Chapter XIII, Etiology of Prolapse, page 223) being dislocated (Part 2)

with a tear in the median line. By the former we assume that the levator ani is injured and by the latter the transverse perineal septum. Often both sulci are affected and there is also a tear in the median line below. Too much can not be said of the importance of making an exact diag- nosis of the situation of the tear in every case of rupture of the pelvic floor, for in this way only can repair be intelligently carried out. (2) Injuries due to coitus are not frequent. Sometimes the first FOREIGN BODIES IN THE VAGINA 377 coitus causes a laceration of the hymen which extends to the vagina and there may be serious hemorrhage. Rape has caused severe and fatal injury of the vagina in children and also in women. In willing coitus whenever there is a large penis and a small vagina injury may occur if force is used. (3) Injuries due to unskillful instrumentation are not very un- common. The violence is done sometimes by the patient intro- ducing sharp instruments into the vagina in an effort to produce abortion, and at others by the ignorant abortionist, also the un- skillful use of the obstetric forceps or other instruments may cause laceration, often of serious import. (4) Falls on sharp bodies, such as the picket of a fence or the handle of a pitchfork, have produced extensive and even fatal in- juries. Hematoma of the vagina is a rare condition. It occurs both as a result of trauma and following labor, the latter being by far the more frequent cause. There is a collection of blood just under the mucous membrane and the tumor is dark in color and fluctuates. FOREIGN BODIES IN THE VAGINA Little girls may introduce foreign bodies in the vagina, just as in the other accessible cavities of the body, from a spirit of inquisi- tiveness. Thus pebbles, seeds, fruit-stones, pencils, hairpins, and other objects have been removed from the vaginae of little girls. Older girls and women, especially the sexually perverted, have introduced the ends of candles, pencils, and other things for pur- poses of masturbation. Spools, rubber balls, sponges, pieces of cotton, and many other substances have been taken from vaginae in which they had been placed in the hope of preventing conception. The vagina has served as a repository for smuggled and stolen property, such as jewelry, gems, and banknotes, and, in the case of the feeble-minded, a legion of strange articles have been secreted there. The foreign body most often found in the vagina is a neg- lected or forgotten pessary. As is well known, a hard-rubber pessary becomes incrusted with lime salts as soon as its polish is gone. The roughened surface chafes the mucous membrane until it ulcerates. Soft-rubber pessaries irritate the vagina more than the 378 DISEASES OF THE VAGINA hard-rubber variety, as a rule, but not being so firm do not cut so far into the tissues. Pessaries have been retained for a long series of years in reported cases, and sometimes with resulting stenosis of the vagina. Sometimes a vesico-vaginal or a recto- vaginal fistula is caused in this way. Pin worms and round worms may inhabit the vagina. There is a foul discharge from the vagina if ulceration is present. The diagnosis of a foreign body is an easy matter when digital and speculum examination are made, attention having been attracted by the vaginal discharge. Gas in the Vagina (Garrulity of the Vagina.) — An accumulation of gas in the vagina that is expelled with a noise on straining or moving the body quickly from one position to another is a not very rare condition. Every gynecologist of experience has seen many cases. In the past it has been thought that such a condition was due ex- clusively to injuries to the pelvic floor, so that in certain positions of the body, as on the side, air entered, to be expelled later when the woman assumed the upright position. Although such a cause may be operative in some cases, the recent investigations of Klein- wachter, Taussig, and Veit ("Handbuch cler Gynakologie," zweite AufL, Bd. Ill, page 201) go to prove that the accumulation of gas in the vagina, a condition most often found in the puerperium, is due to a gas-forming bacterium. The disease is thought to be allied to vaginitis emphysematosa (see page 364) and has been classed by Veit as among the inflammations of the vagina. When the disease is due to injury of the pelvic floor with subin- volution coupled with weakening of the abdominal walls, the diag- nosis is not so difficult. If these conditions do not obtain, and it is due to a gas-forming organism, drying the vagina and packing it with dry tampons on which boric acid powder has been dusted will kill the organism and thus confirm the diagnosis. We must rule out recto-vaginal fistula) in these cases, for gas in the vagina may come from the rectum. VAGINISMUS Vaginismus may be regarded as a symptom rather than a disease. It consists of a hyperesthetic condition of the orifice of the vagina and is characterized by spasmodic and painful contractions of the levator ani and constrictor vagina} muscles. Sometimes the irri- NEW GROWTHS OF THE VAGINA 379 tability extends to the muscles of the thighs or other sets of muscles in the neighborhood of the vulva. Vaginismus is a rare condition found, as a rule, in young, neurotic women and in the newly married. It may occur, however, in women who have borne children. It may be dependent on a local lesion, such as urethral caruncle or inflammation of the vulva. Masturbation, by overstimulation of the sexual organs, causes vaginismus in some instances. Ineffectual attempts at coitus pro- duce in time erosions at the introitus and nervous excitability and dread of pain. A large penis and a small vagina may cause tonic spasms of the muscles of the pelvic floor. Cases are on record where the penis has become imprisoned