CHAPTER XXI THE DIAGNOSIS OF DISEASES OF THE VULVA (Part 2)

gina, which is a solid structure in the early stages of development after the fusion of Miiller's ducts and before the canal is formed, 397 398 DISEASES OF THE VULVA remains impervious in the adult. Be the cause what it may, the result is a damming up of the uterine secretions with resulting hematocolpos, hematometra and even hematosalpinx. The vulva of every female infant should be inspected by the obstetrician and the patency of the orifice of the vagina determined by passing into it a catheter. Most cases of imperforate hymen are not discovered until puberty, in rare instances the malformation has not been suspected until early marriage. There may be few symptoms, and these nothing more than a sense of weight and fullness in the pelvis. As the accumulated blood in- creases in amount the patient may experi- ence colicky pains in the abdomen and in- terference with micturition and defecation. Amenorrhea, when the body shape and the psychic changes of puberty announce the presence of that state, should lead to a local examination, especially if there is a menstrual moli- men. Diagnosis of Im- perforate Hymen. — The diagnosis rests on the physical examination. Inspection shows a bulging in the region of the in- troitus vaginae which is of a bluish tinge. The urethral orifice is dilated. Recto- abdominal palpation reveals the presence of a fluctuating mass in the region of the vagina; if the case is an early one, the vagina alone may be dilated, if a later case the uterus, or the uterus and the tubes are enlarged (see Figs. 171, 172 and 173.) The utmost gentleness should be employed and it is wise not to make too exact a diagnosis because of the danger of rupturing the tubes, should they be distended. A more precise finding is gained after an anesthetic has been administered, and Fig. 171. — Hemato- colpos, Caused by Atre- sia of the Vagina or Imperforate Hymen. Fig. 172. — Hematocolpos and Hematometra. CONGENITAL ANOMALIES 399 this ould not be given until the preparations have been made for evacuating the fluid.- Hermaphroditism. — Hermaphroditism (Hermes and Aphrodite), the union of the two sexes in one individual, is a term generally used to describe a person whose external genital organs partake of the characteristics of both sexes. Every embryo is in the begin- ning potentially both male and female ; some preponderating in- fluence determining the develop- ment of the Wolffian or the Miil- lerian ducts, so that it is not strange that remnants of the un- developed ducts should be found in the adult. The steps of the development of the sexual organs are indicated in Fig. 71, page 198 and in Figs. 158-162. True Hermaphroditism. — A true hermaphrodite, according to Neugebauer, is an individual who can impregnate another and also can be impregnated itself by another individual; not only that, it may impregnate itself. Accord- ing to this definition true hermaphroditism occurs in the lower animals, as in the cestopods. The gastropods, on the other hand, can fructify each other but not themselves. True hermaphroditism in the functional sense does not occur in man, but in the sense that an individual may have a genital gland which contains both ovarian and testicular tissue, an ovotestis, five undoubted cases have been reported, by V. Salen, Garre, Pick, and Schickele. One of Pick's two cases was that of a woman who had borne several children and Garre's case was that of a male hermaphrodite twenty years old. Therefore, true hermaphroditism, defined as the occur- rence of a combination gland of both ovary and testicle in the same person, does occur. A preponderating number of the reported cases are instances of pseudohermaphroditism. Neugebauer in his exhaustive work has gathered together 1,886 cases of pseudoher- maphroditism in addition to the five cases of true hermaphroditism. Fig. 173. — Hematocolpos, Hemato- metra and Hematosalpinx. 