CHAPTER III.

Fig. 1.—Woman in the dorsal position with feet supported in Edebohls’ stirrups.

Vaginal and Bimanual Examination.—Having examined and noted the condition of the external genitals, the physician should next proceed to examine the vagina. The index finger of the right or the left hand should be gently introduced into the vagina. The condition of the vaginal walls, and the direction, consistency, form, etc. of the vaginal cervix, may be determined. The shape and size of the os uteri should be noted. The ulnar edge and the tips of the fingers of the other hand should then be placed upon the abdomen, immediately above the symphysis pubis, and gently pressed backward and downward toward the vaginal finger(Fig. 2). In this way the various pelvic organs, the uterus, Fallopian tubes, ovaries, and ureters, may be palpated between the two hands, and their position, size, shape, and consistency may be determined. Such an examination is, of course, made much more easily in a thin woman than in a fat one. A thin woman a few weeks after labor may be examined most easily, on account of the relaxation of the abdominal and vaginal walls.

Fig. 2.—Bimanual examination.

This is called the bimanual method of examination, and the student will find that as he acquires practice in this method he will gradually depend less upon examination by the uterine sound and the speculum, and will rely altogether upon his sense of touch, his ability to palpate.

It matters not which hand be used in making the vaginal examination. It will, however, be found that the hand that is used the more frequently will become the more proficient.

In making the bimanual examination the structuresshould be palpated methodically in order. The vaginal finger notes the condition of the cervix uteri. If the fundus be in the normal position, the uterus can then be taken between the abdominal hand (upon the fundus) and the vaginal finger (upon the cervix) (Fig. 3). The shape, size, mobility, and consistency are noted. The vaginal finger is then passed anteriorly and laterally toward either uterine cornu, while the abdominal fingers pass over to the posterior aspect of the same cornu. The ovarian ligament and the proximal end of the Fallopian tube may thus be felt. Passing farther outward, the whole of the tube and the ovary may be examined. The same procedure is then applied to the opposite side.

Fig. 3.—Bimanual examination; median sagittal section of the pelvis.

The condition of the ureters may be determined by placing the vaginal finger in either lateral vaginal fornix and drawing it outward and forward, when these structures will pass over the end of the finger. When theureters are indurated by inflammation they can be plainly felt.

By the method of examination here advised the physician will always make a visual examination before making a digital one. There are several advantages derived from this procedure. In the first place, no examination of a woman is thorough unless a careful visual examination of the external genitals has been made. The discovery of discharges and of lesions of the external genitals may throw much light upon the condition found higher up in the pelvis. Again, the examiner protects himself. A great many unfortunate cases of syphilis have been acquired by physicians from a primary sore upon the examining finger. A preliminary visual examination enables one to guard against this danger. The primary sore occurs upon the end of the examining finger or upon the web between the index and middle fingers—the part of the hand that is pressed against the fourchette.

The hands of the physician should, of course, be surgically clean before making an examination, and the grease or oil which is used as a lubricant should be clean. The hands should always be washed, after separating the parts to make the visual examination, before the finger is thrust into the vessel containing the lubricant. It is best to place a small portion of the lubricant on a plate or a saucer for each individual patient, and thus avoid the danger of contaminating the rest. Carbolized oil, borated vaseline or cosmoline, and a thick sterile solution of soap are good lubricants. Neutral green soap diluted with boiled water to the consistency of thin jelly is a very agreeable lubricant which may easily be washed from the hands and the vagina.

If practicable, the woman should receive a vaginal douche of bichloride-of-mercury solution, 1:4000, and the vulva should be washed, before making a bimanual examination. The examiner should always clean the external genitals of all discharges before introducing the vaginal finger. In this way we avoid the danger ofcarrying septic material from the external genitals to the upper portion of the genital tract. This preliminary cleansing is not desirable before the external genitals have been examined; for much may be learned from observation of the discharges which bathe or escape from the various structures. If practicable, a cleansing vaginal douche of bichloride-of-mercury solution should be administered after the bimanual examination.

Fig. 4.—Double tenaculum.

The examination of the uterus and other pelvic structures is often facilitated by dragging the uterus downward with a tenaculum while the vaginal or the bimanual examination is being made. Sensation in the cervix is so slight that little or no pain is experienced in this procedure. The anterior or posterior lip of the cervix is caught with the single or the double tenaculum (Fig. 4), guided along the vaginal finger or introduced through the speculum, and the uterus is drawn down by an assistant in case the bimanual examination is being made, or by the external hand of the examiner in case a simple vaginal examination is made. When this is done the utero-sacral ligaments are made tense, and can be felt like two cords extending from the sides of the cervix outward and backward to the pelvic wall. The posterior surface of the uterus can be palpated often as high up as the fundus. The method is especially useful when the examination is made by the rectum, and in this way the whole posterior surface and the fundus of the uterus may be palpated (Fig. 5).

