CHAPTER IV.

PROLAPSE OF THE POSTERIOR VAGINAL WALL; RECTOCELE,

NEXT to the prolapse of the anterior wall, that of the posterior is the most common form of prolapse of the vagina. It is commonly called "rectocele," but this name is only used correctly if the prolapse contains the rectum, which, as a rule, is not the case. The connective tissue between the rectum and the vagina being much longer and looser than that between the bladder and the vagina, the latter slides away from the rectum, doubles up, and forms a round swelling bulging out through the vaginal entrance. By pinching this fold and by introducing a finger into the rectum we can easily satisfy ourselves that this is so. But in the course of time the anterior rectal wall, lacking its normal support in front, may become distended and form a pouch descending inside of that formed by the vagina.

Etiology. The causes are similar to those enumerated for cystocele, except the weight of the bladder, for which here is substituted constipation.

Symptoms.-The symptoms are a similar dragging sensation. Constipation, besides being a cause of rectocele, is a sequence of it, and may lead to proctitis with ulceration of the mucous membrane. When the patient lies on her back with separated knees, a globular swelling, formed by the posterior wall of the vagina, is seen protruding through the vaginal entrance--a swelling that increases in size when she bears down or stands on her feet.

Treatment. Posterior colporrhaphy consists in the denudation on the posterior wall of an elliptic surface similar to that described in treating of Cystocele, but is seldom resorted to. As a rule, the perineum and the vaginal entrance have been injured, and the operation called for is Hegar's or Emmet's colpoperineorrhaphy. (See pp. 311 and 316.)

Vaginal Prolapse and Inversion.-When the whole vagina sinks down all around, the condition is particularly called prolapse of the vagina, and if this goes so far that the whole tube is turned inside out and forms a sausage-shaped mass hanging between the thighs and surrounding the prolapsed uterus and bladder, and sometimes the rectum, it is called inversion.

The mucous membrane, exposed to the air, becomes dry and scaly, and, on the other hand, the thrown-off epithelial cells, if the parts are not kept clean, form a white, malodorous smegma in the pouch between the prolapse and the perineum, which irritates the mucous membrane and gives rise to vaginitis. This condition is connected with prolapse of the uterus, and will be considered in treating of that disease.

CHAPTER V.

INJURIES; THROMBUS OR HEMATOMA.

THE tear in the hymen produced by the first coition may cause a severe and even fatal hemorrhage. If an artery is found spurting, it must be tied. In other cases an application of, or injection with, liquor ferri will suffice to check the hemorrhage (pp. 170 and 172). In order to prevent its recurrence the tear should be given time to heal, and some vaseline applied before intercourse until the vaginal entrance is dilated.

Much more serious are the tears in the vagina that occur under similar circumstances. The wall has been found torn from the vaginal entrance to the fornix. Tears are also occasionally produced during coition with women who have had frequent intercourse or even borne children, but then there is a strong suspicion, sometimes corroborated by confession, that some hard object has been introduced simultaneously with the penis. Such a tear may also be caused by coition with old women where senile atrophy has taken place, or with women afflicted with stenosis or atresia of the vagina or double vagina. Transverse tears of the fornix have occurred during coition. after the operation for lacerated perineum. In such cases it is probably due to the shortening of the posterior wall. Sometimes the lesion is due to unusual postures during the act.

During childbirth the vagina is quite frequently torn. In most cases the lesion extends only through the thickness of the mucous membrane, and is then of little importance, but it may penetrate through the whole thickness of the wall into the surrounding connective tissue. In regard to these lesions the reader is referred to works on obstetrics.

The vagina may also be injured by falls on a pointed object, by attacks of horned animals, etc., or by obstetrical and surgical operations, especially the extraction of the child by means of the forceps, the replacement of an inverted uterus, or the removal of a large uterine fibroid. Even a fall with the abdomen against the sharp edges of a step on a staircase has indirectly caused a tear of the mucous membrane of the vagina.1

Symptoms.-These tears are, of course, accompanied by considerable pain. They may cause severe hemorrhage. Sometimes the intestine prolapses and may become gangrenous, leaving an ileo-vaginal fistula. There may also remain an opening into the peritoneal cavity, through which the intestine can slip out and be brought back. All Centralbl. für Gynäk., 1892, No. 31, xvi. p. 614.

the symptoms of septicemia may be developed. A permanent rectoor vesico-vaginal fistula may remain.

Prognosis. With proper surgical help the prospects are good.

Treatment. The vagina is cleaned of clots, spurting arteries tied with catgut, the edges of the wound united with sutures, and a few pledgets of iodoform gauze placed over the wound. These are renewed about every three days.

Thrombus or hematoma is a swelling formed by the extravasation of blood under the mucous membrane. It is nearly always due to childbirth, and the reader is, therefore, referred to works on obstetrics for information concerning it.

CHAPTER VI.

FOREIGN BODIES.

Most com

FOREIGN BODIES are by no means rare in the vagina. monly they are objects used by the patient herself in masturbating or as preventives of conception. Sometimes they have been placed there for therapeutic purposes by a physician or a midwife. In rare cases their introduction is due to brutal jokes or acts of vengeance.

