out of the question. K. Schroeder has opened Douglas's cul-desac and removed the cancerous growth from the vaginal vault and wall of the rectum, uniting the wound by deep transverse sutures; two of his patients recovered.

But ordinarily one will be restricted to palliative treatment, partly in the form of disinfecting injections of solutions of salicylic acid, thymol, carbolic acid, or corrosive sublimate; when hemor rhage and decomposition occur, the actual cautery should be applied to the entire carcinomatous surface. Von Gruenewaldt removed a recurrent vaginal cancer with the galvano-cautery, but in so doing cut through a branch of the hypogastric artery, and the patient died from hemorrhage in a few minutes. In my last case I greatly lessened the hemorrhage and decomposition by the free application of the actual cautery; the diseased tissue was so extensive that any union of the wound made by an excision seemed impossible. After the operation if the loss of tissue be too great to admit of union, the bleeding vessels should be separately ligated, the wound cauterized with hot iron, and then tolerably firmly compressed with salicylated cotton. The tampon remains from 12 to 24 hours, and the wound is then treated as in case of cancer of the uterus.

In pregnancy and during labor the treatment will depend upon the size of the tumors; small ones may be left until two or three weeks after labor and then excised. Schroeder claims that the larger ones should be excised during labor, while Spiegelberg and Fritsch recommend Cæsarean section for the sake of the child.

CHAPTER V.

NUTRITIVE DISTURBANCES OF THE VAGINA.

WE distinguish eight varieties of imflammation of the vagina, namely, catarrhal, gonorrhoeal, mycotic, gummatous or syphilitic, croupous and diphtheritic, dysenteric, erysipelatous and vesiculoherpetic.

1. VAGINAL GONORRHOEA AND CATARRH.

Vaginal catarrh may be acute or chronic. In the acute form the mucous membrane is congested, swollen and relaxed, and the columns more marked. The secretion is profuse, at first transparent, but soon becomes clouded, milky and purulent. The epithelium is exfoliated in large masses. The papillæ are swollen; they appear as nodules the size of a millet seed on the summits of the folds, and also over the whole extent of the vagina, giving it an irregular, uneven and rough surface like a file. The swelling of the papillæ in groups is caused by a small-celled infiltration, the superficial layers of their epithelium being exfoliated, so that the deep layers alone remain. At first they are rather pale in color, and situated upon a dark red surface, but they soon become brown or cherry-red, then black from extravasation of blood, and may bleed somewhat when the tender epithelial covering is removed by the examining finger or speculum. Beside this papillary swelling, the muscular tissue or even the paravaginal connective tissue may be cedematous, and the inflammation extend to the walls of the bladder and rectum. The secretion has usually a strongly acid reaction, and often contains the previously described trichomonas vaginalis, in addition to pavement epithelium, mucus, pus corpuscles and rod-shaped bacteria. In gonorrhoeal colpitis the diplococci or gonococci of Neisser are also found. The latter are remarkably large round micrococci, 0.83 mm. in diam., deeply colored by methyl violet, lie by the side of each other, or in groups, several discs of which may be enveloped by mucus, thus forming a colony. This catarrh may affect the entire vaginal canal or only parts of it, in the latter case, generally the lower portions, or the part surrounding the vaginal portion. Catarrh of the uterus, of the vulva, and particularly of the glands of Bartholin, may be associated with vaginal catarrh.

When this affection has become chronic the swelling and the dark red velvet-like character of the vagina are diminished, the mucous membrane becoming more livid in color; the dark-brown spots become slate-colored; the secretion is creamy or greenish and

purulent, often containing the trichomonas vaginalis; the papillary swelling and the unevenness of the surface are less marked.

Symptoms.-A feeling of internal heat, pressure, chilliness and increased secretion are the first symptoms. These soon increase in severity, and are followed by fever, pain in the uterus, desire to micturate, and difficult defecation and coition. The discharge becomes more profuse, produces excoriation of the adjacent parts, and adheres to the hairy portion of the vulva, where its decomposition may cause a very disagreeable odor. Coition is impossible on account of the pain. The urine coming in contact with the inflamed and eroded parts of the introitus causes a violent burning pain. Retention of urine accompanies the severer forms of the affection. The patient is annoyed by desire to go to stool, or by pain during defecation. This condition may last two or three weeks, and she is debilitated by the profuse secretion, fever and pain, after which the disease may subside, or pass into the chronic state. In chronic catarrh attention need be called only to the profuse secretion and its consequences. The patient is weak, becomes pale, has rings about the eyes and anorexia, and is constipated; coition, while no longer so painful, causes some suffering. Conception is rendered more difficult, not only for the reason just given, but because the discharge destroys the spermatozoids.