The contraindications to a vaginal examination arevirginity, the presence of a hymen, and any acute inflammatory or painful condition of the vulva or vagina. None of these conditions, however, forbid an examination if an exact diagnosis is essential to the proper treatment of the case, and can be made only in this way. It may be that in these cases a rectal examination will be sufficient for diagnosis.

Fig. 5.—Bimanual examination with one finger in the rectum. The uterus is drawn down with the double tenaculum.

Rectal examination of the pelvic structures is made in a way similar to that already described for the vaginal examination. Bimanual examination may be made by palpating the various organs between the rectal finger and the abdominal hand.

The Vaginal Speculum.—The speculum is an instrument through which a visual examination is made of the vagina, the external os uteri, and the vaginal cervix. Agreat number of specula have been invented. At the present day the best two instruments of this class are the bivalve speculum, such as Goodell’s (Fig. 6), and the duck-bill speculum (Fig. 7), or perineal retractor, invented by Sims.

Fig. 6.—Goodell’s speculum.

Fig. 7.—Sims’ speculum.

Fig. 8.—Sims’ depressor for the anterior vaginal wall.

The bivalve speculum is introduced with the woman upon her back, in the dorso-sacral position already described. The vulva and the vagina should be cleaned. The speculum should be warmed by placing it in hot water, and should then be lubricated with the soap solution or with vaseline. It should be introduced with the blades closed and the plane of the blades lying not exactlyin the median sagittal plane of the body, but inclined at a small acute angle to this plane, one edge of the speculum being directed toward either vaginal sulcus. The instrument is passed into the vagina toward the position in which, by a previous digital examination, the vaginal cervix had been found to lie. The instrument is then turned with the handles toward either thigh, so that the blades become parallel to the anterior and posterior vaginal walls, in order that, when separated, they will open the vaginal slit. The handles are brought together and the blades opened. When the vaginal cervix comes well into view the blades are fixed in place by the screws (Fig. 9).

Fig. 9.—Goodell’s speculum in position.

In some cases, where the cervix points well forward or well backward, it may be readily brought into view through the speculum by catching it with a tenaculum.

By means of the bivalve speculum we are able to make a partial inspection of the vaginal walls, an imperfect inspection of the vaginal vault, and a good inspection of the vaginal cervix and the external os. Applicationscan be made to the cervix, but none of the minor operations of gynecology can be performed through this speculum.

The Sims speculum enables us to make the most thorough inspection of the vagina, the vaginal vault, and the vaginal cervix. The Sims speculum is merely a hook or retractor for the perineum, and may be introduced with the woman in the dorsal position, the Sims position, or the genu-pectoral position. If the Sims speculum is introduced in the dorso-sacral position, it is necessary to hold forward the anterior vaginal wall in order to obtain a view of the cervix.

Fig. 10.—The Sims position.

The Sims position, which is also called the latero-abdominal position, is shown inFig. 10. The woman is placed on the bed or table upon her left side. The side of the face is upon the pillow; the left arm is behind the back, so that the left breast rests upon the table. The thighs are flexed upon the abdomen at an angle of about 90° to the trunk. The right thigh is more flexed than the left, so that the right knee may touch the table above the left knee. The legs are flexed on the thighs. In this position there is a tendency for the intestines, following the force of gravity, to fall from the pelvis,and for the uterus and other pelvic viscera to be drawn up. When the perineum is retracted with the blade of the Sims speculum, air will enter the vagina and the vaginal slit will become distended (Fig. 11). To facilitate inspection of the cervix it is usually necessary also to push forward the anterior abdominal wall by some kind of depressor, such as the one shown inFig. 8.

Fig. 11.—The cervix uteri exposed with the Sims speculum.

Fig. 12.—The knee-chest position.

The genu-pectoral position or the knee-chest position is shown inFig. 12. The side of the face is upon the pillow; the breast is upon the table; the thighs are vertical. Inthis position the intestines fall from the pelvis, and the other pelvic viscera are drawn upward by the force of gravity. If the anus is opened, air rushes in and distends the rectum. If the perineum is retracted, air enters and distends the vagina. If the urethra is opened, the bladder is likewise distended. The position is the most useful one for inspection of the rectum, vagina and vaginal cervix, and the bladder.

The Sims speculum, with the woman in the dorsal, the Sims, or the knee-chest position, is the most useful instrument by which to expose the cervix uteri for any of the minor operations of gynecology. The manipulations of the operator are not hampered by working between metal walls.

Examination of the Rectum.—If the woman is placed in the knee-chest position, a most satisfactory inspection of the whole of the rectum may be made. The woman should be placed in this position with the buttocks before a good light, and the posterior margin of the anus should be retracted by the small blade of a Sims speculum; the rectum will immediately become distended with air and the rectal walls will be well exposed. Or the rectal specula (Figs. 13, 14) may be used. In employing the longer of these instruments it is best to use light reflected from a head-mirror or thrown directly from an electric head-light into the speculum.

Fig. 13.—Rectal speculum, large size.

