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of any kind, even contact of the clothing. Irritability of the bladder, as indicated by frequent urination, is usually present. Occasionally retention of urine is caused by reflex spasm. Pain and hemorrhage may be caused by sexual intercourse, and in some cases coitus is impossible. The patient's general health necessarily suffers from the constant irritation and she becomes nervous, irritable and despondent.

Polypi of the urethral mucous membrane and prolapsed mucous membrane differ from caruncle in being less vascular and less sensitive. Also, polypi are attached higher, while in prolapse of the mucous membrane the base of the mass includes the larger part, if not all of the circumference of the meatus (Fig. 302).

Treatment.—The treatment for caruncle is removal. First apply a small piece of absorbent cotton soaked in cocaine solution (20 per cent) and leave in place five minutes. Then with a hypodermic syringe inject several drops of a weaker cocaine solution (% per cent) under the base of the growth and wait a few minutes longer. Then clip the growth off with scissors. All the abnormal tissue must be removed. Then introduce one or more fine catgut sutures to close the wound and stop the hemorrhage.

If the base is small and the resulting wound slight and without much hemorrhage, it may be simply touched with carbolic acid or liquor ferri subsulphatis, no sutures being needed. When the growth has a broad base and the patient is very nervous or hysterical it may be necessary to give a general anesthetic. In some cases, anesthesia is required for other reasons, for example, a thorough pelvic examination or curettage or repair of pelvic floor, and in such a case the caruncle may be taken care of at the same time. The urethral and bladder irritation usually subsides rapidly after the growth is removed.

While the patient is waiting for operation, some temporary relief may be given by the frequent application of cocaine solution (5 per cent to 10 per cent).

INFLAMMATION OF VULVOVAGINAL GLAND

Inflammation of the duct of the vulvovaginal gland and of the gland proper, has been considered under Gonorrhea. Inflammation in this gland of Bartholin is sometimes referred to as "Bartholinitis."

ABSCESS OF VULVOVAGINAL GLAND

The cause is infection with the gonococcus or the ordinary pus germs. The first is by far the more frequent, and the gonorrheal inflammation often persists in the gland long after the vaginal inflammation has disappeared.

The infection enters at the mouth of the duct and progresses along the duct to the gland proper. The secretion of the gland is increased, the duct becomes obstructed and a collection of pus forms, distending the gland and pointing in the direction of least resistance. Sometimes the duct alone is involved, the gland proper escaping. This is indicated by the swelling being small and confined to the region of the duct.

Symptoms and Diagnosis.—The symptoms are a painful swelling at the side of the vaginal opening with some fever. Examination reveals a swelling

[graphic]

Fig. 305.—Abscess of vulvovaginal gland, left side. Fig. 30ft.—Another case of abscess of vulvovaginal (Kelly—Operative Gynecology.) gland, right side. tHirst—Diseases of Women.)

[graphic]

Fig. 307.—Case of abscess of vulvovaginal gland on each side. (Weiner—Am. Jour. Obst.)

the size of a small egg situated in the tissues at one side of the vaginal orifice and projecting beyond the median line (Figs. 305, 306, 307). The swelling is tender on pressure and is red and hot. Fluctuation is distinct and the fluid seems near the surface. The orifice of the duct may be seen, but a probe will Fig.

[graphic]

309.—High power of Fig. 308. Chronic inflammation of vulvovaginal gland. Notice pus in lumen and dense inflammatory infiltration helow. Gyn. Lab.

not enter the gland because the duct is obstructed. If the obstruction is so slight that it gives way before the probe, then pus is discharged through the duct. The microscopic changes in the tissues are shown in Figs. 308 and 309.

The following conditions may be confounded with abscess of the vulvovaginal gland.

Cyst Of Vulvovaginal Gland is a chronic affair, the patient usually giving a history of the swelling having been there for a long time and the inflammatory signs (heat and pain and redness) are absent.

Pudendal Hernia must always be taken into consideration in determining the character of a swelling of the vulva. Hernia presents one or more of the hernial signs, such as impulse on coughing, reducibility, intestinal obstruction, resonance on percussion. The first evidence of hernia is usually noticed at once after some straining effort or injury, much more promptly than either abscess or cyst would appear.

Tumor Of Labia differs from abscess in the absence of inflammation, in growing slowly and in presenting the signs that distinguish the various kinds of vulvar tumors.

Treatment.—Open the abscess freely by an incision where the pus is nearest the surface, wash out the cavity with hydrogen peroxide and pack with antiseptic gauze. The wound, should be dressed the next day and as frequently thereafter as is necessary to keep it clean. Care must be taken that a good-sized piece of gauze projects into the cavity, that the edges of the incision may be kept separated until the cavity granulates from the bottom.

SINUS OF VULVOVAGINAL GLAND

In many cases of abscess of the gland, after the pus is discharged the cavity closes entirely and there is permanent cure. In other cases a sinus persists, giving rise to a constant slight discharge. The outer end of the sinus may close and a reaccumulation of pus take place, forming another abscess. This may be repeated several times in the course of a few years. Again, in inflammation of the vulvovaginal gland, the duet may remain open giving exit to the pus as it forms and constituting a sinus or discharging tract.

The diagnosis of sinus of the vulvovaginal gland is made by the history of inflammation of the gland associated with a sinus in that locality. By palpating the gland (Fig. 61), it can often be felt as a small hard lump, indicating infiltration and enlargement. Pressure on this lump will sometimes cause pus to flow from the sinus. A small probe introduced into the sinus passes into the region of the gland.

Treatment.—If the sinus has a good-sized external opening and has been present only a few weeks, it may close if washed out daily with hydrogen peroxide. The peroxide should be forced to the bottom of the sinus and it may be followed by iodoform in glycerin (10 per cent), or argyrol (25 per cent) or protargol (5 per cent to 10 per cent) or silver nitrate solution (2 per cent to 5 per cent). In most cases, however, the only way to effect a permanent cure is to extirpate the sinus tract and the infiltrated gland.

This is a comparatively small operation, but the patient will usually require a general anesthetic for considerable dissection is necessary. The parts are very vascular and there is much oozing. The resulting cavity is closed with sutures. The sutures serve also to stop the bleeding and ligatures are seldom necessary. Quite a depression is left where the inflamed gland was situated. This depression is not of particular importance and in time becomes less pronounced.

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Fig. 310.—Deep relations of vulvovaginal glands when ducts be- Fig. 311.—Cyst of right vulvo

comc cystic. (Cullen, after Hugier—Jour. Am. Med. Assn.) vaginal gland and duct. (Mont

gomery— Practical Gynecology.)

[graphic]

Fig. 312.—Cyst of duct of vulvovaginal gland. Notice how the gland substance has been pushed aside by the cystic duct. (Cullen—Jour. Am. Med. Assn.)

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