DISEASES OF THE VAGINA.
=Inflammation of the Vagina.=--Acute inflammation of the vagina is not
a very common affection. Primary inflammation confined to the vagina
alone is unusual. The disease in most cases is secondary to vulvitis,
urethritis, or endo-cervicitis. The causes of vulvitis (which have
already been considered) are also the causes of vaginitis. It is of
importance to remember that the disease may occur in children as a
result of the same factors which produce vulvitis.
The exanthemata, as measles and scarlet fever, may cause vaginitis as
part of the general involvement of the skin and mucous membrane which
occurs in these diseases. The most usual cause is gonorrhea.
Several varieties of acute vaginitis may be recognized--the simple, the
granular, the senile, and the emphysematous. It is unusual to find the
entire surface of the vagina involved. The disease is confined to areas
or patches separated by healthy tissue.
In _simple vaginitis_ the inflamed membrane remains smooth.
In _granular vaginitis_, which is the variety usually seen, the papillæ
are infiltrated with small cells, and are much enlarged, so that the
inflamed surface has a granular appearance.
_Senile vaginitis_ is due to infection of portions of the vaginal
mucous membrane that have lost their epithelium as a result of the
atrophic changes of old age. This disease occurs in patches of various
size, sometimes presenting the character of ecchymosis; in other
cases the patches have altogether lost the epithelium, and permanent
adhesions may take place between areas which are brought in contact.
This form of vaginitis has also been called adhesive vaginitis. It is
said that a similar condition may occur in children.
The _emphysematous_ form of vaginitis occurs in pregnancy. The vaginal
walls are swollen and crepitating. The gas is contained in the meshes
of the connective tissue.
Acute vaginitis is accompanied by dull pain and a sense of fulness
in the pelvis. The discomfort is increased by standing, walking,
defecation, and urination. There is a free discharge of serum or pus,
which may be tinged with blood. The character of the discharge depends
upon the variety and the period of the disease. Inspection, which can
best be made through the Sims speculum, with the woman in the Sims or
knee-chest position, shows the characteristic lesions of inflammation
of the mucous membrane.
Acute vaginitis, if neglected, may pass into the chronic form. It
usually lingers in the upper part of the vagina, in the fornices,
especially in vaginitis of gonorrheal origin. By careful inspection we
find here one or more granular patches of inflammation, which cause
a vaginal discharge from which man may be infected, and from which
infection of the upper portion of the genital tract, the uterus, and
the Fallopian tubes may be derived.
_Treatment._--Vaginitis, especially of the gonorrheal form, should be
treated vigorously, and treatment should be continued until all traces
of inflammation have disappeared. Inflammation of any part of the lower
portion of the genital tract may have the most disastrous consequences
if it extends to the uterus and the Fallopian tubes.
The woman should be kept as quiet as possible. The bowels should be
moved freely with saline purgatives. She should take, three times in
twenty-four hours, lying upon her back, a vaginal douche of one gallon
of a boracic-acid solution (ʒj to the pint). The temperature of the
solution should be about 110° F.
If the disease be of gonorrheal origin, a warm bichloride solution
(1:5000) should be used in the same way.
After the acute symptoms have subsided local applications should be
made, in addition to the douches. The woman should be placed in the
knee-chest position, and the vagina should be thoroughly exposed with
the Sims speculum. If necessary, the vaginal surface should be gently
cleaned with warm water and cotton. A 4 per cent. solution of cocaine
may be applied to the vagina if there is much pain. Then the entire
vaginal surface should be painted with a solution of bichloride of
mercury (1:1000). These applications should be made daily until the
disease is cured. The vaginal douches should be continued at the same
time.
In the chronic form of the disease and in senile vaginitis the local
patches of inflammation should be painted once a day with a solution of
nitrate of silver, 5 to 10 per cent., or stronger if the condition does
not yield. The senile form of vaginitis, being dependent upon a general
condition, is often impossible to cure. We can sometimes relieve the
discomfort by applying boracic-acid ointment (ʒj to ℥j) to the vagina.
The application of pure carbolic acid to the inflamed patches sometimes
does good.
Urethritis usually accompanies a gonorrheal vaginitis, and demands
coincident treatment.
=Tumors of the Vagina.=--_Vaginal Cysts._--Well-defined cysts are
sometimes found in the vaginal walls. They occur at all ages from
childhood to old age.
Vaginal cysts are usually single. They vary in size from that of a pea
to that of a fetal head. The vaginal mucous membrane covers the free
surface of the cyst, and may either be movable over it or may be much
attenuated and closely incorporated with the cyst-wall. Vaginal cysts
may be sessile or more or less pedunculated. The internal surface of
the cyst is usually covered with cylindrical epithelium, which is
sometimes ciliated. The contents vary in consistency and color. They
are often viscid, transparent, and of a pale yellow tint. They may
contain pus or altered blood.