A diffuse acute or chronic vaginal catarrh is rarely uncomplicated. In 30 cases in girls under eighteen years, Boys de Loury found 20 complicated with vulvitis. It is still more frequently associated with endometritis, or the latter supervenes when the catarrh has been protracted. Other complications will be named when we consider the etiology.

Diagnosis.—When the labia are separated so that the lower part of the vagina is exposed, catarrh of the mucous membrane may be recognized by the naked eye; and from the previous description, it can be known if the disease is acute or chronic. To determine whether the whole vaginal canal or only a part of it is affected, the vagina must be examined by means of specula, or of various retractors.

APPENDIX.

Vaginal and Uterine Specula.

Historical.-Galen* is apparently the first writer who mentions the vaginal speculum. It has been asserted that Aretaust was acquainted with it, because he described ulcerations of the uterus and their treatment; but this conclusion is not justifiable, for what was then called the osculum uteri was really the introitus of the vagina. Aetius knew of the speculum, and often used it; but the instrument was known long before his time, because two and three-bladed specula have been found in Pompeii and Herculaneum.

Jacob Rueff, in his treatise,§ gives an illustration of a threebladed speculum, which he called a speculum matris, and which he used to dilate the os uteri during labor. The speculum was then forgotten until it was discovered or rather reinvented by Récamier, when it rapidly passed into general use. Carl Mayer introduced the milk-glass speculum into Germany, and Fergusson, the silvered-glass speculum into England. Further, Simon, Metzler, and Sims began to use the duck-billed speculum, which led to the many varieties and improvements of the present day.

Varieties. The forms in general use, are the simple and double tubular, one, two, three and four-bladed, and single and double duck-bill speculum.

Any one of these may be with or without a handle, and may be provided with an obturator, or lever and screw, to separate the blades. In order that as much as possible of the vaginal walls may be seen after the speculum is introduced, it is composed of several parts, or made of glass, or fenestrated.

The cheapest and simplest variety for many cases, particularly if the vagina is large and not sensitive, or for the long vagina of pregnancy, is the tubular speculum of milk-glass or of hard rubber. Fergusson's are more expensive, and they illuminate poorly when there is a bloody discharge. The tubular speculum

is not a suitable form when the vaginal portion is drawn backwards and fixed, in retroflexion or in any other condition where it is hard to engage, since one must have a certain size for each case, and then it is sometimes impossible to bring the portion in view by the largest instruments. Moreover, they must be kept by the patient in case remedies are to be applied through them.

Those patients who have noticed what a difference there is with regard to the introduction of the instrument between these and the two-bladed Cusco speculum, invariably prefer the latter. Its most important advantages, however, are the ease and certainty with which the vaginal portion may be engaged, after one has ascertained its direction by touch, and, secondly, when the portion is once engaged, the speculum is self-retaining. Two or three differing in length and width will suffice for almost all

cases.

The blades of Cusco's speculum are placed on the anterior and posterior walls of the vagina.

The duck-bill specula introduced by Sims and Simon, which have contributed so much to progress in the diagnosis and treatment of vaginal and uterine affections, were not devised by them, but, as Schuppert (of New Orleans) has shown, by Metzler in 1846. The latter described his instrument as follows: A silver or plated vaginal speculum which consists of a gutter-shaped conical blade measuring five inches and a half, the lower half of which had a sharp outward curve.

In order that the blades might be separated as widely as possible without being hindered by the screw, Bozeman had a speculum made for his fistula operation, which was to be introduced in the knee-elbow position; the blades are to pass along the sides of the vagina, and have two arms attached to them perpendicular to their long axis which can be separated by a screw. In Smith's and in Goodell's speculum the blades are separated in parallel lines by screws, or may be made to diverge by means of the lever, the screw fixing them in either position: this is an improvement.

The most recent instrument is that devised by Massari. It is to be introduced in the lateral posture, the shorter, more curved blade being for the anterior vaginal wall, the flatter, wider and