tubercular

formation; he does not believe that these formations have any connection with the sebaceous glands.*

According to my experience they occur with marked frequency on the mons veneris, and have short pedicles like mushrooms; they also are found on the labia majora and nymphæ They are not caused by infection, neither do they infect the skin with which they come in contact; they occur in young and in old women with or without leucorrhoea. Very closely related to them are condylomata, to be next described.

2. CONDYLOMATA.

The sharp or acuminate condylomata (see fig. 5) arise also from a multiplication of papillæ, but occur too upon parts

* Path. Anat. d. weib. Sexualorgane, p. 461.

devoid of papillæ. Ranging in size from that of a millet seed almost to that of a walnut, they are always pedunculated, generally flat, at first fringed or shaped like a cock's comb, much softer than papillomata and often easily broken off. They are found upon all parts of the vulva from the perineum to above the mons veneris, over the thighs and upon the abdomen.

They infect the healthy skin with which they come in contact, causing similar formations. They are found singly, and also crowded together in great numbers, and extending both internally and externally. It is not definitely known whether these structures are caused by gonorrhoeal infection, by contact of the parts during coitus, or whether they may not appear spontaneously in pregnancy, independent of any such infection; neither is it known that they have any connection with syphilis proper. Müller recommends the following test: "Those who have the hardihood to doubt or to deny the infectiousness of acuminate condylomata, should possess the courage to substantiate this assertion by a practical test, i. e., sexual intercourse with a woman having condylomata on her genital organs.'

Inoculations have not been invariably successful. Mechanical irritation resulting from cohabitation with individuals affected with catarrh of the genitals, or cohabitation with different men, one or the other of whom deposits an infectious mucous secretion, has certainly much ætiological significance. That it is not simply leucorrhoea, though this is present in almost all cases without exception, is best proved by considering the frequency of these catarrhs compared with the infrequency of acuminate condylomata. Müller acknowledges that condylomata may appear independently of contagion, and that in this case their cause is unknown.

During pregnancy they grow rapidly and are difficult of removal, while in the puerperal state they become paler, smaller, and shrivel up, and often, though by no means invariably, may spontaneously disappear.

3. CYSTS.

Cysts of Cowper's glands are often met with, but in addition

* Grundriss der venerischen Krankheiten, Leipzig, 1884.

to these, cysts are not uncommon at the vulva, usually located between the orifice of the urethra and the clitoris. They vary in size from a lentil to a bean, and their contents may be a thin, serous fluid, or a yellow-clay-colored material. In some instances they are lined with cylindrical epithelium. The majority of the patients having these cysts, 10 out of 18, were multiparæ. Klob's opinion is that they may be produced by dilatation of the lymphatic vessels, probably the result of thrombosis. When the contents are the color of clay or of chocolate, admixture with blood is generally indicated.

a. They usually proceed from the glands which, on the hairy portions of the labia majora, are appendages of the hair bulbs; internally, however, their excretory ducts open directly upon the surface. The glands are most numerous on the internal surfaces of the nymphæ, their excretory ducts being scarcely a millimeter, orth of an inch, apart.

In infants the nymphæ are not provided with glands, these being developed at puberty.*

b. Atheromata of the sebaceous glands are, according to Klebs, most common on the inferior portions of the labia majora; here they form encysted tumors with contents of a more or less liquid consistence. The inner surface of the cyst wall is rough and irregular, and of a whitish color from the epithelium covering it. Syme found an encysted tumor as large as a cherry on the prepuce of a girl of 8 years. I removed, from a woman 33 years of age, an atheroma nearly as large as a hen's egg; it was upon the nates near the vulva.

c. Klebs and Hildebrandt mention true dermoid cysts, their walls having the elements of the skin, papillæ and sebaceous glands, and containing hair and teeth, but neither of these authors presents the proof.†

It is also questionable whether a case, reported by R. Froriep, belongs to this class of vulvar affections. He described a compound cystic tumor, which grew from behind forwards into the left labium majus.

* Henle, Harn- u. Geschlectsapparat, 1864, p. 441.

† Klebs, Handbuch, 1873, p. 987; Hildebrandt, 1. c., p. 57.

4. MYXOMATA.

In general, myxomata of the vulva are uncommon. They are soft, yielding tumors, containing a mucous or fibrillated elementary substance; round or spindle-shaped cells communicate with each other by means of prolongations or projections. If the tissue be fibrillated, the tumor is called a myxo-fibroma. A tumor of this kind which I extirpated was large as an egg, and simple. They may also be multiple, and it is said may be produced by metastasis.

5. FIBROMATA AND FIBRO-MYOMATA.

These tumors are developed from the connective tissue and muscular portions of the vulva, usually from the subcutaneous tissue and muscular fibres of the round ligaments. Varying in size from that of a cherry to that of a man's head, they gradually become pedunculated and may hang down quite low. More frequently they are made up of several small tumors, hence presenting prominences and furrows upon the surface. They are moved about and bruised in walking, causing excoriations and oedematous swelling of the tissues, or extravasation of blood into them. In this way some parts of the tumor become softer, or may even fluctuate; occasionally abscesses are formed. They increase in size during menstruation and in pregnancy, returning to their usual proportions in the intervals.

The tumor may be eliminated spontaneously by the inflammatory processes caused by the irritation to which it is subjected. According to Klebs, Paget diagnosticated and extirpated a fibromyoma of the vulva. Zweifel extirpated a fibroma the size of a child's head from the left labium majus.†

6. LIPOMATA.

The fatty tumors of the vulva may attain to great size, even hanging down to the knees. The largest of the kind were extir

* Koppe, Klinik, 1882, Nr. 179; 18 Jähr. Individ. mit Myxome der rechten Nymphe.

† Schiele, 1. c., p. 10.