[Reprint from The Southern Chlifornia Practioner for December, 1S95.J 
Trachoma of the Female Genital Tract; Hydrocele 
of the Labium Majus.* 
BY WM. A. EDWARDS, M.D., SAN DIEGO, CALIFORNIA. 
FELLOW OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA; FORMERLY INSTRUCTOR 
IN CLINICAL MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA; 
PHYSICIAN TO ST. JOSEPH'S HOSPITAL; ASSOCIATE 
PATHOLOGIST TO THE PHILADELPHIA 
HOSPITAL, ETC., ETC. 
Trachoma of the female genital tract.- 
For the last few years, since coming to California, I have occasionally met 
cases of obliterative inflammation of the genital tract. During six and a half 
years I have observed eight such cases, and these will form the basis of the 
present communication. The condition has been variously designated in the 
literature as vaginismus, vascular degeneration of the vulva and the vagina, 
granular vaginitis, kraurosis vulvae. These terms did not to me correctly ex- 
press the condition, and it was not until the paper of Johnstone, before the 
American Gynecological Society, May 29th, 1895, that the disease received a pro- 
per classification in our nomenclature. It was this observer's previous experience 
as an ophthalmic surgeon which enabled him to correctly interpret the visible 
phenomena of this obliterating inflammatory disease and correctly designate 
it Trachoma. DeSchweinitz, in his book on diseases of the eye, defines trachoma 
as an inflammation of the conjunctiva, in which the membrane looses its smooth 
surface owing to the formation of rounded granulations which after absorption 
leave cicatricial changes; it occurs under two forms, acute granulations, and 
chronic granulations, and we consider that the term trachoma is equally applic- 
able to the disease that we are now describing. 
This form of vulvitis is not described at all in the text books, either old or new. 
The more pretentious treatises as The American Text Book of Gynecology, 
Pozzi's Medical and Surgical Gynecology, and the Clinical Gynecology of Keat- 
ing and Coe are as silent as the smaller volumes of Madden, Martin or Scanzoni, 
indeed Wiuckel's Diseases of Women is the only work that makes a fair attempt at 
the description of the disease, he remarks that very many of these disorders are 
grouped as pruritus of the vulva, because from want of exact observation their 
special character is not known. The study of these diseases has not been inter- 
esting enough to excite close observation. 
Martin, Centralblatt f. Gynaekologie, Leipzig, '94, has described three some- 
what similar cases, under the title Kraurosis Vulvae. He also states that the 
disease cannot be traced to any venereal or microbian influence. It may occur in 
young or old, virgins or multiparae. Sanger has also contributed a paper during 
the year just past. 
With the acute granulations we have little to do, as the patients rarely come to 
us with this condition. All that I have seen presented the chronic forms and of 
three varieties, papillary trachoma, follicular trachoma and mixed trachoma. I 
have never been able to determine the presence of a special form of micro-or- 
ganism which could be looked upon as the causative agent in the production of 
the condition under consideration, nor am I able at present to offer any satisfac- 
tory etiology of the disease. It is a fact that four of my cases were in women 
of advanced years, that is between fifty-five and sixty, one was a young woman of 
*Read before the Southern California Medical Society, Los Angeles, Dec. 4-5, 1895. thirty-seven in whom I removed both ovaries about a year ago. Another was a 
woman who married late in life; she came under my care for dilatation and 
curettage of the uterus and removal of hemorrhoids; the vaginal secretions were 
always scanty and perverted. About three years ago she commenced to develop 
a trachoma, ran through a typically chronic course of the disease, but is now 
practically well. Another case, a woman aged sixty-six, was operated upon last 
January, a pan-hysterectomy was done. Shortly after the operation the disease 
developed but was comparatively easily controlled. The other cases presented 
absolutely nothing that could bear at all on the cause of the disease except that, 
they gave in two cases a distinct history of an antecedent attack of cystitis. 
The usual clinical manifestations of the disease are very similar indeed to those 
of acute or chronic trachomatous inflammation of the eyelid. It usually begins 
in the region of the clitoris extending downwards over the entire vulva and it is 
apt to involve the urethra and vagina. The parts present a peculiar and charac- 
teristic appearance, in places deep red, almost black, resembling a subcuticular 
mottling or a petechial patch not unlike in appearance, the sub-mucus or sub- 
cutaneous hemorrhages of purpura rheumatica. The surrounding tissues are 
apt to be anaemic but the papilla stand up like sago grains, a slight touch is apt to 
produce bleeding. 
After the disease has existed for a time the parts become fissured and cracked 
more or less deeply. A thin ichorous discharge is present but it is always scanty, 
indeed this is somewhat diagnostic. 
