1 -flmi E RARE FORMS 
OF » 
YULYAR TUMOR. 
BY , 
W. P. MANTOA, M.D., 
Visiting Physician to the Woman’s Hospital and Foundlings Home ; 
Secretary of the Detroit Gynaecological Society, 
Ac., &c. 
Reprinted from the Canada Medical & Surgical Journal, December, 1887- 
MONTREAL: 
GAZETTE PRINTING COMPANY. 
1887. SOME RARE FORMS 
OP 
YULYAR TUMOR 
by ) y 
W. P. MAUTOU, M.D., 
Visiting Physician to the Woman’s Hospital and Foundlings Home ; 
Secbetaey op the Deteoit Gynaecological Society, 
Ac., Ac. 
Reprinted from the Canada Medical & Surgical Journal, December, 1887- 
MONTREAL: 
GAZETTE PRINTING COMPANY. 
1887. SOME RARE FORMS OF VULVAR TUMOR.' 
By W. P. Manton, M.D., 
Visiting Physician to the Woman’s Hospital and Foundlings Home, Detroit. 
The exceeding vascularity of the superficial as well as the 
deeper parts of the female pelvic outlet renders dilatations and 
varicosities of the venous radicles of common occurrence in 
pregnancy. Of this nearly every writer on obstetrics takes 
cognizance; and many cases are on record where the bursting 
or accidental puncture of such dilated vessels has led to an 
almost immediately fatal termination. 
A varicose condition of the vulvar veins in the virgin is, how- 
ever, of such rare occurrence, that after a careful search in the 
current literature I am unable to find more than two or three 
authors who cite cases or in any way refer to such a condition 
as possibly existing. 
It is with no hesitation, therefore, that I bring before this 
Society the histories of the two following cases. While on a 
visit to Prof. Credd in Leipsic, in the early part of 1882, I was 
invited by his assistant, Dr. Richard Lomer, to go with him to 
see a case to which he had just been called by the attending 
midwife. The conditions found were a transverse position of 
the child, a cord prolapsed through a fully dilated os, and a 
rapid, irregular foetal heart-beat. In the posterior half of the 
mother’s right labium major, extending inward to the labium 
minor, was a varicose tumor the size of a Florida orange. During 
the extraction of the child, its right clavicle and humerus were 
broken and the varicose tumor ruptured. As soon as the child’s 
head escaped from the vulva, the hemorrhage from the torn 
* Prepared for Ontario Medical Association, 1887. 4 
varix became alarming, the blood soon saturating the bedding 
and forming a pool on the floor beneath. Pressure on the 
wounded parts with the fingers, followed by pledgets of cotton 
soaked in tr. ferri sesquichlor. and the subcutaneous injection of 
ergotine, finally controlled the bleeding. The tear was subse- 
quently dressed with iodoform, and was healed completely by 
the tenth day. I afterwards obtained from the patient the his- 
tory in regard to the varix. 
Case I.*—When a young girl the patient had had a boil or 
abscess at the point where the tumor is now situated, which was 
opened by a physician. The varix had existed for some time 
before marriage; but no direct connection between it and the 
abscess could be traced save in point of location. In the non- 
pregnant state the tumor is about one-fourth its present size, but 
has gradually increased in size from year to year. During men- 
struation it enlarges and becomes painful. During pregnancy a 
great increase in volume takes place, although in former times 
it has never equalled its present dimensions. 
Case II.—Miss A. C., aged 16, was referred to me by Dr. 
Henry A. Cleland of Detroit in October, 1885. The patient 
began to menstruate a little over one year ago. At that time 
a slight fullness of the left labium major was noticed, which, 
after the application of a wash, somewhat diminished. During 
the summer, however, the labial tumor continued to enlarge in 
spite of the applications, and when I saw her in October it had 
reached the size of a large walnut. There was no pain, but 
some itching, connected with the growth, and it was feared that 
this latter condition might lead to habits of self-abuse. Men- 
struation had been irregular, and the flow varied greatly in 
amount. Three weeks before I saw her she had flowed for two 
weeks, and was, as the result, looking rather pale, although other- 
wise a healthy, well-nourished girl. The attending physician 
having already made external applications with no result, I ad- 
vised removal of the tumor. This I did on the following day, 
kindly assisted by Dr. Cleland. The wound was dressed with 
* This case was also reported in the Boston Medical and Surgical Journal for 
December 18,1882. 5 
iodoform, and healed rapidly, the sutures being removed on the 
eighth day. Menstruation set in a week after the operation, 
and lasted three days. For three periods the patient menstru- 
ated every three weeks, and afterwards every 28 to 30 days. 
June 17, ’86.—I again examined her, and found the parts 
in good condition, the place of operation being marked by a 
linear cicatrix. Menstruation is now regular every four weeks 
and lasts four to five days, the amount normal. 
I have no explanation to offer for the occurrence of dilated 
vulvar veins in the unmarried female. It is possible that in my 
first case, the former abscess and the surgeon’s knife had so 
weakened the parts that, as the result of hard work and consti- 
pation, the veins becoming more and more distended, caused an 
absorption of tissue, and thus gradually worked to the surface. 
