CHAPTER II.

DISEASES OF THE VULVA.

DISEASES OF THE VULVA-ERUPTIVE DISEASES OF THE VULVA-PURULENT VULVITIS-CAUSES-TREATMENT-CORRODING ULCER OF THE

LABIA

CAUSES AND TREATMENT-GANGRENOUS VULVITIS, OR NOMA-CAUSES AND TREATMENT-PRURITUS PUDENDI-CAUSES AND TREATMENT-URETHRAL EXCRESCENCES.

ERYTHEMATOUS, papular, vesicular, and pustular inflammations of the vulva are not unfrequently observed, as are, also, squamous diseases. They resemble the same form of disease in other mucocutaneous cavities and the skin, and hence, will not here claim a separate description. A disease somewhat more distinctive, however, and yet resembling a disease of the mouth, is known as purulent vulvitis. This affection is characterized by severe inflammation of the mucous membrane of the vulva, attended with minute points of ulceration, numbering from one to two dozen. The ulcers are small, an eighth of an inch in diameter, slightly excavated, and almost always covered with pus. The vulva is intensely red, and bathed in pus and mucus. The inflammation sometimes extends into the vagina and causes a copious flow of pus and mucus from this cavity. Not unfreqently the labia are very much swollen, and occasionally the deeper tissues are involved in phlegmonous inflammation. This form of inflammation is not unfrequently, in its early stages, attended with considerable febrile excitement. To a superficial observer, it strongly resembles gonorrhoea, from the swollen labia, burning pain, copious mucopurulent discharge, and the difficult and painful micturition. Its occasional sudden and unexpected development adds to this similitude, and legal proceedings have been instituted against parties supposed to have been instrumental in imparting the disease to little girls. It occurs in children generally from two to ten or twelve years of age, and probably results from want of cleanliness, heat, and local irritants, accidentally applied. If allowed to pursue a course undisturbed by treatment, other than cleanliness, it will

generally subside spontaneously in two or three weeks, or in the course of that time become very much subdued, and run into chronic inflammation without ulceration. This last is often extended into adolescence, and as vaginitis, gives origin to the leucorrhoea of girlhood, and finally endometritis of the woman. It is sometimes attended with a debilitated and scrofulous constitution, indigestion, constipation, and ascarides; but it is not likely originated, though it is aggravated and fostered, by these attendant symptoms.

The treatment is general and local. In the beginning, where the inflammation is high, it should be antiphlogistic and soothing. We may administer a mercurial cathartic, and quicken its action by a saline laxative, and after the bowels have been thoroughly moved, nitrate of potassa may be given internally, every three or four hours, to suit the age of the patient. The parts should be frequently bathed or fomented with a decoction of poppyheads, or with the watery extract of opium. In the course of four or five days the acute symptoms will begin to subside. When, in addition to attention to the bowels, we may administer an acid solution of quinine internally, and begin the use of astringents locally. A solution of tannin, sulphate zinci, acetate plumbi, or other such astringents, weak at first, and afterwards increased in strength, may be applied freely to the parts four or five times a day. These remedies will generally remove the inflammation in a reasonable time. The astringents should be increased in strength to a sufficient degree for the purpose. If those mentioned are not strong enough, the chloride of zinc, sulphate of copper, or even nitrate of silver, may be very properly resorted to. Should the inflammation extend into the vagina, the astringents may be injected into that cavity, by means of a small hard rubber syringe. We ought to be careful to use a very small syringe, and not to introduce it too far. The nurse should be carefully instructed in this kind of application. I feel impelled to insist upon the complete removal of this inflammation as early as it can reasonably be done, believing that if it continues until puberty, the inflammation extends into the body of the developing uterus, and entails a very distressing train of suffering upon the patient, that might have been avoided by an early and complete cure of the vaginitis. I am persuaded that too much importance

cannot be attached to these views. I have met with a number of cases of corroding ulceration of the vulva in children, which have been the cause of great suffering and apprehension. It occurs most frequently in children, but is occasionally met with in adults. There is in each case usually but one ulcer, and it is most commonly situated on the lesser labia at first, and spreads to surrounding parts. The ulcer is ragged and irregular, not much excavated, with a dark foul-smelling covering, and the discharge from it is sanious, fœtid, and excoriating. It is not generally rapid in its progress, and sometimes lasts for months, creeping from one part to another, until the anatomical features of the vulva are almost entirely effaced. I have not met with this form of disease except in very debilitated, sallow, and badly nourished persons. The state of the system leading to this sort of ulceration, I have thought to be more the result of living in poorly ventilated houses, particularly; but coupled, also, with imperfect nourishment, or with nourishment of an improper character.

It is generally obstinate, and yields slowly to judicious treat

ment.

