hematoma of this variety result from violent efforts at defecation in an old woman who had never given birth to a child. Gempe observed a similar tumor in a nurse twenty years of age who had lifted patients a great deal. I saw a hematoma of the right labium majus in a woman who was not pregnant, which resulted from a fall against a bath tub. Altogether, I have met with five cases of hematoma vulva of this sort. Blood may also escape into the remains of the hymen and distend these until tumors as large as a bean or a hen's egg are present. I have also seen one such tumor. If the tumor be small it will usually be completely absorbed without causing any great inconvenience. If it be large itching is the initial symptom, followed by an intense local pain and increased swelling. The tumor is hot, of a bluish-red color, elastic, extremely painful to the touch, closes up the entrance of the vulva, and may render urination difficult. Even tumors of this sort, as in Gempe's case, can be completely absorbed in a few days under the application of an ice-bag. If they increase beyond a certain size so that the skin is discolored from the tension, they must be incised, the blood-clots turned out, the cavity thoroughly disinfected, then packed with iodoform gauze, and compression applied.* APPENDIX. Acquired Atresia of the Vulva. These various forms of inflammation of the external genitals may, during childhood, as also at later periods, lead to a complete adhesion of the parts, or to acquired atresia of the vulva. These adhesions, resulting from the raw surfaces of the labia coming in contact, are not often complete, since the discharge of the urine separates the surfaces, at least at the upper portions, but still in very young children only quite small fistula may remain, a sort of raphe indicating the edges of the labia. The longer the adhesions remain, the firmer they become. It is obvious that retention of the vaginal and uterine secretions may * For further details, see Pathology of Childbed. result. In severe cases even the parts in front of the urethral orifice may adhere, and urine be passed only after much straining. As a usual thing it does not proceed to this extent, for small children have difficulty in urinating which attracts the attention of the parents, and an examination reveals the cause. Generally it is quite sufficient to pull the labia apart, thus separating the adhesions, but if not, they should be divided with the knife. Placing salicylated cotton between the lips of the wound will counteract the tendency to adhere, or, if this prove insufficient, cauterizing the surfaces, or, if the wound be large, pulling back the lips by means of sutures passed on either side will most effectually prevent a recurrence of the adhesions. CHAPTER VI. DEFORMITIES AND DISEASES OF THE VULVO-VAGINAL GLANDS. COWPER'S GLANDS in the female are 15 to 20 mill. (% to 1% in.) in length, smooth, irregularly lobulated, and open through an excretory duct of about the same length and with a lumen of 1 to 3 mill. ( to in.), upon that part of the internal surface of the introitus which marks about the middle of the hymen, and just in front of the latter. The gland is embraced by the bulbocavernous muscle, contraction of which causes the ejaculation of its contents. During coition the gland is compressed, prostitutes therefore being especially liable to diseases of these glands. Lascivious dreams likewise cause a reflex ejaculation of their secretion, i.e., pollution in the female, and the same may be produced in sensitive individuals by a gynecological examination.* When the labia majora are imperfectly developed, these glands may be wanting (Zeissl). Their most common disease is * Erich., Paroxysms in the Female Resembling Nocturnal Emissions in the Male. Maryland M. J., Balt., 1882-3, ix., 348. A. CATARRH, HYPERSECRETION. Boerhaave is said to have been acquainted with this disease as a form of gonorrhoea in the female. I have observed it clinically for months in a young person. The orifice of the excretory ducts will be found distended so that a sound may readily be introduced. The adjacent surface is reddened, and when the introitus is put on the stretch a drop of transparent tenacious mucus will be seen to exude from them. The quantity secreted is much increased when either external or internal pressure is exerted upon the glands; in long-standing catarrh the secretion is opaque, the mouth of the duct becomes occluded causing retention. This causes, first, an ovoidal distension of the duct which may later affect the gland, and lead to the formation of B. CYSTS. As long as the duct alone is implicated the tumor will be globular and the walls uniformly smooth. When the gland also is affected the tumor appears compound, and while, as a rule, appropriating only the posterior and external third of the labium majus, may occasionally grow into the vagina and pelvic cavity even above the vault of the vagina. A case described by Hoening* will serve as an example. The tumor, palpated through the abdominal walls, was as large as a goose's egg and extraordinarily soft and elastic; below, a tumor of a bright red color, which occluded the entrance to the vagina, was seen. The tumor