The diagnosis is not difficult if the blind sac extend to the ostium vaginæ and be felt running alongside of the vaginal canal or winding round it. If, however, it be limited to the side of the uterus or only extend partially on to the vagina, it may easily be mistaken for other para-uterine tumours-most frequently for hæmatocele (Schroder). To clear up the diagnosis and also as a step towards treatment, we puncture the sac with the aspiratory-needle. The character of the discharged blood will indicate the diagnosis.

The treatment consists in slowly but thoroughly evacuating the sac, washing it out and establishing a permanent opening from it.

A septate vagina is sometimes found with a septate uterus (v. fig. 142), both halves being pervious so that there are no symptoms. Traces of a septate condition may persist as bands.

CHAPTER XLII.

VAGINITIS: VAGINISMUS.

LITERATURE OF VAGINITIS.

Barnes-Op. cit., p. 865. Hennig-Der Katarrh der weiblichen Geschlectsorgane. Hildebrandt-Monat. f. Geb., Bd. XXXII., S. 128. Macdonald, Angus-Edin. Med. Jour., June 1873. Naggerath-Latent Gonorrhoea in the Female Sex: Am. Gyn. Trans., Vol. I., p. 268. Ruge-Zeitschrift, f. Geb. u. Gyn., Bd. II., S. 29, and Bd. IV., S. 133. Schroeder-Op. cit., S. 460. Thomas-Op. cit., p. 211. Winckel-Arch. f. Gyn., Bd. II., S. 406.

VAGINITIS.

SYNONYMS.-Colpitis (Gr. Kóλπos, a fold); Elythritis (Gr. ëλUTpov,

a sheath).

NATURE AND VARIETIES.

Vaginitis is an inflammation of the mucous membrane of the vagina. The structure of this mucous membrane has been already described (v. p. 26). From its consisting of connective-tissue papillæ covered with several layers of squamous epithelium, it resembles the structure of the skin rather than that of a mucous membrane; it is a disputed point whether true mucous glands with ducts are present. Consequently, the inflammatory changes are more allied to those of the skin than to those of a mucous membrane (Schroder).

According to etiology, vaginitis is either simple or gonorrhoeal. Apart from the history, we cannot for certain distinguish between these (v. Etiology).

The clinical distinction between acute and chronic vaginitis is merely a question of degree.

iphtheritic vaginitis will be referred to by itself.

Senile vaginitis is one of the physiological retrogressive processes occurring after the meno-pause.

PATHOLOGY.

Vaginitis occurs most frequently in the form of slight elevations of the mucous membrane, which produce a granular surface. These granulations, according to Ruge, consist of groups of papillæ infiltrated with

small cells; these swell up and push before them the stratified squamous epithelium, the superficial layers of which are shed (fig. 307).

Fig. 307.

Granular vaginitis-acute form (Schroeder).

When the condition has existed some time, the surface becomes more equal through the thinning of the epithelial covering (fig. 398).

Associated with vaginitis in pregnancy, there is sometimes an emphysematous condition of the vaginal mucous membrane.

Winckel has

described cysts containing gas and fluid; according to Ruge, the air is present in spaces among the cellular tissue (fig. 309).

The cicatricial contraction of the vagina observed after the menopause, is due to a senile vaginitis. The epithelium is shed in patches, and the raw surfaces thus produced adhere together (Hildebrandt). This process is similar to that which produces occlusion of the cervical canal after the meno-pause.

Diphtheritic vaginitis occurs either as localised patches or as an In the latter case, the mucous affection of the whole vagina. membrane may be so swollen that the finger scarcely reaches the

cervix which also is found to be thickened and covered with the diphtheritic membrane.

ETIOLOGY.

The following are the most important causes :

Gonorrhoeal infection;

Irritating discharges from the uterus;

Injurious vaginal injections, badly-fitting pessaries or other causes
which injure the vaginal mucous membrane;
Exanthemata.

Gonorrheal infection produces the most intractable form of vaginitis, We have not space here to which may extend over months or years. discuss the question whether there is a specific poison in the gonorrhœal discharge.

Irritating discharges from the uterus, as in endometritis, produce a secondary vaginitis which can only be treated by curing the uterine affection. In carcinoma and vesico-vaginal fistulæ, vaginitis arises secondarily.

Among the causes which irritate or injure the vaginal mucous membrane, we mention injections of too hot or too cold water and of substances to produce abortion, badly-fitting pessaries, tampons or pieces of sponge which have been allowed to lie some days in the vagina. Vaginitis may also develope on a patient's entering married life, simply from awkwardness in sexual intercourse; on being consulted about such cases, we must remember that a simple vaginitis may produce all the symptoms of one due to gonorrhea.

Diphtheritic inflammation occurs usually in the puerperal condition and that through bad hygiene. It has been observed in typhus, smallpox, and cholera, and also in some cases of gonorrhoea. Localised diphtheritic patches are seen in fistula, in carcinoma, and round badly fitting pessaries.

SYMPTOMS.

These are the following:

A burning heat in the vagina;

Pain in the floor of the pelvis;

Frequent desire for micturition, with a scalding sensation while water is passing;

Free muco-purulent leucorrhoea.

These symptoms are present both in simple vaginitis and that due to gonorrheal discharge. In the latter case, the urinary symptoms are more pronounced; there is a distinct period from which all the symptoms commenced, their duration is longer, and they resist treatment; they are often complicated with those of endometritis, cystitis, or pelvic peritonitis.

DIAGNOSIS.

On vaginal examination, the finger recognises the discharge which escapes on separating the labia and, in many cases, the rough condition of the mucous membrane.

The speculum shows that the mucous membrane is inflamed and covered with muco-purulent discharge; the redness is usually in the form of patches but may be diffuse.

The appearance of the cervix must be noted to ascertain that the leucorrhoeal discharge does not come from it; the differentiation of discharge from the uterus and that from the vagina, is made as described on page 280.

The differential diagnosis between simple and gonorrhoeal vaginitis is often very difficult. The history of a distinct source of infection is the only certain guide, and the ascertaining of this is a very delicate question. Apart from this, the following conditions point to a gonorrhœal origin sudden development of vaginitis with urinary symptoms, in a patient who has had previously no marked leucorrhœal discharge; absence of any other cause to explain these ; protracted duration of symptoms and resistence to treatment. However convinced the practitioner may be in his own mind that the vaginitis is of a specific nature, the social unhappiness caused by his expressing a decided opinion should deter him from giving it in cases where a cause is not admitted.

Pelvic abscesses discharging through the roof of the vagina have been mistaken for vaginitis (Thomas). Such a mistake will not arise when the bimanual and other methods of examination are employed. We must not be satisfied with finding vaginitis; the whole routine exam