Inflammation of the Vagina.—Acute inflammation of the vagina is not a very common affection. Primary 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 recognized—the 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 boracic-acid solution (?j 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 (1:1000). 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 boracic-acid ointment (?j to ?j) 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 cylindrical epithelium, which is sometimes ciliated. The contents vary in consistency and color. They are often viscid, transparent, and of a pale yellow tint. They may contain pus or altered blood.

The origin of vaginal cysts has been much disputed. It is probable that they arise from the remains of the Wolffian canal—the canal of GÄrtner. In the embryo the transverse or longitudinal tubule of the parovarium extends to the side of the uterus and thence down the side of the vagina to the urethral orifice. It persists in this condition in some of the lower animals—the sow and the cow—and may also persist as a closed tube in woman. In such cases it may become distended and form the vaginal cyst.

The treatment of vaginal cyst is removal. If the tumor be situated near the vulva, it may be extirpated by careful dissection. If this operation be deemed impracticable, partial excision of the cyst should be practised. The tumor should be seized with a tenaculum, opened by the scissors, and part of the wall, with the overlying mucous membrane, should be excised. The interior of the cyst should then be packed with gauze.

Fibroid Tumors of the Vagina.—Fibroid tumors sometimes occur in the vagina. They are usually found in the upper part of the anterior wall. They are sometimes adherent to the urethra. They are usually of small size, but may attain a diameter of six inches. The treatment of such tumors is removal.

Cancer and sarcoma may attack the vagina, though these diseases as primary conditions are very rare. When possible, complete removal should be done.

Atresia of the Vagina.—Severe puerperal infection or mechanical injury, followed by extensive destruction of the tissues of the vagina, may result in a cicatricial narrowing or complete closure or atresia of the vaginal canal.

The symptoms of this condition are due to retention of the uterine discharges. There is no discharge of menstrual blood from the vagina. Attacks of pain occur periodically at the menstrual periods. A cystic tumor, which may be felt by rectal examination, is present. The tumor consists of the distended portion of the vaginal canal (hematocolpos), and sometimes of the distended cervical canal and body of the uterus. The contents of the hematocolpos are usually sterile, although they may become purulent (pyocolpos).

The diagnosis is readily made by vaginal and rectal examination.

Treatment consists in incision and excision of the vaginal septum and the suture of the vaginal mucous membrane above to that below the obstruction. In very severe cases it is difficult to maintain the patulous condition of the vaginal canal on account of subsequent cicatricial contraction. In such cases the repeated passage of vaginal bougies or the transplantation of mucous membrane has been resorted to.

Vaginismus.—The term “vaginismus” has been applied to a condition characterized by a spasmodic contraction of the muscles which close the vaginal orifice. The muscular spasm occurs reflexly when penetration of the vagina is attempted, as at coitus or a digital examination. The condition is due to dread of pain, and is usually the result of some painful local lesion, such as a urethral caruncle, fissures or sores of the vulva or anus, etc.; or it may be due to some painful condition of the tubes and ovaries. Similar contraction is observed in the sphincters of the anus when there is present a painful anal lesion.

Vaginismus has been said to occur in neurotic and hysteric women in whom there was no discoverable local lesion.

Treatment consists in the removal of any local cause of pain or irritation.

If the reflex spasm of the muscles persists when coitus is attempted, notwithstanding the removal or the absence of any discoverable local cause, operative measures have been advised.

Under anesthesia the vaginal entrance has been stretched by means of large dilators or the fingers, or the fibers of the sphincter vaginÆ have been cut on each side of the fourchette and a glass or vulcanite tube of suitable size has then been placed in the vagina and retained for two or three weeks by a perineal pad and T-bandage.

Vaginismus is a very rare condition. Operative treatment, except that which may be required for the removal of some local cause of irritation, is rarely, if ever, necessary.

Coccygodynia.—Coccygodynia is a rare affection characterized by pain in the coccyx and surrounding structures. The pain is caused by pressure, as in sitting, or by any movement involving the muscles attached to the coccyx. The disease is usually caused by traumatism, and in most cases is due to injuries to the coccyx in labor, as a result of which the bone is fractured or dislocated, and becomes fixed in an abnormal position. Sometimes osteitis or necrosis develops. In the unusual cases, in which no structural changes are detected, the condition may be due to rheumatism. Coccygodynia is very rarely found in men.

The diagnosis may be made by introducing the index finger in the rectum and palpating the anterior and lateral surfaces of the coccyx, and by moving the bone between the finger in the rectum and the thumb placed in the crease of the nates. The mobility, deformity, and tenderness may be readily determined. If a local lesion is found, and the symptoms have not yielded within a reasonable time to expectant treatment, removal of the coccyx by operation is indicated. The coccyx is exposed by a median incision, the bone is separated from its muscular and tendinous attachments, and is removed at the sacrococcygeal articulation with scalpel or scissors. If the articulation is ankylosed, it may be necessary to use the chain-saw. The wound is drained with a few strands of silkworm-gut and closed with interrupted sutures.

Operation should not be advised hastily. The painful symptoms are not always relieved by it. Operation should not be performed unless bony deformity or other distinct lesion is found.