PERIVAGINITIS PITLEGMONOSA.
A third group of inflammatory affections of the vagina is formed by phlegmonous perivaginitis (dissecans), where, in contra-distinction to vaginitis, not the mucous membrane, but the perivaginal connective tis sue is the chief seat of the process, the extension of which sequestrates the vagina, so that eventually, together with the vaginal covering of the cervix, it is thrown off. In the majority of cases both the mucous mem brane and muscular layers are affected. This rare affection was first de scribed by Marconnet, who saw two cases in young women, both of whom recovered. As .regards etiology there are no data. Although Minkie witsch's patient died of typhoid fever, as also Tschernfischew's, in the second case of the last observer there existed a febrile affection of three weeks' duration where no diagnosis was reached. Bizzozero's patient died of pneumonia. In the case recorded by Syromiatnikoff, and seen by Zirkun henko, gonorrhcea may have been the c,ause. At least, ells stated that two weeks before the onset of her disease, her husband complained of great pain on micturition, and that her disease began with leucorrho3a, and two days afterwards severe pain on micturition and fever set in. In the re maining cases (Marconnet, Wiegandt) no definite etiological factor was determined although all three cases appeared at the menstrual period.
In all the cases there was fever; in Marconnet's, Bizzozero's, Tscher niischew's cases there was slight hemorrhage; in the remaining cases there was only a purulent discharge. Great pain was present in all the cases; the labia were always swollen, and occasionally ulcerated. The vaginal mucous membrane was swollen, pale, and, except in Marconnet's cases, where the blood supply was not entirely cut off, it was discolored and necrotic. The expulsion usually occurred spontaneously, often at stool. Bizzozero removed the sequestrated skin by slight traction. With the exception of Minkiewitsch's case of severe typhoid, all recovered after suppuration and granulation. (Syromiatnikoff's case is not counted. among the fatal, since she was discharged cured, and died a few months later from rupture of a pelvic abscess into the peritoneal cavity.)
It is of interest that as much atresia and union of the granulating war fa,ces did not occur in all the cases as was to be expected.
In both of Marconnet's cases the vagina3 remained patent, although he only kept them a short time under observation. Tschernfischew's cases give us no data except that they were discharged cured. In the re maining cases great stenosis resulted in consequence of the peri-vaginitis; nevertheless in Wiegandt's case pregnancy ensued within a year.
The treatment aims, of course, at modifying the complications, and until the expulsion of the membrane it consists in the strictest possible antisepsis, camphor, iodoform, careful cleansing of the genitals. As soon as the separated parts can be removed without injury this should be done.
After expulsion the canal should be irrigated with carbolized water, and the like, and tampons smeared with some ointment should be inserted, or else iodoform gauze, to control the tendency to shrinkage.
In addition to peri-vaginitis phlegmonosa, there occur phlegmonous inflammations in the peri-vaginal connective tissue as the result of gravita tion of pus from pelvic abscesses. They are far more frequent, and or dinarily affect the posterior vaginal wall, although their seat depends on that of the primary affection, and hence may be met with elsewhere. These peri-vaginal inflammations lead rather to fistulous communications than to undermining of the mucous membrane. In the recto-vaginal septum perforation rather occurs towards the rectum than towards the vagina, in the median division; in the upper and lower division, on the contrary, they more frequently perforate into the vagina. The incom plete evacuation of the pus through the fistutous opening is the reason for the extension and chronicity of the process, and the treatment should aim at making a free outlet. Finally, we must refer here to the chronic peri vaginal inflammations which develop as the result of syphilitic ulceration in the rectum and from periproktitis, and which are characterized by cicatricial contraction of the cellular tissue, there existing fistulous com munication with the rectum.
Of the remaining infectious processes in the vagina we must still speak of: