DISEASES OF THE VAGINA AND VULVA.
BY EDWARD W. JENKS, M.D., LL.D.
DISEASES OF THE VAGINA.
The subject will be considered in the following order: Anatomy, Vaginitis, Atresia, Prolapsus Vaginæ, Cicatrices, Double Vagina, Growths, and Vaginismus.
Anatomy.
The vagina is a musculo-membranous canal extending from the neck of the uterus—which it embraces—to the vulva. It is usually attached to the uterine neck at a point midway between the os internum and the os externum. This canal is composed of three layers or coats: the outer one is of fibrous and elastic tissue; the middle, of unstriped muscular fibre and fibre-cell; the inner coat or lining is mucous membrane, composed of connective tissue and elastic fibre and covered with squamous epithelium. The outer and middle coats spread out at the upper portion of the perineum, making the perineal septum, and attach themselves to the ischio-pubic rami. One of the peculiarities of the middle coat is that during utero-gestation it becomes much hypertrophied like the same structure in the uterus, and following labor undergoes a similar process of involution. The inner or lining coat extends to the fourchette.
Savage1 has described the general form of the vagina as similar to that which would be assumed by a flexible tube if shortened to nearly half its length by a cord passed from end to end through one of its sides. The ridge thus formed is called the anterior column of the vagina, and marks the vesico-vaginal septum; it is about two inches long, while the posterior wall or posterior column is twice that length. The anterior column or cord causes the investing mucous membrane to be puckered and thrown into folds or rugæ which run transversely toward the posterior column. "This mucous membrane is studded with papillæ which are covered with pavement epithelium. The papillæ of the vagina, which were first fully described by Franz Kilian, were regarded by him as having for their function the transmission of sensation. He represents them as being thread-like and filiform."2
1 Anatomy of the Female Pelvic Organs, London, 1870.
2 Thomas on Diseases of Women, Philada., 1880.
Anatomists have differed regarding the existence of muciparous glands in the folds of the vaginal mucous membrane, some asserting that they are present, and others being equally positive that there are none. Notwithstanding this lack of uniformity, the fact that some have discovered muciparous follicles, while others have failed, enables recent writers to state that there is no doubt of their existence.
The vagina is lined with mucous membrane and covered with pavement epithelium, studded with projecting filiform papillæ. This membrane lies in folds, between which are numerous muciparous follicles.
Vaginitis.
DEFINITION.—Vaginitis is a term used to designate inflammation of the mucous membrane of the vagina.
SYNONYMS.—Colpitis, Elythritis.
VARIETIES.—Three distinct varieties of vaginitis are met with—viz. simple, specific, and granular.
ETIOLOGY.—Predisposing Causes.—Young girls are not unfrequently the subjects of vaginitis in consequence of want of cleanliness, exposure to cold, ascarides migrating from the rectum into the vagina, or the introduction of foreign substances. It also frequently appears in consequence of smallpox, measles, and scarlatina. In adults it may be caused by exposure to cold or wet, more particularly at or near a menstrual period. The insertion of a sponge into the vagina, as is not uncommon for the purpose of topical medication or uterine support, acts as an irritant if allowed to remain a few days, which may cause severe inflammation. Pessaries, irritating vaginal injections, gonorrhoeal infection, certain conditions of the urine, as in diabetes, acrid uterine discharges, childbirth—more particularly if there has been retention of putrefying secretions—and chemical agents used in treatment of uterine diseases, are sometimes causes. Uterine discharges which cause vaginitis are not generally irritating until they reach the vulva, where by exposure to the air they become changed, first causing vulvitis, and next inflammation of the vaginal mucous membrane.
Some women have slight attacks of vaginitis after each menstrual period, but they are generally slight and soon subside; others will have attacks after each coition or after great physical exertion, but with such patients the disease is not severe, and usually passes off without any signs remaining. It is quite common among prostitutes, independent of specific causes, in consequence of excessive coition. Chronic vaginitis or vaginal leucorrhoea is not uncommon with newly-married women in consequence of excess or awkwardness in coition.
Granular vaginitis is generally caused by pregnancy, but occasionally it seems to be produced by simple or specific vaginal inflammation. A strumous diathesis or a disordered state of the blood, as in phthisis or other constitutional disorders, are predisposing causes.
Mention has been made by some writers of diphtheritic and senile vaginitis. Diphtheritic inflammation of the vagina is sometimes seen during epidemics of the disease or among puerperal women in crowded lying-in hospitals. Senile vaginitis is occasionally met with in women after the climacteric period. Its cause is wholly in consequence of the physiological retrogressive processes incident to the change of life. The epithelium is shed in patches, and, according to Hildebrandt, the raw surfaces adhere, causing contraction of the vagina.
SYMPTOMATOLOGY, COURSE, DURATION, PATHOLOGY, TERMINATION, AND COMPLICATIONS.—The subjective symptoms of the three varieties of vaginitis which have been mentioned are nearly identical, but in their physical signs a marked difference is perceptible. In the outset there is a sense of heat and burning in the vagina, a feeling of pain and weight in the perineum, and a frequent desire to urinate. The passage of urine causes pain and a feeling of scalding in the urethra. It is believed by many authorities that the sense of scalding is more pronounced in the specific variety. Not unfrequently there are backache and pain radiating down the thighs into the hips, along the spine, and into the head. Sometimes, with the other symptoms mentioned, there will be a decided febrile disturbance, chilliness alternating with heat, a rapid pulse, and a foul tongue. With such symptoms the thermometer will show an elevated temperature. Coincident with the beginning of pain and irritation the patient has an itching sensation, which sometimes becomes intolerable, and is generally worse at night when she is warm in bed. Emmet states that some cases are so severe as to require anæsthetics before relief can be obtained. After the lapse of from twenty-four to seventy-two hours these symptoms subside, and there is a profuse purulent discharge, yellowish or greenish in appearance and of an offensive odor. In many cases the discharge is of so acrid a character that it excoriates the vulva and surrounding parts. Walking, or even standing, is often painful, particularly the former, owing to the attrition of the inflamed or excoriated surfaces.
A physical examination causes pain, and if the inflammation has extended to the vulva, urethra, or the vulvo-vaginal glands, it will often produce intense suffering. When the vaginitis is acute, the labia are swollen, the vagina assumes a more or less intense red color in place of the light or pale rose-color of health; it will also be swollen, and at the beginning seem unnaturally dry, but very soon, although still red, it will be covered with a yellowish or greenish-yellow, muco-purulent discharge of an offensive odor. By careful examination with the speculum the vaginal canal will be seen to have a congested appearance, with abraded points, and sometimes follicular ulceration will be found. Generally, the appearance of thick mucus within the os uteri indicates an extension of the inflammatory process into the cervical canal.
Sometimes in gonorrhoeal vaginitis the full force of the disease seems to be chiefly expended in the urethra; when this is the case, and patients complain of intense scalding in passing urine, a finger pressed against the anterior vaginal wall will usually cause pus to exude from the urethral canal.
The duration of vaginitis depends largely upon the treatment. If appropriate treatment is begun early in the course of the disease, a cure can be effected in two or three weeks. On the other hand, it may continue an indefinite length of time or assume a chronic form, constituting a catarrhal condition of the vaginal mucous membrane, or vaginal leucorrhoea.
Sometimes inflammation of the lining of the vagina, more especially specific vaginitis, extends beyond the cervix into the cavity of the uterus, along the Fallopian tubes to the ovaries and to the pelvic peritoneum, or it may travel along the mucous membrane until it reaches the lining of the bladder, causing a cystitis, or in a similar manner involve the vulvo-vaginal glands.
It is not unusual after all the signs of a vaginitis have entirely disappeared that the inflammation recurs without any apparent exciting cause, but wholly in consequence of a diseased condition of the mucous lining of the cervix uteri, designated cervical endometritis, chronic inflammation, or uterine catarrh. In consequence of this there is an increased and changed secretion, which acts as an irritant and causes vaginitis. These recurrent attacks of vaginitis can be prevented only by a successful treatment of the cervical disease.
Chronic vaginitis or vaginal catarrh occurs after repeated attacks of the acute form in persons of a strumous diathesis, and from uterine disorders, such as catarrh, displacements, or polypi of the uterus.
Vaginal catarrh from any cause may lead to other difficulties; thus, if it is the primary affection it may lead to catarrh of the uterus and of the Fallopian tubes. Its long continuance with or without the co-existence of uterine disorders may lead to relaxation and subsequent prolapsus of the vaginal walls.
In the beginning of vaginitis, as in inflammations of mucous membranes elsewhere, the vaginal lining becomes first very vascular, presenting a congested and swollen appearance, with a diminution in the quantity of normal secretion; but within a few days portions of the epithelium are cast off, leaving abraded spots which sometimes ulcerate and become covered with exudation. Occasionally complete casts of the epithelial lining of the vagina are desquamated. In lieu of the natural secretions, within thirty-six hours after the inception of the disease the vagina is filled with an acrid, foul-smelling muco- or sero-purulent fluid, having the appearance of unhealthy pus. The discharge consists of serum, numerous epithelium cells, pus-corpuscles, blood-globules, and infusorial animalculæ designated Trichomanas vaginalis, and mucus. When an attack is very severe a true phlegmonous inflammation is often developed in consequence of the submucous cellular tissue first becoming involved.
In specific vaginitis it not infrequently occurs that the disease is confined to the vaginal cul-de-sac—a fact which, according to Guérin,3 explains how sometimes apparently healthy women communicate gonorrhoea to the male.
3 Mal. des Organes génitaux, Paris, 1864.
In granular vaginitis the mucous membrane extending throughout the entire canal and over the neck of the uterus is covered with numerous minute elevations or granulations of about the size and shape of half a millet-seed. Thomas says: "This variety of the disease appears to bear about the same relation to simple vaginitis that follicular vulvitis does to the purulent form of that affection."4 The same author mentions having seen a patient with granular vaginitis so striking in its features that the family physician believed it to be malignant disease developing, until convinced to the contrary.
4 Thomas on Diseases of Women, 5th ed., p. 219.
Simple acute vaginitis frequently causes and remains associated with vulvitis, urethritis, and less frequently endometritis, salpingitis, and pelvic peritonitis. The chronic form is not unfrequently complicated with uterine catarrh. Acute specific vaginitis is often complicated with buboes from inflammation of the femoral and inguinal glands and inflammation and abscess of the vulvo-vaginal glands. This variety more frequently than the others is liable to give rise to violent urethritis, cystitis, salpingitis, ovaritis, and pelvic peritonitis.
DIAGNOSIS.—If one is familiar with the symptoms which have been mentioned, the diagnosis of vaginitis is not a difficult task; but it is sometimes not only difficult, but quite impossible, to determine whether a case is one of simple inflammation or of gonorrhoeal contagion.
The symptoms which are most liable to lead one to decide that a case is specific are their severity, the sudden development of virulency, the scalding micturition, urethritis with pus in the urethra, the greenish-yellow discharge of a foul odor, the very irritating quality of this causing gonorrhoeal ophthalmia if applied to the conjunctiva or gonorrhea in the male following coition; the occurrence of buboes, inflammation of the vulvo-vaginal glands, peritonitis, and salpingitis. We meet with cases where it is extremely difficult to decide as to the nature of the disease, and especially when we have every reason for believing that the subject herself is chaste; on the other hand, the mere fact of a woman infecting her husband and causing him to have a urethral discharge is not always sufficient proof of her having gonorrhoea, as it is well established that certain forms of leucorrhoea will produce such a result. It is not necessary for us always to express an opinion of the character of the disease, even when convinced that it is specific, but it is always our duty "to lean to the side of charity when the question is one of chastity."5
5 Edis, Diseases of Women, Philada., 1882.
PROGNOSIS.—If appropriate treatment is instituted, the disease will usually subside in the course of a few weeks, or it will assume a chronic form, lasting indefinitely.
