vaginitis, but

said also to be occasionally consequent on there is much doubt if such is ever the case. On the side of the urethra, also, cystitis is said to follow urethritis. As this happens in men, it is also possible in women; but it is never observed. In the vulva the irritation of the surface often causes suppuration of the sebaceous follicles and abscess in Bartholine's glands.

Vaginitis, which is the most common of all venereal affections among the lower classes, is much less often seen by the surgeon in its early acute stages than in the chronic form, or as an extension from the point and form by which it commences. Among my out-patients at the Lock Hospital, out of 157 cases of non-syphilitic venereal disorders, 94 had vaginal and uterine discharge, without ulcers of the external genitals, but the vagina was acutely inflamed in only 19 of them; in the rest the inflammation had become chronic by the time they applied for relief.

Acute vaginitis may be set up by several causes, besides contact with gonorrhoeal matter. Violent sexual intercourse, especially when that is much repeated about the menstrual period, often causes inflammation of the mucous membrane. Vaginitis is also commonly seen in children who have been subjected to criminal attacks, and it may occur in newlymarried women. The presence of foreign bodies, such as a sponge, or pessary, or strong injection, when used for some disease of the uterus, will cause vaginitis, but inflammation thus engendered will often subside readily if the cause is removed; the acute vaginitis of contagion is more violent, and consequently more prone to become chronic before it subsides. Acute vaginitis will sometimes arise in the course of measles or small-pox, or after exposure to damp and cold. Chronic vaginal catarrh may be produced by chlorosis, by congestion of the hæmorrhoidal and uterine vessels, and other conditions in weakly women.

Gonorrhoeal Vaginitis.-The inflammation of the vagina produced by the gonorrhoeal discharge is not different from that caused by any other irritant; hence the symptoms are merely those of vaginitis, at first in an acute form, and afterwards becoming chronic before it ceases altogether.

The

Symptoms. A few days after coitus, a tickling sensation changing to heat and burning, occupies the external genitals. The mucous membrane grows dry, brightly red, and tender, the labia swell, and cause discomfort or pain in walking. Sometimes even sitting down must be cautiously done to avoid pain; scalding with micturition is usual. The swelling often becomes considerable by the oedema extending throughout the external genitals; a condition which corresponds to balanitis in the male is thus produced. Dull aching pain in the sacral region, and in the limbs or body generally, is not infrequent when the attack is severe. discharge is at first thin and watery, and small in quantity; but it soon grows whitish yellow, or even greenish in colour, of an offensive odour, and so profuse that it flows copiously from the vagina when that is opened by the finger. If the finger is passed into the vagina, the papilla are felt to be prominent and distinct on the fore part of the mucous membrane. When the speculum can be introduced, the mucous membrane of the whole vagina, and often over the vaginal portion of the uterus, is seen to be bright red, while around the os tincæ it may be raised into a group of papillæ, which gives the cervix a strawberry-like appearance. These papillæ or granulations are sometimes. ulcerated, and then form yellowish dots about the margin of the os uteri. The cul de sac behind the neck of the uterus is generally filled with thick yellow matter, and the epithelium of the whole of the vagina is easily abraded, SO that it bleeds if any roughness is employed in using the speculum. When the inflammation is very intense, the

constitution participates in the disturbance. There is loss of appetite, thirst, hot skin, pains in the limbs and restlessness, with other signs of fever.

When the acute congestion and copious discharge have continued a few days the irritation subsides, the discharge is whiter, the mucous membrane assumes a somewhat livid hue and is very lax; here and there, patches of it are excoriated or even ulcerated. The granular condition is still present, and generally very distinct. If the patient avoids fresh irritation, the discharge gradually gets less in quantity and more like the natural secretion, and the parts return to their ordinary condition in two or three weeks. But this termination is often missed; and the inflammation before it ceases, changes its ground to the urethra, or neck of the uterus; or it may still hang about the upper part of the vagina, when it has ceased near the entry. The glands of the groin often swell and grow tender while the vaginitis is at its height; or the irritation may even proceed to abscess, which is simply sympathetic and never virulent. This complication is much more frequent when the vulva as well as the vagina is inflamed, but it is not necessary it should be so.