in the vagina by vaginismus so that it was necessary to administer an anesthetic to the woman before the couple could be separated. The vagina may be very sensitive, so that the slightest touch or even taking a douche causes contraction of the muscles, and a vaginal examination is impossible without an anesthetic, or it may be caused only by violent inter- course. The nervous system suffers when vaginismus has existed for any length of time and various nervous stigmata may be present. A vaginal examination will determine the cause of the condition. If necessary a second examination with an anesthetic must be made. Vaginismus is one of the causes of dyspareunia, — painful coitus. (See Chapter X., page 146.) NEW GROWTHS OF THE VAGINA The new growths of the vagina are: (1) cysts, (2) myomata, (3) sarcomata, (4) carcinomata. (i) Cysts. — Cysts of the vagina are the most frequent of the tumors found in this organ. As a rule, they are between the size of a pea and an English walnut, are single, and found on the anterior rather than on the posterior wall. Very large cysts may develop in exceptional instances, and in such cases the cyst develops in the broad ligament; very rarely a series of cysts is found. A cyst of the vagina appears as a bluish-white, rounded eminence in the pink mucous membrane of the vagina. It is elastic to the feel. If the cyst is situated superficially it projects more into the lumen of the vagina and is of a darker color because of its thin walls ; if it 380 DISEASES OF THE VAGINA is situated deep in the vaginal wall it projects less prominently and is not so dark in color. Cysts of the vagina are due to (a) inclusions of epithelial tissue during operations for the repair of lacerations of the perineum, or during spontaneous healing of such injuries; (b) vaginal gland tissue, and (c) the remains of embryonic structures, such as Gartner's and Mid- ler's ducts. The inclusion cysts are generally found in the neighborhood of the perineum, in the posterior wall, low down. These are small, spherical in shape, have as contents mucus made turbid by desquamated epithelium, and are lined with a layer of stratified squamous epithelium. Not much is known about the cysts which arise from vaginal gland tissue. They are infrequent as compared with the other two varieties, however. Cysts originat- ing in persistent Gartner's ducts are comparatively frequent, and are situ- ated in the lateral or anterior walls of the vagina. These cysts are more apt to be cylindrical in shape than per- fectly globular, corresponding in their long axis to the axis of the duct, are filled with a clear straw-colored fluid, and are lined with cylindrical epithelium. A persistent Miiller's duct has been referred to in the chapter on anomalies. A blind end of a misplaced ureter has been known to form a cyst of the vagina. The diagnosis offers little difficulty. Cystocele, urethrocele, and rectocele must be ruled out, also other tumors of the vagina. An arjerio-venous aneurism has been mistaken for a cyst of the vagina, also vaginal hernia, or collection of blood in a double vagina. A sound in the urethra or bladder will assist in excluding urethrocele and cystocele, and a finger in the rectum, rectocele. A cystocele or rectocele should increase in density on straining, whereas a cyst does not. A vaginal hernia should transmit an impulse on coughing and has a characteristic doughy feel. It dis- Fig. 153. — Inclusion Cyst of Vagina Occurring Three Years after Repair of a Peri- neal Tear. (Cullen.) NEW GROWTHS OF THE VAGINA 381 appears when the patient is placed in the knee-chest position. An aneurism should have a thrill. The characteristics of double vagina have been described in the section on anomalies. Echinococcus cysts of the vagina are very rare and are generally due to echinococcus colonies in the mesometrium burrowing in the recto- vaginal septum. (2) Myomata. — Myomata or fi- broids of the vagina are rare. Some seventy authentic cases have been reported in the literature, being found in most cases in women be- tween forty and fifty years of age. They occur as small, spherical, hard, nodular tumors, seldom over two inches in diameter, projecting from the vaginal wall into its lumen. They are usually single, but may be multiple and are not associated with fibroids of the uterus, although a case where both existed in the same patient has been reported by Fabri- cius (Zentralblatt fur Gyndkologie, 1908, No. 36, 1191) and another by Kelly and Cullen ("Myomata of the Uterus,' ' page 440). The tumor is sessile and has a fibrous capsule of its own separating it from the surrounding tissues. The etiology of these tumors, just as in the case of fibroids of the uterus, is unknown. They are apt to be the seat of edematous degeneration. The diagnosis is generally easy, the fluctuating character of a vaginal cyst serving to distinguish it from a myoma, and in the case of sarcoma and carcinoma the mucous membrane covering the tumor is involved, whereas in myoma it is not. The hard character of the tumor serves to distinguish it from cystocele, rec- tocele, or hernia. (3) Sarcomata. — Sarcoma of the vagina is of two sorts, (a) sarcoma of the vagina in children, and (b) sarcoma of the vagina in adults. Fig. 154. — Cyst of Anterior Vaginal Wall Probably Due to Occlusion of Gartner's Duct. (Cullen.) 