We should endeavor, as one of the main objects, to correct the constitutional condition as speedily as possible. To this end the circumstances of the patient should be changed to the most favorable sort. Good ventilation at home, frequent and prolonged exposure to the fresh air, nourishing diet, of which animal food should be a large ingredient, and comfortable clothing, kept thoroughly clean, are indispensable to success. The bowels should be kept in as correct a condition as possible by gentle laxatives. The digestion, which is always feeble, if not otherwise faulty, may be improved by the administration of infusion of cinchona, quassia, or colomba, with the mineral acids; the sulphuric being, perhaps, the best. The chlorinated tincture of iron is also an excellent general remedy. The next thing to be accomplished is to convert the ataxic, half-sloughing, and corroding chronic ulcer, into an acute inflammatory one. This is done by profoundly stimulating it with the stronger caustics. The one which has seemed to me to be most successful is the caustic potassa. It should be applied to the whole surface, by passing a stick, not very rapidly, all over it. After this burning, we may dress the ulcer with calamine ointment twice a day. This will almost immediately improve the condition

of the sore. Unless there is some considerable firmness around and beneath it, in thirty-six or forty-eight hours after the application, caused by the effusion of fibrine in the submucous substance, not much good will result from it, and it will be necessary to resort to it or some other in a few days. The strong nitric acid is also very useful. I have not tried the actual cautery, but should expect it to be very useful. We may often cure this ulcer by the weekly use of the solid nitrate of silver to it, dressing between times with lint saturated with black wash or calamine ointment. We ought not to be afraid of strong treatment, nor to continue it, or reiterate it in conjunction with a highly roborant general course of exercise, diet, and medication.

Gangrenous Vulvitis, or Noma.-This is a very severe and generally fatal affection of the genital organs, occurring almost, if not wholly, among children. It may attack one or both sides simultaneously. In the few cases I have seen, there appeared a blab or blister on the inside of the mucous surface of the labium, which at the same time became enlarged, hard, tender, and painful. In a few hours the blister breaks, and from its side a not very abundant, but acrid serum is discharged. At this time a peculiar odor is emitted from the parts. All around the ashcolored surface, which represents the place where the blister was developed, the substance of the labium is very hard and much swollen. In two to four days the affected side is in a state of gangrene, the discharge is very much increased, the parts upon which it runs are excoriated and inflamed, and an intolerable stench is exhaled. I have not seen an instance in which the gangrenous parts were cast off; the patients having died beforehand. Generally, though not always, in the very beginning, the circulation and nervous system are very much disturbed. The pulse is quick and feeble, the patient nervously restless, or else stupid, the extremities cool, the body-particularly about the pelvis-hot, the tongue furred, generally brown, and the skin dingy and sallow. As the disease advances the pulse becomes still more rapid and weak, the extremities cold, the mind wandering, and the restlessness amounts to the frantic efforts of some sort of delusion. The tongue becomes dark-brown or black, the teeth are covered with sordes, and in the end, the patient sinks into profound collapse, and often coma, and dies.

The disease runs its course sometimes in forty-eight hours, and again, in milder forms, it may last five or six days. The causes, although unknown, must undoubtedly be of a depressing nature, overwhelming the organism very rapidly. It occurs sporadically, when it is comparatively mild, and epidemically. In this last state it is very rapidly fatal.

The prognosis is very bad, as it is always, or pretty nearly always, fatal. The profession, so far as I am aware, has not decided whether the disease is a general one, and the affection of the genital organs an incident, or whether the local disease inaugurates the general symptoms. The former is most likely the truthful interpretation of the phenomena.

In such a disease there is but little prospect of a cure by treatment; we should, nevertheless, institute such a course as is clearly indicated by the symptoms and signs. The general treatment should be strongly stimulant, tonic, and supporting; quinia, brandy, tincture cantharides, and beef essence, as much as the patient can bear, should be administered. I do not think the strong caustic local treatment, generally advised, any better, if as good, as the charcoal and yeast poultices, chloride of lime, anodyne fomentations, and cleanliness. Much attention should be devoted to thorough ventilation, isolation of the patient, and the neutralization of the fœtor by disinfectants.

Pruritus Pudendi.-A very annoying, and often obstinate affection of the genital organs, is an inordinate itching of the vulva. The itching returns by paroxysms. The patient will sometimes be free from it except when standing by a warm fire, or becoming heated by exercise, passion, &c. Or she may be affected only for a short time before, at the time, and after menstruation. Again, the paroxysms return without any apparent reason. The sensation sometimes is that of a burning glow, attended with an irresistible desire to rub or scratch the parts, a desire which the most delicate sense of propriety cannot always keep within due bounds. At other times the sensation is such as might be produced by the crawling of pediculi, and the patient is assured that thousands of these animalcula are moving upon her person, and will be convinced to the contrary only by inspection. This sense of formication, although very disagreeable, is a slight inconvenience compared to the sufferings of the other variety.