400 DISEASES OF THE VULVA Pseudohermaphroditism. — Pseudohermaphroditism is more often of the male variety. Male False Hermaphroditism. — Here the body form, stature, hair, and breasts are of the male type; testicles are always present, but the external genital organs are malformed. The penis is un- dersized and the glans imperforate, while the penile urethra is represented by a groove running into a cul-de-sac which corre- sponds to an incomplete vulva. The two halves of the scrotum have failed to unite in the median line, thus resembling the labia majora, and enclose a rudimentary vulvar orifice scarcely admit- ting a finger tip. One half of the scrotum may contain a testis, and the other testicle may be in the inguinal canal. It is a condition of hypospadias in the male. There are many varieties of this type. The cases are apt to be regarded as females and are brought up as girls until after puberty when they show sexual inclination toward females. Female False Hermaphroditism. — This is less common than the male kind. The ovaries are always present, but may be in the labia majora. The body form, stature, and hair are of the female type, but the individual may have a beard and the breasts may be poorly developed. The clitoris is large, resembling a penis, the labia majora are fused in the median line so that they are like a scrotum, and the vagina is small. For a complete exposition of this subject, with descriptions and illustrations of the many cases of hermaphroditism that have been reported, the reader is referred to Neugebauer's work ("Her- maphroditismus beim Menschen," 1908). INJURIES OF THE VULVA Injuries of the vulva may be divided into (a) those due to child- bearing, (6) those due to direct violence, and (c) those due to coitus. (a) Childbearing. — The labia majora are apt to be bruised and lacerated, more often the former, by the obstetric forceps. Lacera- tions are generally superficial, but may involve the vulvo-vaginal glands. Hematoma of the labium majus occurs occasionally follow- ing difficult labor and may attain great size. It is especially liable to occur in patients who have suffered with varix of the vulva INJURIES OF THE VULVA 401 during late pregnancy. Hematoma is diagnosed by a tense swelling of a dark color, due to the clotted blood showing through the skin of the labium, and it is very sensitive on pressure. Such a hema- toma very seriously complicates labor. The nymphaB are torn now and then, but such wounds are seldom serious. The vestibule may be torn near the clitoris so that dangerous hemorrhage may result, but this is an unusual occurrence. Injuries of the hymen have been referred to under the malformations of the hymen, page 396, and lacerations of the perineum are treated in the chapter on diseases of the vagina, page 372. (b) Direct Violence. — The vulva, because of its situation, is pro- tected from the more common forms of injury, but may be injured by falls astride of a sharp object, or by kicks, or blows. The close proximity of the unyielding bony arch of the pubes and the abun- dant blood supply of the parts make wounds in this region more serious. Women have fallen astride of a chair, or a pitchfork, or the saddle of a bicycle, or a fence picket, with resulting wound of the vulva, generally attended by excessive bleeding. Blows or kicks are apt to take effect on the labia majora with resulting hematoma, generally of one labium, and sometimes of considerable size. The hematoma may suppurate, become gangrenous, or, if not of a severe grade, may be absorbed. The dark blood generally shows through the skin; the hematoma is not often larger than a closed fist, and of course is very sensitive. Children have been injured by splinters of wood penetrating the vulva while sliding down a board, or by being thrown on sharp objects while coasting. (c) Coitus. — Injury of the hymen at the first intercourse often results in bleeding which has been known to be alarming in amount in very rare cases; usually the bleeding is of no moment. Severe injury of the vulva from rape upon young girls has been reported, the wound involving the perineum, labia, or even the recto- vaginal septum, there being cases on record where a recto-vaginal fistula resulted from brutal coitus. Disproportion in the size of the penis and the vagipa in the case of young girls and old women has given rise to injuries, which must be considered as of infrequent occur- rence. 402 DISEASES OF THE VULVA INFLAMMATION OF THE VULVA: VULVITIS The vulva, being covered by modified skin and hair, is affected by the same sort of skin diseases as the other hairy parts of the body. The forms of skin diseases that most frequently affect the vulva are, erythema, eczema, herpes, acne, tuberculosis, con- dylomata, kraurosis, elephantiasis, thrush, pediculus pubis, syph- ilis, erysipelas, diphtheria, and gonorrhea. The last is the most frequent of the causes of inflammation of the vulva; other causes are, lack of cleanliness, irritating vaginal discharges, or irritating urine, as in diabetes mellitus, local irritation, as from scratching or an ill-fitting napkin, and, finally, any constitutional exhausting diseases that lessen the resisting power of the tissues. Simple or Catarrhal Vulvitis. — Simple or catarrhal vulvitis is the most common form of vulvitis and may be due to want of cleanliness, pediculi pubis, excessive coitus, abnormal discharges from the uterus, fecal or urinary fistula?, or malignant disease. In the acute form it is characterized by tenderness, burning and throbbing at the vulva, smarting on urination, and profuse, non-purulent discharge. In the chronic form itching and burning are noticeable symptoms, also a discharge that is thinner and less in quantity than in the acute stage of the disease. The vulva is congested and more or less swollen in its various parts and there may be excoriations or even ulcerations. In some cases the hair and sweat follicles are infected and the vulva is studded with papules and pustules. This follicular vulvitis is a rare form of vulvar inflammation seen mostly in the clinics of Europe. In diphtheritic vulvitis a characteristic gray membrane, composed of fibrin, is formed on the vulva, and a similar appearing membrane, but with little fibrin, also occurs in puerperal cases from the action of bacteria other than the Klebs- Loeffler bacillus, generally the streptococcus. The superficial inguinal glands take up infective matter from the vulva and even in the simple, catarrhal vulvitis may be enlarged. The disease has no tendency to invade the vagina or urethra and microscopic ex- amination shows the absence of the gonococcus. Gonorrheal Vulvitis. — In this variety, by all odds the most fre- quent form of vulvar inflammation, the disease has a tendency to invade the neighboring organs, and we have vaginitis, endocervi- INFLAMMATION OF THE VULVA 403 citis, urethritis, and inflammation of Skene's and Bartholin's glands, as well as the vulvitis proper; the vulvitis, in fact, being the least important of the gonorrheal processes. The discharge is purulent and of a yellow or greenish-yellow color; the disease affecting the urethra early, there is burning, and frequent micturition from the beginning. The inguinal glands may be involved and a "bubo" is developed in the course of a few days; also, the vulvo- vaginal glands are apt to be infected. The diagnosis rests on the severity of the inflammation following a suspicious intercourse, on the presence of urinary symptoms, on being able to express a drop of pus from the urethra or one of Bartholin's glands, and on finding the gonococcus in the discharge. Gonorrheal vulvitis is not un- common among infants and little girls, especially in institutions, and may lead to adhesions of the labia minora or even the labia majora. The entire vulvar cleft may be closed except a small operi- ing either in front or behind through which the urine escapes. Lesser degrees of adhesions are by no means rare, and careful ex- aminations of the women who present themselves in the out-patient clinics will reveal many cases of agglutination of portions of the nymphse, or adhesions burying the glans clitoridis. Diabetic Vulvitis. — Diabetic vulvitis is an inflammation of the vulva caused by the decomposition of the urine in diabetes mellitus by the saccharomyces fungus. Its symptoms are burning and intense itching, and tenderness of the vulva. On inspection the vulva is of a dull, reddish color and the surfaces of the labia and vestibule are parchment-like, corrugated, and dry. Excoriations from scratching are to be expected, or even the presence of small boils, and in time the disease affects the skin of the mons veneris and the insides of the thighs and the anal region. The diagnosis is made by finding sugar in the urine and by the appearance of the vulva, which is most characteristic. Thrush of the Vulva. — This rare disease is caused by the Sacchar- omyces albicans, just as in the case of parasitic stomatitis. It is found most often in nursing women, in advanced diabetes, tuber- culosis, cancer and in women who are exhausted physically. The parts affected are covered with slightly elevated, snow-white spots, which have a tendency to coalesce and leave shallow ulcers. The saccharomyces fungus in the form of mycelium and spores may be found in the discharges scraped from the surface. 