Fig. 14.—Rectal speculum, small size.

The instrument should always be introduced for thefirst two inches with the obturator in place. The obturator should then be withdrawn and the speculum pushed farther in, the operator watching and guiding its course around the rectal valves or folds of mucous membrane, so as to prevent injury to the walls of the rectum. Anesthesia is not necessary for this procedure.

Examination of the Bladder.—It will readily be understood that all the hollow viscera are much more easily examined when their walls are separated by distention with air than when the walls are collapsed. The bladder is most readily examined in this way. The woman should be placed in the knee-chest position, or in the dorsal position with the hips elevated above the abdomen. In either position the intestines fall from the pelvis, and when the urethra is opened air enters and distends the bladder. This distention is most certainly accomplished in the knee-chest position. In women who are not very fat, however, the extreme dorso-sacral position is equally good. The details of this method of examination are described on a later page.

The uterine soundis an instrument by which the length of the uterine cavity may be determined (Fig. 15). The sound, which is a large surgical probe, somewhat curved to adapt itself to the normal shape of the uterine axis, is made of pliable metal, so that the curvature may be changed readily to suit any case. The sound is graduated, and at a position of 2½ inches from the tip is a small elevation marking the length of the normal uterine cavity.

Fig. 15.—Uterine sound.

The uterine sound was at one time used a great deal to determine the length and direction of the uterus, andperhaps to assist in determining the character of the uterine contents or of the endometrium. With our present methods of examination, however, the sound is of but little if any use. The size and direction of the uterus can in nearly all cases be determined by bimanual examination. The use of the uterine sound is by no means free from danger. Many cases of septic endometritis and salpingitis have been caused by it, and the physician has often unintentionally committed an abortion by passing the sound in a pregnant woman. The uterine sound should never be used in a routine way. It should never be used unless one expects to determine with it something that cannot be determined by simpler methods of examination.

The most thorough aseptic precautions should be observed when the sound is introduced. The vulva, vagina, and cervix should be cleaned and the sound should be sterilized. The sound should never be introduced if there is any suspicion of pregnancy.

ANTISEPSIS—In all examinations the physician should observe every precaution to avoid carrying infection from one patient to another. All instruments used in the examination should be thoroughly cleansed with soap and warm water, and then boiled for five minutes in a 1-per cent. solution of carbonate of soda.

Vulvitis.—Vulvitis, or inflammation of the vulva, is not a common disease. The vulva is composed of several parts which are anatomically distinct, and, though all these parts are usually involved in an acute attack of inflammation of the vulva, yet the symptoms of the disease and the pathological appearance depend to a great extent upon the structures which are principally affected. The labia majora, the nymphæ, the vestibule with its mucous crypts or glands, the clitoris, the external urinary meatus, and the ducts of Bartholin’s glands may all be involved in the inflammation. The sebaceous glands of the labia may be especially involved, producing a form of sebaceous acne which has been calledfollicular vulvitis. Inguinal adenitis may accompany vulvitis.

The appearance of the parts is that characteristic of inflammation of the skin and mucous membrane in any other part of the body. The mucous membrane becomes red and swollen; the labia may become edematous; an abundant purulent discharge covers the parts, and unless cleanliness is practised the irritation from the discharge spreads to the inner aspects of the thighs, the perineum, and the anal region.

The patient suffers with local pain, which is increased by walking and by the passage or contact of urine.

The usual cause of vulvitis is gonorrhea. The condition is sometimes secondary to other diseases. It may be caused by the irritation from the discharges of a vesico-vaginal or recto-vaginal fistula, from a cancer of the cervix or in some forms of endometritis. Girls andwomen who are unclean may be attacked by vulvitis as a result of irritation from decomposed smegma, sweat, urine, etc. The oxyuris, or thread-worm, may enter the vulva from the rectum and cause, in unclean children, sufficient irritation to produce inflammation. Vulvitis from uncleanliness is most likely to occur in hot weather after prolonged exercise. It not infrequently attacks children, especially those of a strumous diathesis, whose hygienic surroundings are poor. In such cases the suspicions of the parents may demand a medico-legal examination; and it is of importance to remember that vulvitis of this kind is not rare, and is not due to violation or contagion. Vulvitis in little girls may be also due to gonorrhea, independently of violation. This is the cause of epidemics of vulvitis and vaginitis in girls crowded in houses, hospitals, or asylums. The disease is spread by contamination from towels or bed-clothing.

The essential points of treatment to observe in the acute stage of vulvitis are rest in the recumbent posture and perfect cleanliness. The labia should be separated and the parts frequently bathed and cleaned with warm water. Various local washes or applications are of use. A warm solution of boracic acid (ʒj to a pint of water), the dilute solution of the subacetate of lead, or a solution of bichloride of mercury (1:5000) may be used.

If the disease is of gonorrheal origin, the parts should be painted once or twice a day with a 2 per cent. solution of nitrate of silver, applied after the discharges have been gently washed away.

