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.
{383} In a recent work Kustner[8] 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.
[Footnote 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 {384} 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.
[Footnote 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]
[Footnote 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]
[Footnote 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]
[Footnote 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;
{385} 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.
Sinéty[13] 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." Emmet[14] 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. Thomas[15] says that
it is curious to perceive how, from different standpoints regarding the
pathology, "both parties were led to the same surgical resource."
[Footnote 13: _Manuel pratique de Gynécologie_, par L. de Sinéty,
Paris, 1879.]
[Footnote 14: _Op. cit._, p. 607.]
[Footnote 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 {386} 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 {387}
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.
[Illustration: 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]
[Footnote 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 {388} 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.
{389} 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.