In the second case, the irritation and congestion kept up by the 
varicose condition undoubtedly accounted for the profuse and 
irregular menstruation, but no cause could be found for the 
dilated vessels. Tilt* offers the suggestion that “ varicose veins 
may be gradually caused by the menstrual nisus,” and quotes 
Gay, who found the condition most frequent during the first two 
or three years of menstruation, and in connection with either 
too profuse or too scanty an amount of secretion. He states 
that at this time the femoral vein is liable to become surcharged, 
and on account of the unyielding nature and small size of the 
femoral ring, dilatation of the vessel may readily follow. This 
might possibly explain the origin of a varicose condition of the 
internal saphenous vein, but we cannot for a moment imagine 
that it would affect the corpus cavernosum urethrae bulb of the 
vagina, especially if the other veins did not participate in the 
dilated condition. In my first case, as 1 remember, there was 
no other varicosity besides the vulvar tumor ; and in my second 
case, I am positive that no such condition existed. 
Hildebrantf states that large varices can only be formed 
during pregnancy. This Winckelij: denies, and referring to my 
* Uterine and Ovarian Inflammation, London, 1862, p. 160. 
t Die Krankheit der Aeussere Weiblichen Genitalien, Stuttgart, 1877, p. 53. 
t Die Patholi>gie de Weiblichen Sexual Organe, Leipsic, 1881, p.37. 
Lehrb. der Piauenkrankheiten, Leipsic, 1886, p. 58. 6 
first case, with one or two others in the literature of the subject, 
says: I saw in 1869, in the case of an unmarried woman who 
had never borne, and who complained of great pain in the left 
side, etc., a varicose tumor of the left labium major the size of 
a hen’s egg. This author states that except during pregnancy, 
this condition is seldom seen ; in his own enormous special prac- 
tice he had only met with eleven cases of large varix of the 
vulva in the non-gravid. 
As to the treatment of such cases, my own opinion is, that 
when the tumor gives rise to annoyance by burning pain, itch- 
ing, etc., or where the increase in size is rapid, surgical inter- 
ference is necessary, and a complete removal of the growth 
demanded. 
A third case which I desire to bring to your notice is, per- 
haps, not so uncommon as those already mentioned, but as it is 
rarely spoken of in the text-books devoted to the diseases of 
women, it is worth a moment’s consideration. 
Case III.—A., aged 17 years, was admitted to the House of 
the Good Shepherd in September, 1886. Very soon after, the 
nurse having charge of the children noticed that she was affected 
with a yellowish vaginal discharge, which continued for a month, 
and had a penetrating, offensive odor. At this time, according 
to the nurse’s statement, numerous “ small red pimples with 
white caps” made their appearance, being scattered all over the 
vulva to the mons veneris. These were treated with a wash and 
other remedies by the visiting physician, Dr. W. R. Chittick of 
Detroit, but were made rather worse than benefitted. In two 
weeks time the papules had run together, and the labia had in- 
creased perceptibly in size, first on the right side and then on 
the left. In January, 1877, at the request of Dr. Chittick, I 
examined the patient. The vulva presented a most revolting 
sight, Two large growths, the size of the doubled fist, projected 
from and involved the labia majora—the whole mass irregular, 
horny, and bathed in a stinking discharge. Careful measure- 
ment showed that the growth on the right side had a length of 
8f inches and a thickness of 1£ inches ; on the left side, the 
length was 3J inches, thickness 1£ inches. Secondary growths 7 
were scattered about the mons, surrounded the anus, and ex- 
tended on to the inner aspects of the thighs. The skin at the 
base of the tumors was infiltrated and brawny. I diagnosed 
condyloma, or verruca acuminata, and suspected syphilitic in- 
fection, but a careful catechising of the girl elicited no specific 
history. At the doctor’s request I removed the growths next 
day, using a clamp, the scissors and the Paquelin, and tying 
vessels as the tumors were separated. The hemorrhage was 
quite extensive—a general oozing rather than direct bleeding 
from the vessels. This was finally controlled by iron-cotton and 
the T bandage. The patient did nicely,—had but little pain, 
no rise of temperature, and in a week’s time was about again. 
In two weeks from the first operation, some of the growths about 
the anus, which had been left, began to increase rapidly in size, 
and I again operated as before, with the same result. To-day 
the vulva has a normal appearance, except that the labia majora 
are a little flattened, and is in a perfectly healthy state, save at 
one point where a growth of the size of a three-cent piece still 
exists and requires removal. After the operation, not feeling 
satisfied with the history of this case, although it appeared that 
the patient was free from specific disease, I had the parts bathed 
in black wash and gave small doses of biniodide of mercury, 
under which treatment the patient improved both in general 
health and locally. 
Writers on venereal and skin diseases speak of the occurrence 
of such warty growths in young girls, and agree that they are 
due to other than specific cause.