incisions, washed out with disinfectants, and filled with iodoform gauze.

Parts affected with diphtheritic infiltration should be cauterized with chloride of zinc dissolved in equal parts of distilled water.' The healing process should be carefully watched, so as to avoid secondary deformities.

CHAPTER VI.

INFLAMMATION OF THE URETHRAL DUCTS.

THE urethral ducts described on p. 76 may become inflamed. Their mouths are then seen outside of the meatus in consequence of the swelling and prolapse of the mucous membrane. They appear like very small ulcers of a yellowish-gray color, surrounded by a deep-red circle, and a purulent fluid may be pressed out of them. The lower third of the urethra is sometimes swollen. It is exquisitely tender to touch, and causes the patient much discomfort, but micturition is not particularly painful.

Treatment. The ducts should be washed out by injecting carbolized water or the saturated solution of boracic acid. If a more active treatment is needed, tincture of iodine or a strong solution of nitrate of silver (14) may be injected, or a fine probe covered with nitrate of silver in substance may be introduced into them. In a recalcitrant case I obtained a cure by introducing a probe and slitting the canals open from the vagina with Paquelin's thermo-cautery (p. 182).

CHAPTER VII.

GANGRENE OF THE VULVA.

THE Vulva may become gangrenous in consequence of contusion, or overdistension due to edema or extravasated blood, or from the use of a tampon with undiluted liquor ferri chloridi (p. 179). Gangrene may also be caused by inflammation, especially diphtheritic infiltration. It occurs sometimes in eruptive fevers. An idiopathic gangrene identical with noma is found in young children, and is said to be contagious. It begins as a white blister, which soon changes into an ulcer, that takes a diphtheritic aspect and becomes gangrenous. It is a dangerous disease, usually ending in septicemia.

1 For the details of this treatment I must refer the reader to my other writings: "Puerperal Diphtheria," Trans. Amer. Gyn. Soc., 1885, vol. x. p. 109; "Puerperal Infection," Amer. Syst. Obst., ii. p. 363; Antiseptic Midwifery, p. 61.

Treatment. The affected part should be cauterized with a 50 per cent. solution of chloride of zinc, or with the thermo-cautery, and covered with iodoform or compresses dipped into a saturated solution of chlorate of potash. Tonics and stimulants should be used freely. As soon as a line of demarkation is formed the dead tissue should be removed.

CHAPTER VIII.

EXANTHEMATOUS DISEASES.

IN exanthematous fevers the genitals may be the seat of an eruption like other parts of the body. They may also be attacked by skin diseases, such as furunculosis, erythema, eczema, etc.; but as these diseases offer nothing peculiar in this region, and are treated as in other parts, the reader is referred in regard to them to works on the practice of medicine and skin diseases. Only one exudative skin disease shall be described here, on account of its frequent occurrence and great diagnostic importance-viz. herpes.

Herpes Progenitalis.-Herpes progenitalis is a mild inflammatory affection, consisting of one or more vesicles or groups of vesicles. The eruption may occur without any prodromal symptoms, but in most cases it is preceded by a burning and itching sensation.

First appears a small round red spot. On this the epidermis is soon raised, forming a vesicle of the size of a pin-head to a hemp-seed, filled with clear serum. This ruptures and leaves a shallow ulcer of the size of the vesicle. Its floor is at first of a deep rosy red, with a finely uneven surface and its edges sharply cut as with a punch, and sometimes undermined, but, as a rule, not to the same extent as in chancroid. Sometimes there is so much edema of the labia minora that the eruption is concealed until they are separated. On the skin the vesicle is followed by a scab. The disease lasts from a few days to two weeks, but is apt to return. It may lead to the development of a bubo.

Etiology. It is due to congestion and inflammation of the genitals and pelvic organs. It is only found in adults, especially in prostitutes. It appears often as a concomitant of menstruation.

Diagnosis. It may be very like a chancre in the erosive stage, but this has a deeper and duller red, coppery color, and its floor is smooth and shining, without the small granulations found in herpes. Its areola is very slight and of a dark red color, and there is a general absence of inflammation about the lesion. On pressure a chancrous erosion does not yield any fluid, while a herpetic vesicle gives issue to several drops. The history may also offer some help to a

diagnosis, but it is advisable to be a little reserved until we see the course the disease takes.

Treatment.—The parts should be cleansed and all irritation avoided. Milder cases get speedily well when covered with lint soaked in—

The dry powders mentioned above (see Vulvitis, 269) hasten the healing, and the iodoform ointment (p. 178) relieves pain. Persistent neuralgic and burning pains require cauterization with carbolic acid or a strong solution of nitrate of silver (1:8), followed by the leadand-opium wash.'

CHAPTER IX.

TRICHIASIS.

INVERSION of the hairs of the labia is a rare condition which causes intense itching. The offending hairs must be removed and their bulbs destroyed by electrolysis.

CHAPTER X.

PRURITUS VULVE.

PRURITUS VULVE is characterized by an itching sensation on the inner or outer surface of the vulva, sometimes extending up into the vagina or over the lower half of the abdominal wall. It may be symptomatic or idiopathic. When it is symptomatic it may be a symptom of a disease of the genitals, especially follicular vulvitis, eczema pudendi, or trichiasis, or it may be a reflex symptom of disease in other organs, such as hemorrhoids, pin-worms in the rectum, diseases of the kidneys, ureters, bladder, or urethra, congestion of the pelvic organs, etc.

Predisposing causes are pregnancy, menstruation, the menopause, old age, the gouty diathesis, or general nervousness. Sometimes the itching is due to direct irritation by parasites (lice or acarus scabiei), acrid discharges from the vagina or uterus, or urine containing sugar.

In other cases no cause, near or remote, can be found, and then it has been surmised that the disease is located in the nervous centers.

1 For further details the reader is referred to Robert W. Taylor's Atlas of Venereal and Skin Diseases, Philadelphia, 1888, p. 72.

Symptoms.-The chief symptom is an itching that is so violent that it irresistibly drives the patient to scratch herself, a procedure which gives a momentary relief, paid for by increased itching. The scratching produces excoriations and inflammatory conditions, especially eczema, which, again, contribute to the morbid sensation.

In its higher degrees the disease is a very serious one. The patient scratches so that she wears off the hair of the mons Veneris and labia majora; she avoids company; she becomes melancholy and morose; she loses her appetite; her sleep is disturbed; she becomes the victim of an abnormally increased sexual desire or contracts the habit of masturbation; she may finally become insane, succumb to exhaustion, or end her miserable existence by suicide.

The itching may be continuous, but is more frequently interrupted by free intervals of hours and days. It increases by heat, and is, therefore, worse at night, in a warm room, and during physical

exertion.

Prognosis. The prognosis depends on the possibility of removing the cause. If no cause can be found, it is often very obstinate, and sometimes, it would seem, incurable.

Treatment. First of all, we must try to find and remove the cause. If there are crab-lice among the hairs on the pubes, the hairs should be cut short or shaved off, and the skin smeared with blue ointment or Peruvian balsam, or washed with a strong solution of corrosive sublimate (1 gr. to alcohol and water aa. 3ss), and general warm baths with 2 drachms of the same drug should be given.

If the acarus scabiei is the offender, as a rule a treatment for itch of the whole body will be needed. Locally, beta-naphthol in vaseline (gr. xxv to 3j) or sulphur ointment should be rubbed in.

Inflammation of the vulva must be treated as described above (p. 260). Eczema is treated with unguent. diachyli. Pin-worms are removed from the rectum by means of extr. sennæ et spigeliæ fl. (3ss, t. i. d.), given by the mouth, and rectal injections of a strong infusion of quassia (3ij-Oj) or corrosive sublimate (gr. in 3viij of water). Hemorrhoids, glycosuria, and other diseases causing the pruritus should be treated according to the rules of medical and surgical practice.

The diet is of great importance. Besides the special diet called for by diabetes and gout, alcoholic drinks and spiced food should be avoided. The food should be nourishing, but bland. Milk in large quantities (two or three quarts a day) is to be recommended if it can be digested. If it causes dyspepsia in its natural state, it should be tried boiled, skimmed, or peptonized.

The general treatment should be tonic, sedative, and narcotic. Arsenic and quinine are particularly recommended. Bromide of potassium in large doses (3j-ij daily) is often very valuable. Tinct.

cannabis Indica (20 to 40 drops, t. i. d.) is preferable to opium. It may be necessary to procure sleep by means of chloralamid, sulphonal, urethane, trional, or the other modern hypnotics.

The local treatment is of the greatest importance. Vaginal injections and affusions of plain hot water, solutions of carbolic acid, bichloride of mercury, or borax should be freely used many times a day. If any irritating discharge dribbles from the vagina, relief is obtained by keeping it back by means of a cotton tampon wrung out of some mild antiseptic solution. The vulva may be covered with fomentations of lead-water with or without opium or the saturated solution of potassium bromide, or painted several times a day with glycerin mixed with chloroform (1:8), hydrocyanic acid (p. 269), or morphine (gr. ij or iij to 3j), or the parts may be painted at longer intervals with a 10 per cent. solution of cocaine in water, a similar solution of carbolic acid, or a strong solution of nitrate of silver (p. 269), followed by cold applications. For base of ointment vaseline is the best. It may be mixed with acetate of lead, chloral, camphor (p. 269), or chloroform (of each 3j-3j). The affected part may be rubbed with a menthol stick or solid nitrate of silver. Some claim to have successfully applied the galvanic current. As a last resort, when everything else had failed, the removal of the affected portions of skin or mucous membrane by cutting instruments has effected a cure in several cases.

During pregnancy only the milder of the above-named remedies may be used. Large and frequent vaginal injections must be avoided. A tampon soaked in equal parts of sulphurous acid and glyceratum boracis may be introduced into the vagina. One case is reported in which tobacco-smoking gave relief.

Burning Sensation in the Genitals and the Abdomen.-This affection is probably nearly related to pruritus, but differs from it in the character of the sensation. It is not very rare-in my experience, if anything, more common than its universally recognized sister, and still itself is hardly mentioned anywhere. It seems to be fully as recalcitrant to treatment, if not more so. Applications of compresses soaked in cold water to the abdomen, the above-mentioned vaginal injections, and bromide of potassium internally have given me the best results.

1 W. Blackwood, Polyclinic, Philadelphia, 1885, No. 9, vol. ii. p. 141.