Clinical Features.—The condition of the mucous membrane which is affected with the catarrh has much influence upon this. The changes incidental to advanced life, to the hyperplasia of gravidity, to pathological processes which have become stationary, may modify the picture greatly. Apart from these latter, the usual appearances in the adult non-pregnant woman are as follows: In acute catarrh congestive swelling prevail& The diffuse redness, re laxation, and tumefaction may affect the entire vagina, or may be limited to its upper or lower segments. The rugosities are less prominent, and the redness is most intense at their summits. With the naked eye, or more plainly with a ma.gnifying glass,' we can see that the papilla) are somewhat swollen and injected, causing a fine roughness and a dark punc tation of the vividly red surface of the mucous Nuembrane. Here and there minute extravasations are visible, and sometimes eroded strips or spots. The mucosa bleeds easily when touched, and is immediately Tetovered with secretion after its removal. The vagina often feels warmer than usual, and in acute catarrh the introitus is always sensitive. This tenderness is more marked when the catarrh has spread to parts in the neighborhood of the introitus; in which cases the swelling of the columna rugarum is always more marked, and the hymen participates in the swelling and redness. There are then frequently eroded spots on that membrane. If the catarrh affects especially the upper portion of the Taginal tube, the vaginal covering of the portio will participate in the process. Upon its surface the papilla) will appear as injected protru berances, and we will frequently see erosions of the os uteri and neigh boring structures.
While at the very beginning the secretion is scanty and serous, it is usually abundant, muco-purulent, and yellow in color by the time we ex amine the patient. Its reaction is generally faintly acid; it contains clesquamated epithelium cells, numerous leucocytes, cell detritus and various cocci and bacteria. These latter, which are found in the healthy vagina also, become important when pathogenic forms prevail. The gonococcUs of Neisser has been the most carefully studied of these organ isms, and the proof of its existence in any given case furnishes perhaps our best criterion as to the existence of gonorrhcea; since the clinical pictures presented by catarrhs of various origin are entirely alike, and the other criteria, such as the involvement of the urethra, are not always present' Naturally we must be cautious and not take cervical for vaginal secretion. The cervix should be closed with a small tampon, and the vagina first cleansed of the mixed sec.-136°n, before collecting the vaginal fluid for ex amination.
In chronic catarrh there are certain symptoms which show the long continuance of the affection, and especially the following: 1. The swelling and relaxation for a long period of time has caused an incre,ase in the mass of the mucous membrane, in consequence of which the relaxed wall is folded upon itself, with furrows containing the patho logical aecretion between the folds.
2. The mucosa is no longer evenly injected. Upon the grayish (pig mented) surface there appear circumscribed, red, vascular areas and apots, corresponding to the apices of the rugosities; and here and there we will see eroded places.
3. The papillEe are no longer so diffusely swollen, though to a greater degree than in acute catarrh. But it is especially in chronic gonorrhoeal catarrh that the hypertrophy of the papilla3 becomes very marked, even in non-pregnant women. It is seen in three forms. There may be papillary hypertrophy over large areas, giving the mucous membrane an even sandy appearance of a pale grayish color; or the papillEe may grow in circumscribed spots to form papillomata and pointed condylomata; or finally there may be a moderate and general papillary hypertrophy, giv ing rise to club-shaped protrusions, each one of which corresponds to a group of hypertrophic and swollen papillEe. These papillary granulEe cannot be microscopically distinguished from the granuhe which we will describe further on, in which the papillEe are not involved. Only the extent and the evidences of other changes enable us to decide as to the latter form.
The secretion in chronic vaginal e,atarrh may vary very much.. Some times it is abundant, cheesy, or purulent; at other times it is grayish white and mucoid. Even in the latter case it may contain many gonococci. The amount of epithelium present in the fluid is usually very great; there are leucocytes in varying quantity; in fact acute and chronic catarrh contain the same formed elements, their amount and relative proportion varying with the consistency and color of the secretion. In the cheesy yellow secretion of chronic catarrh, we not infrequently find the tri chomonas vaginalis which Donne has described, and &linker and Sc,an zoni have investigated; but we do not know that the occurrence of this infusorium bears any relation to the composition of the secretion.
Follicular Vaginitiy.—In exceptional cases of chronic catarrh we find as the most striking change of the mucous membrane the development of those round granula or noduli, whose origin is still a matter of dispute. Some authorities consider them to be lymphatic follicles ( Birch-Hirschfeld, Winckel); others, mucous glands (Thomas, Heitzmann); others again, papillary structures (Rokitansky, Bois de Loury, Costilhes, Kiwisch, Rage); and still others, circumscribed sub-epithelial inflammatory foci (Eppinger, Ruge). Clinically we must separate this form from the catarrhs accompanied by the usual papillary changes. Deville first characterized it as vaginite granuleuse; but it has been known as vagini tis granularis, follicularis, miliaris, psorelytrie, etc.