Acute vaginitis causes more pain and actual suffering than the chronic variety, but is less rebellious to means of cure. Simple vaginitis, of itself, cannot be considered a grave disease, but the consequences may prove of a most serious character—viz. extension of the inflammation to the bladder, uterus, Fallopian tubes, ovaries, and peritoneum.
Specific vaginitis is more virulent than the other varieties, and consequently there is more tendency to the extension of inflammation than with them. Sterility is not infrequently a sequel of specific vaginitis in consequence of contiguous parts, more especially the Fallopian tubes, being implicated in the disease. Such patients, even long after the acute symptoms have passed, are unfavorable subjects for surgical operations, even of a trivial character.
TREATMENT.—The treatment of acute vaginitis is the same in the different varieties. From the commencement of the attack until the severest symptoms have subsided patients should rest in a recumbent position, walking and coition being forbidden. If the inflammation is severe, with febrile symptoms and a furred tongue, saline laxatives, cooling drinks, and a non-stimulating diet should be prescribed. If pain exists, anodynes of some kind should be given. The best mode of administering anodynes is by means of rectal suppositories. Warm hip-baths every six or eight hours for the first twenty-four hours of the disease ought to be employed, and at the same time quite warm water should be thrown into the vagina with a syringe; this is beneficial in curing the disease and contributing to the patient's comfort.
A much better mode of irrigating the inflamed parts is as follows: The patient is to be placed on her back with her hips slightly elevated over a bed-pan, and then by means of a syringe a stream of warm or hot water should be thrown into the vagina for fifteen to thirty minutes. It has been advised by Emmet that the temperature of the water should be raised rapidly from blood-heat to 110° F., or as hot as the patient can well bear. By elevating the hips venous congestion is considerably lessened through gravitation of the blood, and, the hot water causing contraction of the blood-vessels, the mucous membrane will present a blanched appearance. The vagina becomes distended by the weight of water, and somewhat with air, by reason of position, so that with the hips elevated the injection comes in contact with every portion of the vaginal mucous membrane.
In addition to hot water or after its use, other injections are useful, as a decoction of flaxseed alone, or one of the following remedies, either in the decoction of flaxseed or in water: viz. borax, bicarbonate of sodium, hyposulphite of sodium, chlorate of potassium (drachm j ad pint j), or permanganate of potassium (gr. viij ad pint j). Hydrate of chloral and fluid extract of eucalyptus, either alone or combined, have proved useful quite a number of times in my own practice.
Mild attacks will usually subside in a few days without further treatment than has already been mentioned; but in severe cases, when the disease has got under full headway before treatment is begun, more heroic measures become necessary, especially in specific or granular vaginitis, where there is itching and a greenish offensive discharge. The vagina should be exposed by means of a speculum, the mucous membrane thoroughly dried by the use of absorbent cotton, and a solution of nitrate of silver (gr. xl ad fluidounce j) be applied to every part of the inflamed vagina. Wherever it is applied the mucous membrane presents a whitened appearance. If the vulva is involved, the same application should be made to it. After the parts thus treated become dry a piece of soft linen or a small roll of absorbent cotton should be thoroughly smeared with vaseline or soaked with carbolized glycerin, and inserted within the vagina. The pain caused by the nitrate of silver is usually better borne than the intense itching which it takes the place of. After the lapse of eighteen to twenty-four hours the linen or cotton can be removed and an injection of carbolic acid drachm ss, sulphate of zinc and borax each drachm j, in a quart of warm water, is to be used three times a day for two or three days; then a weaker solution of nitrate of silver is applied and the tampon inserted as before. This is to be followed the next day by the carbolized injection, and three days later a weaker solution of nitrate of silver is applied. The alternate use of these remedies is to be continued until the mucous membrane appears pale, and the discharge instead of being a greenish-yellow is white, when it should be discontinued, and borax alone or combined with hyposulphite of sodium is to be used as an injection; and immediately after the injection the tampon is inserted, or instead of the injection tannin dissolved in glycerin is to be painted over the vaginal walls and followed by the tampon.
The cure of vaginitis in many instances is obtained by securing rest to the parts. One of the chief objects of the tampon is to give rest to the inflamed walls by keeping them apart, rather than to make it the medium of a topical application. Some gynecologists instead of using a tampon insert one of Sims's glass vaginal dilators to keep the walls from coming in contact, directing that it shall be worn most of the time and that the patient shall rest in the recumbent posture.
The treatment of chronic vaginitis or vaginal leucorrhoea, when caused by acute vaginitis alone, should be essentially the same as in the latter after the severest symptoms have subsided, as clinically the distinction between acute and chronic vaginitis is one of degree.
Generally, vaginal leucorrhoea is an accompaniment of other affections, notably uterine diseases, and hence a consideration of its treatment and its complications would necessarily include everything pertaining to the therapeutics of leucorrhoea.
Atresia.
DEFINITION.—The term atresia ([Greek: a] privative, and [Greek: trêsis], perforation) means, in its literal sense, an imperforate condition or an entire absence of an orifice or a canal, but custom has sanctioned a more liberal use of the word; thus, atresia is the term sometimes made use of to designate a partial obliteration of a canal; e.g. atresia vaginæ, which means literally an absence or obliteration of the vagina, is also applied to a partial imperforation of the canal; hence atresia of the vagina, like that of any other portion of the generative passages, may be either complete or incomplete.
Atresia of the vulva cannot in a strict sense be considered under the head of vaginal malformations or disease, but it seems quite necessary in writing of occlusion of the vagina not to omit a consideration of similar conditions of the vulva. The writer of this article, therefore, has followed the lead of most medical authors in including vulvar under the head of vaginal atresia.
Atresia Vulvæ.
The labia majora may be adherent, and for a long time no suspicion arise of the condition, as such adhesion does not prevent the exit of menstrual blood; but, on the other hand, it does sometimes interfere with micturition, and then calculi are formed, which require surgical interference for their removal. The adhesion of the labia minora, like the same condition of the greater lips, is usually the result of accident or disease, giving rise to the same difficulties in voiding urine. Unlike adhesion of the labia majora, adhesion of the lesser lips may cause retention and accumulation of the menstrual blood. Atresia of either the greater or lesser lips may be consequent upon smallpox, measles, scarlatina, or any constitutional or local disorder that can cause inflammation of these mucous surfaces. Such occurrences are, without doubt, more common in infancy and childhood. This affection is occasionally found to be congenital, and is due to a simple agglutination of the contiguous mucous surfaces of the labia. The nurse in washing the child sometimes discovers that the vulvar orifice is closed, and it is thus brought to the notice of the physician.
Atresia Hymenalis, or Imperforate Hymen.
Although included under the head of Vulvar Atresia, this will be considered chiefly in connection with atresia of the vagina. This is a congenital condition of more frequent occurrence than the other forms of vulvar atresia.
SYMPTOMS.—If the age of puberty has been attained and the subject has all the symptoms of menstruation excepting the characteristic sanguineous flow, an imperforate condition of the genital canal is suspected. Monthly pain of a bearing-down character in the hypogastric region, and pain in the back and thighs or uterine colic, are among the symptoms. At such times the abdomen may become tender and tympanitic, the pulse more frequent, and slight febrile reaction with nausea and vomiting may occur.
These symptoms closely resemble those of an attack of peritonitis, but usually, after a few days of great distress, they gradually disappear. After a lapse of three or four weeks they again return with increased severity. The girl's general health is impaired, the appetite is poor, there is constant nausea and sometimes vomiting, the bowels are constipated, the eyes lose their brilliancy, the skin presents a dirty appearance and is often covered with an eruption. Headache is almost constant. The abdomen is often very prominent from intestinal tympanitis. Later the lower extremities become oedematous, and there are indications of septicæmia, and great constitutional disturbance. The gradual accumulation of menstrual fluid, first filling and then distending the uterus and vagina, causes a gradual enlargement of the abdomen, often giving rise to a suspicion of pregnancy.
| FIG. 26. |
| Hæmatometra.—Imperforate Hymen, causing distension of uterus and vagina: H. Hymen; V, Vagina; U, Uterus; B, Bladder; R, Rectum. |
DIAGNOSIS.—If there is an accumulation of menstrual fluid in consequence of an imperforate hymen; the latter can be observed as an elastic tumor of a red color protruding outwardly between the labia. A rectal examination is necessary in order to complete the diagnosis, as by this means the presence of menstrual fluid is determined, for if it be present in sufficient quantity to distend the hymen a finger in the rectum can detect fluctuation in the vagina.
If there is no escape of the menstrual fluid beyond the vulva on account of an imperforate hymen, the vagina first becomes gradually distended, then the uterus, and finally the Fallopian tubes. As this distension increases, fluid may be forced beyond the fimbriæ of the tubes into the peritoneal cavity, or, instead, one of the tubes may rupture from the pressure within. In other instances the uterus itself ruptures from over-distension and thinning of its walls. Cases are on record where, the accumulation increasing for years, the uterus has become distended to the size attained in the latter months of pregnancy; under such circumstances its walls as well as the walls of the Fallopian tubes become thinned.
PROGNOSIS.—The physician should be careful and guarded in his prognosis. The health may become much impaired, and sometimes this is the case prior to the cause being ascertained. The chief dangers are in connection with the accumulation of menstrual fluid, such as its discharge at the fimbriated extremity of the tubes, or rupture of the tubes or uterus, and consequent escape of the fluid into the peritoneal cavity. There is also great danger in incising the hymen to permit the exit of the fluid, as will be shown under the head of Treatment. Therefore the longer has been the retention, the greater is the liability of rupture and danger in treatment.
TREATMENT.—As this is of necessity surgical, but brief allusion will be made to it. A simple incision of the hymen will permit the escape of the fluid, but the admission of air by this means is liable to cause sudden contraction of the uterus and a reflex escape of the fluid at the fimbriated extremity of the Fallopian tubes, with all the severe consequences of an intra-peritoneal hemorrhage.
The admission of air is liable to cause decomposition of retained fluid, and this in time produces septicæmia. Further, the sudden admission of air where there has been none before is liable to cause inflammation of the lining membrane of the uterus and tubes, resulting in septic peritonitis. To avoid such risks as have been enumerated two plans are recommended by authors—one being a slow draining away of the menstrual fluid and the other its rapid evacuation and washing out of the uterus and vagina. Graily Hewitt makes an opening of a valvular character in the hymen, permitting only a slow escape of the fluid. Others use a small trocar and draw off the fluid slowly, and at different times if there is a large quantity.
The aspirator is to be preferred to the trocar for emptying the vagina, and of late years has been more generally used; either instrument, but especially the former, permits of the discharge of the fluid at different times, and in such quantities as the physician may desire, without the admission of air. The rapid evacuation is best represented by Emmet's mode of procedure. He first cuts the protruding membrane sufficiently to admit the index finger, and tears the tissues enough to allow the fluid to escape rapidly, and then washes out the vagina and uterus with warm water, after which he introduces a glass plug for the purpose of dilatation and to prevent the action of air upon the parts.
Atresia Vaginæ.
Atresia of the vagina may be congenital or accidental, and, like atresia of any other portion of the genital canal, may be partial or complete. In complete congenital atresia of the vagina an examination per rectum with the index finger fails to discover the fluctuation of menstrual fluid, as in atresia from imperforate hymen, but in its place can usually be felt what seems like a hard fibrous cord. If, however, this cannot be discovered, no doubt remains of entire absence of the vagina. Sometimes the cord can be felt a portion of the distance, which indicates that there is a corresponding portion of an undilated vagina.
