and bladder, I am obliged to say that my experience has not yet been
sufficient to enable me to speak definitely. Rapid and free dilatation
is not sufficient to effect a cure; at least it has failed in one case.
Division of the stricture by incision suggests itself, but I am
confident that that operation would be unsatisfactory, because of the
great irritation which always occurs when there is a solution of
continuity at this point. My practice, therefore, has been to produce
slow and gradual dilatation by the use of graduated sounds, and the
application of oleate of mercury or iodine to the anterior vaginal wall
at the site of the stricture. More extended observation may develop
other and better methods of treatment, but for the present that is all
that I have to offer on this subject.
{367}
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.
Savage[1] 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]
[Footnote 1: _Anatomy of the Female Pelvic Organs_, London, 1870.]
[Footnote 2: Thomas on _Diseases of Women_, Philada., 1880.]
Anatomists have differed regarding the existence of muciparous glands
{368} 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 {369} 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, {370} 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.
[Footnote 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.
[Footnote 4: Thomas on _Diseases of Women_, 5th ed., p. 219.]
Simple acute vaginitis frequently causes and remains associated with
{371} 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]
[Footnote 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 {372} 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 {373} 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 {374} 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.