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DISEASES OF THE VAGINA.

Inflammation of the Vagina (Kolpitis or Vaginitis).

THE most frequent cause of vaginitis is gonorrhoea. This produces almost always the very acute form of the disease in which we find the vagina vividly inflamed, swollen, very painful, with a copious purulent discharge upon its surface. On the introduction of the speculum bleeding is produced. Apart from gonorrhoea, such acute states only arise from the presence of foreign bodies in the vagina (pessaries, neglected tampons, sponges, worms, and the like), from the use of too hot and too long continued injections despite the increasing tenderness, from sanious discharge in the later stages of cancer, and from the use of strong caustics. The chronic forms, which are by far the most common, are met with from defective vaginal closure and from increased uterine secretion, which brings on a rapid epithelial desquamation. The vaginal discharge has a peculiar creamy appearance. The anatomical condition in this chronic form, according to C. Ruge, consists of scattered smallcelled infiltration of the papilla which have cast off their epithelium down to the deepest layers (kolpitis granularis). At the menopause the so-called kolpitis senilis often comes on, in which the papillæ throw off their epithelium completely, and thus adhesions are produced in the vagina (vaginitis ulcerosa adhesiva). Both forms are recognised by the spotted dark redness of the vaginal mucous membrane. The senile kolpitis, in addition to causing a free purulent discharge, produces severe burning pains and

itching. Diphtheritic, or croupous, kolpitis is seen in infectious diseases with gangrene of the vulva.

Treatment. Since the various forms of kolpitis are either of infectious origin or owe their long existence to the influence of micro-organisms present in the vagina, they should be attacked by antiseptic means. The most useful solutions in the acute gonorrhoeal form are 1 per cent of lysol, or 1 in 1000 of corrosive sublimate used once a day as vaginal douches. After careful drying of the vagina with lint on a holder through a speculum in order to prevent poisoning, a strip of iodoform gauze is introduced and left in the vagina. When the patient cannot come so often to see the doctor, washing out with 1 per cent zinc chloride solution at 37° C. (98.6° F.) must be ordered twice a day. In the manifold gonorrhoeal vulvo-vaginitis of little children the author has seen the best results from the injection of a 10-20 per cent solution of silver nitrate two or three times a week by means of Braun's syringe, followed by a 3 per cent solution of common salt to neutralise it. In the chronic forms, dilute acetic acid is the surest and quickest agent. This is poured into the vagina through a Fergusson's speculum two or three times a week, after douching with solutions of 1 per cent lysol or 1 in 1000 corrosive sublimate, and by gradual withdrawal of the speculum it is brought into contact with the walls of the vagina on every side. The lowest segment of the vagina is then mopped with lint squeezed out of the acetic acid. The residue of the acetic acid is removed by repeated douches of simple water or of 1 per cent solution of lysol. From a consideration of the etiology, it is seen that the discharge, which comes from above and runs downwards, must be tackled at its source. General treatment has also its rôle. In chlorosis, the discharge which is so much complained of can usually be stopped by giving iron. In this way the local examination of virgins may be avoided. The latter should never be resorted to unless absolutely necessary. Other indications for the treatment of vaginitis are plainly evident when the etiology is carefully considered.

Swellings and Tumours of the Vagina.

Herniæ, hæmatomata, and cysts have been already mentioned (see p. 62).

A multiple formation during pregnancy of little cysts filled with gas has been described by Winckel as kolpo-hyperplasia cystica. Their contents, according to Zweifel, consist of trimethylamine, which is also present in the vaginal secretion of pregnant women, and he says that they are derived from dilated vaginal glands. Treatment is unnecessary. Pointed condylomata are found in the vagina, even as high as the portio vaginalis, but they do not form such large growths as those outside the vagina.

Of true tumours, arising primarily from the vagina, we may mention fibroma, carcinoma, and sarcoma.

The treatment consists in total removal, wherever possible, with wide cutting into healthy tissue and filling in of the gap by plastic operations.

Vesico-vaginal and other Fistula of the Genitals.