As the disease subsides the inflammation may be found to persist in the crypts of the vestibule, the urinary meatus, and the ducts of Bartholin’s glands. It is very important that all remains of the inflammation, especially if it be of septic or gonorrheal origin, should be eradicated before the woman is discharged from treatment. The presence of any focus of inflammation, even though latent, is a constant source of danger to the woman; for septic organisms or material may be carried from the externalgenitals to the higher parts of the genital tract, as the uterus and Fallopian tubes, with the most disastrous results.

Sometimes a small drop of pus will be observed escaping from one of the small glands or crypts of the vestibule, about the urinary meatus, after the inflammation has disappeared in other parts of the vulva. In this case the gland should be punctured with a fine cautery-point or a fine wooden probe or point saturated with pure carbolic acid or other caustic.

If the disease persists in the external meatus or urethra, it must be treated by the local applications appropriate for urethritis.

Fig. 16.—Appearance of the external genitals in a woman with gonorrhea:G. m., gonorrheal macula situated at the base of a vaginal caruncle.

Inflammation of the Vulvo-vaginal Glands.—The vulvo-vaginal glands are two in number. They are about the size of a bean, and are situated deeply on the inner aspect of the labia majora, where they may be felt in thin women. The duct of the gland is about oneinch in length, and opens immediately in front of the hymen, about the middle of the side of the ostium vaginæ. In cases of vulvitis the duct of the gland usually becomes inflamed, and the inflammation may extend to the gland, producing abscess of the vulvo-vaginal gland.

Inflammation of the duct and the gland may also occur independently of vulvitis, from direct septic or gonorrheal infection.

Suppuration of the duct may be demonstrated by pressing over the course of the duct, when a drop of pus will escape from the opening. In such cases the orifice of the duct is usually surrounded by a red areola, resembling a flea-bite, which has been called the gonorrheal macula (Fig. 16). This macula persists long after all other traces of inflammation about the vulva and vagina have disappeared, and after all frank suppuration in the duct has subsided. Its presence indicates at least the probability of previous gonorrheal infection.

When the duct of the gland alone is the seat of inflammation, it should be laid open with fine scissors or knife, and the tract thoroughly cauterized with the nitrate-of-silver stick, pure carbolic acid, or a solution of chloride of zinc (2 per cent.).

Suppuration of the vulvo-vaginal glandis accompanied by marked swelling and peripheral edema. The swelling may extend to the anus, and is of characteristic shape (Fig. 17). The pain is always severe. Fluctuation is first apparent on the inner surface of the labium majus. If the condition is not treated, one or more fistulous openings appear below the orifice of the duct, and the pus is discharged. The condition then becomes chronic. The fistulous openings persist. Acute inflammation disappears from the gland, leaving it in a condition of hypertrophic induration. A thin, milky or greenish, purulent fluid may be pressed out of the duct or the fistulous openings. Infection from this discharge may be communicated to man, or may ascend the genitaltract, producing inflammation of the endometrium or of the Fallopian tubes.

Fig. 17.—Abscess of right vulvo-vaginal gland.

In abscess of the vulvo-vaginal gland a free incision should immediately be made into the labium at the junction of the skin and the mucous membrane. The interior should be wiped out with pure carbolic acid and the cavity packed with gauze. If the disease is first seen in the chronic stage, after the abscess has evacuated itself, the only method of cure is to excise, with curved scissors, the whole of the indurated gland, the duct, and the fistulous tracts. The wound may be left open and packed, or it may be closed immediately with buried catgut sutures.

Cysts of the Vulvo-vaginal Glands.—Cysts mayoccur in the duct of the vulvo-vaginal gland or in the gland itself. Cysts of the duct are small—about the size of a chestnut. They are situated superficially, lying immediately under the mucous membrane of the vagina at the base of the labium minus.

Fig. 18.—Cyst of the right vulvo-vaginal gland (Hirst).

Cysts of the gland may be unilocular if formed at the expense of a single lobule of the gland, or multilocular if several lobules enter into their formation. These cysts may attain the size of the fetal head (Fig. 18).

Cysts of the gland or of the duct are formed by retention of the cyst-contents. The retention is due to occlusion of the duct, usually the result of inflammation. In some cases the duct remains pervious, and the retention is due to the altered character of the secretion of the gland, which becomes too viscous to pass, except under unusual pressure, along the duct.

These cysts contain clear yellow or chocolate-coloredfluid. The diagnosis of cyst of the vulvo-vaginal gland is usually not difficult. If we are in doubt in regard to the fluid character of the tumor, this may be determined with the exploring-needle.

Inguinal hernia, hydrocele of the canal of Nuck, cysts of the round ligament, and sacculated cysts of old hernial sacs may be mistaken for cysts of the vulvo-vaginal glands. In such cases, however, the tumor lies more in the upper and outer part of the labium majus, and extends to, and may be connected with, the external inguinal ring.

