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inflammation. Erysipelas is rare in adult life, and indeed may be said to occur most frequently in the very earliest infancy. In its local treatment sugar-of-lead lotions may be applied, and internally tonics and stimulants. The prescription which has given me the most satisfaction is as follows: Borax, one drachm; tincture of opium, one ounce; glycerin, three drachms; and water, three ounces. The parts should be kept constantly moistened with this.

Diphtheria of the vulva occurs in some cases when the exudation exists in the pharynx or larynx, and rarely as an independent disease. Its treatment is constitutional.

Noma, or gangrene of the vulva, is perhaps best considered in connection with the eruptive diseases. The first indication is a swelling of one of the labia majora, which becomes of a grayishgreen color, followed by vesicles; the color changes to brown, and gangrene rapidly sets in.

Causation.-Noma occurs in children whose general health is poor, either from insufficient and improper food, or from having lived in squalid tenement-houses; or, indeed, from both combined. It may also occur as a complication of one of the contagious diseases— scarlet fever, measles, or small-pox.

The prognosis in noma is very grave.

Treatment. This should be directed to sustaining the failing powers of the patient. For this purpose quinine, iron, and stimulants should be freely administered, and antiseptic dressings applied to the affected parts. It has been recommended to excise the gangrenous tissue, and to apply the actual cautery to the underlying parts.

CHAPTER VI.

DISEASES OF THE VAGINA.

Anatomy of the Vagina. The vagina is the continuation of the genital tract from the uterus to the vulva. It is curved to coincide with the axis of the pelvic excavation; this, to some extent, renders it much shorter in front than behind. The anterior wall is about two inches long, while the posterior is nearly twice that length. The anterior wall is further shortened by the cervix uteri which joins the vagina much nearer to the vulva in front.

Fig. 59 shows the comparative length of the vagina in front and behind..

The vagina is attached above to the cervix, about midway between the body of the uterus and the termination of the cervix uteri. Below, it unites with the floor of the pelvis and the structures which

cervix

posterio

than behind.

form the vulva. Anteriorly, it is FIG. 59.-Length of vagina, less in front

united to the bladder and urethra ;

Skin

to the former loosely, and to the latter so firmly that it is almost impossible to separate these structures even by dissection. Posteriorly, the vagina and rectum are united and form the rectovaginal septum. Below, they are separated by the sphincter-ani and tranversus-perinei muscles and cellular tissue. Fig. 60 shows the triangle formed by the bifurcation of the two canals and the divided muscles between them.

[graphic]

FIG. 60. Triangular shape of perineal body.

The vesico-vaginal septum is the most resist

ant portion of the vaginal walls, and, when put upon the stretch, feels like a cord lying beneath the mucous layer; this is called the anterior column of the vagina.

The vaginal walls are composed of three coats-an external, middle, and internal; the external consists of fibrous, elastic, and areolar tissue the middle of unstriped muscular fiber; and the internal of mucous membrane. The muscular coat is continuous with the middle coat of the uterus, and the two are alike in structure, and in the fact that they both undergo extraordinary hypertrophy during utero-gestation. The mucous membrane of the vagina is continuous with the endometrium, but differs from the latter in structure to a marked extent. It is arranged in transverse folds, which are most prominent anteriorly, and is studded with papillæ and covered with pavement epithelium. In general structure the mucous membrane of the vagina resembles very much the skin. This is noticeable in cases of prolapsus, in which the membrane, by being exposed, becomes dry and its epithelium hardened.

The structure of this membrane is like the skin to some extentits secretion is serous and of acid reaction. There has been some discussion among anatomists regarding the presence or absence of muciparous glands in this vaginal membrane. The fact is that they are abundant in the lower third, but nearly absent in the middle and upper thirds.

The vagina is developed like the uterus, from Müller's ducts, and is liable to malformations from arrest or defects of development.

Malformations of the Vagina.-Imperforate hymen has been al ready discussed under the head of menstrual disorders due to malformations of the sexual organs generally.

Double vagina usually occurs in connection with double uterus, and in such cases no harm to the patient is likely to result.

Perpetuation of the septum between the most dependent portions of Müller's ducts has been found. In one patient who came under my observation a thick septum extended from just within the hymen upward about an inch and three quarters. This malformation gave rise to no symptoms, and was not recognized until the birth of her first child, when the attending physician found that it caused some obstruction to delivery. I examined the case about two months after her confinement and found this septum, about a quarter of an inch thick and quite resistant. It was divided by two incisions parallel to the axis of the vagina, and about three quarters of an inch apart. The strip thus removed was not the whole of the septum, but it was sufficient, as the ends remained contracted. The

divided edges were brought together with sutures, and healing took place very promptly.

Imperforate Vagina.-Absence of the vagina has been described as one of the malformations, but it is doubtful if there is not in these cases a rudiment of vagina, which is imperforate, and hence absent to all intents and purposes. In the most complete case of the kind that I have seen the rectum and bladder were near together. With the finger in the rectum, and a large sound in the bladder, a rather dense cord running upward from the vulva could be felt. The uterus was also rudimentary, and although the patient had passed the period of puberty, and had the outward characteristics of her sex, she had never menstruated. This was evident from the absence of menstrual flow in the uterus and Fallopian tubes.

In cases like this nothing can be gained by treatment. So long as there is no excessive menstruation, which would endanger the life of the patient, there should be no interference.

Atresia of the Vagina. This is the more common affection. It may be either complete or partial, congenital or acquired.

In the congenital form the atresia may extend the whole length of the vagina, and that condition is generally associated with an undeveloped uterus. The incomplete, or partial, atresia is usually at the lower third, but it may occur at the upper or middle portion of the vagina.

Congenital atresia occurs under two different conditions. The one is associated with defective development of the uterus or ovaries, or both, sufficient to prevent menstruation altogether. In the other, menstruation takes place, but the flow being obstructed, accumulation occurs in the uterus and sometimes in the Fallopian tubes. These differing conditions require different management. I will therefore consider them separately.

Atresia of the vagina, with defective development of the uterus and ovaries, is only of interest with reference to the diagnosis. Nothing can be done, nor is there any active demand for treatment. The patient does not suffer, as a rule, except from the consciousness of her deformity, which would only cause mental distress in case she intended to get married.

Two such cases have come under my observation. The most typical one was of a good family, strong, but inclined to flesh. She did not change much in general appearance at puberty, but maintained considerable of the masculine type. She never showed the slightest disposition to menstruate. She was asked by a worthy man to marry, but she was afraid to do so without advice, knowing

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that she was "unlike other women.' She sought advice, and on examination there was found atresia of the vagina, and apparently the uterus and ovaries were rudimentary. Nothing could be done to help her. She took up nursing as a profession, and has succeeded remarkably well. This case is briefly given in order that this variety may be contrasted with the next form.

Atresia associated with fully developed uterus and ovaries may be complete or incomplete. Usually, there is no notice taken of the deformity until puberty arrives, unless the attention of the mother or physician is directed to the pelvic organs for some other reason. There are no symptoms until puberty. Then the patient, after having undergone the changes characteristic of the period, has all the symptoms of menstruation without the flow.

The symptoms, or menstrual molimen, as they are called in their totality, are more marked than in normal menstruation, and great pain, fullness, and tenesmus, come on during the period. The first effort at menstruation is not usually attended with such severe suffering, but each succeeding period is worse, and very soon the evidences of the accumulated fluid become tangible.

Physical Signs.-Inspection of the parts shows a complete closure of the vulva. Combined touch with a straight sound in the bladder and a finger in the rectum, reveals the fact that in absence of the vagina the rectal and vesical walls come together, and are thin and elastic. If the vagina is present, but closed, it is felt between the sound and finger as a firm cord. When the uterus is distended with menstrual fluid, the accumulation causes a tumor, which is elastic and obscurely fluctuating. The signs of partial atresia differ according to the location of the occlusion. When the atresia is in the upper third of the vagina the lower portion of the canal ends in a cul-de-sac. If the atresia is at the lower third, the obstruction is found below, and, by means of the sound in the bladder and the finger in the rectum, the upper portion of the vagina is found distended with menstrual fluid.

Causation. Congenital atresia is produced by some arrest of development or disease during embryonic life. When it is acquired between birth and puberty, it is usually due to acute inflammation occurring in connection with some constitutional disease, such as scarlatina, diphtheria, or measles.

Gangrenous vulvitis and vaginitis, which may occur in the course of any of the above-named diseases, may also terminate in atresia. I have seen two cases of partial atresia, caused by some acute inflammation during the course of typhoid fever, occurring near the period of puberty.

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