Granular Vaginitis.-This variety, which was at one time supposed to be peculiar and distinct from ordinary vaginitis, appears to be simply the result of the congestion of the mucous membrane being greater in certain parts than in others, and always accompanies the ordinary form.1 It is most usually seen in pregnant women, especially when they are about twenty-eight to thirty years of age. If this condition is produced, the mucous membrane is dark purplish in patches, and dotted with little granular elevations of a darker hue than the surface they spring from.

1 Scanzoni: Traité pratique des maladies des organes sexuels de la femme. Traduction française, p. 449. Baillière, Paris, 1858.

As they have but very slight prominence, these little elevations may be bathed in discharge and escape notice, unless the vagina is cleared by an injection or by wiping it with a dossil of cotton-wool. The cervix uteri is very often the seat of these little granulations, and, as before said, will give that part a strawberry-like appearance. Granular vaginitis has the same course, duration, and termination as the ordinary form, and requires similar remedies; but is a sign of obstinacy in the inflammation.

The diagnosis of vaginitis from other disorders is seldom a difficult matter. The bright red mucous membrane which secretes serous pus, or thick matter, and is tender and bleeds if chafed, distinguishes vaginitis. The mere presence of pus in the vagina is not sufficient to diagnose vaginitis, as the matter may come from an abscess in the wall of the vagina, or from an ulcerated tumour of the uterus; but the speculum shows at once if the discharge come from such a cause. It may be impossible to say, when the vaginitis has no complication, whether it arises from contagion or from other causes; nor is the infectious nature of the secretion peculiar to gonorrhoeal vaginitis, as it is tolerably certain, that the discharge of any vaginal inflammation is more or less contagious. The only condition on which reliance can be placed, is the co-existence of urethritis with the vaginitis. This complication very rarely follows any vaginal inflammation than that produced by contagion. Indeed, Guèrin1 still maintains that gonorrhoea alone produces urethritis, and that urethritis is the inevitable consequence of vaginitis from contagion.

The prognosis of vaginitis is very favourable when it is not neglected, or allowed to extend to the urethra or uterus. If, on the contrary, it reaches the urethra, it causes obstinate

1 Maladies des organes génitaux externes de la femme, p. 303. Paris,

urethritis; and when the uterus is also inflamed, the disease is more difficult to treat, and the suffering of the patient is greatly increased, while there is some risk of pelvic peritonitis or abscess in the wall of the vagina, though these results of gonorrhoea are exceedingly rare.

A more interesting question to be decided is, the possi bility of a particular discharge communicating gonorrhœa. This is often extremely difficult to settle; very often the discharge becomes apparently merely mucus, yet retains the infectious quality very strongly. Again, the greater part of the vagina may have recovered its natural condition, while a certain small area, the cul de sac behind the uterus, for instance, still secretes a contagious discharge. Guèrin believes that the urethra, and some of the ducts of the glands in the vulva, may continue long inflamed after gonorrhoea; then if the genital organs are irritated, or unusually excited, these small foci of disease may secrete matter in sufficient quantity to propagate the disease, if sexual intercourse be indulged in at the time.

The discharge at the chronic stages is generally whitish, milky, even creamy, or translucent like gum, when the congestion is very slight; the reaction is always acid. The discharge consists of pavement epithelium, pus, and mucus corpuscles, and very often infusoriæ; one of them, the trichonomas, was at first supposed to distinguish a gonorrhoeal from simple vaginitis, but Scanzoni has detected them in every form of abnormal vaginal discharge, though not in healthy mucus.

TREATMENT OF VAGINITIS.

Attempts to cut short the inflammation at the beginning by any kind of abortive treatment, are seldom of any avail. While the swelling and irritation continue, the patient must