Cysts of the vulvo-vaginal glands should be treated by free incision and packing, or by extirpation. If the sac is emptied by the aspirator or by a small incision, it will refill. The best method is to extirpate the cyst. In case there has been no inflammatory action binding the cyst to surrounding structures, extirpation without rupture is easy. If rupture occurs, the cyst-wall may be dissected off with the knife or removed with the curved scissors. The wound may be immediately closed with deep and superficial sutures.

Pruritus Vulvæ.—Pruritus vulvæ, or itching of the vulva, may be due to a great variety of causes. Eruptions of the vulva, such as eczema, cause itching. Irritation from the discharge of vaginitis, metritis, cancer of the cervix or body of the uterus, the presence in children of the thread-worm, the irritation from diabetic urine, or trophic lesions of the nerves due to diabetes, may result in pruritus. Some of the pathological conditions of the uterus, tubes, and ovaries may produce reflex irritation of the nerves of the vulva, and cause itching, in a manner similar to that in which vesical calculus causes itching of the glans penis.

The congestion of the external genitals that accompanies pregnancy may also produce pruritus.

There are some cases of pruritus vulvæ, however, in which no physical cause for the intolerable itching can be discovered, and in which minute examination of the affected portions of skin or mucous membrane demonstratesno pathological change. Such cases are called idiopathic.

The itching may be so severe that the woman cannot refrain from scratching and rubbing the parts on all occasions. She becomes debarred from the society of her friends, and seeks relief in anodynes and hypnotics. The continual scratching increases the irritation of the vulva, and an eczematous eruption may result, which produces an irritating discharge that spreads the irritation to other parts of the body with which it may come in contact.

The itching of pruritus may extend into the vagina, to the skin of the abdomen, to the inner aspect of the thighs, and to the anus.

In the treatment of pruritus it is first of importance to discover, if possible, the cause of the itching. Any vaginal or uterine discharge should be investigated. Discharge from the uterus can be eliminated as a cause by placing against the external os a pledget of cotton, frequently renewed, to absorb the discharge before it reaches the vulva, or the parts may be kept clean by frequent douches. In children the stools should be examined for the thread-worm. The urine should always be examined. Diabetes is a frequent cause of pruritus vulvæ in old women. Any pathological condition of the uterus, Fallopian tubes, and ovaries should be treated before we can eliminate this as a possible cause of pruritus.

In the cases of so-called idiopathic pruritus in which no local lesion can be discovered attention should be directed to the general nutrition of the patient. As in pruritus ani, the gouty diathesis may cause the disease. Alcoholic drinks, rich food, fish and shell-fish, may assist in its production.

Treatment.—A great variety of local applications have been used for the relief of pruritus. In case of diabetes the urine should, as much as possible, be kept from contact with the parts, which should be thoroughly dried after urinating, and dusted with a powder consistingof equal parts of subnitrate of bismuth and prepared chalk.

The following local applications are useful in pruritus:

A powder of 1 grain of morphine to 2 grains of prepared chalk, applied twice a day.

An ethereal solution of iodoform sprayed into the folds of the vulva with an atomizer.

Cauterization with pure carbolic acid.

In pruritus of gouty origin an ointment, composed of 15 grains of calomel to 1 dram of cerate, will often relieve or cure the local condition. A small quantity should be rubbed over the itching area at bed-time. Often one or two applications give immediate relief. If the condition does not quickly improve it is useless to continue this treatment. The danger of salivation from its prolonged use should be remembered.

In cases which have resisted all local applications the affected areas of mucous membrane have been excised. Even this method, however, does not promise certain cure. It should be tried, however, when the pruritus is localized and has resisted the milder forms of treatment.

Kraurosis Vulvæ.—Kraurosis vulvæ is a very rare disease, of chronic inflammatory nature, affecting the vulva. The disease is characterized by cutaneous atrophy, with very marked shrinking and contraction ofthe vaginal orifice. The lesions may be unilateral or circumscribed, but usually the tissues of the labia majora, the nymphæ, and the area surrounding the clitoris and urinary meatus are more or less involved. The cause of the disease has not as yet been determined. It has been observed at every age after puberty, in the nulliparæ as well as the multiparæ, and in the parturient woman. It must be differentiated from pruritus and the atrophic changes which take place after the physiological and induced menopause.

The first symptoms noticed by the patient are usually those of pruritus—an intense itching and burning about the vulva. In some cases the affected tissue early becomes excessively hyperplastic. The mucous membrane and the skin of the vulva are often discolored, small red spots appearing, which are sensitive to touch. Later a peculiar shrinking of the superficial tissue takes place, and the diseased surfaces become dry and whitened. The nymphæ gradually disappear, fusing with the labia majora; and the mucous membrane and skin become shiny and drawn smoothly over the shrunken clitoris. Cracks or fissures appear on the dry surfaces. A sensation of drawing and shrinking of the vulva is now usually experienced. The vaginal orifice gradually narrows and contracts, until frequently the little finger can scarcely be introduced. When this last condition of atrophy is reached, the pathological process is arrested, the subjective sensations of shrinking pass away, and the symptoms resembling pruritus are no longer experienced. The shrunken and contracted vaginal orifice, however, persists and is never spontaneously restored.