contained a tenacious, thick, grayish, fatty mass, consisting of normal and degenerated epithelium, and drops and crystals of fat. The inner surface of the cyst wall was alternately smooth and rough. Huguier reports a similar case though the cyst was not so large. The ordinary contents of simple cysts of these organs are serous fluid, mucus or blood, and vary in consistence. Cysts of Bartholin's glands occur upon the right as well as upon the left side-according to Huguier eighteen times upon the left side, eleven times on the right, and five times in both labia majora. I have observed them five times left, six times right, and once on both sides. In cysts of the excretory ducts the labia appear as though * Monatsschrift, xxxiv., p. 130. divided into an inferior and superior portion. In cysts of the gland itself the distension is more in the lower and posterior portions, while, according to Huguier, when the tumor is developed from the most superficial acini, it may ascend along the edge of the ramus of the ischium above the middle line and even above the urethra. If the process proceed to the C. FORMATION OF ABSCESSES, The pus may be spontaneously evacuated. In abscess of the excretory duct Huguier says the evacuation occurs about 1 centim. (in.) below the orifice of the same; in inflammations of the gland the perforation invariably is found on the internal surface of the labium majus. Evacuation of the pus is usually followed by a rapid recovery, but fistula may occasionally be formed. These inflammatious are characterized by redness and swelling of the skin, a feeling of heat and weight, and shooting, piercing pain along the ischium. Standing and sitting become intolerable, and cohabitation is impossible. The inguinal glands are generally enlarged, though painless. The abscesses may be as large as a hen's egg. I have seen this disease thirteen times, in two cases the abscesses occurring on both sides, in seven cases on the left side. One case was associated with cancroid of the vaginal portion. Diagnosis. The diagnosis is confirmed by the location of the tumor in the middle and lower half of the labium majus, its circumscribed character, the enlarged gland, the presence of fluctuation, and the impossibility of lessening or pressing out the contents. These tumors may be differentiated from hernia, first, by the dullness of the latter on percussion; secondly, by the limitation of the tumors to the labium majus as a general thing, though not always, as Hoening's case shows; again, by the redness and swelling of the skin in abscesses. Hydrocele of the vulva is located in the superior portion of the labium majus, is covered by healthy skin, and is not painful. When a hematoma situated in the lower third of the vulva has begun to suppurate, it may easily be confounded with an abscess of the gland, but they can usually be differentiated if attention is paid to the previous history, to changes in the skin especially suffusion, to preexisting varices, and to its rapid development. Moreover, the confusion of these conditions would produce no unfavorable results. Congestive abscesses and abscesses from paracolpitis involve the same parts of the vulva; the first are covered with normal skin, reach a higher level in the vagina, generally originate in disease of the vertebral column, and after incision a sound may be passed high up in their course. Phlegmonous abscesses are the result of a trauma or of diffuse inflammation; are consequently not limited to certain portions of the vulva; usually open not internally but externally, or in several places; often cause fistula; are much more painful, and the general symptoms are graver. When once healed, there is no tendency to a recurrence. * There is, however, another form of abscess met with in this region which is still more liable to become confounded with those of Bartholin's glands, viz., abscesses caused by periproctitis abscedens, or, as they have been named by the French, stercoro-vulvaires. I have seen several examples of this variety, even in young persons, associated with periproctitis and rectal carcinoma. A careful examination will always reveal the fact that in such cases the rectum was first diseased; we will find hemorrhoids, swelling, fistulæ, and fissures; when the finger is introduced it causes excessive pain, and, if fistulæ are present, a sound will pass through them as far as or into the rectum. We also discover the swelling in the vicinity and the disease of the rectal wall. According to the statements of French authors prærecto-vulvar abscesses also occur in the septum between the vagina and rectum, resulting from excesses in venery, or from some lack of symmetry in the two sides of the genital apparatus at the beginning of the menstrual process. They are said to open at the same points as gland abscesses, and, as a rule, to heal rapidly and without the formation of fistulæ. I have never seen a case of this kind. Etiology.-Diseases of Bartholin's glands are comparatively rare in the better classes but very common in clinical and polyclinical practice. Young persons after the age of puberty are especially liable. It is possible that trauma and great changes * Huguier-Aubenas, 1. c., p. 16. |