In case of complete congenital atresia of the vagina an operation should be avoided, unless there is an accumulation of menstrual fluid or a uterus can be distinctly felt by rectal and vesical examination, or the patient is suffering from the absence of menstruation. To these may possibly be added instances, as mentioned by Thomas, where there exists an imperative necessity for sexual intercourse. Where there is no menstrual molimen or distension of the uterus cannot be detected, and there is non-development of the uterus and ovaries, as shown by the condition of the external organs, surgical interference should be indefinitely postponed.
Accidental atresia of the vagina may be produced by causes heretofore mentioned. When the canal, which has previously been pervious, is entirely obliterated from any cause, an operation becomes, as a rule, an imperative necessity by reason of the accumulation of menstrual fluid and consequent distension of the uterus and Fallopian tubes.
In partial or incomplete atresia it frequently happens that a sinuous canal remains which serves as a guide to the surgeon.
The reader is referred to systematic treatises on surgical diseases of women for the details of the various modes of operating for these affections.
Prolapsus Vaginæ.
Displacements of the vagina are usually secondary, either in consequence of relaxation of the walls or of some form of uterine displacement. Prolapsus of the vagina is usually associated with prolapsus of the uterus, yet it may exist independently. It may be present for some time without prolapse of the uterus, or exceptionally it may be the exciting cause.
DEFINITION.—When the tonicity of the vaginal walls is from any cause impaired and they protrude downward in the direction of the vulva, the condition is called prolapsus.
SYNONYMS AND CLASSIFICATION.—Owing to the anatomical arrangement, it is impossible, with one exception, for any form of prolapsus of the vagina to occur without the coincident prolapse of some viscera. The single exception is the rare occurrence of prolapsus of the posterior wall without the rectum being similarly displaced. These displacements of the viscera with prolapsus of the vagina are commonly described by medical writers as vaginal herniæ, of which there are three different forms, as follows: cystocele vaginalis, rectocele vaginalis, and enterocele vaginalis or hernia vaginalis posterior.
ETIOLOGY.—The causes of displacements of the vagina and the different varieties of vaginal herniæ can very properly be considered together, as they are identical. Laceration of the perineum, an enfeebled condition of the vaginal structure, and a retarded involution of the vagina and uterus in consequence of pregnancy or childbirth are the most frequent causes. Other occasional causes may be mentioned, as former distension of the vagina from repeated childbirths or by tumors, and senile atrophy.
PATHOLOGY.—Following childbirth, the vagina, like the uterus, undergoes a process of involution, but if this is retarded from any cause the vagina is rendered more capacious, its tonicity is impaired, and the uterus, being heavy, crowds down upon it and causes it to be displaced. If the vaginal sphincters or the posterior wall are torn or enfeebled or the perineum lacerated, in addition to the presence of a heavy uterus, prolapsus of the vagina, associated with some form of vaginal hernia, is quite sure to follow.
There is a condition which acts as a common cause in producing vaginal and uterine displacements that has failed to receive on the part of medical authors the notice it deserves—namely, a relaxed condition of the vaginal walls and the perineum, in which there may be observed, in many instances, all of the disturbances caused by a laceration, and yet a careful examination fails to reveal where any tearing has taken place. The continuance of this excessive relaxation and atony of the vaginal walls and the perineum for a long time after parturition is, doubtless, due to subinvolution.
SYMPTOMATOLOGY AND COURSE.—The patient will complain of a bearing-down sensation in the vagina, with a sense of fulness and heat in that locality, sometimes extending to the vulva. These symptoms are aggravated by any muscular exertion, particularly by walking. A physical examination will show the presence of an elastic, globular tumor between the labia. In case it protrudes beyond the vulva, it is not unusual to find scattered over its mucous surface excoriated patches of various sizes. Sometimes these become ulcerated. In other instances the tumor has a smooth, shining appearance. Where there is simply prolapsus of the vagina without the coexistence of a hernia, it will, as a rule, be found that it is the posterior wall. If there is a prolapsus of either the anterior or posterior wall with a hernia, there will be additional symptoms to those above mentioned, which will be referred to in connection with cystocele and rectocele.
Cystocele Vaginalis, or Cysto-Vaginal Hernia.
This is sometimes designated as prolapsus of the bladder, and consists of a descent of the bladder and the anterior wall of the vagina, the two being closely adherent to each other. In consequence of such a descent a pouch is formed which becomes filled with urine. The pouch is in the outset quite small, but gradually becomes larger, so that it is not unusual for one to become of sufficient size to protrude beyond the vulva. In consequence of the pouching of the bladder only a portion of the urine is evacuated by the effort of micturition, and, remaining in the bladder, it decomposes, causing cystitis or vesical catarrh.
The SYMPTOMS are a frequent desire to urinate, with tenesmus and scalding; there is also a sense of heat and pain in the bladder. There is usually more or less ropy mucus discharged with the urine. If a uterine sound or catheter is passed into the bladder with its point downward, and can be felt protruding into the pouch, there remains no doubt as to the case being one of cystocele vaginalis.
Rectocele Vaginalis, or Recto-Vaginal Hernia.
This consists in a protrusion inward of the posterior vaginal wall and a pouch of the rectum, which is carried with it. The tendency to rectocele is seen in the natural bulging of the rectum caused by its expansion just above the sphincter ani. This is more readily perceptible in cases where the perineum has been torn. If from perineal laceration or any cause the posterior wall of the vagina fails to give adequate support to the anterior wall of the rectum, the bulging just mentioned increases, forming a pouch which becomes filled with fecal matter. The bowel becomes more distended with feces, which usually accumulate and harden, and, acting as an irritant, produce tenesmus with mucous discharges. The venous circulation being interfered with, hemorrhoids are common, adding to the patient's suffering.
On examination a tumor is found, sometimes as large as a man's fist, which can be felt projecting from the posterior vaginal wall and over the perineum; sometimes it is soft and compressible, while at other times it is quite solid, depending on the absence or presence of hardened feces. To leave no room for doubt in diagnosticating a case of rectocele, the rectum should be explored with the index finger.
Enterocele Vaginalis, or Entero-Vaginal Hernia.
This consists in a portion of small intestine dilating the cul-de-sac so that the peritoneum is carried down with the intestine between the vagina and rectum as far as the perineum, sometimes forming an elastic tumor at the vulva. The chief dangers arising from this form of vaginal hernia are from its being strangulated or lacerated during childbirth.
Enterocele vaginalis is not frequently met with, but it is important for the physician to know that such a condition is possible and difficult to differentiate from some forms of vaginal tumor. A thorough and careful rectal examination is requisite for diagnosis. An enterocele has the peculiar elastic feeling of a tumor distended with air, a tympanitic resonance on percussion, and a peristaltic movement. If there remains any room for doubt, aspiration with the smallest needle will enable the physician to perfect his diagnosis, for if the needle enter the intestine it is not in any sense a dangerous procedure.
TREATMENT.—The treatment of prolapsus and hernia of the vagina is similar to that of prolapsus of the womb.
If a prolapsus of the vagina has existed but a brief period or has come on suddenly, it should be immediately reduced and proper measures taken to prevent its recurrence. To accomplish this the patient should assume the genu-pectoral position, while the physician with well-oiled fingers restores the parts to their normal position. The patient should then lie upon her back with the hips elevated; astringent vaginal injections ought to be used every four or six hours; and quiet secured or discomfort or pain relieved by opiates. Sudden displacements of the vagina not being of frequent occurrence, the physician more frequently meets with cases of long standing which have come on gradually and slowly.
Attention to the general health is an important requisite: with this in view tonics should be prescribed in many cases, the bowels regulated by means of proper diet or if necessary by medicine, and the bladder more frequently evacuated than in health. Astringent injections are fully as useful in cases of long-standing displacements of the vagina as in those of more recent occurrence; among those more generally used are solutions of tannin, sulphate of zinc, or alum (drachm iv ad pint j). Sea-bathing and injections of sea-water into the vagina are beneficial. It is sometimes more convenient to make topical applications with vaginal suppositories containing one of the astringents just mentioned.
Where cystocele exists it is important that the bladder be completely emptied when the patient urinates; to accomplish this she may assume the genu-pectoral position, and at the same time push the tumor up into the vagina. If after this urine remains in the bladder, a catheter should be employed.
If in any form of vaginal displacement the means which have been alluded to fail, then some form of support or some surgical procedure will be necessary. In very fleshy women considerable benefit is sometimes obtained by means of an abdominal band with a perineal pad attached to it. Pessaries, which have been heretofore quite generally depended upon, are now considered as of secondary importance. Sometimes, however, when the hernia is not of great size or when associated with uterine displacement, a pessary proves of service. A Hodge's pessary with a cross-bar, or the one devised by Skene of Brooklyn, will often prove of great benefit in cystocele. For either cystocele or rectocele the most serviceable form of pessary is one like Cutter's or McIntosh's cup pessary, which is retained within the vagina and supported in position by external attachments. To effect a radical cure in either cystocele or rectocele, especially in the latter, some surgical procedure generally becomes requisite.
Of the different operations which have secured the general approval of gynecologists, the most common is perineorrhaphy: this is the name given to the operation for a torn perineum. Another operation sometimes performed with success is colporrhaphy or elytrorrhaphy, which consists of lessening the calibre of the vagina by removing a portion of the mucous membrane and bringing the edges of the wound together by sutures. This can be performed on either the anterior or posterior wall, depending on which seems to demand it the most; and if the operation on one wall is not likely to be sufficient, it should be made on both. Not unfrequently the most perfect success can be attained by a surgical procedure designated as colpo-perineorrhaphy, which combines the two operations that have been mentioned. Full descriptions of these different operations and the best modes of performing them can be found in all late standard works on surgical gynecology.
Cicatrices.
Cicatrices of the vagina may occur in consequence of lacerations or injuries received in childbirth, surgical operations, wounds from accident, or the use of caustics about the uterus. If any of the causes named excite inflammation, there may be more or less sloughing of the parts, and, as healing must take place by granulation, cicatrices of various dimensions are formed. These cicatrices may be sufficient to cause partial or complete atresia, or they may be merely in the form of projections or bands, dragging the uterus out of its normal position or interfering with its natural mobility, and cause dyspareunia and other discomforts.
Recently, since attention has been directed to the reflex symptoms produced by cicatricial tissue in the neck of the uterus, there has been a growing belief that similar symptoms are often caused by cicatrices in the vagina. Thus it is the opinion of some who have investigated this subject that many cases of remote neuralgia and other nervous disturbances may often be caused in this way.6
6 Vide Skene on "Cicatrices of the Cervix Uteri and Vagina," Amer. Gynæc. Soc., vol. i., 1876.
TREATMENT.—This is of necessity surgical, although some cases can be successfully treated without having recourse to cutting operations, but are treated by pressure. One method is to tampon the vagina with cotton or marine lint previously saturated with carbolized glycerin. The tampon can be left in position four or five days, when the vagina may be washed out and again tamponed. Another method of treating with pressure is by means of a Sims's dilator, either worn continuously or a few hours at a time. Generally a quicker and more effectual mode of treatment is to nick the bands with scissors or a knife in several places sufficiently for the vagina to assume its natural shape, and then insert the dilator. In some instances it is advisable to cut away portions of the adventitious membrane. On account of the tendency to hemorrhage after operations in the vagina the physician should avoid cutting more than is requisite, and must use a finger as a guide in cutting, to inform him when he has cut sufficiently.
If there is considerable hemorrhage it may be necessary to use a styptic, but usually the glass dilator, by putting the walls on the stretch and by pressure, will check the bleeding. It is important that the dilator be worn for several hours each day after the nicking, for fear that there will again be contraction. After each removal of the dilator the vagina should be syringed out with warm carbolized water or a very weak solution of permanganate of potassium (gr. ss ad fluidounce ij), that no septic matter may be retained and so that healing of the cuts may be more rapid.