These arise most commonly from long-continued pressure of the foetal head in labour, and less frequently from extraction with forceps. Still less frequently they may arise from operative methods, by which the vesicocervical or vesico-vaginal wall is cut through, such as turning and perforation. They may also arise from vesical calculus and ulceration, and from the use of pessaries.

The commonest form is the vesico-vaginal fistula; if it involves the anterior cervical lip then one speaks of deep or superficial vesico-utero-vaginal fistula. If the opening lies above the intact os uteri, then it is termed a cervicovesical fistula. In addition we find urethro-vaginal and uretero-vaginal as well as uretero-uterine fistulæ. The

uretero-vaginal fistulæ arise now and then in connection with vaginal total extirpation of the uterus.

Fistulæ vary very much in size. They can be as small as a pin's head or as large as the palm of the hand.

The symptoms of fistulæ come on (when the latter is not due to direct laceration) a few days after the confinement. In urethro-vaginal fistula the urine is retained and cannot be passed in the usual stream, but runs out of the vagina. In vesico-vaginal fistula the urine dribbles out of the vagina continuously and involuntarily. If the catheter be used the bladder is found empty. This is the case also with the various vesico-uterine fistulæ.

In the uretero-genital fistulæ, on the other hand, the patient passes water from time to time voluntarily; on passing the catheter, urine is found in the bladder, but urine also dribbles away continuously from the vagina. The continuous wetting with urine of the vagina and the parts around the external genitals produces intense inflammation and eczema. As a result of urinary decomposition the patient gives off a urinous odour. The disease invalids the patient and renders her incapable of getting about.

The diagnosis is at once known from the patient's account, and the only difficulty is to discover the site of the fistula when this is small and surrounded by cicatricial tissue.

Larger fistulæ are to be made out with the catheter and finger, whilst the smaller ones are sought out by the aid of Sims' speculum and the use of a small sharp hook to draw the parts asunder. If the fistula cannot be found, then milk is injected into the bladder, and this trickles out of the mouth of the fistula, or in vesicocervical fistulæ from the os uteri. It is only in cases of uretero-vaginal fistula that the injected milk remains in the bladder.

The prognosis of fistula has become a good one, owing to the improvement in treatment. Only in a few specially complicated cases is the direct closure of the fistula

impossible. Many fistulæ, the cervico-vesical fistulæ specially, heal spontaneously under the use of caustics.

Treatment. In small and recent fistulæ an attempt to cure with caustics should be made. For this a selfretaining catheter must be used to allow the urine to run off continually. If these attempts fail, or the fistula is large then the edges of the fistula must be vivified freely with the knife and united with sutures. The elements necessary for success are accessibility of the fistula, sufficient freshening of its edges, exact suture, and careful antisepsis. As a result of a correct estimation of the value of the first three points, Sims and Simon had great success, even before the antiseptic period.

For exposing the fistula to free view the most varied postures have been invented, as the side position, the knee, elbow, and the elevated lithotomy positions. The last suffices for most of the cases. By means of Simon's specula the fistula is brought into view, and the operator uses a sharp hook or volsella to spread out the region of the fistula. When the fistula is surrounded by scar tissue a long preparatory course is necessary, by which the cicatricial bands are partly cut through and partly stretched with hard rubber cylinders or balls (after Bozemann). Any vesical catarrh must be removed before operation by preparatory treatment, including injections into the bladder. The freshened surface has generally an oval shape, and lies transversely with the fistula in its middle. The margin of the wound, which is marked out previously with the knife, lies about 1-2 cm. ( to inch) from the edges of the fistula. From the marked-out wound margin a tenotomy knife, of which there must be several with blades at different angles, is pushed through deeply into the fistula, but just missing the vesical mucous

2

1 [The retained catheter may, of itself, induce healing in a recent fistula. When this treatment is adopted two catheters must be used (preferably the short bulbous-ended catheter of Skene), and the instrument must be changed every night and morning. Many surgeons always use Skene's catheter for two weeks after operation.-J. W. T.]

2 This applies to vaginal contraction preventing accessibility.

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