The origin of vaginal cysts has been much disputed. It is probable
that they arise from the remains of the Wolffian canal--the canal of
Gärtner. In the embryo the transverse or longitudinal tubule of the
parovarium extends to the side of the uterus and thence down the side
of the vagina to the urethral orifice. It persists in this condition in
some of the lower animals--the sow and the cow--and may also persist as
a closed tube in woman. In such cases it may become distended and form
the vaginal cyst.
The _treatment_ of vaginal cyst is removal. If the tumor be situated
near the vulva, it may be extirpated by careful dissection. If this
operation be deemed impracticable, partial excision of the cyst should
be practised. The tumor should be seized with a tenaculum, opened by
the scissors, and part of the wall, with the overlying mucous membrane,
should be excised. The interior of the cyst should then be packed with
gauze.
_Fibroid Tumors of the Vagina._--Fibroid tumors sometimes occur in the
vagina. They are usually found in the upper part of the anterior wall.
They are sometimes adherent to the urethra. They are usually of small
size, but may attain a diameter of six inches. The treatment of such
tumors is removal.
Cancer and sarcoma may attack the vagina, though these diseases as
primary conditions are very rare. When possible, complete removal
should be done.
=Atresia of the Vagina.=--Severe puerperal infection or mechanical
injury, followed by extensive destruction of the tissues of the vagina,
may result in a cicatricial narrowing or complete closure or atresia of
the vaginal canal.
The _symptoms_ of this condition are due to retention of the uterine
discharges. There is no discharge of menstrual blood from the vagina.
Attacks of pain occur periodically at the menstrual periods. A cystic
tumor, which may be felt by rectal examination, is present. The tumor
consists of the distended portion of the vaginal canal (hematocolpos),
and sometimes of the distended cervical canal and body of the uterus.
The contents of the hematocolpos are usually sterile, although they may
become purulent (pyocolpos).
The _diagnosis_ is readily made by vaginal and rectal examination.
_Treatment_ consists in incision and excision of the vaginal septum
and the suture of the vaginal mucous membrane above to that below
the obstruction. In very severe cases it is difficult to maintain
the patulous condition of the vaginal canal on account of subsequent
cicatricial contraction. In such cases the repeated passage of vaginal
bougies or the transplantation of mucous membrane has been resorted to.
=Vaginismus.=--The term “vaginismus” has been applied to a condition
characterized by a spasmodic contraction of the muscles which close the
vaginal orifice. The muscular spasm occurs reflexly when penetration
of the vagina is attempted, as at coitus or a digital examination. The
condition is due to dread of pain, and is usually the result of some
painful local lesion, such as a urethral caruncle, fissures or sores
of the vulva or anus, etc.; or it may be due to some painful condition
of the tubes and ovaries. Similar contraction is observed in the
sphincters of the anus when there is present a painful anal lesion.
Vaginismus has been said to occur in neurotic and hysteric women in
whom there was no discoverable local lesion.
_Treatment_ consists in the removal of any local cause of pain or
irritation.
If the reflex spasm of the muscles persists when coitus is attempted,
notwithstanding the removal or the absence of any discoverable local
cause, operative measures have been advised.
Under anesthesia the vaginal entrance has been stretched by means of
large dilators or the fingers, or the fibers of the sphincter vaginæ
have been cut on each side of the fourchette and a glass or vulcanite
tube of suitable size has then been placed in the vagina and retained
for two or three weeks by a perineal pad and T-bandage.
Vaginismus is a very rare condition. Operative treatment, except
that which may be required for the removal of some local cause of
irritation, is rarely, if ever, necessary.
=Coccygodynia.=--Coccygodynia is a rare affection characterized by
pain in the coccyx and surrounding structures. The pain is caused by
pressure, as in sitting, or by any movement involving the muscles
attached to the coccyx. The disease is usually caused by traumatism,
and in most cases is due to injuries to the coccyx in labor, as a
result of which the bone is fractured or dislocated, and becomes fixed
in an abnormal position. Sometimes osteitis or necrosis develops. In
the unusual cases, in which no structural changes are detected, the
condition may be due to rheumatism. Coccygodynia is very rarely found
in men.
The _diagnosis_ may be made by introducing the index finger in the
rectum and palpating the anterior and lateral surfaces of the coccyx,
and by moving the bone between the finger in the rectum and the
thumb placed in the crease of the nates. The mobility, deformity,
and tenderness may be readily determined. If a local lesion is
found, and the symptoms have not yielded within a reasonable time to
expectant treatment, removal of the coccyx by operation is indicated.
The coccyx is exposed by a median incision, the bone is separated
from its muscular and tendinous attachments, and is removed at
the sacrococcygeal articulation with scalpel or scissors. If the
articulation is ankylosed, it may be necessary to use the chain-saw.
The wound is drained with a few strands of silkworm-gut and closed with
interrupted sutures.
Operation should not be advised hastily. The painful symptoms are not
always relieved by it. Operation should not be performed unless bony
deformity or other distinct lesion is found.