382 DISEASES OF THE VAGINA (a) Sarcoma oj the vagina in children is of doubtful etiology, but has been observed very soon after birth. It generally develops in the first year of life and is fatal within a year or two. In one case reported the child lived to be six years old. About forty cases of this disease are on record. The disease is characterized by the development of vesicle-like polypi of a dark red (hemorrhagic) and pinkish-gray (translucent) color, arranged in racemose clusters. In the beginning of the disease the first appearance is a polyp, usually attached to the anterior wall of the vagina. In five out of the six- teen of the twenty-six cases analyzed by Starfinger ("Sarcom der Vagina bei Kindern," 1900) however, the disease began on the posterior wall. Its surface is smooth and it resembles a mucous polyp of the uterus. From this polyp there develop in the course of time, weeks or months or even years, proliferations of cystic polypi until they fill the vagina and project through the vulva. The disease is apt to involve the bladder at an early date, then the cervix and uterus, and finally the peritoneum. Metastases are infrequent, the growth extending mostly by continuity and generally forward into the bladder and peritoneum and not backward into the rectum. Histologically the growth consists of round and spindle-shaped cells, also giant cells and striped muscle fibers. The diagnosis before the disease has progressed extensively is very difficult. A vaginal discharge in an infant should lead to a speculum exami- nation, a Kelly cystoscope with a reflected light being the best instrument for this purpose. (b) Sarcoma of the Vagina in Adults. — Fifty-two cases of this disease are on record. It is a disease of later adult life, few of the cases being under forty years of age. Here, as in the case of the child, the disease begins as a polyp most commonly, although instances of its starting as a diffuse infiltration are reported. It appears to lie latent for a considerable time, just as with the child. The primary lesion may be on either wall of the vagina, and it progresses in its development as a ring-like infiltration so that the vagina is narrowed, or it grows as a diffuse tumor of one wall. Ulceration occurs. The disease does not often penetrate the vesico- vaginal or recto-vaginal septa or extend largely, but metastases to other organs are formed relatively early. Histologically the tumor is made up of small round cells, spindle cells, and giant cells, but not striped muscle fibers. Melanotic sarcoma has been report- NEW GROWTHS OF THE VAGINA 383 ed in three cases. The appearance of a polyp situated on the vaginal wall, usually with a broad base and of firm consistency, should excite a suspicion of sarcoma. Microscopic examination of the removed polyp will distinguish sarcoma from myoma or carcinoma. (4) Carcinoma of the Vagina. — Carcinoma of the vagina is sec- ondary to cancer of the uterus, in which event it is relatively com- mon, or it is primary, when it is comparatively rare. Schwarz observed 84 cases of primary cancer of the vagina among 35,807 gynecological patients, or something over two-tenths of one per cent. It forms about one per cent of all carcinomata of the gen- erative organs. Primary cancer of the vagina is a disease of advanced life, but may occur as early as the twenty-sixth year; it occurs only in women who have borne children and is more often found in the posterior wall. When seen early it is a nodule an inch or an inch and a half in diameter. The edges are sharply defined, infiltrated, and injected. The surface soon becomes necrotic and ulcerated and may exhibit papillary elevations. The nodule is firmly em- bedded in the surrounding tissues after the very earliest stages. The disease extends extremely rapidly both superficially and deeply, and if the lower portion of the vagina is infected the inguinal lymph glands are involved. The disease tends to extend to the rectum more often than to the bladder and it may reach to the vulva; it originates in the squamous epithelium and has all the character- istics of squamous-celled cancer (see Cancer of the Uterus, page 267). In getting a specimen of tissue for microscopic examination the deeper tissues must be excised because the superficial portions consist usually of inflammatory products only. The symptoms in the early stages are bleeding from the vagina, on coitus espe- cially, also a watery vaginal discharge. In making the diagnosis we must rule out secondary carcinoma of the vagina. This is done by discovering cancer of the cervix, cervical canal, or fundus uteri, or cancer of the rectum or bladder. Carcinoma in these situations must be rigidly excluded before pro- nouncing the disease primary in the vagina. Myoma is excluded by the physical appearances of myoma and by the microscope. If a primary cancerous area lies behind a stenosis of the vagina the diagnosis is more difficult. Inflammations of the vagina with ul- cerations are differentiated by the absence of infiltration under the 384 DISEASES OF THE VAGINA abcess. If an ulceration caused by an ill-fitting or neglected pessary does not heal rapidly a portion should be excised for microscopic examination. There have been reported a case or two of 'primary chorioepitlie- lioma of the vagina, and venereal warts in conjunction with condy- lomata of the vulva occasionally occur. FISTULA OF THE VAGINA An opening between the vagina and the surrounding hollow viscera is called a fistula. Of such fistulae there are five sorts: — ■ (1) Vesicovaginal, (2) Urethrovaginal, (3) Uretero-vaginal, (4) Recto-vaginal, and (5) Entero-vaginal. The last is extremely rare. For the sake of completeness we must mention a communi- cation between the vagina and a pelvic abscess, or the peritoneal cavity, openings made, as in the case of (5), fistula into the in- testine, in the course of operations. Vaginal fistulae are caused by sloughing of the vaginal walls due to prolonged pressure of the child's head during labor, by injuries from obstetric instruments, by ulceration due to pessaries and other foreign bodies, or by ulcerations from foreign bodies in the bladder. They result also in the late stages of carcinoma of the cervix, vagina, rectum, and bladder, and following operations, especially hysterectomy. In the last case and also when a vesico- vaginal