pate in the pathological condition of the follicles, and thus we find the main channel through which the oleaginous matters of the digested food find their way into the circulation cut off. It follows that the patient cannot take on flesh. Since the material out of which blood and fat are constructed fail to enter the circulation, no wonder then we find the patient anemic; no wonder we find him in low flesh; no wonder we find his recuperative powers are gone.

Now let us see if we can trace the analogy between typhoid fever and tabes mesenterica. It only remains in this connection to indicate the special points connected with tabes mesenterica, which constitutes a most important disease in children and young persons. It may exist independently, but is more frequently associated with so-called tubercular ulceration of the intestines; or, as in this case with ulceration of the patches of Peyer as the result of typhoid fever. How far the mesenteric lesion in the specimen before us is indebted to the lesion involved in typhoid fever can only be speculative, but it may be remarked that recent pathological investigations point with such unerring certainty to the existence of important relations between certain diseases— of which typhoid fever is one-and the absorbent system, as scarcely to admit of a doubt as to the fact of the mesenteric trouble being the outcome of the typhoid lesion. In this case this view gains fresh confirmation in the well-established fact that the absorbent system is concerned in a large degree in conveying morbid products from one part of the body to another, such as the syphilitic poison, tubercle, cancer, dissection wounds, puerperal septicemia, etc. Thus we find by tracing the analogy between the lesions in typhoid fever and the lesions in tabes mesenterica, we connect the origin of the mesenteric trouble with typhoid fever.

Now let us see if we can account for the continued anemic and emaciated condition of the lad. Clearly it is traceable to the pathological state of the patches of Peyer, which form their close and intimate relations with the absorbent system of the abdominal viscera affecting the latter secondarily. Owing to the impoverished blood state the vital forces were not sufficient to enable

the vis medicatrix naturæ to come to the rescue of the system by providing rich blood out of which to construct anew the various tissues of the body; hence the more the lymphatic and lacteal vessels and glands become invaded, the less chance is afforded the system to recuperate, until finally the structures in the immediate vicinity of the receptaculum chyli were so far destroyed as to cut off the supply of oleaginous elements which, as we have shown, pass into the circulation mainly through the thoracic duct, thus depriving the blood of the element which is most largely effective in producing adipose tissue, leaving the system in the main dependent upon the nutrition it can obtain through the absorptive powers of the capillary blood vessels in the villous prolongation of mucous membrane which hang out, as it were, along the alimentary tube. The elements of nutrition thus afforded are not only insufficient to cause a patient to recuperate from a severe attack of disease which consumes the adipose tissue of the body, but it is likewise incapable of sustaining the vital powers of the system; therefore the equilibrium between waste and repair being destroyed, there is but one alternative left, which is to succumb to the ravages of the disease.

CLINICAL LECTURE.

BY

PROF. THEOPHILUS PARVIN, M.D., PHILADELPHIA.

[Reported specially for the Southern Practitioner.]

VULVITIS AND VAGINITIS.

This is a girl, who, after exposure to cold (she says) some six weeks ago, had a discharge commence from the vagina. She neither had nor has she any trouble in urination, but there was and is considerable scalding and itching about the vulva and lower part of the vagina. The discharge, she tells us, has not been enough to cause her to wear a napkin; but I ask her about

the character of the stain that it leaves on her underclothing, for this is a very important factor from a diagnostic point of view. She says the stain is slightly yellow, but not stiff. Whenever you have a stiff, starchy, decidedly yellow stain, you can be sure that your patient has endo-metritis. Vaginitis may be caused by cold, by excessive exercise, by the presence of foreign bodies, or by excessive coitus. When with the vaginitis is associated vulvitis, you have good reason to suspect a specific cause, for specific vaginitis seldem exists without vulvitis; but in the specific disease there is also almost always uretheritis, and in consequence pain in urination, which does not exist here. It is not an easy matter to make a differential diagnosis between specific and non-specific vaginitis, so that you must be very guarded in expressing an opinion. The only way to be absolutely sure is by the aid of the microscope, when, if it be gonorrhoea, we will find the gonococcus. In this case the exemption of the urethra makes me incline to the idea that it is not specific. Another point in diagnosis has reference to the reaction, for we must remember that while the uterine mucous is alkaline, that from the vagina is acid. But if the patient has been using alkaline injections, as for example, chlorate of potash, the vaginal mucous would likewise be alkaline, so you must be on your guard for this source of error. Upon inspecting the parts I find peripheral redness with a deposit of mucus and other secretions on the external genitalia, and by digital examination I find the vagina swollen and the secretion excessive. If the discharge is very copious and of a greenish yellow color it favors a speciic origin, and in this connection the history plays an important part if the patient be a prostitute; or if a married woman she is known to be unfaithful, then the presumption favors specificity. I will here correct an erroneous impression that has some believers. A woman cannot give gonorrhoea unless she has it. I believe it is possible for a woman to convey syphilis when she has it not, because the virus. may be deposited in her vagina, and a man having connection with her, shortly after its deposition, may contract the virus before the woman herself has absorbed it. The same phenomenon may occur with gonorrhoea, so that a woman may convey the dis

