in men.

The following points' may occasionally be found useful in making a differential diagnosis: In herpes progenitalis the inguinal glands are not affected; the base is soft; the contour is polycyclicthat is to say, composed of regular segments of small circles that have been blended together; the development is more limited, and the excoriation heals rapidly; the affection itches; and, as a rule, the erosions are multiple. Chancroid is nearly always multiple. It forms a deep ulcer of yellowish red color, with perpendicular, undermined edges, uneven, worm-eaten floor, soft base, and abundant purulent secretion; the pus, when inoculated on the patient, forms another chancroid; the inguinal glands are not swollen or form an inflammatory bubo which may produce an abscess with simple or chancroidal

pus.

Treatment. The primary lesion being a symptom of an infection that already has taken place, cauterization is useless, and objectionable on account of the inflammation it brings about in the circumference. The genitals should be kept clean and the ulcer dressed with absorbent lint or cotton soaked in bichloride-of-mercury solution (1 : 1000 or 2000) or one of the other solutions mentioned above in speaking of chancroid, the dressing to be changed every two hours. If the ulcer suppurates or is the seat of molecular disintegration, it should be dusted with iodoform or equal parts of calomel and bismuth, or dressed with the lotio hydrargyri flava containing corrosive sublimate, or lotio hydrargyri nigra, made with calomel. In cases of considerable induration blue ointment may be rubbed on the seat of the swelling and applied to it spread on lint.

If the sore is covered with a pultaceous mass, cauterization with carbolic acid, nitric acid, or chloride of zinc, dissolved in equal parts of distilled water is indicated. In regard to phagedena the treatment is the same as described under Chancroid, combined with general antisyphilitic treatment.

Secondary Syphilis.-The vulva is the seat of predilection of mucous patches in women. In the vagina they are exceedingly rare, but appear more frequently on the cervical portion of the uterus. They are often found symmetrically on both sides of the vulva, not on account of auto-inoculation, but because the irritation is the same. They form round or oval spots, with a tendency to coalesce. They are a little elevated above the mucous membrane, and have well-defined steep borders. The color is rosy or grayish red. They have a somewhat granular surface, and secrete a malodorous serous fluid. They are quite amenable to treatment, but may, if neglected, form large cauliflower-shaped tumors like vegetations, and may, like them, become gangrenous. On the vaginal portion mucous patches appear as A. Fournier, Leçons sur la Syphilis étudiée particulièrement chez la Femme, Paris, 1873, pp. 261, 281.

small red erosions, or, more rarely, as superficial ulcers. Combined with general mercurial treatment, mild cauterization with nitrate of silver makes mucous patches soon shrivel and disappear, without leaving any cicatrix.

Tertiary Syphilis.-Gummous nodes are not rare in the labia majora. They form first deep-seated globular tumors, which may break and leave ulcers. These latter may be difficult to diagnosticate from other ulcers in the same locality, but are distinguished from them by being rapidly healed by the internal use of potassium iodide. At the same time, the usual precautions in regard to cleanliness and protection that have been detailed above should be observed.

CHAPTER XVII.

PROLAPSE OF THE URETHRA.

To describe all the diseases of the urethra and the bladder would require more space than we can afford, and they do not strictly belong to those organs the diseases of which form the subject of this treatise. It might, however, be advisable to say a few words about prolapse of the urethra, on account of the diagnosis and the treat

ment.

While a slight eversion of the mucous membrane of the urethra is exceedingly common, especially in women who have borne children, the extrusion of a sufficiently large part of it to form a tumor is of rare occurrence. It is mostly found in children, old people, or weak subjects. It is caused by straining during micturition or defecation -e. g. when a stone is lodged in the bladder or the anus is the seat of a fissure.

The disease may implicate the whole circumference of the urethra or only a part of it, most commonly the lower. In the first case the urethral canal is found in the centre of the tumor; in the second, it is placed excentrically.

The prolapse gives rise to or increases vesical tenesmus and may produce cystitis. In the beginning the tumor has the appearance of the normal mucous membrane, but later it becomes darker and denser, and is sometimes excoriated.

Diagnosis. When the prolapse is total, the presence of the lumen of the canal in its center settles at once the diagnosis. If it is partial, it may be taken for a caruncle, but it differs from the latter by always having a broad base and by being easily reduced.

Treatment.-Simple reduction with a finger or sound, followed by the use of a cupped bougie, with tannin or the application of tincture

of iodine, rest in bed, and hot vaginal douches and affusions, may be tried. If they do not succeed-which can only be expected in slight cases-operative interference is called for: 1. The tumor may be transfixed at its base, tied in two halves, and cut off. 2. The deeper part of the mucous membrane may be secured by inserting a suture on either side, and uniting the two edges of the wound with a continuous catgut suture after cutting the redundant tissue off. 3. Emmet's buttonhole-operation may be performed by placing the patient in Sims's position, introducing his speculum, making a longitudinal incision on the vaginal wall corresponding to the course of the urethra down to the mucous membrane of the latter, pulling this through the opening made, introducing some transverse sutures through the vaginal and urethral mucous membrane, cutting off the redundant tissue over the sutures, and closing the latter.

The prolapsed portion may also be cut off in front of the meatus with galvano- or thermo-cautery, but then steel bougies should be introduced during and after the healing in order to avoid stenosis. The cutting operations with sutures are the best.

CHAPTER XVIII.

MASTURBATION.