Treatment.—Palliative treatment by local applications may be tried, or a cure may be attempted by operation. The palliative treatment is simply directed toward the relief of the subjective symptoms, which at times are exceedingly painful. Pure carbolic acid or a solution of cocaine applied locally, or pure nitrate of silver applications frequently repeated, afford temporary relief. Clothswrung out of hot water and placed over the vulva also lessen the suffering. A solution of the neutral acetate of lead in glycerin, on cotton placed between the labia, is recommended. Forced dilatation of the vaginal orifice under ether has been practised with good result. The most satisfactory treatment is complete excision of the diseased tissue. Unless all affected tissue is removed, the disease may return.

Varicose Tumors of the Vulva.—Varicose tumors of the vulva are usually the result of pregnancy. They may, however, accompany any form of pelvic or abdominal tumor, the pressure of which interferes with the venous circulation of the pelvis. The varicose condition usually affects the labia majora. It varies from a mere increase in size of the veins of the vulva to a varicose tumor the size of the fetal head. The condition, being secondary, usually disappears with the removal of the exciting cause. The labia may be supported with a compress and a bandage.

Hematoma of the Vulva.—Hematoma of the vulva is due to the subcutaneous rupture of a vein. Blows, kicks, or falls cause this condition. It is usually produced by rupture of a varicose vein during pregnancy or labor.

The affected labium is purple in color and may reach the size of a fetal head. When the hematoma is small the vagina should be kept as clean and aseptic as possible, and a light compress should be applied. Absorption usually takes place. If the collection of blood is large or if it has become infected, a free incision should be made into the labium, the clots should be turned out, and the cavity thoroughly washed and packed with gauze.

Papilloma.—Papillomata or warts of the vulva are not uncommon. They may occur singly, scattered over the vulva and the neighboring skin, and extending up the vagina as far as the cervix uteri, or they may occur in large cauliflower-like masses. They are pink or purplish in color. They often exude a bloody, offensive discharge,which is capable of exciting a similar condition by contact. Papilloma is usually the result of gonorrhea or syphilis. It may, however, be caused by irritation from filth or by the leucorrhea of pregnancy.

The treatment of papilloma is by excision. The small warts should be picked up with forceps and clipped off with curved scissors. Every one should be removed or the condition may recur. In the case of large papillomatous tumors the wound of excision should be closed with continuous sutures. Pregnancy is no contraindication to excision of papillomata.

The vulva may be the seat of epithelioma, lupus, sarcoma, fibroma, fibromyoma, myxoma, lipoma, or enchondroma. These tumors present the same characteristics and demand the same surgical treatment as in other parts of the body.

Small cysts have been found in the labia majora and minora, the vestibule, the hymen, and the clitoris.

Elephantiasis.—True elephantiasis of the vulva (elephantiasis Arabum), due to the presence of the Filaria sanguinis hominis, is a rare disease in this climate. The disease occurs especially in Barbadoes. It may affect the labia and the clitoris. The hypertrophied labia may attain the size of the adult head.

The treatment of this condition is excision of the affected structures.

There is a syphilitic form of hypertrophy or elephantiasis of the vulva which is not uncommon in this country. The labia minora and majora may be transformed into enormous flap-like folds. Though at first free from ulceration, this may subsequently result from chafing. Warty growths may cover the hypertrophied labia, the perineum, and the buttocks. The disease usually affects both labia, though it may be confined to one.

This manifestation of syphilis does not yield readily to constitutional or local medicinal treatment. Many cases prove to be incurable by medicine. Antisyphilitic treatmentshould always be tried at first, and if this fails, the hypertrophied structures should be excised with the knife.

If, in such cases, there is any doubt in regard to diagnosis between syphilis and cancer, a small portion of tissue should be excised and submitted to microscopic examination.

Adhesions of the Clitoris.—Adhesions between the glans of the clitoris and the prepuce or hood which covers it are exceedingly common. Usually no trouble whatever is caused by these adhesions, unless an accumulation of smegma takes place, or irritation is produced by the presence of a concretion.

In case of any irritation about the genitals, the prepuce and clitoris should always be carefully examined. In fact, a careful examination of the clitoris should form a routine part of all examinations of the external genitals.

When trouble arises from the presence of adhesions, the prepuce should be drawn back and the adhesions freed with a blunt probe. A 20 per cent. solution of cocaine should be applied to the clitoris for ten minutes previous to the operation. The whole corona and the sulcus back of the corona should be exposed. The raw surface should be covered with vaseline, and the patient should abstain from walking as long as pain is caused by it. The prepuce should be drawn back and vaseline applied every day for two weeks, to prevent the formation of adhesions.

