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.
[Illustration: 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.
{375} 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.
{376} 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.
{377} 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 {378}
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
{379} 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.
{380} 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]
[Footnote 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 {381} 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]
[Footnote 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 {382}
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.