Etiology.-Old women are liable to have vaginitis without any other particular cause than their age. Young children often suffer likewise from vaginitis, due to the accumulation of old epithelial cells in the vagina, whence they do not easily escape on account of the smallness of the opening in the hymen. The great afflux of blood and formation of new tissue that take place in pregnancy lead very frequently to it. Even menstruation is liable to cause it, or make it worse if already present. Anemia and scrofula predispose to it. Often it accompanies eruptive fevers, especially measles. Direct causes are exposure to cold, especially sitting on a cold stone; excessive coition, masturbation, or rape; the presence of foreign bodies, especially pessaries; the use of too hot or too strong injections; operative interference; the irritation caused by urine or fecal matter entering the vagina through fistulæ, or by an acrid discharge coming down from the uterus or from a pelvic abscess. The most common cause by far of the acute form is infection with gonorrheal discharge in whatever way the infecting principle may enter the vagina.

Symptoms. The patients have a disagreeable sensation of heat in the vulva and the vagina. They have pain in the pelvis and the groins, which increases by walking or any other exercise. They complain of general malaise, and are often feverish. Micturition is accompanied by a burning sensation. Defecation may also be painful. The vagina is so tender to the touch that the introduction of a speculum causes great pain, and sexual intercourse becomes impossible. The mucous membrane is red and swollen. At first it is dry, but in a day or two a discharge begins, which first is mucoid, then mucopurulent, and finally consists of thick creamy pus. The vaginal portion presents a deep red areola around the os, which easily bleeds on being wiped, and a plug of thick muco-purulent matter is seen in the cervical canal. By pressing on the urethra a drop of pus is commonly brought out. The inflammation is apt to remain long in the upper part of the vagina. Sometimes it spreads to the vulvo-vaginal or the inguinal glands, where it may end in resolution or induration, or cause the formation of an abscess. At the menstrual periods the symptoms of vaginitis are apt to become more marked, and a decided exacerbation is caused by pregnancy and childbirth.

In chronic catarrhal vaginitis the symptoms have much less passed quickly through the flame, and placed from two to three minutes in a solution of gentian violet, prepared according to the following formula: to 10 cc. of water add 2 cc. aniline oil, shake well, and filter through moist filter-paper. To the clear aniline water obtained add 1 cc. of 97 per cent. alcohol and 1 cc. of a saturated alcoholic solution of gentian violet. The excess of fluid is drained off from the coverglass with filter-paper. Next, the cover-glass is placed for five minutes in Gram's iodine solution, which consists of iodine, 1 part; iodide of potash, 2; water, 300; and then placed directly into alcohol, 97 per cent., in order to wash out all the coloring matter. (Henry Heiman, "A Clinical and Bacteriological Study of the Gonococcus (Neisser)," New York Medical Record, June 22, 1895.)

intensity. The patient may, however, complain of a sensation of heaviness or smarting. The chief symptom is the discharge, which sometimes is more purulent, in other cases more mucoid. The vagina is of a dark red, bluish, or grayish color, and often the seat of erosions. The mucous membrane is thickened, folded, and often more or less prolapsed.

Vaginitis may have the chronic type from the beginning, or the chronic may be a continuation of the acute form. Gonorrheal vaginitis is particularly liable to become chronic, because the infecting element is retained in the urethral ducts, the ducts of the vulvovaginal glands, or the small vestibular glands.

The chronic form is often secondary, due to an irritating discharge trickling from the uterus, or of constitutional origin in scrofulous or chlorotic women. It is a frequent accompaniment of old age, and is quite common during pregnancy.

Diagnosis. The signs of vaginitis are so distinct that the disease is easily recognized. Still, the physician must be on his guard in order not to mistake for vaginitis a discharge from the interior of the womb due to endometritis, cancer, fibroma, or other affections of the uterus, or a pelvic abscess discharging its contents through a fistulous tract into the vagina.