Inflammation of the Vagina.—Acute inflammation of the vagina is not a very common affection. Primary inflammation confined to the vagina alone is unusual. The disease in most cases is secondary to vulvitis, urethritis, or endo-cervicitis. The causes of vulvitis (which have already been considered) are also the causes of vaginitis. It is of importance to remember that the disease may occur in children as a result of the same factors which produce vulvitis.

The exanthemata, as measles and scarlet fever, may cause vaginitis as part of the general involvement of the skin and mucous membrane which occurs in these diseases. The most usual cause is gonorrhea.

Several varieties of acute vaginitis may be recognized—the simple, the granular, the senile, and the emphysematous. It is unusual to find the entire surface of the vagina involved. The disease is confined to areas or patches separated by healthy tissue.

Insimple vaginitisthe inflamed membrane remains smooth.

Ingranular vaginitis, which is the variety usually seen, the papillæ are infiltrated with small cells, and are much enlarged, so that the inflamed surface has a granular appearance.

Senile vaginitisis due to infection of portions of the vaginal mucous membrane that have lost their epithelium as a result of the atrophic changes of old age. This disease occurs in patches of various size, sometimes presenting the character of ecchymosis; in other cases thepatches have altogether lost the epithelium, and permanent adhesions may take place between areas which are brought in contact. This form of vaginitis has also been called adhesive vaginitis. It is said that a similar condition may occur in children.

Theemphysematousform of vaginitis occurs in pregnancy. The vaginal walls are swollen and crepitating. The gas is contained in the meshes of the connective tissue.

Acute vaginitis is accompanied by dull pain and a sense of fulness in the pelvis. The discomfort is increased by standing, walking, defecation, and urination. There is a free discharge of serum or pus, which may be tinged with blood. The character of the discharge depends upon the variety and the period of the disease. Inspection, which can best be made through the Sims speculum, with the woman in the Sims or knee-chest position, shows the characteristic lesions of inflammation of the mucous membrane.

Acute vaginitis, if neglected, may pass into the chronic form. It usually lingers in the upper part of the vagina, in the fornices, especially in vaginitis of gonorrheal origin. By careful inspection we find here one or more granular patches of inflammation, which cause a vaginal discharge from which man may be infected, and from which infection of the upper portion of the genital tract, the uterus, and the Fallopian tubes may be derived.

Treatment.—Vaginitis, especially of the gonorrheal form, should be treated vigorously, and treatment should be continued until all traces of inflammation have disappeared. Inflammation of any part of the lower portion of the genital tract may have the most disastrous consequences if it extends to the uterus and the Fallopian tubes.

The woman should be kept as quiet as possible. The bowels should be moved freely with saline purgatives. She should take, three times in twenty-four hours, lying upon her back, a vaginal douche of one gallon of a boracic-acidsolution (ʒj to the pint). The temperature of the solution should be about 110° F.

If the disease be of gonorrheal origin, a warm bichloride solution (1:5000) should be used in the same way.

After the acute symptoms have subsided local applications should be made, in addition to the douches. The woman should be placed in the knee-chest position, and the vagina should be thoroughly exposed with the Sims speculum. If necessary, the vaginal surface should be gently cleaned with warm water and cotton. A 4 per cent. solution of cocaine may be applied to the vagina if there is much pain. Then the entire vaginal surface should be painted with a solution of bichloride of mercury (1:1000). These applications should be made daily until the disease is cured. The vaginal douches should be continued at the same time.

In the chronic form of the disease and in senile vaginitis the local patches of inflammation should be painted once a day with a solution of nitrate of silver, 5 to 10 per cent., or stronger if the condition does not yield. The senile form of vaginitis, being dependent upon a general condition, is often impossible to cure. We can sometimes relieve the discomfort by applying boracic-acid ointment (ʒj to ℥j) to the vagina. The application of pure carbolic acid to the inflamed patches sometimes does good.

Urethritis usually accompanies a gonorrheal vaginitis, and demands coincident treatment.

Tumors of the Vagina.—Vaginal Cysts.—Well-defined cysts are sometimes found in the vaginal walls. They occur at all ages from childhood to old age.

Vaginal cysts are usually single. They vary in size from that of a pea to that of a fetal head. The vaginal mucous membrane covers the free surface of the cyst, and may either be movable over it or may be much attenuated and closely incorporated with the cyst-wall. Vaginal cysts may be sessile or more or less pedunculated. The internal surface of the cyst is usually covered withcylindrical epithelium, which is sometimes ciliated. The contents vary in consistency and color. They are often viscid, transparent, and of a pale yellow tint. They may contain pus or altered blood.

The origin of vaginal cysts has been much disputed. It is probable that they arise from the remains of the Wolffian canal—the canal of Gärtner. In the embryo the transverse or longitudinal tubule of the parovarium extends to the side of the uterus and thence down the side of the vagina to the urethral orifice. It persists in this condition in some of the lower animals—the sow and the cow—and may also persist as a closed tube in woman. In such cases it may become distended and form the vaginal cyst.

