MARCH 2, 191241 . PRURITUS VULVAE. TM:I JoDUA 469 s irritation increases in direction the amount of friction grows in proportion, until finally what has been aptly 3Trturt termed "hysteria of the skin" is developed, and the poor ON woman scratches herself until she is quite exhausted and the paroxysm is over. It is in these severe cases that so PRURITUS VULVAE: much harm is done to the delicate mucous membrane, for thle scratching leads to changes in the tissues which keep ITS ETIOLOGY AND TREATMENT. up abnormal irritation. DELIVERED AT THE MEDICAL GRADUATES' COLLEGE AND ETIOLOGY. POLYCLINic, DECEMBER 13TH, 1911, The more experience one the more one is impressed Y gains, -$ Y by the fact that true essential pruritus vulvae must be R. A.. GIBBONS, M.D., F.R.C.S.E., very rare indeed. In all the cases I have had to deal with I could say was a pure PHYSICIAN TO THE GROSvENORIO HOSPITAL FOR WOMEN, LONDON. I have rarely met with one which neurosis. By this I mean that the causation of the suffer- the our ing is located in the spinal centres, and that changes I HAVE chosen the subject of pruritus vulvae for which gives risc to lecture this afternoon because I think that a careful study there leadtheto pruritus, eventually greatest no local signs ofchlange in the mucous membrane. Accord- of the etiology and treatment will be of the ing to my own experience-and I have had a fairnumllber possible value to any who are attending a post-gradutat of severe however, by nio means course with a view of benefitingthemselves by practical thlese cases,which are, work hereafter. common-Ihave found that in nearly every case a local than is cause can be discovered, even though it may take a PrPritus of the vulva is far more common considerable amount of time to ascertain. generally supposed, because in the milder forms, on account of natural advice not sought from lThe following case quite illustrates what I mean, andl principally modesty, is shows how careful one to be before stating the and whien the y has increased, ought family physician, maladl that no external cause can be discovered: the case may be seen only for the first time by a gynaeco- dogmatically logist. It is an affection whichb, in its severe form, short Alady aged 58 consulted me in December, 1903, on account of jeopardizing life, may be considered one of the most ofdiscomfort caused by a caruncle of the urethra. Shelhadnlo terrible with which woman be afflicted, for it uterine history. Her period had ceased seven year; s any may previously.special She had had two children, the last born over gives no peace-no lengthened freedom from irritation or twenty- years ago, and her recoveries from her confinements itching. When a paroxysm comes on or passes off there is were satisfactory. She - had what she termed" a nervous always the mental strain and anxiety concerning the next illiness " some years before, and eighteeii months beforeher which may occur, and in cases which have lasted some visit to me shehad acute cystitis, whenshewas laid up for present. In three weeks. Therewasnothing to be discovered on examinationt time the apparent hopelessness of cure is ever of the abdomen orpelvis, but there wasasmall fleshyearuncle on some, unquestionably, death is looked forward to as a happy the posterior wall of the urethra. I remnoved-the carunclanle, da.lI release, and occurs by suicide. It may truly be said that local (liscomfortceased. Aboutthree years latershe again com- amongst those who have suffered severely, andhlave been plained of local pain and'discomfort on' micturition, an(d o cured will be found the most examinationI found a recurrence of the caruncle. I'againi by judicious treatment, removedthe caruncle, which brought immediate relief. This grateful patients. It is a disease whlichl, once established, lasted several months, when she began to complain of frequent is exceedingly difficult to cure thoroughlly and com- attacks of pruritus vulvae, coming on at allhours, but worst pletely, whilst the milder forms readily yield to proper (luring the night, breaking hex rest. There was no trace of management. caruniicle left, and the urethral orifice appeared perfectly SYMPTOMS. healthy.l'here wasnothing about the clitoris ornymphlace calling for attention. The attacks were becoming more fre- It will be most simple to divide the subject into quenit, in'spite of all the treatment adopted, until opium in the (1) synmptomatic and (2) essential pruritus vulvae. The form of pill was the only drug which brought relief. When latter must be considered a neurosis. micturitioni took place' itfrequentlv wasfollowed by a paroxysm. The word"pruritus" merely means itching, and of She could not quite locate the origin of the attacks, but the else. itching seemed to start from a point between the clitoris an(d course must be