Double Vagina.
Among the congenital deformities occasionally met with is a vagina divided by a longitudinal septum, constituting a duplex or double vagina. The septum is not always so situated as to make the passages of equal size, nor does it invariably divide the canal through its entire length. It is stated by most writers on the subject that usually with a double vagina there will also be a double uterus. The author has met with only two cases of duplex vagina, neither of which was associated with a double uterus. The treatment is of necessity surgical, and consists in dividing the partition with scissors, and inserting a tampon with some styptic or a Sims's dilator for the arrest of the bleeding which invariably occurs from cutting operations in the vagina. If there is persistent hemorrhage, a galvano- or thermo-cautery may be used.
Growths in the Vagina.
New formations of any kind are not of frequent occurrence in this locality. They consist almost exclusively of cystic tumors, fibroid tumors, papillary excrescences or vegetations, sarcomata, epithelioma, and carcinoma.
Cystic Tumors of the Vagina
are sometimes observed, but are by no means common. Their origin and nature has not seemed to be well understood. Hugier and Guérin are of the opinion that they are caused by the mucous follicles being obstructed. In this view they are sustained by Preuschen.7
7 "Die Cysten die Vagina," Centralblatt für Med., 1871, p. 775.
Sinéty remarks that there are two varieties of vaginal cysts—one superficial and the other profound. The superficial are developed in the mucous membrane, are small in size, and contain fluid which is watery or clear and glairy. The profound cysts are developed in the vaginal walls, and are of various dimensions, from the size of a walnut to an orange, and capable of attaining to much greater dimensions than is possible for the superficial variety. Their contents vary greatly; sometimes clear, mucous, and ropy, in other cases they are colored brownish or chocolate.
Cysts of the vagina are not to be confounded with those of the vulva or those which develop in the vulvo-vaginal glands, nor are they as common.
TREATMENT.—Cysts of the vagina can often be cured by laying them freely open with a bistoury and wiping out the cavity with tincture of iodine, carbolic acid, or a solution of nitrate of silver. The tincture of iodine preferred by the author is Churchill's or a saturation tincture, either being much more effective than the simple tincture. Nitric acid and the actual cautery are mentioned by Barnes as having been used for destroying vaginal cysts. Entire removal of these formations can be effected by cutting into or through the mucous membrane and dissecting them out in the same manner as they are removed from other localities.
Fibrous and Sarcomatous Tumors.
Fibrous or fibroid tumors are by no means as common in the vagina as in the uterus. It has been observed that they are frequently but not invariably associated with the latter. They are developed in the muscular or fibrous structure of the vagina in the same manner as similar formations in the muscular tissue of the uterus.
Some authorities assert that they frequently have the point of departure from the uterus, and then descend little by little between the walls of the vagina.
Sarcomatous tumors are developed in the same tissues and similarly to fibrous growths of the vagina. They are, however, of less frequent occurrence. They sometimes appear primarily in the vagina, but more frequently are consecutive to sarcoma of the uterus.
It is a difficult and often impossible task to make out the differential diagnosis of sarcomatous and fibrous growths in the vagina except by means of the microscope. The symptoms of each are similar to those which indicate sarcomatous and fibrous growths of the uterus, it being accompanied by profuse leucorrhoea, more or less sanious, and occasional hemorrhage. If tumors acquire much size, they interfere with the functions of the rectum and bladder, and cause pain and discomfort by their pressure in the pelvis; sexual intercourse is difficult, frequently painful, and followed by a flow of blood.
DIAGNOSIS.—If of a large size, diagnosis is easily made. Uterine tumors and prolapsed uteri have been mistaken for vaginal growths. By using a uterine probe and inserting a finger in the rectum there need be no error in these respects. By careful examination there is little difficulty in diagnosis.
TREATMENT.—This consists of removal by the knife, scissors, écraseur, or galvano- or thermo-cautery. If there are reasons for believing that a tumor is sarcomatous, it is important that every particle be removed. For this purpose scissors or the galvano- or thermo-cautery are preferable to the ordinary écraseur, which by its action crushes and bruises tissues, and is liable to draw into the chain or wire and crush off more than the operator desires. Serious accidents, such as opening into the peritoneal cavity or the bladder, have occurred in this way in the practice of distinguished and experienced surgeons.
Papillary growths and vegetations in the vagina will receive merely a brief allusion, as they are rarely seen even in the practice of gynecologists. They are not commonly limited to the vagina, but are of more frequent occurrence about the vulva and on the cervix uteri. Vegetations of considerable size sometimes develop in consequence of pregnancy or of granular vaginitis. Sometimes papillary growths within the vagina assume a cauliflower shape with well-defined stalks, or about the ostium vaginæ they may take the form of condylomata. These formations may be confounded with epithelioma.
Treatment consists of removal by scissors or with the thermo- or galvano-cautery, and to guard against hemorrhage some styptic and a vaginal tampon will be required.
Cancer of the Vagina.
Carcinoma or epithelioma rarely occurs as a primary affection in the vagina; it is generally secondary, extending from the neck of the uterus. The author has met with only three cases which were primary cancer.
In a recent work Kustner8 has collected statistics of twenty-two cases of primitive cancer of the vagina. The result of the analysis of these observations is, that nearly always the posterior wall is first affected in primary cancer, while in secondary cancer the anterior wall is the first to be attacked.
8 "Ueber den Primären Scheidenkrebs," Arch. f. Gyn., t. ix. p. 279.
The symptoms after the disease is somewhat advanced are similar to uterine cancer—viz. a sanious, watery discharge of an offensive odor or sometimes a veritable hemorrhage. There is no pain peculiar to or pathognomonic of the disease. It is not until infiltration causes pressure on nerves or there is considerable ulceration that pain is experienced; in either of these conditions the sufferings are often excruciating. Occasionally in women of advanced age, in consequence of cancerous infiltration before ulceration has occurred, the vagina is found to be contracted and there is roughness and induration of the walls.
Epithelioma generally occurs in young women. The early symptoms are pain and hemorrhage following coition. A digital examination will show the friable nature of the formation and an indurated base: the examination will cause blood to flow. In the early part of this stage, before there has been much ulceration, the disease is sometimes mistaken for syphilis and the growths for syphilitic condylomata. It is not an uncommon occurrence for the disease to propagate itself by contact, the opposite wall from which it primarily appeared becoming in this way affected. Later, deeper tissues are infiltrated, the bladder or rectum becomes implicated, ulceration occurs, and subsequently perforation. The progress and terminations are similar to uterine cancer.
TREATMENT.—In carcinoma there seems to be no opportunity for anything more than a palliative course of treatment. Medicine or surgery is here of but little avail. If epithelioma be detected sufficiently early, there is some hope of cure, but this lies only in complete removal. For this purpose the knife or scissors or the galvano- or thermo-cautery can be used. When there is much hemorrhage, some styptic, like the perchloride of iron, should be applied, or the cautery or curette may be of service. Unfortunately, the physician is seldom consulted early enough—prior to the cellular tissue being too much infiltrated—for the thorough eradication of the disease.
Death occurs from exhaustion, hemorrhage, septicæmia, uræmia, or from infiltration interfering mechanically with the function of the bladder, kidneys, or intestine.
For the purpose of correcting the offensive odor and lessening pain there seems to be nothing superior to chloral and glycerin (drachm j-drachm ij ad ounce ij) on a tampon of cotton; the fluid extract of eucalyptus combined with the chloral and glycerin (ounce ss ad ounce ij) has proven an excellent deodorizer in the author's hands.
Vaginismus.
DEFINITION.—This affection, which was first called vaginismus by our distinguished countryman the lamented J. Marion Sims, consists in a hyperæsthesia or peculiar sensibility of the site of the hymen and vaginal outlet, associated with involuntary spasmodic contraction upon irritation of the sphincters of the vagina.
ETIOLOGY.—Predisposing Causes.—This is sometimes an idiopathic affection, but more frequently is symptomatic of some other disorder. When idiopathic, it is due to a diathesis generally termed hysterical, or an excessive nervous irritability affecting the entire system. The symptomatic causes are quite numerous—more frequently some insignificant local disorder than any grave form of disease. The more common causes are irritated or inflamed carunculæ myrtiformes, excoriation, and irritable ulcers and eruptions about the vulva, vaginitis, uterine catarrh, inflammation, growths and fissures of the urethra, disorders of the bladder, fissure of the anus, and inflamed hemorrhoids. Other less frequent causes have been mentioned by writers, as neuromata, an unusually rigid perineum, and a disproportionately large male organ. Neftel of New York asserts that lead-poisoning has been the cause of some cases under his own observation.9 It is sometimes associated with or apparently caused by congestive dysmenorrhoea and uterine displacements and engorgements.
9 N. Y. Med. Journ., vol. ix. p. 81.
Emmet's views regarding the etiology and pathology of this affection differ from those of the majority of writers on the subject. He regards it as purely a symptom denoting reflex irritation, and says that with it he has never failed to find some condition, as a displacement, a limited cellulitis, or a fissure in either the rectum or the neck of the bladder, as the exciting cause.10
10 The Principles and Practice of Gynæcology, by Thomas Addis Emmet, M.D., 2d ed., Philada., 1880, p. 607.
SYMPTOMATOLOGY, COURSE, DURATION, TERMINATION, AND COMPLICATIONS.—The most prominent symptom is excessive pain upon the sexual intercourse; this is often so marked that subsequent attempts, or even a digital examination, will throw the patient into a state of extreme nervous trepidation and apprehension. If attempts at coition are persevered in, the symptoms are further intensified, so that the spasm and violent contraction of the sphincter vaginal muscles induce agonizing pain. Besides having the characteristic pain, patients with this disorder are, as a rule, sterile. If a physical examination be made in a well-marked case of vaginismus, it frequently occurs that the slightest touch on the part of the physician about the site of the hymen will bring on painful contraction of the vagina and sphincters, and cause the patient to spring up and show much nervous disturbance. In the same class of cases it may be brought on by walking. Thomas says that "in some cases a marked tendency to spasm will have been noticed upon sudden changes of position or washing the genital fissure."11
11 Op. cit., p. 206.
Barnes remarks that in some women the irritability of the nervous centres becomes so great, the sensitiveness of the peripheral nerves at the vulva so acute, and reflex action thereby so intensified, that the attempt at intercourse will induce convulsion or be followed by syncope.12
12 Edis, Diseases of Women, p. 533.
One case came under the writer's observation where the sensitiveness was so marked that a slight touch with cotton or a camel's-hair brush would bring on severe painful contraction.
Course and Duration.—This is an affection of indefinite duration; unless relieved it may continue through years of discomfort and misery. Cases are reported as lasting twenty-five or thirty years. There is a mild form sometimes occurring among the recently married which will either disappear of itself or yield to simple treatment. More generally, the discomfort and pain continue unless successfully treated, and in well-marked cases attempts at intercourse increase the suffering; there is nervous exhaustion, the health breaks down in consequence and from what has been called "the disappointment of nature under an unfulfilled function."
PATHOLOGY.—In certain morbid conditions the nerves distributed about the outlet of the vagina may possess such a high degree of irritability that a foreign substance coming in contact with them will cause contraction and spasm of the tissue in which they are distributed and connecting muscles.
Sinéty13 is of the opinion that "in milder forms of the disorder the constrictor vaginal muscles alone may be the seat of the spasm; but more generally all of the muscles forming the floor of the perineum, the constrictors of the vulva and vagina, muscles of the anus and of the urethra, superficial and deep," in truth, "all the muscles of the region," can "simultaneously be the seat of spasm." Emmet14 considers vaginismus as kindred to neuralgia, for the reason that it more frequently occurs among anæmic and excessively nervous women, and those who have in some manner overtaxed their nervous systems, the locality being determined as it were by accident, and that only in exceptional instances can there be any local exciting cause. Thomas15 says that it is curious to perceive how, from different standpoints regarding the pathology, "both parties were led to the same surgical resource."
13 Manuel pratique de Gynécologie, par L. de Sinéty, Paris, 1879.
14 Op. cit., p. 607.
15 Op. cit., p. 205.
The author's own observation will not permit of his ascribing the majority of cases wholly to morbid constitutional conditions, to the exclusion of local lesions. The reason of his belief is that the greater number of cases he has observed have been treated and cured by surgical measures, having in view the relief of morbid conditions of some pelvic structures.
DIAGNOSIS.—The diagnosis is attended with no difficulty, as there is no other affection presenting similarities.
PROGNOSIS.—Sims remarks that he knows of "no serious trouble that can be so easily, so safely, and so certainly cured." Scanzoni, Tilt, and others, who hold different views as to the pathology and means of cure, express themselves as favorably regarding prognosis. Thomas has never met with a case that he could not relieve or cure. Nearly all gynecologists are of the opinion that a favorable prognosis is warrantable in the majority of cases.
TREATMENT.—In cases where it seems quite difficult to ascertain the etiology and pathology a palliative course may at first be pursued, such as vaginal injections of acetate of lead or borax in warm water (drachm j ad pint j), to which may be added carbolic acid or laudanum or the wearing of the vaginal rest or dilator, and total abstinence from any attempts at coition. If the chief cause seems to be in some constitutional trouble, then as complete physiological rest as possible should be enjoined. With this in view, all attempts at sexual intercourse must be discontinued, as it will keep up nervous suffering and local pain and discomfort. The vaginal dilator of Sims secures a rest by keeping the walls apart; it also dilates and benumbs the parts, thus rendering them more tolerant of a foreign body. With every mode of treatment or in cases occurring from any cause the vaginal dilator is required; this is to be worn for two or more hours at intervals of six to twelve hours, according to the degree of tolerance with which it is borne. It should be smeared previous to insertion with some soothing lubricant, as iodide of lead and glycerin (drachm j ad ounce j) or atropia and vaseline (gr. ij ad ounce j) or stramonium ointment. Vaginal suppositories containing morphia, extract of opium, belladonna, hyoscyamus, or stramonium will usually prove of great benefit as local sedatives. In some instances suppositories containing five to ten grains of iodoform may be of service. Copious vaginal injections of warm or hot water alone are beneficial in the majority of cases, as they wash away irritating discharges that aggravate the disease, and by lessening the congestion frequently do away with the necessity of surgical operations.
A careful examination should be made in every case for the purpose of ascertaining whether the vaginismus is not caused or aggravated by fissures, ulcers, or excoriations about the parts; if any are found, they should be properly treated. If any symptoms point toward the rectum or urethra, they should be examined. A patient of the author's suffered from vaginismus during some years, owing wholly to a fissure of the anus, and was cured by an operation for the anal disease alone.
Owing to the pain an ordinary examination produces, it will generally be necessary to etherize the patient before attempting to make a thorough and careful examination.
In anæmic or excessively nervous patients other treatment than local is necessary. Tonics, such as iron, quinia, strychnia, sea-bathing, etc., change of scene, and such kinds of exercise as improve the tone of the nervous organism, should be prescribed. If the trouble is due to some uterine or pelvic disorder, a cure can be effected only by attention to the primary affection.
Some of the modes of treatment that have been mentioned, if persevered in, will succeed in curing many cases without having recourse to any surgical procedure. If, however, a case has not yielded to any of the means heretofore suggested, then some form of surgical operation becomes necessary. The simplest is the one advocated by Scanzoni and Tilt, and consists in a forcible dilatation of the ostium vaginæ with the thumbs, after the manner first practised by Récamier of forcible dilatation of the sphincters in fissure of the anus. Temporary paralysis of the vaginal sphincters is by this means effected, and should be followed by the insertion of a large vaginal dilator, to be worn for several days and held in position by a T-bandage. This sometimes effects a permanent cure, but if a single trial fails to accomplish it, yet the patient is considerably benefited, it ought to be repeated; in the mean time the use of the dilator with one of the ointments previously mentioned should be persevered in.
When the disorder has existed a long time, the muscular power has increased, and the forcible dilatation may require more exercise of strength than can be exerted by the thumbs alone; under such circumstances the writer has been in the habit of using Symes's universal speculum or a tri-bladed rectal speculum, and gradually dilating the vagina to the extent required.
If any of the modes of treatment that have been mentioned fail to effect a cure, or reasons exist for not making use of them, then the radical treatment of Sims or some one of its modifications will be requisite.
A full description of the various surgical procedures and the views of different authorities cannot with appropriateness be presented in this work.
Sims's operation is made as follows: The patient is fully anæsthetized and placed upon her back; then with curved scissors every vestige of the hymen is removed. It is important that this be most thoroughly done, for it has occurred that by leaving a small portion success has not been complete. As soon as the bleeding has stopped the fourchette is put upon the stretch by inserting the middle and index fingers, and with a scalpel a Y-shaped incision is made through the mucous membrane and part of the muscular fibres on each side of the perpendicular line extending into the perineum. After this a glass vaginal dilator is placed in the vaginal canal and worn two hours each morning and night, or as much of the night as it can be tolerated. This should be continued for about a month. There are several sizes of the dilator, and in selecting one to be worn care should be taken not to use one that is too large. Morphine suppositories per rectum should be used as often as is requisite for the relief of pain. A copious vaginal injection is necessary for the sake of cleanliness after each removal of the dilator.
Sims's dilators are made of glass, the outer end open, the inner closed, and of a conical shape; on the upper side is a depression to avoid pressure on the urethra.
| FIG. 27. |
| Sims's Vaginal Dilator. |
Emmet's operation is a modification of the above, and consists in inserting an index finger in the rectum, and then putting the sphincter on the stretch, when with scissors he divides the fibres encircling the vagina on each side just within the fourchette and about three-fourths of an inch apart. He claims that this method "does not allow a prolapse of the vaginal wall, as when the perineum is lacerated, but does permit of an equal extent of dilatation of the outlet by the glass plug."16
16 Op. cit., p. 609.
The plan of dividing the pudic nerve, as practised by Sir James Y. Simpson, has met with little favor.
The author has been successful in several instances by a less formidable operation than any herein described. His operation has simply consisted of entire removal of every vestige of the hymen or carunculæ myrtiformes with scissors, followed by wearing of the glass plug such length of time as is requisite. This procedure is simply the first part of Sims's operation.
Parturition would, as a rule, cure this affection in an effectual manner but its subjects are generally sterile. The reason of sterility in vaginismus is often owing to the extreme suffering whenever there is an attempt at coition; this pain prevents its perfect performance, and often all further attempts are abandoned. When we are convinced that such a condition is the cause of sterility, the patient may be etherized, and while in that condition complete coition may result in fruitfulness and ultimately perfect cure of the vaginismus.
DISEASES OF THE VULVA.
The subject will be considered in the following order: Anatomy, Vulvitis, Phlegmonous Inflammation of the Labia, Furuncles, Pruritus, Hyperæsthesia of the Vulva, Tumors, Atresia, and Eruptions.
Anatomy.
As regards the anatomy of the generative organs of women in this and the preceding chapter, it has not been deemed necessary by the author to consider the subject in extenso, but to give a brief résumé, as better suited to the needs and wishes of the busy practitioner.
The generative organs of women external to the hymen, in their relative order from before backward, consist of the mons veneris, clitoris, vestibule, meatus urinarius, and orifice of the vagina, and the labia majora and minora on either side. All these are known under the name of pudendum or vulva.
The mons veneris is a rounded cushion of fatty tissue immediately over the os pubis, and from puberty is covered with hair.
The labia majora are two folds of skin extending longitudinally from the mons veneris to the perineum. In them are found all the elements of the skin. The subcutaneous tissue is of loose texture. A noticeable fact is that here the sebaceous glands are remarkable for their size, some of them being 0.5 millimeters in diameter and opening directly on a free surface. The labia majora resemble the skin of other portions of the body in that they contain papillæ, nerves, vessels, and Pacinian bodies. Internally they are lined with mucous membrane in which are numerous sebaceous follicles. A quantity of fat, areolar tissue, and tissue analogous to the dartos of the scrotum, including vessels, nerves, and glands, constitutes the contents of the labia, and gives them a rounded appearance, larger in front and decreasing in size toward the perineum. The extremities of these folds, joining together, form the anterior and posterior commissures of the vulva.
The labia minora, sometimes called nymphæ, are two membranous folds of erectile tissue within the labia majora, beginning at the anterior commissure and passing down and disappearing midway between the two commissures. They also contain sebaceous glands.
The clitoris is an erectile organ covered with mucous membrane, and is the analogue of the penis. It arises by two crura, is situated beneath the anterior commissure, and is partially concealed by the labia minora.
The vestibule and the fossa navicularis are triangular spaces on the mucous membrane, the first immediately posterior to the clitoris, the second anterior to the perineum.
The meatus urinarius is the external orifice of the urethra, and is situated in the vestibule about one inch posterior to the clitoris. The mucous membrane is slightly raised above the meatus, giving it prominence, and thus serves as a guide to the introduction of the catheter without exposing the person.
The orifice of the vagina is an elliptical opening just below the meatus urinarius. It is partially covered over in the virgin by a fold of mucous membrane called the hymen.
The vulvo-vaginal glands, or the glands of Bartholin, are two in number, situated anterior to the hymen, each with a single duct opening on the inner side of the nymphæ. They are analogous to the glands of Cowper in the male.
The bulbi vestibuli, on either side of the vestibule, extend downward from the clitoris for about one inch. They consist of a thin layer of fibrous membrane ensheathing a plexus of veins.
Vulvitis.
DEFINITION.—Vulvitis is the term used to designate inflammation of the vulva. It may be purulent, follicular, or occasionally but rarely gangrenous.
ETIOLOGY.—The purulent form may be specific or the result of want of cleanliness, exposure to cold, over-exertion, the strumous diathesis, pruritus, urinary fistula, or cancer. It is also produced by awkward or excessive coitus and masturbation, the irritation of urine, and frequently is caused by pregnancy. Vulvitis is not uncommon with little girls, resulting from some of the innocent causes mentioned, though the symptoms may expose the patient unjustly to the suspicion of having been tampered with.
SYMPTOMATOLOGY, COURSE, AND DURATION.—At first there is heat, dryness, and more or less pain in the affected parts, followed by a profuse flow of yellow pus. There is also tumefaction, hypersensitiveness, and often pruritus. Follicular vulvitis is the term employed to indicate an inflammation of the mucous or sebaceous glands and of the hair-follicles of the vulva. This disease may be the result of any of the causes of purulent vulvitis, as alluded to in the preceding clause. The subjective symptoms are common also to the purulent form. Objectively, the mucous membrane will appear to be very red in spots, resembling in this respect the raised papillæ of the tongue. These spots frequently bleed on slight provocation. The internal surface of the nymphæ and vestibule is the seat of the disease when the mucous glands are involved, but where the sebaceous glands are mainly affected the inflamed papillæ will be found on the surface of the labia and at their juncture anteriorly. In the course of the inflammation a drop of pus will exude from the papules, and they then gradually disappear. Occasionally, collections of exudate from the diseased glands accumulate beneath the labia minora, concealing the diseased surfaces and becoming quickly very offensive. The disorder, though sometimes persistent, is seldom chronic. The acute affection may be the cause of urethritis in the male closely resembling gonorrhoea if coition occurs during its existence, and thus not infrequently giving rise to suspicion of infidelity.
TREATMENT.—In the matter of treatment, touching the inflamed points with carbolic acid or caustic sometimes favorably influences the course of the disease. Cleanliness is the most important item in the treatment of the two forms of the disease, for without it the application of remedies will be of little avail. Strict attention to this, with perfect rest of the parts, will not infrequently be all that is requisite to effect a cure, but in cases that do not yield to this treatment sedative, astringent, or alterative applications are indicated. These should be applied after bathing. In the purulent variety such remedies as the lead-and-opium wash after the following formula will prove serviceable:
| Rx. | Tinct. opii, | fluidounce j; |
| Plumbi acetat. | drachm j; | |
| Aquam ad | fluidounce viij. |
Lint may be saturated with this lotion and applied between the labia. If the disease does not yield to the treatment already mentioned in the course of two or three days, a solution of argentic nitrate (gr. x to ounce j) should be brushed upon the parts, and between the intervals of its application bismuth or starch may be kept constantly on the parts. In cases associated with vaginitis a much stronger solution is sometimes required. (Vide chapter on Vaginitis.) The author has used powdered iodoform in some cases with very good results.
| FIG. 28. |
| Follicular Vulvitis (Huginer). |
In the follicular variety the disease is more severe and usually of longer duration than the purulent, although the principles of treatment are essentially the same. In this as in the other variety cleanliness is of paramount importance, frequent washing being very essential. To the inflamed follicles such applications as nitrate of silver, persulphate of iron, and carbolic acid are the more frequent remedies used in this disease. After the application of any of these remedies the parts should be rendered dry, and then a piece of soft linen or a roll of absorbent cotton should be smeared with vaseline or soaked with carbolized glycerin and inserted within the vulva in a way to keep the labia apart. Occasionally the practitioner will meet with a chronic form of vulvitis, and the rareness of its occurrence is fortunate, for the reason that it is a very obstinate and intractable variety of the disease. Vulvitis is very frequently associated with vaginitis, owing to the fact that the mucous membrane is continuous in both vulva and vagina. On this account the principle of treatment of inflammation of either locality is essentially the same. To avoid repetition, the reader is therefore referred to the section on Vaginitis for a more detailed description of treatment.
There is a form of this disease described by Vinay17 as ulcerous or aphthous vulvitis. This is an affection peculiar to childhood, occurring only when the general health is much impaired. It is often a sequel of fevers, and may even become epidemic. It attacks children of any age, but is of more common occurrence in infancy. The disease appears first upon the mucous membrane in the form of small and round patches of a white or grayish-white color, which soon ulcerate, and at a more advanced stage are liable to become gangrenous. This variety of vulvitis has long been known, and is mentioned in the works of Hippocrates. This disease is rarely met with in this country.
17 Nouveau Dict. de Méd., tome xxxiii., 1885.
Phlegmonous Inflammation of the Labia Majora.
DEFINITION.—The adipose and areolar tissue which compose the greater bulk of the labia majora often become the seat of acute inflammation, in consequence of direct injury, excessive or awkward coition, exposure to cold, from irritating discharges, scratching in pruritus, vulvitis, or that peculiar blood-state which predisposes to the formation of boils or carbuncles.
SYMPTOMATOLOGY AND DIAGNOSIS.—The patient will first complain of heat and pain, increased by standing or walking, and later throbbing and shooting pains in the affected parts. In the outset the part is congested, followed by induration from effusion in the loose tissues, and next suppuration ensues. An examination in the last-named stage will reveal the existence of an abscess in one labium. The diagnosis is by no means difficult, but the physician, however, should bear in mind that this same locality may be the site for pudendal hernia, a dislocated ovary, hæmatocele, or vulvitis.
TREATMENT.—In the outset the inflammation may be caused to disappear by resolution, by means of cold and sedative lotions, such as the lead-and-opium wash, saline laxatives, non-stimulating diet, and perfect rest. In the majority of cases the disease proceeds to suppuration. When it is found that resolution is unattainable, then means should be taken to promote and hasten suppuration. This is best effected by the frequent application of hot poultices. The mistake is often committed of permitting too long intervals to elapse between the application of poultices, and allowing the one applied to become cold before another one takes its place. The patient can be saved many hours of suffering by keeping hot applications constantly on the inflamed labium. As soon as suppuration is detected the abscess should be opened, for two reasons aside from the one of affording relief: First, the tissue resists early natural evacuation; second, owing to the laxity of the tissues, pus will sometimes force itself upward toward and through the abdominal ring.
Furuncles of the Labia.
DEFINITION.—Closely resembling phlegmonous inflammation are the furuncles or boils which are quite common on the labia. They occasion much pain and distress, for the reason that they are very obstinate and apt to recur, one forming as soon as its predecessor has apparently healed. In many instances these boils seem to be consequent upon inflammation of sebaceous glands. They differ in size, some being no larger than a pea, while others are the size of a filbert.
TREATMENT.—This should be constitutional and local. Quinine, arsenic, cod-liver oil, and other remedies of a tonic character should be administered. The bromide of arsenic has been used by the author in a few cases with quite satisfactory results. As soon as one of these furuncles shows that it contains pus, it should be freely opened and a crucial incision made to prevent immediate healing; after which poultices should be applied. These small boils are extremely painful, and are very troublesome, owing, as previously stated, to their liability of recurrence. To prevent their recurrence is one of the reasons why immediate healing of the incisions should be prevented. If contraction of the sacs of the abscesses does not occur, pus will continue to be formed and the tissues in their immediate neighborhood will become indurated. In this way the furuncles may become of a chronic character. To further facilitate healing and aiding their contraction the sacs should have applied to them some stimulating remedy, such as carbolic acid or nitrate of silver. Edis says that painting the surface of the affected labium with tincture of iodine is beneficial in some instances.
One of the most important requisites in treatment is perfect cleanliness.
Pruritus Vulvæ.
DEFINITION.—Pruritus vulvæ, although merely a symptom of disease, characterized by itching of the vulva and contiguous neighborhood at times wellnigh intolerable, has, because of its occasional obscure etiology and severity, always been considered by medical authors as a disease of itself, instead of a symptom of other disorders, in treatises on diseases of women.
ETIOLOGY.—Predisposing and Exciting Causes.—It frequently occurs from external irritation, as animal parasites, or such as may be produced by acrid discharges, particularly in gonorrhoea and uterine cancer, changes in the normal composition of the urine, especially diabetic, and not infrequently during the menstrual flow. Pruritus may occur in connection with inflammation of the uterus and vagina without any irritating discharge; likewise it occurs in diseases of the urethra, bladder, and kidneys. Sometimes masturbation may be the cause as well as the effect of pruritus. Secondarily, there may be an insufferable itching in consequence of the continued titillation or irritation of the parts, although masturbation by no means invariably leads to pruritus. The habitual use of opium or alcoholic drinks often causes intractable forms of this disorder. Edis states "that the custom of immoderate tea-drinking is a by no means infrequent cause of pruritus." But instances of pruritus occur where all of the causes mentioned are lacking, and they are instead purely of a reflex character, such as are met with in women about the time of the change of life and during the latter months of pregnancy, or from the presence of worms in the rectum. If the worms migrate to the vulva, as they sometimes do, the irritation then becomes direct. Interference with the circulation of the vulva by pregnancy and tumors may cause pruritus: unquestionably, certain varieties of the disorder are idiopathic or neurotic.
SYMPTOMATOLOGY AND COURSE.—When the complaint has existed for some time, the itching will be pretty well diffused from the pubis backward, but in more recent cases it may be localized at the perineum, nymphæ, clitoris, or portions of labia. The itching is not always constant, but subject to exacerbations. It is usually much worse when the patient becomes heated from exercise or is warm in bed, thus preventing comfort or sleep, and thereby adding an additional complication to treatment. The sufferer naturally seeks relief by scratching the involved tissues, and for this very transient satisfaction spreads the disease by increasing the irritability of the parts and inducing a condition closely resembling eczema.
TREATMENT.—Inasmuch as the etiology of the complaint is often uncertain, as heretofore stated, it is highly important that the physician should ascertain if possible the cause of the disease, and thereby be better enabled to treat the complaint intelligently. In case the itching can be traced to the animal parasites most common in this region, such remedies as the black or yellow wash, mercurial ointment, or the oleate of mercury will usually prove sufficient; but if it be found that the Acarus scabei is the cause of the itching, the application of the ordinary sulphur ointment will destroy this parasite and the itching will consequently cease. If due to uterine catarrh or any vaginal affection, attention should be directed to the removal of the primary disorder by appropriate means, for it cannot be expected that itching of the vulva can be relieved so long as there is any irritating discharge constantly exciting it. The most important measure of all is perfect cleanliness. This can be secured by sitz-baths, sometimes several being necessary daily. At the same time, the vagina should be syringed with warm water or water with the addition to it of such remedies as are used for the relief of leucorrhoea. The irritated surfaces of the vulva should be prevented from coming in contact by vaseline spread upon absorbent cotton or lint, or by powders, such as bismuth, starch, etc.
In case there is an unmistakable acrid discharge from the uterus causing pruritus, proper topical applications should be made to as much of the endometrium as is diseased; the vagina should be thoroughly douched night and morning, and then there should be placed against or around the neck of the womb one or more tampons of cotton saturated with the boro-glyceride or with glycerin, in which has been dissolved borax or acetate of lead in the proportion of ounce ss of one of these salts to ounce ij of glycerin.
In some instances, where there is a profuse discharge, simply packing the vagina with dry salicylated or borated cotton will suffice. This should never be allowed to remain longer than twelve hours without removal. In those cases where the discharge is less acrid a single tampon saturated with one of the remedies named or glycerin alone, and placed against the cervix daily, will suffice, as it will prevent the discharge from coming in contact with the vulva. In severer forms of this affection a number of tampons saturated in the same manner will be more efficacious, and still permit the patient to move about. When several tampons are used they should be loosely rolled, and each one should have a string attached for convenient removal. In the mean time, topical applications can be made to the vulva, and washing of the parts will not interfere with the tampons. The author has found the following prescription of Thomas very efficacious as a vaginal injection and wash for the vulva:
| Rx. | Plumbi acetatis, | drachm ij; |
| Acidi carbolici, | scruple ij; | |
| Tr. opii, | fluidounce j; | |
| Aquæ, | pint iv. M. |
Another prescription which has demonstrated its value is:
| Rx. | Bismuthi subnitratis, Acaciæ pulv. aa | drachm ij. M. |
Sig. Add water to the consistency of cream and apply frequently with a brush.
A somewhat similar prescription, to be applied in the same way, is the following:
| Rx. | Pulv. acaciæ, | drachm ij; |
| Bals. Peru, | drachm j; | |
| Ol. amygdalæ, | drachm iss; | |
| Aquæ rosæ, | fluidounce j; M.; |
or,
| Rx. | Acidi carbolici, | drachm ij; |
| Glycerinæ, | fluidounce j; | |
| Aq. rosæ, q. s. | fluidounce viij. M. Ft. lotio. |
In all cases of pruritus, except from parasites, much benefit can be derived from washing the parts two or three times daily in a weak solution of bicarbonate of sodium (half a tablespoonful in a quart of water, with a tablespoonful of eau de Cologne).
In pruritus from diabetes some relief may be afforded by the administration of alkaline mineral waters or salicylate of sodium. In pruritus associated with chronic cystitis the last-named remedy is very useful.
In pruritus of a neurotic character a solution of the muriate of cocoaine of the strength of 4 per cent., sprayed upon the parts or applied with a camel's-hair brush, has often in the author's hands afforded relief when every other application has failed.
One of the latest publications relating to the treatment of pruritus vulvæ is a paper by Kustner,18 agreeing with Schroeder that the results of operative treatment for pruritus vulvæ are encouraging. This author publishes several cases resulting successfully. A synopsis of one will suffice to show his mode of treatment. A patient, unmarried, suffered for a long time from uterine catarrh and pruritus vulvæ: the former was relieved after prolonged treatment, but there still remained two symmetrical spots between the hymen and labia minora which were the seats of most troublesome itching and were exceedingly sensitive to touch. These portions of the mucous membrane were rich in sebaceous glands, and were also studded with small retention-cysts. The author dissected off the two elliptical portions of mucous membrane, each 1 cm. broad and 3 or 4 cm. long, and containing the small retention-cysts, and then united each wound with interrupted sutures. The pruritus entirely disappeared, and did not again return, though some years after the patient again suffered with uterine catarrh. Other cases are related by the same author, notably one case of pruritus where there was a lacerated perineum. The operation for repair of this perineum was performed, with the result of the permanent disappearance of the pruritus. The author does not give any definite rule as to how and in what cases he should have recourse to operative treatment, but, admitting that pruritus may arise from causes heretofore mentioned in this article, he asks whether those cases where secondary pathological changes have occurred in the vulvar mucous membrane cannot be definitely cured by excision of the affected portion. Not enough cases of cure of pruritus by surgical treatment have been reported to fully establish the theory of Kustner, yet it is a matter of sufficient importance to merit our attention and warrant further investigation.
18 Centralbl. f. Gyn., No. 12, 1885.
Hyperæsthesia of the Vulva.
DEFINITION.—This is a disorder first described by Thomas under the above caption.19 It consists of a hypersensitiveness of the nerves supplying some portion of the mucous membrane of the vulva. Sometimes the area of tenderness will be confined to one of the lesser lips or it will be limited to the vestibule, and in other cases a number of parts may be simultaneously affected. "It is a condition of the vulva closely resembling that hyperæsthetic state of the remains of the hymen which constitutes one form of vaginismus," and doubtless is often confounded with the latter.
19 Op. cit., p. 145.
ETIOLOGY.—It is more common about the time of change of life, and occurs more frequently among women of hysterical diathesis where there exists a morbid mental condition with a tendency to melancholia. In some instances the disease seems to be excited by vulvitis or vascular growths in the urethra.
SYMPTOMATOLOGY.—The slightest friction causes intense pain and nervousness, and even a current of cold air produces very great discomfort. Coition causes such severe pain that for this cause the subject usually consults her physician. As in vaginismus, the mental distress is often of an exaggerated character, in some instances bordering upon monomania.
PATHOLOGY.—In this disorder there are no indications of inflammation except occasional spots of erythematous redness. It is not a neuralgia in a true sense of the term, but an abnormal sensitiveness of diseased nerves supplying the vulva.
DIAGNOSIS.—The affections most liable to be confounded with this are vascular growths (or irritable caruncles) of the urethra and vaginismus, but ocular inspection and digital examination will enable the physician to determine the character of the disease.
TREATMENT.—This is far from satisfactory in many cases. Thomas speaks most discouragingly concerning it, and states that "the treatment of this condition is most unsatisfactory."
The author has at this time a patient with hyperæsthesia of the vulva who has been treated by him for many months, and up to the time of this writing has obtained no relief. Thomas recommends sending the patient "away from home, where, in addition to enjoying changes of air, scene, and surroundings, she would live absque marito."
In this, as in all disorders which depend on or are associated with the hysterical diathesis, galvanism and massage are, as a rule, of decided benefit. In addition, general tonics, such as arsenic, strychnia, quinia, and iron, should be prescribed. If any local affection exist, such as vulvitis or urethral vegetations, it should be cured first. Warm fomentations, the frequent use of warm water, sedative lotions, and ointments consisting of opium or its salts, carbolic acid, chloroform, and iodoform, are useful topical remedies. Much benefit may be derived by the application of a 4 per cent. solution of hydrochlorate of cocoaine by means of a spray or soft brush. Strong solutions of alum and tannin have sometimes proved beneficial.
No good results have been derived from the use of the knife or caustics in cases where they have been used.
Tumors of the Vulva.
Under this head will be included any enlargement, neoplasm, or adventitious growth which has the vulva for its site. The most common are the following, which will be considered in the order named: viz. Cysts, Hydrocele, Hernia, Hypertrophy, Elephantiasis, Hæmatoma, Cancer, and Urethral Caruncle. There are other growths of the vulva, such as fibroma, lipoma, sarcoma, lupus, etc., but they are of such rare occurrence that their discussion is necessarily omitted.
Cysts and Inflammation of the Vulvo-Vaginal Glands.
The frequent concomitance of cysts and abscesses in these glands has caused the author to consider them here under the same caption.
The most frequent cysts of the vulva are those springing either from the ducts or glands of Bartholini, or, as more commonly known, the vulvo-vaginal glands, situated near the lower part of the labia. Cysts having their origin in the ducts are single and are invariably of an oval form; such also is the more common shape of those springing from the gland, yet sometimes they are lobulated, of an irregular form, and comprise one or more in number. Inasmuch as this same locality is sometimes the site of hernia, and cysts of the labia often of a similar form, the physician should be positive that the tumor is a cyst before having recourse to any active mode of treatment.
If fluid accumulates in a cyst in such quantity as to cause the subject inconvenience or discomfort, surgical treatment will be required, of which there are three different modes in common use.
The first mode is to remove by scissors a segment of the sac, allowing escape of its contents, after which the cavity is filled with marine lint or carbolized cotton, which is allowed to remain for about forty-eight hours before renewal. By this plan of treatment the sac will usually be obliterated. Another method is to freely open the cyst and apply some caustic, preferably the galvano- or thermo-cautery. In the absence of either of the last named nitric acid may be used with good effect. The third and last method has in the author's experience proven the most efficacious, though objection has been made to it on account of its being a more bloody operation—namely, complete extirpation of the gland.
The causes of inflammation of these glands are the same as those that cause vulvitis; in truth, they are often accompanying disorders. The symptoms are pain, heat, itching, and an increased redness, particularly about the opening of the duct. If a finger be pressed over the location of the gland, it will elicit signs of pain.
| FIG. 29. |
| Abscess of Glands of Bartholini. |
In the outset of the inflammation it is felt hard and unyielding, but two or three days later a fluctuating tumor may be easily discerned. An abscess of the gland should be easily distinguished and rarely mistaken for a cyst. There are the history and ordinary signs of inflammation to aid in diagnosis. If, on the contrary, there is simply a cyst, it can be rolled about under the finger and no indications of pain produced. Further, it may exist an indefinite length of time, and unless the gland from some cause become inflamed no great inconvenience is experienced. It is not an infrequent occurrence, from some cause, for inflammation to attack a cyst-wall, in which event the symptoms of inflammation ensue. Where such is the case the treatment should be the same as in inflammation of the gland—namely, absolute rest and any soothing or anodyne lotions which favor restoration. Should indications of suppuration occur, it should be promoted by the frequent application of hot poultices. If the pain is not severe, the abscess may be left to nature; but if it be severe, then the abscess should be emptied by a free incision at the most prominent point.
Hydrocele, or Cysts of the Canal of Nuck.
DEFINITION.—An accumulation of fluid in the canal of Nuck, constituting a hydrocele or cyst, is of rare occurrence. It is to be found in the upper part of the vulva. Owing to the rarity of this affection the greatest caution should be exercised in its diagnosis. The absence of inflammatory symptoms, of resonance when percussed, and the ordinary signs of hernia, together with a gradual growth of the tumor without constitutional disturbance, would by the exclusive mode of diagnosis leave but little room for doubt as to its character. If, however, the physician still feels uncertain, the means which are used for the cure of this disorder will also aid in diagnosis—namely, aspiration with a fine needle about the size of those used on a hypodermic syringe. Even where hernia exists no harm will be done, for this is not an uncommon practice for the reduction of hernia in this locality.
TREATMENT.—Frequently nothing further is required in the way of treatment than the reduction of the tumor by aspiration. If, however, additional treatment seems to be necessary, it is best to inject tincture of iodine by reversing the action of the syringe. The use of iodine in this manner is for the purpose of obliterating the sac by inducing adhesive inflammation, as is done in the treatment of hydrocele in the male.
Pudendal Hernia.
DEFINITION.—If the process of peritoneum surrounding the round ligaments as they emerge from the inguinal canal to become lost in the dartos-like tissue of the labia is not obliterated at birth, the channel thus formed is known as the canal of Nuck, and furnishes a path for hernia. Besides a loop of intestine or portion of mesentery the ovary or bladder may descend through this canal and constitute an inguinal or labial hernia. The uterus has even been said to have descended by this route. The infrequency of pudendal hernia makes it all the more important to recognize it when it does occur, that serious injury may be avoided when operating on supposed cases of labial abscesses or cysts.
ETIOLOGY.—Pudendal hernia may be produced by blows, falls, coughing, or sneezing, and by violent muscular exertions, as in the male.
SYMPTOMS.—The presence of a part of the intestine can be diagnosticated by the peculiar crackling feeling, the impulse communicated on coughing, and sometimes the disappearance of the tumor on taxis. Occasionally reduction is very difficult, and exceptionally it may become strangulated.
TREATMENT.—The patient being placed on her back with her hips elevated, a gentle taxis will usually suffice to cause reduction. The physician should be positive that the tumor has been returned to the abdomen. After this is accomplished a truss should be adjusted so as to press on the inguinal canal. Usually a perineal band will be necessary to keep the truss sufficiently low to accomplish the purpose for which it was adjusted.
If taxis has proved inefficacious, and strangulation has occurred, a surgical operation will be necessary.
Hypertrophy of the Vulva.
Hypertrophy of the vulva occurs among certain peoples, as the Bushmen and Hottentots, so commonly as to constitute a race-peculiarity, and on account of size and form has been designated as the Hottentot apron. There is also said to be a peculiar deposit of fat in the nates of Hottentot women, but this should not be confounded with the vulvar peculiarity of the same race. Occasionally in our own country hypertrophy of one or more labia will be met with. Sometimes the nymphæ are hypertrophied, so that they hang down much lower than the greater lips; owing to this dependency and their usual pigmentation of a brownish color they bear some resemblance to elephantiasis. In simple hypertrophy the progress is gradual, and there is an entire absence of the inflammatory attacks to which a labium affected with elephantiasis is subject, nor are there any superficial abscesses as in the latter affection. Although there is usually the brown color on the surface in simple hypertrophy, the color is not the same as in elephantiasis. In the latter there is the peculiar pigmentation, also roughness and deep crevices in the skin, so closely resembling in appearance an elephant's skin that there need be no difficulty in the differential diagnosis of simple hypertrophy and elephantiasis of the vulva.
Hypertrophy of the clitoris sometimes occurs as a congenital deformity, and sometimes it is acquired. There has seemed to be quite a general belief that masturbation is one of its most common causes, but there are no substantial grounds for such belief. On the contrary, it has been frequently observed where women were known to have indulged in this habit that no increase in the size of the normal clitoris could be perceived.
TREATMENT.—If a subject of hypertrophy of the vulva suffers any degree of inconvenience therefrom, the affected parts should be removed. A surgical operation for this purpose is an exceedingly simple one and demands no special description.
An operation for the removal of an hypertrophied clitoris is more bloody than one for the removal of the labia; still, with ordinary precautions it need be neither a severe nor dangerous one. Clitoridectomy for the purpose of curing masturbation or various neurotic affections is happily not of as frequent occurrence as formerly. The author is firmly of the opinion that neither in cases of masturbation, epilepsy, nor hystero-epilepsy is the removal of the normal clitoris beneficial or even justifiable.