404 DISEASES OF THE VULVA Elephantiasis of the Vulva. — Elephantiasis is extremely rare ex- cept in tropical climates. It affects mostly the labia majora, but may involve the clitoris or the nymphse. It occurs between the twenty-fifth and fiftieth years of life, and is characterized by thickening and enlargement of the tissues, sometimes forming a large tumor that has fissures and ulcerations on its surface. Pruritus Vulvae. — This is a symptom which may be due to a variety of causes, and consists of intense itching of the vulva. (See also Chapter X., page 160.) The various skin diseases such as eczema and pediculosis are characterized by itching, also the vulvitis due to diabetes, and the presence of Ascaris lumbricoides and Oxyuris vermicularis, especially in young subjects. Lack of cleanliness may cause itching and so may irritating discharges, as well as con- gestion of the vulva, as in varicose veins of the vulva and in preg- nancy. Aside from these definite causes the terminal nerve fila- ments in the vulva may be affected so that itching results, as in the case of some old women and in certain nervous diseases, and we are ignorant of the causation. For the purposes of prognosis and treatment it is important to determine, as far as possible, a definite cause. Great sensitiveness of the vulva may be due to a neuritis affecting the nerves of this region, and the physician will do well to rule out this affection before resorting to local treat- ment. Kraurosis Vulvae. — Kraurosis vulvas is a progressive atrophy and contraction of the tissues of the vulva of unknown cause, occurring mostly after the age of forty. The disease affects the nymphse, clitoris, and vestibule and begins as small brown spots, of irregular shape and slightly depressed, on the surface of the labia minora and the vestibule. Soon the tissues of the vulva become tense, shining, white, and contracted; the meatus urinarius pre- sents a reddened prominent appearance, and along the carunculse myrtiformes are small patches of subcutaneous hemorrhage. The nymphse atrophy. The orifice of the vagina becomes contracted so that it will barely admit the tip of a finger without causing hemorrhage or great pain. The pubic hair has a peculiar stubbly appearance and may be broken or may come out. The labia majora are not much affected by the atrophic process, as a rule. Micro- scopic examination of the tissues shows small- round-celled infil- tration and great development of fibrous tissue, with absence of INFLAMMATION OF THE VULVA 405 hair follicles and sebaceous glands. Left to itself the disease runs a chronic course of five or six years. The symptoms are great irritation, smarting on urination, and painful intercourse, which may cause lacerations, the parts being very friable; the lacerations being severe if pregnancy and labor occur. The symptoms may be entirely relieved when the atrophic process has reached its climax. The diagnosis is established by the appearance of the vulva. Edema and Gangrene of the Vulva. — Edema of the vulva may occur as a result of vulvitis, but is more commonly the result of interference with the pelvic circulation by pressure on the pelvic veins by tumors, pelvic inflammatory masses, or the pregnant uterus, or it may form a part of a general anasarca. The nymphse and the prepuce of the clitoris are the parts mostly affected, but in extreme cases the labia majora and even the mons veneris become enormously distended. Pitting of the tissues on pressure is the diagnostic sign to be looked for. Gangrene may follow excessive edema or erysipelas of the vulva, or as a complication of the exan- themata, also in dirty, underfed children, where it is analogous to noma, or as an epidemic puerperal disease, or an acute inflammation independent of contagion. The nymphae are the portions of the vulva most affected by gangrene. It begins usually as a livid red, indurated swelling of one labium, soon breaking down into dirty gray or dull red ulcerations and followed by a greenish-black layer of gangrene. Varix or Varicose Veins of the Vulva. — Varix is found often during the later months of pregnancy. The enlarged veins are in the labia majora, and one or both sides may be involved, the left more often than the right. The vulva being well supplied with blood-vessels and also with erectile tissue, it is not surprising that obstruction to the veins should result in varix. The dark veins may be seen through the skin of the labium, and to the touch present the characteristic feeling of a bag of worms, as in the case of vari- cocele of the scrotum. Similar varicosities are