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SUMMARY.

Vaginitis is acute and chronic. The inflammation begins at the fore part of the yagina, and extends over the vagina to the uterus, and over the vulva to the urethra. In doing this it sometimes produces abscess of accessory parts. In the cervix uteri and the urethra it becomes chronic and very obstinate. When seen by the surgeon the acute stage is usually over, and the chronic catarrh remains. The causes of vaginitis are chiefly contagion; next, violent sexual indulgence, rape, the irritation of foreign bodies left in the vagina, and certain disorders, such as measles. Chronic catarrh, besides being a relic of gonorrhoea, is common in chlorotic women or others subject to cold and damp, and to congestion of the pelvic bloodvessels. Acute vaginitis causes swelling of the genitals, with heat, itching, smarting on making water, and aching pain at the sacrum and loins. The mucous membrane gets dry and bright red; at first, it secretes thin, transparent mucus, which quickly becomes thick, creamy matter, and copious in quantity. The mucous membrane is more or less studded with little eminences (vaginitis granulosa). This condition is especially well seen if the patient is pregnant. The inflammation subsides by becoming chronic; the pain, swelling, and congestion cease, but the discharge, though less creamy than before, remains plentiful. It is usually secreted in the cul de sac, or in the cervix, or some other part less easily cleared than the anterior part of the vagina. The diagnosis of vaginitis depends on the swelling and red congestion, in the acute stage; on the partial congestion, excoriation, and copious discharge, in the chronic stage. The discharge may come from the cervix, or it may come from an abscess in the wall of the vagina; but the introduction of the speculum soon makes this clear. The distinction between vaginitis from

contagion and vaginitis from non-specific irritation is often difficult, and sometimes impossible; it generally has a contagious origin if there be urethritis present also. The prognosis is favourable; sometimes the disorder is cured before it becomes chronic, and dangerous complications are very uncommon. Great difficulty exists in deciding whether a particular discharge is likely to communicate disease. Probably any discharge, however scanty and serous it may be, provided it is the remnant of inflammation from contagion, will be again contagious if increased by accidental irritation. The treatment during the acute stage consists in allaying irritation, by rest in bed, repeated warm baths, injections of warm water, and moderate purgation. As the congestion subsides, an astringent injection and the alum or tannin in powder must be applied, by means of the speculum, to the interior of the vagina. Copaiba and cubebs are useless in treating vaginitis; the only general treatment of any value is regulation of the general health and habits of the individual.

The Complications of Gonorrhoea.-Among the earliest is vulvitis; the labia and clitoris grow red, swell, and a fœtid discharge is secreted by the mucous membrane. If irritation is allayed by baths and clean applications, the inflammation subsides in a few days. Sometimes when neglected it causes sloughing of the parts, or abscess in the groin. Urethritis is the most constant, and, according to some, an inevitable consequence of gonorrhoeal vaginitis. It is rarely acute enough to cause much irritation. It is marked by itching and smarting at the meatus, which is red and swollen. A purulent or mucous discharge oozes or can be pressed from the passage, unless the patient has just micturated. Even then a little can be found in the ducts of two glands. which open close to the meatus. This discharge is very persistent, and probably continues a source of contagion for a long time after the discharge from other parts has

ceased. Unlike male urethritis, inflammation of the female urethra does not excite cystitis. The best treatment is frequent baths, weak astringent injection, and the application of caustic, either in a concentrated solution, or by a pencil of solid nitrate of silver. In acute inflammation of the cervix and os uteri, the neck of the uterus is swollen, red, and often excoriated about the os, whence a copious discharge issues, at first clear and viscid, then purulent. This subsides in a short time to a thin mucus, and either shortly ceases, or more commonly passes to chronic catarrhal flux, that lasts an indefinite time, and long retains its contagious quality. Acute inflammation of the cervix is best treated by complete rest, warm baths, warm injections, and saline aperients. In the chronic stage its treatment is that for uterine catarrh. Metritis and perimetritis are observed in a certain number of cases, but these are rare consequences of gonorrhoeal inflammation of the mucous surfaces, and have no peculiar characters when originating in this way.

DIVISION V.

ACCESSORY VENEREAL DISORDERS.

FEMALE Warts-Inflammation; of Bartholine's glands; of the sebaceous follicles of the vulva, of the vagina and cervix-Ulcers of the os uteri, — Uterine Catarrh or Leucorrhoea.

MALE: Chafing and herpetic eruptions-Lacerations; of the frenum; of the membrane lining the furrow behind the glans penis-Rupture of the corpus spongiosum at the bulb; of the corpora cavernosa-Hæmorrhage and extravasation into the erectile tissue.

WARTS, though nearly always the result of secretions disordered through venery, do not owe their origin to any specific secretion, but arise from continual moistening of the parts with unhealthy discharges. Thus gonorrhoea and syphilis, especially the former, are frequent causes of warty growths, yet they do not exclusively arise from either. Gonorrhoea produces them by furnishing a copious irritating discharge which trickles down the parts where the warts spring up. So syphilis furnishes, by its suppurating mucous patches, a secretion and a congested surface on which warts may grow, hence it is not uncommon to see warts growing on mucous tubercles, or the latter changing into the former. Warts do not secrete a discharge that will reproduce warts on other individuals; hence, they are not contagious. Probably, as warts are so numerous on some persons, and do not form on others who apparently have similarly irritating discharges trickling over congested surfaces, a peculiarity of constitution or a certain

predisposition may be necessary, as well as the exciting causes, to produce warts.

The mucous membrane of the female external genitals is so frequently irritated by acrid discharges from the vagina, the uterus, and other parts, that warts are more often produced in this situation than in any other part of the body, and far more often in women than in men; but they are identical in the two sexes, and their appearance in men has already been described. Of the female genitals the great and small labia, the clitoris and its prepuce, and the entry to the vagina, near the carunculæ, are favourite localities for warts. They also grow on the deeper parts of the genitals, on the cervix uteri, or within the meatus urinarius, but far less often than on the external organs. Outside the genitals the perinæum and the margin of the anus are again common situations for these

excrescences.

They assume various shapes, are mostly of a pinkish red colour, some pedunculated, others sessile. They divide and sprout out into numberless points or eminences. They are sometimes small and isolated, sometimes they coalesce and spread widely, or thicken into large masses. Some are very turgid or readily dilated, and bleed easily, others do not bleed, but are exceedingly sensitive when touched. Whatever promotes congestion favours their growth, thus they are more frequent and more difficult to eradicate during pregnancy, when the impediment to the return of the blood causes passive congestion of the mucous membrane on which they grow. If allowed to take their course unchecked, they may attain the size of a fist or of a child's head, and being chafed and ulcerated, they cause much suffering. In this condition they secrete a thin, purulent, foul-smelling discharge that produces fresh outgrowths on the parts it trickles over. They have various terminations, the large

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