Thetreatmentof vaginal cyst is removal. If the tumor be situated near the vulva, it may be extirpated by careful dissection. If this operation be deemed impracticable, partial excision of the cyst should be practised. The tumor should be seized with a tenaculum, opened by the scissors, and part of the wall, with the overlying mucous membrane, should be excised. The interior of the cyst should then be packed with gauze.

Fibroid Tumors of the Vagina.—Fibroid tumors sometimes occur in the vagina. They are usually found in the upper part of the anterior wall. They are sometimes adherent to the urethra. They are usually of small size, but may attain a diameter of six inches. The treatment of such tumors is removal.

Cancer and sarcoma may attack the vagina, though these diseases as primary conditions are very rare. When possible, complete removal should be done.

Atresia of the Vagina.—Severe puerperal infection or mechanical injury, followed by extensive destruction of the tissues of the vagina, may result in a cicatricial narrowing or complete closure or atresia of the vaginal canal.

Thesymptomsof this condition are due to retention of the uterine discharges. There is no discharge ofmenstrual blood from the vagina. Attacks of pain occur periodically at the menstrual periods. A cystic tumor, which may be felt by rectal examination, is present. The tumor consists of the distended portion of the vaginal canal (hematocolpos), and sometimes of the distended cervical canal and body of the uterus. The contents of the hematocolpos are usually sterile, although they may become purulent (pyocolpos).

Thediagnosisis readily made by vaginal and rectal examination.

Treatmentconsists in incision and excision of the vaginal septum and the suture of the vaginal mucous membrane above to that below the obstruction. In very severe cases it is difficult to maintain the patulous condition of the vaginal canal on account of subsequent cicatricial contraction. In such cases the repeated passage of vaginal bougies or the transplantation of mucous membrane has been resorted to.

Vaginismus.—The term “vaginismus” has been applied to a condition characterized by a spasmodic contraction of the muscles which close the vaginal orifice. The muscular spasm occurs reflexly when penetration of the vagina is attempted, as at coitus or a digital examination. The condition is due to dread of pain, and is usually the result of some painful local lesion, such as a urethral caruncle, fissures or sores of the vulva or anus, etc.; or it may be due to some painful condition of the tubes and ovaries. Similar contraction is observed in the sphincters of the anus when there is present a painful anal lesion.

Vaginismus has been said to occur in neurotic and hysteric women in whom there was no discoverable local lesion.

Treatmentconsists in the removal of any local cause of pain or irritation.

If the reflex spasm of the muscles persists when coitus is attempted, notwithstanding the removal or the absenceof any discoverable local cause, operative measures have been advised.

Under anesthesia the vaginal entrance has been stretched by means of large dilators or the fingers, or the fibers of the sphincter vaginæ have been cut on each side of the fourchette and a glass or vulcanite tube of suitable size has then been placed in the vagina and retained for two or three weeks by a perineal pad andT-bandage.

Vaginismus is a very rare condition. Operative treatment, except that which may be required for the removal of some local cause of irritation, is rarely, if ever, necessary.

Coccygodynia.—Coccygodynia is a rare affection characterized by pain in the coccyx and surrounding structures. The pain is caused by pressure, as in sitting, or by any movement involving the muscles attached to the coccyx. The disease is usually caused by traumatism, and in most cases is due to injuries to the coccyx in labor, as a result of which the bone is fractured or dislocated, and becomes fixed in an abnormal position. Sometimes osteitis or necrosis develops. In the unusual cases, in which no structural changes are detected, the condition may be due to rheumatism. Coccygodynia is very rarely found in men.

Thediagnosismay be made by introducing the index finger in the rectum and palpating the anterior and lateral surfaces of the coccyx, and by moving the bone between the finger in the rectum and the thumb placed in the crease of the nates. The mobility, deformity, and tenderness may be readily determined. If a local lesion is found, and the symptoms have not yielded within a reasonable time to expectant treatment, removal of the coccyx by operation is indicated. The coccyx is exposed by a median incision, the bone is separated from its muscular and tendinous attachments, and is removed at the sacrococcygeal articulation with scalpel or scissors. Ifthe articulation is ankylosed, it may be necessary to use the chain-saw. The wound is drained with a few strands of silkworm-gut and closed with interrupted sutures.

Operation should not be advised hastily. The painful symptoms are not always relieved by it. Operation should not be performed unless bony deformity or other distinct lesion is found.

An accurate knowledge of the anatomy and mechanism of the female perineum is essential to an understanding of the nature and treatment of injuries to this structure. The anatomical structures lying between the anus behind and the symphysis pubis in front are those that most directly interest the gynecologist. Proceeding frombelow upward, we find the following structures lying in superimposed planes: the skin, the superficial fascia, the deep layer of the superficial fascia, the transversus perinæi and the sphincter vaginæ muscles, the anterior layer of the triangular ligament, the posterior layer of the triangular ligament, the levator ani muscle (Fig. 19).

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