Hypertrophy of the Vagina.
Excessive use, as in all organs of the body, will cause hypertrophy of the vagina. Its walls may merely be thick ened or they may be disposed in folds and ridges. It may be due to excessive child-bearing, excessive coitus, or to an accumulation of fat and connective tis sue, which is part of a general process. If it is unattended by prolapse, it may give rise to no disagreeable symptoms, and consequently calls for no particular treatment.
Prolapse of the Vagina.
This condition of the vagina may exist without hypertrophy, but is usually asso ciated with it. Either the anterior or the posterior wall or both may be prolapsed. The conditions which cause hypertrophy are also in most cases the cause of pro lapse.
Treatment.—The treatment may be palliative or radical. The former con sists in the use of pessaries, electricity, or astringent substances to contract the redundant tissues. Though this may be effective for the time, the moment the treatment is discontinued the imfavor able conditions will recur. Hence rad ical surgical measures are to be recom mended as preferable. Such measures consist in the removal of superfluous tis sue and the restoration of the vagina to its normal condition. Various opera tions have been suggested for this pur pose, but I shall describe only those which have been of greatest service in my own experience. For prolapse of the posterior wall the simplest operation and the one which will be applicable to the greatest number of cases is that which was devised by Hegar. It consists, in brief, in the removal of a triangular or nearly triangular strip of the vaginal mucous membrane, the apex of the tri angle being near the os uteri and the base at the introitus The size of this triangle must be regulated by the degree of prolapse and the width of the vaginal wall. By depressing the vaginal wall in its middle line with a sound and drawing the mucous membrane over it on either side until the necessary amount of slack has been taken up, the sides of the triangle may be determined. Having outlined the sides by incision with a scalpel uniting them as near the os uteri as the redundancy of the tissue demands, grasp the tissue at the apex and dissect downward as rapidly as possible, remov ing as little of the submucons tissue as is convenient, and remembering that the rectum lies immediately under the va gina, and that it is very undesirable to enter it. The ha norrhage is sometimes
very profuse, but it can generally be checked by pressure with gauze pads. The junction of the mucous membrane of the vagina with the skin of the per ineum may form the base-line of the triangle, the tissue being removed to this junction. The wound may then be irri gated with hot saline solution, and then covered with a very hot gauze pad or sterilized towel until the sutures are ready for insertion. Fine aseptic catgut (No. 1 or No. 2) may be used and a sharp-pointed half-round needle an inch and a half or two inches long. The su tures may be interrupted or continuous, the latter being introduced the more easily and quickly. It is essential that the edges of the wound be carefully ap proximated to each other. The denuded area having been closed, a gap in the skin of the perineum will remain as the result of bringing the ends of the base line together. This may be closed with three deep, interrupted sutures which must make a sufficiently broad sweep in the perineum to draw forward the re tracted muscular tissue. If the injury is of long standing, much of the original muscular tissue of the perineum will have atrophied; much of it may have entirely disappeared. It will therefore be a futile task to attempt to recover by dissection that which does not exist, or seldom exists,—namely: the muscles of the perineum,—as they were related and disposed prior to the accident which tore them apart, exposed them, and was fol lowed by degenerative changes. The en tire wound may then be irrigated, dried, and covered with a thin film of iodoform collodion, the vagina then receiving a light dressing of iodoform gauze, while the wound is protected outwardly by ab sorbent cotton and a T-bandage. Per fect cleanliness of the wound for the suc ceeding week, the patient being kept quietly in bed upon her back, with legs tied together, will favor a successful re sult. It is not insisted that failure will follow less rigorous measures. I have found that the extra trouble and self denial on the part of the patient usually paid. Ten days or two weeks in bed will usually suffice. Instead of catgut for the perineal sutures one may use worm-gut or silver wire with good satis faction. They cause a little more trouble in introduction and require removal when the wound is healed; that is, in ten days.