therefore symptomatic of something the oritice of the urethra. Here was a case which seemed one of It is a subjectivesymptom, and may be present in a varying essential pruritus. As she had had twocaruncles removed,and(1 degree. Sometimes it feels as if there AN-ere sliglht smarting an attack often followed micturition, I thought it would pos- accompanying the itching, and sometimes a tingling, burn- sib)ly throw some light upon the case if the bladder and urethra or the variety termed were carefully examined. Under ether I dilated the urethra ing, pricking, sensation. Perlhaps and explored the bladder, and then discovered oIn the posterior "formication," where the sensation is that of thousands of wall of the urethra a small, deep, oval ulcer, 1j mm.long1) insects crawling over the skin, is the most terrible to bear. I40 mm. broad. This I touched with the Paquelin cautery and The objective signs are usually those of someinflammatory she recovered rapidly, having no more attacks for a consider- disturbance, as a rule confined at the commencement to able time until aniother urethral ulcer developed. This might tIme neighbourhood of the clitoris and nymphae, and easily have passed as a case of essential pruritus had the gradually involve the whole region of the vulva. urethra not been dilated. In an ordinary slight case of pruritus vulvae there In discussing the etiology of this affliction, it may be nmay be little or nothing to observe; but even in the remembered in the first place that most of the cases met slight cases there is usually some form of irritation about with of true pruritus vulvae are in women who are passing tlle mucous surfaces of the labia majora, or on the througll or who lhave passed through the climacterie nymphae or vestibule, to be detected if carefully looked period, that is to say, when the ovarian functions are for. The amount of itching may be quite trifling, and dimninishing or have ceased. Whether there is any con- only occurring occasionally during theday, and especially nexion between the pruritus and the gradually failing at night, when the patient is in bed. In the more severe glands, or wlhetlher it is merely a coincidence, we cannot cases of symptomatic pruritus tlie paroxysms of itching positively say in tlle present state of our knowledge, but it are more pronounced but longer, and are accompanied by is a fact. Every case must be thoroughly investigated, well-marked changes locally. The parts feel lhot and anid inmost it will not be difficult to ascertain the cause if burning, and, if much scratclhing has taken place they seen reasonably early. According to Bronson,' mnay be swollen, raw, and bleeding. After a paroxysm is Of the conditions that act as predisposing causes of pruritus, over the surfaces are exquisitely tender in the early stag'es, whether it occurs as an essential disease or is predomiinate(d by and the patient cannot bear the least touclh witlhout pailn. some other disease of which it is a symptom, by far the inost The attack may begin by a slight point of itching in the imnportant is hyperaesthesia. This may be either congenital or nieighbourhood of the clitoris or in the vestibule, and very acquired, either local or general. It may b3 acquired throuhl But diseases which affect the economy at large, or that are localize(d slight friction may for the moment give relief. the in the skin. The general diseases producing it may be i(lio- itching recurs and the scratclhing is repeated, the area of pathic neurosis, such as hysteria and hypochondriasis and(l irritation growing larger and requiring more friction to other affections of the nerve centres, or general nutritive give relief, until finally the field of- irritation, whiich diseases affectingi the nervous system secondarily, suchi as, started about the size of a pea, grows sufficiently large arthritis or diabetes mellitus. In all the cases the prinaif-ry the effect of th-e general disease is simply to heighten the suscepti- to include the whole of the vulva, and sometimes b)ility of the pe.ripleral nerves, causing exaggerated sensatiolis pabes, leading to gradual wearing away of the hair and from the slightest contact. The exciting causes consist of clhanges in the skin of the lower abdomen. As the rritartion'sthat Laav he either indirect and conveyed to the slin [2670] or direct, in whicllTIRURITUS VULVAE. excit3tionthe40isLproduGed-byinteriormzDicALjoumAof thelocalbody, case the [MARCH 2, 19I2. fromestrawneous irritants, - sources or. whether -.- L from sourcas that are intracutaneous.arisi-llg from from the interior of the body, or direct, in which case the According to Moraezowski, glycosuria is accomnpanied by excitation is produced-by local irritants, whethier ar.ising from an elimination of extraneaus sources or from sources that are intracutaneous.