ease when she does not know that she has it, but it is absolutely imperative that the virus must be there, either as the disease or as a deposit.

Now for treatment: We must commence with hot hip-baths and mucilaginous injections, or acetate of zinc, one grain to one ounce of water; or we may use tampons rolled in dry powdered tannin, or smeared with an ointment of one part of tannin, three parts of vaseline, and three of starch, allowing them to remain in position for some hours. If you prefer it you may use powdered alum, pure or diluted with oxide of zinc or starch. You will be asked by these patients how soon they will get well. While it is difficult to set a time, yet in the non-specific form it will usually take five or six weeks to effect a cure, while the specific will usually hold on for two or three months. If the measures already indicated do not seem to be doing good, it will be necessary to distend the vagina so as to expose the whole surface and paint it with a five or ten per cent. solution of nitrate of silver, for the disease is likely to lurk way up in the posterior wall. This is the treatment indicated for the non-specific form. In the specific form, after a few days of laxatives, it will be well to commence the injection of 1-1000, 1-2000, or 1-3000 solution of corrosive sublimate once or twice daily, which will destroy the gonococci.

SUB-INVOLUTION AND EROSION.

I say that this woman is suffering from sub-involution, but I am not sure that this expresses the fact. During pregnancy the uterus undergoes a great evolution, and after labor it is involuted, and the usual notion conveyed by sub-involution is that this latter process is arrested. Dr. Emmett tells us that he has never seen a case of so-called sub-involution where there was not laceration of the cervix. It is my opinion that this laceration is the starting point of metritis, and that it would be more correct to recognize as parenchymatous metritis that which is usually called sub-involution. Remember that the mucus membrane covering the neck of the womb contains no glands, while that which lines it is rich in them. Hence if we have a glandular mucus membrane visible about the os, we may be sure that we have an ero

sion, an ectropion, or a turning out of the lining membrane due to a cervical laceration.

We will now examine our patient. She is married, twentythree years old, and had a miscarriage at five months, brought about by a fall, which had the effect of detaching the placenta, thus making the foetus a foreign body, and it was expelled. At the time of the abortion she had some hemorrhage,"lasting for two days and then disappearing. Five or six weeks later the hemorrhage recurred. Some authors estimate the puerperal period at six weeks, because if a woman is not nursing her child she is likely to have a discharge for that period. This woman says that she had milk fever, and in this connection I will say that there is almost always an effort at lactation made, even though the abortion may occur as early as the second or third month; therefore you must not be surprised (as you would likely be if you did not bear this in mind) when your patient, who has aborted, asks you what to do "for the milk." When this hemorrhage recurred it lasted for about fourteen days, at which time something (probably a remnant of the placenta) was removed from the uterus. German authorities leave nothing for nature, scrupulously removing every thing immediately after the abortion. But here we have a case where, for six weeks, a portion of the placenta remained without septic infection; but it may happen, and I am commencing to lean more toward the German teaching than I used to. The French do not agree with the Germans, and some of their authors, in commenting on the habits of the latter, naively say that it must be a very complacent womb that will not resent so much scraping. If there is an offensive discharge or much hemorrhage I would say remove every thing. Schroeder even goes so far as to slit up the cervical canal to enable him to thoroughly empty the uterus. Seatangle tents take too much time, and there is dar ger of infection from sponge tents. Rather than slit the cervix I would prefer to use Hagar's dilators, which are made of hard rubber and rendered aseptic by carbolized water and oil.

This patient complains also of pain in the abdomen, and it hurts her when she sits down on a hard chair. Examination re