The differential diagnosis between gonorrheal and simple non-virulent catarrh is of great importance, both as to treatment and from a medico-legal standpoint, but science, as a rule, does not warrant us in going beyond a diagnosis of probability in this respect. We try to obtain the history of the case. Very often the mere behavior of the patient furnishes already a strong suspicion that her conscience is burdened with guilt, and by following this hint the physician may be able to elicit a confession. Sometimes it is possible to examine the man who is the source of the infection. The presence of purulent ophthalmia in children of the family makes the gonorrheal nature of the vaginitis probable, the germs of the disease having been carried to the children by fingers, sponges, towels, etc. On the other hand, the presence of a gonorrheal vaginitis in a child may be traced to the same disease in the mother or other female member of the household, and thereby an innocent man, who is accused of rape, saved from unmerited punishment. There is no feature in the disease itself that with absolute certainty can serve to prove whether it is of gonorrheal origin or not. Severe cases of common catarrhal vaginitis produce a pus that is contagious. Certain circumstances, however, are more frequently found in gonorrhea than in non-specific catarrh. The mucous membrane is of a particularly bright red color; the discharge consists of thick creamy pus; as a rule, the cervical canal and the urethra are implicated; there is greater tendency to inflammation of Bartholin's glands; the development of vegetations, if the patient is

not pregnant, speaks also in favor of the specific nature of the case. The presence of recent tears and bruises may be of great importance as evidence of rape, in which connection it may be worth mentioning that, unfortunately, there reigns a wide-spread superstition among uncultivated men that a gonorrhea is cured by connection with a virgin, which often leads to assaults upon little girls.

The most conclusive proof is thought to be the presence of gonococci, but there are as yet so great differences between the views of bacteriologists on this subject, that it would be unjustifiable to base on the bacteriological investigation alone an assertion which may cause the conviction of an innocent man accused of rape or cast the opprobrium of infidelity on a faithful wife. From a clinical standpoint we must say there is always doubt as to the specific or non-specific nature of vaginal catarrh, and therefore, when called upon to give an opinion as experts, we must give the accused the benefit of the doubt. I have seen cases of urethritis followed by epididymitis where it was as sure as any human thing can be that neither husband nor wife had worshiped strange gods, and I have also seen a newly-married girl, of good family, æt. 17, get all symptoms of gonorrhea, inclusive of salpingitis, although the husband was examined by a prominent andrologist, who declared there were no gonococci, but many other kinds of cocci, in his urethra.

Prognosis.-Non-virulent catarrhal vaginitis is, as a rule, not a dangerous disease. The acute form yields readily to treatment: the chronic form may be protracted through years. Gonorrheal vaginitis is a much more serious disease than gonorrhea in men. It is true that urethritis, on account of the wideness, shortness, and comparatively straight course of the canal is cured more easily than in men, even without treatment, the mere gush of urine serving the purpose of a thorough cleansing. But, on the other hand, the disease is apt to linger in the folds of the vagina, in the deep depressions of the plica palmatæ, in the cervical canal, in Bartholin's glands, in the urethral ducts, and in the smaller vestibular glands, so that it is hardly possible to prognosticate its duration. If it extends up through the uterus and the tubes to the peritoneal cavity, it becomes not only a disease hard to cure, and sometimes calling for capital operations, but it jeopardizes of itself the life of the patient. Even in children it has become necessary to remove the appendages of the uterus on account of pyosalpinx due to gonorrhea. Apart from the danger to life and health, it is apt to cause sterility by closure of the tubes or by imbedding the ovaries in exudative inflammatory masses. If the woman conceives and gives birth to a child, the chances of catching puerperal infection are much increased, probably because the presence of gonococci facilitate the development of pyogenic microbes.