Later in the course of the disease, like its analogue in the eye, diffuse scar 
tissue results and it is then that the disease may be called trachoma deformans. 
In some cases this deformity is most marked, the normal contour of the vulva 
is obliterated, the labia minora first adhere to the larger labia and then become 
obliterated by scar tissue, the vaginal outlet contracts and the orifice is almost 
closed, a condition well illustrated by the accompanying photograph. These 
women are perhaps the greatest sufferers that we are called upon to meet and I 
must confess that the resources of our art do not afford them very much relief. 
The cases are essentially chronic in nature, and the stubbornness with which the 
disease persists is often most discouraging. My own plan of treatment has been 
to keep the parts as clean as possible either with pyrozone solutions of varying 
strength, saturated boric solution or, in some cases, a 20 per cent, salicylate of 
soda solution. These solutions are to be injected into the vagina after a bath 
speculum has been introduced in order that all the folds and interstices of the 
vagina may be thoroughly cleansed; better still if the patient can command the 
services of a trained nurse, is the thorough cleansing of the genital tract in a 
similar manner to that which is preparatory to a plastic operation. The granula- 
tions, cracks and fissures are touched occasionally with campho-phenique or 5 per 
cent, pyrozone solution and the parts thoroughly dusted over with compound 
stearate of zinc. The patient is instructed to bathe the parts in a soda solution 
after each urination and again apply thoroughly the zinc powder. 
Johnstone recommends an ointment of the yellow oxide of mercury, 4 to 10 
grains to the ounce, used twice daily. 
My experience accords with Johnstone in that the cases will persist from six 
months to two years under any and all kinds of treatment, and will usually result 
in great deformity. 
Hydrocele of the Labium Majus.- 
A prolongation of peritoneum may reach below the mons veneris through the 
inguinal ring, covering the round ligament, this peritoneal investment may be- 
come adherent about the ring and a transudation of serum occur into the cavity 
2 3 
thus formed. The condition is then known as hydrocele of the round ligament 
or hydrocele of the labium majus. The labium presents a fluctuating egg shaped 
tumor, more or less firm. The round or as it is sometimes styled the utero 
inguinal ligament is a stout cord twelve and a half centimetres in length which 
with its fellow on the opposite side, arises from or is attached to the uterus on its 
anterior superior surface just in front of and below the fallopian tube. It consists 
of areolar tissue, dense fibrous tissue, unstriped muscular tissue, vessels and 
nerves, enclosed in a peritoneal covering. The unstriped muscular fibres seem to 
be continuous with the superficial uterine fibres; each ligament, then, as McClel- 
lan states, "passes forward in the folds of the broad ligament to the deep abdo- 
minal opening on either side behind the epigastric artery, where it enters the 
inguinal tract. Here there is already provided a process of the peritoneum 
called the canal of Nuck, similar to the processus vaginalis, and the ligament pur- 
sues a course analogous to the spermatic cord in the male, eventually losing its 
character in the tissues over the pubes." "In the adult there is rarely any trace of 
the peritoneal process or of the muscular tissues of the round ligament beyond 
the middle of the inguinal tract. Occasionally the canal of Nuck remains patent 
and may become the seat of congenital hydrocele or even of inguinal hernia." 
The ligament in the canal receives a small accesion of striped fibres, which some- 
times are attached to the pillars of the ring and to the spine of the pubis. 
As we have seen, the ligament, as it leaves the ring breaks up, as Morris says, 
into a number of delicate fasciculi which become lost among the interlobular 
connective tissue of the large pad of fat which occupies the labium majus. It is 
on account of the anatomy of the round ligament that I have always raised my 
voice in opposition to Alexander's operation or any of its modifications, but this 
is only by the way in the present communication. 
Hydrocele of the ligament or of the labium as you may prefer to call it is a 
comparatively rare condition. In fifteen years I have met but one case, the 
salient points of which are as follows: Mrs. A. B.; aged 35 years. HIpara. Seen 
in consultation with Dr. Johnson of National City April 17th, 1895. The woman 
was in the seventh month of utero-gestation, the left labium majus was enlarged, 
swollen, oedematous and fluctuating; measured about 10 centimetres in its long 
axis and 6 centimetres in the transverse axis. The prominence was elliptical and 
to a certain extent retained the normal contour of the parts. The surrounding 
tissue was somewhat oedematous from pressure; the vaginal tube was encroached 
upon and the pelvic fascia and muscles on the left side were infiltrated with serum, 
particularly the anterior portion of the levator ani, some of the fibres of which 
could be plainly outlined by their tenseness. It resembled the case of Schroeder 
(Krank. d. Weib., Geschlectsung. v. Auflage 1881. Winckel.) in that the fluid 
could be returned to the general peritoneal cavity, showing that the communica- 
tion between the vaginal process and the abdominal cavity was patulous. 
