pated by Koch* and Stiegele;† one of the tumors measured 55 centimeters or nearly 22 inches in length, and weighed 10 pounds.

Lipomata are found not only on the mons veneris and labia majora, as stated by K. Schroeder and Hildebrandt, but also on the nymphæ. A lipoma, situated on the free border of the right nympha, is represented in my Atlas, plate iv., p. 100. These tumors are, as a rule, lobulated, tolerably soft, slightly sensitive, often grow rapidly, and are, on account of their form, consistence,

sensitiveness, and the burning sensation produced by them, most frequently confounded with sarcoma of the vulva.

7. ELEPHANTIASIS OF THE VULVA.

Elephantiasis most frequently occurs on the clitoris or labia majora, though the nymphæ may also be affected. Compare fig. 6, with plate i., fig. 1, p. 266, Atlas.

The hypertrophy of the different parts of the skin is very va

* Graeffe und Walther's Journal, 1856, Bd. 24, S. 308.

† Zeitschrift f. Chir. und Geb. 1856, ix., 243.

riable, so that the tumor may appear globular, lobulated, or like a massive condyloma. It is still a mooted question whether the deeper layers of the cutis are first affected, or the capillary lymph vessels of the corium, or whether the lymphatic congestion is caused by the hyperplasia and pressure exerted by the swollen lymphatic glands upon the lymphatic vessels. The following varieties of elephantiasis are recognized, the division being based upon the external appearance:

Elephantiasis glabra (smooth); E. verrucosa (warty); and E. papillomatosa (papillary); according to their consistence, they are designated E. dura and E. mollis; when there is much hypertrophy of the horny layer of the skin the condition is known as ichthyosis vulvæ.

Klebs makes the following divisions, dependent upon the nature of the disorder:

The lymphangiectomatic, epidermoidal, and elephantiasis of

Elephantiasis Nymphæ. Hartnack, S. 4, O. 2.

the connective tissue. He and Petters have described a case showing most marked lymphatic disturbance.*

Mechanical irritation, excess in venery, climatic influencesthe disease is said to occur oftener in the Orient-but especially syphilitic infection, are all of great significance in determining

* Prager Vierteljahrsschrift, Bd. 124.

this affection. In my second case the patient asserted with the greatest emphasis, that syphilis could be the only cause.

Veh has recently reported two cases, in one of which syphilitic infection could be proven, in the other scrofula only. Upon section of such a tumor, considerable quantities of a serous fluid escape, the epidermis (see fig. 7) is thickened by several new layers, the papillæ are hypertrophied, the cutis much thicker than normal, its deeper portions often changed into dark-brown indurated striæ, and the fatty tissue more or less absent. Pale dense connective tissue alternates with softer portions; they are quite vascular and contain spindle and round cells and abundant nuclei.

Etiology.-These tumors are produced gradually, often growing very slowly for years, then suddenly rapidly increasing in size, it may be with the occurrence of pregnancy or of the menopause. When they have once reached a certain size, formed a pedicle, and thus by their weight increased the local congestion, they appear to grow much more rapidly. Menstruation causes swelling, a greater degree of congestion, and some pain. In some cases the tumor decreases during the puerperal state, as occurred in one of my patients (Atlas, p. 371). Elephantiasis occurs more frequently before the fortieth year, and between the twentieth and thirtieth years. When we consider that in some cases there are acute lesions, in others more permanent but less considerable irritations, such as the smarting and itching of vulvitis, eczema, leucorrhoea, etc., we see that these slight affections, and especially pruritus of the vulva, are so very common, and so seldom lead to elephantiasis, it seems probable that other wholly specific causes are to be sought for, probably in a peculiar bacillus which may be similar to the bacillus lepræ.

The symptoms are at first often insignificant; some burning pain in the tumor, pain on urinating, and a purulent discharge; the tumors are more painful only after they have become inflamed and the surface ulcerated, or when they have begun to cause inconvenience in walking. Then the symptoms are aggravated, unpleasant odors, dragging and pulling upon the urethra, and very great difficulty in urination, bringing about disturbances of general nutrition, loss of sleep, and emaciation. Gangrene may

occur, and Klebs reports a case of death from peritonitis in a lying-in woman who had elephantiasis.*

Treatment. Such tumors may generally be extirpated with little danger or trouble; they seldom recur, but in one of our cases the next pregnancy brought with it a return of the disease, and that in a very aggravated form. The operation, therefore, becomes imperative; one may choose between the knife, scissors, Paquelin's thermo-cautery, and the galvano-caustic loop. The écraseur is no longer employed, because it stretches or lacerates the soft tissues, and may even injure the urethra or bladder.† If the pedicle be small, or if the tumor originate from the clitoris alone or from a labium majus, it may be easily removed with a redhot wire. If several parts of the vulva are involved, and the tumor has a broad base, the lower portions should be excised with the knife, and the opposite margins of the wound united by sutures at once, and then the most vascular portions removed with the galvano-caustic loop.

Ligation with an elastic ligature, with silk or other material, is not to be recommended, because excessively painful, slow in action, and may cause gangrene.

8. LUPUS OF THE VULVA.

This is a very uncommon affection. I have seen it but four times. Two of the cases have been described in the Atlas, p. 268-70, and another is shown in plate iii., fig. 3. The forms usually met are, hypertrophic and perforating lupus.

The first may occur upon either the labia majora or minora, or upon both. The tumors are smooth, often of a bright-red color, varying in size from a pea to a pigeon's egg, and healing in one place while ulcerating in another. These tumors are also found on the prepuce and frenulum. The cutis and papillæ are not hypertrophied (see fig. 8), the infiltration, as shown in the figure, is composed of small cells, is partially circumscribed and atypical, and in concentric layers around the capillary vessels whose walls are thickened. Other parts of the infiltration are

*Path. Anat., p. 983.

† Bourguet, 1867: Gaz. des Hôp., No. 140.

more diffuse, and involve the papillæ, the sebaceous and sweat glands, and the muscles of the skin. In some sections the lupus is principally located in the papillary bodies, in others in the deeper layers of the cutis. The infiltrating cells are round, the

size of a white blood-corpuscle, and show a granular cloudiness, or the débris of degeneration.

The condition is different in perforating lupus. In our case all parts of the vulva were swollen and resistent, with flat indurations and oedematous parts here and there upon the labia majora and nymphæ. At the base of the clitoris, and between the nymphæ and right labium majus, were several rather long, suppurating fissures, one of which had perforated the right nympha. A similar fissure was found at the posterior commissure.

Microscopical examination of excised pieces showed a moderate hyperplasia of the epithelial stratum, partly in the form of shaggy villous growths, partly in a sprouting out and hypertrophy of the interpapillary cones. In the connective tissue was a new formation, consisting of round cells and an accumulation of nuclei, especially marked in the layer next to the rete malpighi. More internally the growth became less compact, single nodules and bundles appeared, containing in many places numbers of