CHAPTER IV.

DISEASES OF THE VAGINA.

Primary

Inflammation of the Vagina.-Acute inflammation of the vagina is not a very common affection. 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 recognizedthe 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.

In simple vaginitis the inflamed membrane remains. smooth.

In granular 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 vaginitis is 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 the

patches 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.

The emphysematous form 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 bo

racic-acid solution (3) 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 (11000). 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 boracicacid ointment (3j to 3j) 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 with

below 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).

The vagina passes through these structures. They surround and support the ostium vaginæ as the fascia and muscles surround and support the opening of the

FIG. 20.-Dissection of female perineum, showing the deeper structures after removal of the levator and sphincter ani muscles.

rectum or the anus. The muscles and fasciæ are attached in the median line between the anus and the vagina, and therefore this part of the body, which is called the perineum, is supported or maintained in its proper position by these various structures. The transversus perinæi arises from the ramus of the ischium and

is inserted in the perineum. The bulbo-cavernosus, or sphincter vaginæ, arises in the perineum and is inserted in and about the clitoris. The inner fibers of the levator ani arise from the symphysis pubis and are inserted in the perineum and the lower part of the vagina (Fig. 20). When these muscles contract, their action, therefore, is to draw the perineum upward and forward. At the same time the anus is drawn upward and forward, and so also is the posterior margin of the ostium vagina and the lower portion of the posterior vaginal wall.

The vagina has no circular sphincter like the anus, but the vaginal mouth is kept closed by the action of the transversus perinæi, sphincter vaginæ, and levator ani muscles, which draw the perineum forward, and thus keep the posterior vaginal wall in apposition with the anterior wall.

This sling of muscles and fascia, which surrounds and supports the opening of the vagina, may readily be felt in