vaginal canal and cervix with hæmatometra. The septum which separates the urethra and bladder from the rectum is split up so as to form a new vagina, and the cervix is thus exposed. To form the new cervical canal, Breisky employs a knife-edged trocar running in a canula. The canula is pressed firmly against the cervix, and the knife is run out piercing through the cervix into the dilated uterus above; the canula is then run on the knife into the cavity, and the knife withdrawn. The contents of the sac escape through the canula. The forceps represented at Fig. 305 are now passed in with one blade on each side of the canula. They are forcibly opened so as to distend the new canal still further, and they serve to keep it patulous while the canula is withdrawn and the tube represented at Fig. 305 inserted in its place. This tube has two channels; into one of

these a nozzle (Fig. 305) fits and is employed to pass the stream of water into the sac, while the outflow takes place by the other.

4. Atresia of One Half of a Septate Uterus and Vagina.-This form of atresia has certain characteristics which distinguish it from the other forms described above.

The chief peculiarity is that it presents the phenomena of free menstruation those of retained menstruation.

The pathological condition is apparent from Fig. 306. Spontaneous rupture of the septum with escape of the retained fluid (in this case through the patulous uterus or vagina) occurs more frequently in this than in other forms of atresia; rupture of the Fallopian tube, with its fatal consequences, is also a more frequent occurrence (Puech). The spontane

ous rupture of the septum does not usually occur at its lowest point; hence there is liability to accumulation of purulent matter in the pouch below the point of perforation, which is a source of septicemia.

The symptoms are the same as in the other forms of atresia, but they are marked by the presence of a menstrual flow. This visible menstruation is often irregular, and profuse leucorrhoea (from the patulous cavity) is frequently present.

The physicial examination shows a fluctuating tumour lying beside the uterus and alongside of the patulous vaginal canal. Sometimes it winds in a spiral manner round the latter.

The diagnosis is not difficult if the blind sac extend to the ostium vagina and is 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 (Schroeder). 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, Vol. I.), both halves being pervious so that there are no symptoms. Traces of a septate condition may persist as bands.

CHAPTER XLIV.

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. Noeggerath-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. κóλños, a fold); Elythritis (Gr. Avrpov, 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. Vol. I., p. 27). 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 (Schroeder).

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.

Diphtheritic vaginitis will be referred to by itself.

Senile vaginitis is one of the physiological retrogressive processes occurring after the menopause.

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

Fig. 307.

Granular vaginitis-acute form (Schroeder).

epithelium, the superficial layers of which are shed (Fig. 307). When the condition has existed some time, the surface becomes more equal through the thinning of the epithelial covering (Fig. 308).

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 menopause.

Diphtheritic vaginitis occurs either as localised patches or as an affection of the whole vagina. In the latter case, the mucous 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, which may extend over months or years. We have not space here to discuss the question whether there is a specific poison in the gonorrhoeal 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