The most diverse objects, such as pessaries, sponges, hairpins, sticks, needle-cases, snuff-boxes, glasses, pomade-jars, bottles, etc., have been introduced and remained for months or years in the vagina. Intestinal worms and insects have found their way to the same place. Symptoms. According to their size, shape, and length of sojourn foreign bodies may give rise to a great variety of symptoms. The patient complains of pain in the pelvis, the hypogastric and the lumbar regions, or shooting down along the inside of the thighs. A purulent and offensive discharge, dysuria, dyschezia, and dyspareunia are developed. The presence of the foreign body may cause ulceration; gangrene; fistulous communications between the vagina and the urethra, the bladder, or the rectum; peritonitis; and pelvic abscess.

Diagnosis. Often the patient has forgotten the origin of her trouble or is restrained by shame from telling it. Besides a vaginal examination with finger and speculum, often the examination through the rectum or with catheter or finger in the bladder may be of great help in arriving at a diagnosis. The object may change much in shape by the deposit of calcareous matter around it. It may become entirely hidden from view by burrowing into the tissues, which close over it, or migrate into the abdominal cavity. A sponge giving rise to hemorrhage and a foul discharge has more than once been taken for a carcinomatous cervix.

Treatment. The treatment consists in the removal of the foreign

body and in combating the inflammation and other disorders caused by its presence. While the first indication in most cases is simple enough to fulfil, in others all the ingenuity of a surgical mind and the resources of a good armamentarium are required. As a rule, the object can be removed through the vulva, but in exceptional cases it has been found advantageous to withdraw it through the rectum or the bladder. Lengthy objects occupying a transverse position must be seized near one of the ends. Large objects must sometimes be broken with shears or lithotriptic instruments. Considerable help is often afforded by introducing a finger into the rectum and hooking it over the body from above. In regard to hairpins, it must be remembered that they almost invariably are introduced with the ends pointing downward to the vulva, which ends must be freed before the pin can be extracted. Sometimes an incision must be made to reach the body. If the vagina contains pieces of broken glass with sharp edges, the walls should be lubricated and plaster of Paris poured in, which will settle around the pieces and form one mass with them that may be withdrawn without cutting the vagina.'

The second indication will in most cases be met by using antiseptic and astringent vaginal injections. Sometimes a consecutive endometritis calls for treatment, and in rare cases fistula operations, or even laparotomy, may be required.

CHAPTER VII.

VAGINITIS.

VAGINITIS is the word commonly used in America to designate inflammation of the vagina, but as the suffix -itis is of Greek origin and vagina Latin, exception has been taken to it. German authors have substituted the term colpitis, and English sometimes use elytritis.

Under the term "vaginitis" are comprised so very different conditions that it is necessary to admit certain divisions and subdivisions of the subject, which is done in many different ways by different authors choosing different standpoints.

Thus we distinguish between acute and chronic vaginitis, the difference being not only limited to the time the disease lasts, but also to the greater and lesser intensity of the symptoms. The acute form commonly ends in less than a month; the chronic has no definite limit.

A vaginitis is called primary when it appears first in the vagina; secondary if the inflammation invades this organ from another part

1 R. J. Levis of Philadelphia.

of the body, especially the vulva, the uterus, the rectum, or the urethra.

In regard to the chief feature of the disease we distinguish between catarrhal vaginitis, characterized by a discharge from the mucous membrane; exudative vaginitis, in which a solid inflammatory exudation takes place either on the surface of the mucous membrane (croupous vaginitis) or in the depth of the same (diphtheritic vaginitis); and phlegmonous vaginitis, also called dissecting vaginitis or perivaginitis, in which the inflammation has its seat in the connective tissue surrounding the vagina, and leads to the severance and expulsion of the whole tube.

As subdivisions we unite under the term "catarrhal" the following forms of vaginitis: 1, the granular (also called follicular, or glandular); 2, the simple; 3, the adhesive; 4, the gonorrheal; 5, the exfoli ative; and 6, the emphysematous vaginitis. To the diphtheritic vaginitis belongs the dysenteric.

A. Catarrhal Vaginitis.-Pathological Anatomy.-In granular vaginitis the epithelium as a whole becomes thicker, the papillæ become larger, and circumscribed groups of small round cells are formed under them and send proliferations into them. When the papillæ increase in length and width, the epithelial cover immediately over them, and the tongues it sends in between them become thinner; at the same time the blood-vessels are much developed. These cellgroups and the swollen papillæ on their top form on the surface of the vagina circular prominences as large as lentils.

In simple catarrhal vaginitis a similar process takes place on a smaller scale, so that the cell-groups and the swollen papillæ remain under the level of the epithelium. In the chronic form pigment is imbedded in the deeper cells of the epithelium.

The adhesive form is especially found in old women, but clinically a similar condition is also observed in young children. The vagina is spotted or striped, being the seat of ecchymoses and superficial ulcerations, and there is great tendency to coalescence between the surfaces lying in contact with one another. The microscope reveals similar cell-groups under the surface as in the two other forms, but here the whole epithelial layer is lost over the infiltrated spots.

In the discharge is commonly found an infusorial animalcule called Trichomonas vaginalis. Even in the secretion of the normal vulvovaginal tract in children there are found epithelial cells, in some quite a number of pus-cells, numerous bacteria, cocci, diplococci, bacilli, and spirilla, but never the gonococcus of Neisser, which is pathognomonic of gonorrhea. It is a diplococcus found in the interior of the epithelial cells and of pus-corpuscles, and is characterized by becoming decolorized by Gram's method,'

1 1 Gram's Method.-The cover-glass smeared with the substance to be examined is