MASTURBATION consists in the production of venereal orgasm by means of the hand, the tongue, or any kind of foreign body on one's self or another person. It is also called onanism, but not correctly, for a closer scrutiny of the ninth verse of the thirty-eighth chapter of Genesis will show that Onan had sexual intercourse with Tamar, but deprived her of his semen by spilling it outside of her body (an act called withdrawal). It is not usual to treat of this subject in works on gynecology, but since the thing exists, since it appears in innocent childhood, since it produces certain symptoms, since it may be the cause of the most serious diseases, since the physician called as expert in a suit for rape may be able to exonerate an innocent man by knowing the effects of masturbation,-it is, in my opinion, proper to give some information about it here.

Masturbation may be indulged in by infants of either sex who have no idea what they are doing. They may either be taught the vice by unscrupulous nurses in order to make them quiet, or they may accidentally find out that certain movements produce a pleasur

1A. Jacobi, "On Masturbation and Hysteria in Young Children," Amer. Jour. Obst., vol. viii. No. 4, 1875, and vol. ix. No. 2, 1876.

able sensation. In older female children I do not believe the vice is so common as among boys, but later in life it is probably much more so in women than in men. This cannot be explained merely by the greater facilities offered the male sex for normal satisfaction of the sexual instinct without running the risk of having offspring. There are several reasons for it, one of which is the less degree of orgasm felt by women during normal sexual intercourse (p. 121). This, at least, would seem to explain the fact that many married women are given to this vice-a thing that certainly is exceedingly rare in the male sex.

The most common form of masturbation in women consists in titillation of the clitoris, be this executed by the person's own hand or that of another, or by the tongue of another human being or of a dog, or by any other object. Less frequently the finger or other more or less penis-shaped bodies, such as roots or needle-cases, are introduced into the vagina.

1. Masturbation in Infancy.-Masturbation in early childhood being in many respects peculiar, we must consider its symptoms and treatment separately. In some cases there may be local changes, such as redness of the entrance of the vagina, moisture of the labia and vagina from over-secretion of the glands of Bartholin and the smaller muciparous glands of the vulva. But these cases are by no means frequent. Of much greater importance are certain other changes observable in the child, such as the occurrence of sudden redness in the face, followed by paleness, twitching of the muscles about the eyes, hurried breathing, and a deep sigh. These spells come on when the child is sitting on the floor, often rocking to and fro or pressing the fists into the iliac fosse or against the genitals. These attacks lead to anemia, bloatedness, and irritability of temper.

Treatment.-First of all, infants and their nurses should be carefully watched. If there are pin-worms in the rectum, they should be removed (p. 273). If the composition of the urine is abnormal, it should be remedied by proper medicine, especially alkalies and anodynes. The couch should be hard, the cover not warmer than what is necessary to protect the child. It should not have too rich food: large quantities of meat, eggs, spices, salt, and beer are injurious. Drugs that irritate the uropoietic system, such as cantharides or nitrate or chlorate of potash, should be avoided or handled with care. During the act the child should be taken up, her thighs separated, her hands removed from her abdomen, and her mind diverted. The anemia and nervousness should be treated with strychnine, iron, and arsenic.

2. Masturbation in Older Children and Adults.-Symptoms.— The frequently repeated act of self-abuse or masturbation with another person leaves certain local changes in the genitals which it is useful

to know. It is true that not one of them is pathognomonic, but the presence of several of them must, to say the least, awaken suspicion and may help to find out the truth. The clitoris is both thickened and elongated. The glans is red and protrudes beyond the prepuce. The prepuce is lax, red, and thickened. The labia minora are elongated, flaccid, wrinkled, of brown, gray, or slate-like color, with black irregular spots due to the deposit of pigment in the deep layer of the epidermis. This change in size and aspect is often unilateral. On the inner surface of the labia minora is found a series of minute white or yellow spots like insect eggs, formed by hypertrophied glands. Sometimes the labia majora are likewise enlarged, flaccid, and wrinkled. The hymen may be torn, but is more commonly not so, but so lax that the finger enters without meeting any resistance. The vaginal entrance and the rima pudendi may be gaping. Often leucorrhea and other signs of vulvitis (p. 266) are present. The vulvo-vaginal glands may be inflamed. The vulva may show fresh scratches or old cicatrices, and the clitoris has been found wounded and nearly bitten off-conditions which may cause hemorrhage or leave wounds slow to heal.

As to the general health, women seem to have a greater power of resistance in regard to the effects of masturbation than men. There are, indeed, women who are confirmed masturbators, and yet enjoy excellent health, but, as a rule, they pay as well as the other sex for their illicit pleasure by pain, ache, and ailment. The works of specialists in this line must, however, be read with more criticism than their authors usually show in writing them, nearly every known disease, inclusive of pneumonia, that ever has been observed in a woman addicted to masturbation having been put on the list of the consequences of the habit. Certain diseases are, nevertheless, found so often in masturbators, and the connection between them and the vice is so easy to understand, that we do not hesitate in looking upon them as cause and effect. We find inflammation of any part of the genitals, periuterine hematocele, and pelvic peritonitis-conditions which all stand in a natural relation to the irritation and frequent congestion of the genitals and pelvic organs.

The nervous system suffers more than any other, and in all its functions: the hands are apt to tremble or the gait may become unsteady; the perception of all the senses loses more or less of its acuteness; the memory weakens; interest in all intellectual matters diminishes; wandering pains of neuralgic origin are quite common; hysteria, epilepsy, chorea, paralysis, and insanity may be developed, but it may be hard to decide whether the masturbation was the cause of the insanity or if the lurking insanity impelled to masturbation. I have seen a peculiar nemesis in a young lady who was accustomed to discount the pleasures of married life, and who, when she married