Pain was present to a very slight degree, except on manipulation and then the 
greatest tenderness was in the vagina and left pelvic fascia and not over the 
hydrocele. Mental distress was marked, the patient and her friends were ex- 
tremely anxious over her condition, on this account mainly she was placed in the 
recumbent position by Dr. Johnson, as most of the fluid would return to the 
abdomen when she was prone. Utero-gestation progressed in a healthy manner 
and the woman passed through a normal puerperium under the care of Dr. 
Johnson. 
A hydrocele in the labium may be one of several varieties: 
1st. That which we have described, in which there exists a patulous canal of 4 
Nuck. The fluid is excreted from the peritoneal surfaces covering the ligament 
and is free to return within the general peritoneal cavity. 
2nd. The sac may be entirely cut off from the abdominal cavity and dropsy 
occur in this closed sac. Such cases have been observed and recorded by Sacchi 
and Fleming (Gaz des Hop., 1885, p. 21; Bush, Ec., 82-Winckel.) 
3rd. The cellular tissue of the labium majus consists of two layers which are 
prolongations of the superficial abdominal fascia. These two layers which are 
considered the analogue of the dartos tunic and between them a serous tumor 
may form. This is considered by some to be the true hydrocele in a woman. 
4th. The substance of the round ligament itself may be the site of a cyst. 
The gubernaculum of Hunter in the foetus becomes the round ligament in the 
female. This foetal structure is at first hollow, as demonstrated by Weber, 
(Centr. f. Gyn. 1887, No. 21.) and as Staffel, (Ueber Cysten der Canalis Nuckii, 
Centr. f. Gyn. 1888, p. 273, Pozzi,) states there may be a persistence of this foetal 
condition which allows the formation of a cyst within the round ligament itself. 
Eisenhart, Muchener med. Wochensch., Munich, 1894, has collated the 48 
cases of hydrocele in the female in the literature and finds that 29 were upon the 
right side and 19 upon the left; he considers traumatism and congenital defect to 
be the most frequent causes. Smith, (Sajous' Annual, Vol. II, H-8, 1895,) believes 
that the disease is not so rare as I have stated. During a period of four years, 
he says, five cases have been operated upon in the Tottenham Hospital. 
The treatment of hydrocele feminina is operative. Expose the cyst by a linear 
incision, ligate the neck and enucleate. The wound is to be closed by superim- 
posed layers as in the closure of hernia. The suture material is at the pleasure of 
the surgeon, personally I rarely use cat gut, as I do not believe that at present it 
is possible to render it absolutely sterile in all instances. I use silk. Unless the 
wound is closed as we would an inguinal hernia the woman is rendered liable to 
an hernial protrusion. Simple puncture of the hydrocele is of little avail. For- 
tin, however, tapped twice, in the first instance he injected a two and one half 
per cent, solution of zinc chloride and a glycerine solution of creasote in the 
second; a cure was established. 
RECENT BIBLIOGRAPHY. 
Eisenhart H. Ueber Hydrocele feminae. Munchen med. Wchnschr. 1894, 
XEI, 164. 
White J. W. Hydrocele of canal of Nuck; operation; recovery. Univ. Med. 
Mag. Phil. 1893-4, VI. 379. 
Gerke O. Zur Therapie der Hydrocele feminina. Deutsche med. Wchnschr., 
Leipz. u. Berl. 1894, XX, 502. 
Smith E. G. On five cases of hydrocele in the female. Brit. Med. Jour., 1894, 
H, 179. 
Wolters Joh. Ueber Hydrocele femininae Kiel, 1891. L. Handorf. 17, p. 8vo. 
Lammert J. Beitrag zur casuistik der Hydrocele femininae. Munchen med. 
Wchnschr., 1891, XXXVIII, 507-509. 
Coley. Index Med. 1892, p. 400 for reference. 
The Index Catalogue of the Eibrary of the Surgeon General's Office, vol. VI, 
p. 549, contains 23 references to hydrocele in females and one reference to a case 
of hydrocele of the round ligament mistaken for and operated upon as a strangu- 
lated hernia. Hart Amer. J. Obst. N. Y., 1871-2, IV 15-20. 
Annual Univ. Med. Scien. 1895, vol. II, H. 8-9, contains four references.