Treatment.-Patients affected with severe acute vaginitis should

stay in bed for eight or ten days, or at least lie quietly on a lounge. They should be given a saline aperient. Their diet should be bland in quality and moderate in amount. Vaginal injections of plain hot water should be given, and in order to reach all the recesses of the vagina it is best to stretch it by means of a wire speculum-e. g. Blakeley's resilient speculum. If the tenderness is so great that no instrument can be introduced, much relief is experienced by frequent hot alkaline affusions of the external genitals (borax or bicarbonate of soda 3j to Oj, with addition of tinct. opii 3j). To the water used for injection may be added emollient or aromatic substances, such as linseed meal or chamomile flowers. When the pain and tenderness subside and the discharge diminishes, bichloride of mercury (1: 5000) or chloride of zinc (1 : 100) are used. In pregnant women it is better, on account of the risk of mercurial poisoning, to avoid the corrosive sublimate, and use creolin or permanganate of potassium (1 per cent.) instead. Still later it is well to paint the affected part of the vagina with nitrate of silver in substance or in a strong solution (3ss-3j) twice a week. If the uterus is affected, that should be treated separately. If it is not, a tampon of absorbent gauze with astringent substances mixed with glycerin, such as subnitrate of bismuth (1 : 4), boroglyceride (1:16), tannin (1:8, see p. 178), is introduced, and changed every day. Iodoform gauze has also a very good effect, but has an offensive and tell-tale odor. After the nitrate of silver has been used several times, powdered boracic acid may be introduced through a speculum into the fornix vaginæ, and retained by means of a tampon. Antiblennorrhagic drugs (ol. santali, bals. copaivæ, and cubebs) are less well borne by women than by men, and should, therefore, be given in somewhat smaller doses. They should only be used in the subacute and chronic stages.

In chronic vaginitis astringent injections and applications are used. Extr. pini Canadensis, used on tampon, is praised. For chronic urethritis small rods made of iodoform and cacao-butter are introduced and squeezed against the walls. If the gonorrheal poison lurks in glands and ducts, these must be slit open, touched with pure carbolic acid, and dressed with iodoform gauze. For further information the reader is referred to the chapter on Leucorrhea (p. 250).

Exfoliative, or Epithelial, Vaginitis is a rare disease. It is mostly combined with exfoliative endometritis (membranous dysmenorrhea) and found in hysterical women. The vagina shows the usual changes due to catarrh. Membranes as much as an inch in diameter, and consisting of the epithelium and blood-corpuscles, are, with larger or shorter intervals, sometimes as often as twice a week, found lying loose in the vagina, or are easily detached from it without causing bleeding. At other times the membranes consist of coagulated fibrin, including blood-corpuscles and epithelial cells.

Astringents make the condition worse. General treatment, especially with bromide of potassium in large doses, has had better effect. Emphysematous Vaginitis (Colpohyperplasia cystica-Winckel).— Although not very common, this disease is frequent enough to have been observed by a number of different gynecologists, and some have treated several cases of it. A prominent gynecologist of this city has told me how puzzled he felt when he was consulted about a case of this kind, as he had not the slightest idea what it was. It is characterized by the presence in the upper part of the vagina and on the vaginal portion of numerous translucent, pink, gray, or blueish, soft cysts, varying in size from a millet-seed to a hazelnut. They are situated superficially, contain a serous fluid, and often gas. Some have a central depression. Sometimes they give a crackling sensation like emphysema. When pricked, the gas escapes with a distinct wheezing sound and the cyst collapses. The disease is most common in pregnancy, but has been found in virgins, but always in women suffering from profuse catharrhal discharge. It does not give rise to any symptoms, except that the introduction of the speculum is painful, and it disappears within two weeks after childbirth.

It is not definitely determined where the gas is found, whether in the interstitial connective tissue, in lymph-follicles, or lymphatic vessels; but it seems most likely that the condition is caused by stasis in veins and lymphatics, extravasation of blood, and decomposition of the same, with formation of gas. That atmospheric air should be drawn in and prevented from escaping by closure of the entrance seems hardly possible.

Treatment. In pregnant women no treatment is needed, since the disease causes no discomfort and disappears after childbirth. In others it has been recommended to pour dilute hydrochloric acid (1 per cent.) through a Fergusson speculum on the affected parts, or use injections with solutions of carbolic acid or corrosive sublimate.

Mycotic Vaginitis.-Two kinds of fungi may grow in the vaginanamely, Leptothrix vaginalis and Oidium albicans. Leptothrix consists in fine threads with oval spores. Oïdium has hair-like branches. It is probably the same fungus as the one forming thrush in the mouth.

Symptoms.-Leptothrix gives rise to hardly any discomfort. Oïdium causes sometimes intense pruritus, a burning sensation, swelling, discharge, and even fever. The disease may end in a few days, but may also last several weeks or months, especially in pregnant women. The mucous membrane of the vagina is red, tender, and studded with small white spots, which can only be removed together with the epithelium, and under the microscope prove to be composed of hyphæ and spores.

Etiology.-Vaginitis and pregnancy predispose to the development