Elephantiasis of the Vulva.
DEFINITION.—The vulva is sometimes the site of neoplasms known as elephantiasis arabum. The labia may become so hypertrophied that they hang down to the middle of the thighs in the form of tumors; the clitoris and perineum may also be affected. The skin is generally of the peculiar brownish color of an elephant's skin, and hence the name of the disease. The surface of the skin will present many tuberosities due to hypertrophy of the cutaneous papillæ. Superficial abscesses and ulcerations often occur, causing discomfort and pain.
ETIOLOGY.—It is said that elephantiasis of the nymphæ sometimes results from onanism; it is also congenital. Scrofula, malaria, syphilis, and filth are generally considered as among the direct causes of elephantiasis arabum in the countries where it is the most common. Occasionally it is produced by a blow or contusion. Although this disease is not very common in this country, yet a sufficient number of cases have been seen from time to time to call forth a number of articles in the medical periodicals of our country.
PATHOLOGY.—The pathological changes, according to Mayer, consist in a dilatation of the lymphatic spaces and ducts with secondary formation of connective tissue and thickening of the layers of the cutis vera; sometimes the papillæ are specially enlarged, producing swellings which resemble condylomata in form. The labia majora are most frequently affected, next in frequency the clitoris; more rarely are the labia minora hypertrophied. This affection is developed during that period of life when sexual activity is the greatest.
| FIG. 30. |
| L, Right labium majus, healthy; A, upper part of pachydermatous tumor, covering a part of the mons veneris; B, lower portion of the tumor, occupying the perineum. This tumor measured from anterior to posterior margins nearly nine inches. In its widest portion it measured three inches. |
TREATMENT.—The treatment of elephantiasis of the vulva must necessarily be surgical, and therefore will be omitted here, excepting that which is embodied in the following report of cases by the author in the Detroit Review of Medicine in December, 1875, and are briefly reproduced here:
Case No. 1.—Fig. 30 shows the condition of Mrs. ——, aged thirty, the mother of several children and four months advanced in pregnancy at the time she came to my clinic. She walked with difficulty and complained of pain on the left side of the genitalia. She had been troubled with the tumor hereafter described for more than two years, and during her last pregnancy, because of its becoming larger and more painful, it proved a serious impediment to childbirth. For these reasons she wished it removed before being further advanced in pregnancy. The contiguous parts were irritated by fluid discharged from small integumentary abscesses. I removed the tumor by a surgical operation, and the patient made a perfect recovery without any return of the growth. A feature of the case observed during the operation was that an incision made in any portion of the tumor caused a serous discharge to exude, so that at all times it was possible to tell whether I was cutting beyond the diseased tissue or not.
| FIG. 31. |
| FF, Folds of anterior portion of labia majora, the remaining portion of the great lips being hidden from view; L, anterior part of the left labium minus; R. middle part of the right labium minus; M, enlarged left labium minus; N, enlarged right labium minus. A B, the light line between these letters, is designed to indicate the introitus vaginæ, but the actual opening to the canal had its anterior boundary immediately backward of the nodule seen near the letter B. The urine was voided just above the nodular point, near the letter C. The figure does not well exhibit the elongated clitoris, which was fully an inch and a half long, and could be felt in the mass like a hard cord. The tumor seemed to begin at the clitoris and the anterior portions of the labiæ minora, and as it increased in size the introitus was filled by it anteriorly. |
Case No. 2.—Miss ——, æt. twenty-two, a brunette of French parentage, came to the clinic for the purpose of having removed from the vagina a tumor of a year's growth, which she said was still rapidly growing, making it difficult and painful for her to walk or engage in any pursuit. The tumor of which she spoke is the one represented by Fig. 31. The operation for the removal of the tumor simply consisted in excising the entire mass and putting a ligature around the base of the hypertrophied clitoris. Three days after a hard-rubber vaginal dilator was inserted, and ordered to be worn most of the time until the parts were healed.
In the first case here reported there was no evidence of any syphilitic taint, but the woman lived in a markedly malarial district. In the last one there were indications of a syphilitic taint. A microscopic examination of the tumor of each case plainly showed its pachydermatous character. Both women were very dark brunettes, each having a coarse, tawny skin, and neither was over-cleanly in her habits.
An important indication relating to operative treatment in this locality is the use of the galvano- or thermo-cautery, particularly the latter, owing to the great vascularity of the parts and the lack of points upon which to exercise counter-pressure to control hemorrhage.
Hæmatoma.
DEFINITION.—Hæmatoma of the vulva is also designated as thrombus or pudendal hæmatocele. This affection consists of an effusion of blood in subcutaneous or submucous cellular tissue of the vulvo-vaginal region; the effusion occurs usually in one labium or in the cellular tissue surrounding the vaginal walls, and, later becoming coagulated, forms a tumor which may vary in size. The tumors sometimes attain the size of a foetal head.
ETIOLOGY.—Hæmatoma generally occurs during pregnancy or during labor, usually from some injury, but rarely spontaneously or in the non-pregnant. Muscular effort during childbirth, blows, kicks, falls, the passage of the foetal head, or anything which can obstruct the return of venous blood or produce rupture of the veins, may be a cause.
SYMPTOMATOLOGY.—The patient will have a feeling of discomfort, later pain of a throbbing character, and often difficult urination on account of the tumor encroaching upon the urethra. If the tumor is very large she will experience some degree of faintness.
DIAGNOSIS.—The sudden appearance of the tumor with the symptoms alluded to usually renders diagnosis an easy task. The affections which may possibly be confounded with this are abscess of the labia, inflammation or cysts of the glands of Bartholini, and pudendal hernia.
TREATMENT.—If the effusion should be small and the symptoms light, but little is demanded except quiet and cooling lotions, like the lead-and-opium wash. If there is effusion in the labia and there are indications of suppuration, it should be treated as phlegmonous inflammation by hot poultices, etc.20
20 Vide Phlegmonous Inflammation of the Labia, p. [391].
It is sometimes necessary during labor, in order to complete it, that a free incision is made in the tumor and the clot turned out with the fingers. This same treatment is often requisite when the tumor is very large and there are good reasons for believing that it will not undergo absorption. It is generally advisable to pursue the same course if a thrombus has existed for some time and there are no signs of absorption or suppuration, by reason of the continued discomfort and pain to which the patient is subject.
After the clot is removed there is often a renewal of the bleeding, in which case the cavity should be plugged with lint or surgical cotton and pressure applied by means of vaginal tampons and external bandages. Sometimes it is requisite to saturate lint or cotton with liquid persulphate of iron, and finally pack the cavity with it in order to check the bleeding. If there is no hemorrhage after the evacuation of one of these tumors, then there is no need of packing or making use of styptics, but it is necessary to prevent phlegmonous inflammation or septicæmia. For this purpose iodoform or carbolic acid should be used and a free outlet provided for the discharge of pus. Washing out the cavity with a weak solution of the permanganate of potassium21 also serves a good purpose.
21 The author usually directs that from 4 to 8 grains of this salt shall be added to each pint of warm water when it is to be used as an injection or wash.
Cancer of the Vulva.
Cancer is not a common disease of the vulva, yet as a primary affection it attacks this locality more frequently than the vagina.
Epithelioma is the most common form, and generally appears in the outset near the clitoris or on one labium as a small hard and warty growth, which at first itches and later smarts, but is not painful.
After an indefinite length of time the growth, which has increased somewhat in size, becomes painful, ulcerated, and there is more or less of an offensive ichorous discharge. If the disease pursues its natural course, the ulceration will rapidly extend until neighboring tissue becomes involved; the inguinal glands become affected, and after the characteristic cachexia becomes apparent there is no known remedy or means of treatment that can prevent the progress of the disease to a fatal termination.
If the clitoris becomes affected with this form of malignant disease, it can be detected earlier than epithelioma of any other portion of the organs of generation on account of its more external position, its greater sensitiveness, and the increasing pain which the affection and its enlargement produce.
TREATMENT.—If the disease is detected sufficiently early, an entire removal of all the affected parts, including a wide margin of healthy tissue, will generally effect a cure; but postponement until neighboring parts, more particularly the lymphatic glands, are implicated leaves little or no hope of cure through any mode of treatment. Carcinoma of the vulva is generally an extension of the same disease from the uterus or the inguinal glands, and rarely occurs as a primary affection.
Urethral Caruncle.
This painful affection, commonly included by medical authors as among diseases of the vulva, will be very briefly considered.
DEFINITION.—The most common neoplasm to which the urethra is subject is known as urethral caruncle, vascular tumor, or irritable vascular excrescence of the urethra. These growths consist of all excrescences located at the mouth of the urethra, and sometimes extending within the canal for a short distance. They are of a deep-red color, soft and friable, sometimes regular in shape, but more frequently irregular, and then resemble a small cockscomb. They vary in size from the head of a pin to a raspberry, occasionally attaining that of a walnut.
ETIOLOGY.—No definite cause can be given for the development of urethral caruncle. These growths occur among married and single, old and young.
SYMPTOMS.—The first symptom generally is that the patient experiences a severe smarting pain during or immediately after voiding urine. Pain is also caused by walking, pressure, friction, or even the slightest contact of clothing. Also sleep is frequently disturbed in consequence of slight movements of the body. Coition not only causes a severe pain, but, owing to the friable and vascular character of the growth, it often causes a flow of blood, which leads the subject to believe she has cancer or some other serious disorder. In addition to the foregoing symptoms the patient usually becomes fretful, nervous, hysterical, and melancholy. The severity of one's suffering when thus affected is very much out of proportion to the size of the growths giving rise to it.
Occasionally there will be a feeling of weight and pain in the pelvic region, extending down the thighs. There will also be a muco-purulent discharge from the urethra.
PATHOLOGY.—Urethral caruncles may be briefly defined as consisting of "dilated capillaries in connective tissue, the whole being covered with squamous epithelium."22
22 Hart and Barbour.
DIAGNOSIS.—(This has been given in part under head of Symptoms.) If there is protrusion of any portion of the caruncle the diagnosis is easy. Yet a prolapse of the urethral mucous membrane or of the urethra may be mistaken for a vascular tumor, but there will not be the characteristic pain attending either of these conditions that invariably accompanies caruncle of the urethra.
Syphilitic growths are sometimes located here, but they are wart-like and painless, and generally have companions in the same neighborhood.
By placing the patient on her back in the lithotomy position and carefully inspecting the parts a diagnosis is by no means difficult. When the growths are within the meatus slight dilatation may be requisite to see them, for which purpose a pair of ordinary dressing-forceps will usually suffice.
TREATMENT.—Owing to the liability of the recurrence of caruncles their simple removal by a cutting instrument will not, as a rule, suffice. Various modes of treatment have been recommended, but the most efficacious can be very briefly stated as follows: The patient being anæsthetized and placed on her back, the growths are then removed and their bases thoroughly cauterized by Paquelin's thermo-cautery at a dull heat; if of a large size it is a better plan to first remove them by scissors and then apply the cautery. If a thermo- or galvanic cautery is not at hand, a knitting-needle heated in the flame of a spirit-lamp will serve a good purpose.
Atresia.
Although the subject is referred to here in its regular order, yet for the greater convenience of the reader vulvar atresia has been included by the author in the preceding section on Diseases of the Vagina (see p. [373]).
Eruptions.
The skin and mucous membrane of the vulva may develop eruptions common to such tissues in other parts of the body. Those most often found are eczema, erythema, herpes, and acne. They are not distinguished from eruptions located elsewhere, except it may be their greater obstinacy in responding to treatment.