of equal parts of subnitrate of bismuth and prepared chalk.

The following local applications are useful in pruritus:

Bichloride of mercury,

gr. 2;

Emulsion of bitter almonds,

3j,

applied twice a day.

A powder of I grain of morphine to 2 grains of prepared chalk, applied twice a day.

applied once or twice in the twenty-four hours.

An ethereal solution of iodoform sprayed into the folds of the vulva with an atomizer.

Cauterization with pure carbolic acid.

In cases which have resisted all local applications the affected areas of mucous membrane have been excised. Even this method, however, does not promise certain cure. It should be tried, however, when the pruritus is localized and has resisted the milder forms of treatment.

Kraurosis Vulvæ.-Kraurosis vulvæ is a very rare disease, of chronic inflammatory nature, affecting the vulva. The disease is characterized by cutaneous atrophy, with very marked shrinking and contraction of the vaginal orifice. The lesions may be unilateral or circumscribed, but usually the tissues of the labia majora, the nymphæ, and the area surrounding the clitoris and urinary meatus are more or less involved. The cause of the disease has not as vet been determined. It has been observed at every age after puberty, in the nulliparæ as well as the multiparæ, and in the parturient woman. must be differentiated from pruritus and the atrophic

It

changes which take place after the physiological and induced menopause.

The first symptoms noticed by the patient are usually those of pruritus—an intense itching and burning about the vulva. In some cases the affected tissue early becomes excessively hyperplastic. The mucous membrane and the skin of the vulva are often discolored, small red spots appearing, which are sensitive to touch. Later a peculiar shrinking of the superficial tissue takes place, and the diseased surfaces become dry and whitened. The nymphæ gradually disappear, fusing with the labia majora; and the mucous membrane and skin become shiny and drawn smoothly over the shrunken. clitoris. Cracks or fissures appear on the dry surfaces. A sensation of drawing and shrinking of the vulva is now usually experienced. The vaginal orifice gradually narrows and contracts, until frequently the little finger can scarcely be introduced. When this last condition of atrophy is reached, the pathological process is arrested, the subjective sensations of shrinking pass away, and the symptoms resembling pruritus are no longer experienced. The shrunken and contracted vaginal orifice, however, persists and is never spontaneously restored.

Treatment.-Palliative treatment by local applications may be tried, or a cure may be attempted by operation. The palliative treatment is simply directed toward the relief of the subjective symptoms, which at times are exceedingly painful. Pure carbolic acid or a solution of cocaine applied locally, or pure nitrate of silver applications frequently repeated, afford temporary relief. Cloths wrung out of hot water and placed over the vulva also lessen the suffering. A solution of the neutral acetate of lead in glycerin, on cotton placed between the labia, is recommended. Forced dilatation of the vaginal orifice under ether has been practised with good result. The most satisfactory treatment is complete excision of the diseased tissue. Unless all affected tissue is removed, the disease may return.

Varicose Tumors of the Vulva.-Varicose tumors. of the vulva are usually the result of pregnancy. They may, however, accompany any form of pelvic or abdominal tumor, the pressure of which interferes with the venous circulation of the pelvis. The varicose condition. usually affects the labia majora. It varies from a mere increase in size of the veins of the vulva to a varicose tumor the size of the fetal head. The condition, being secondary, usually disappears with the removal of the exciting cause. The labia may be supported with a

compress and a bandage.

Hematoma of the Vulva.-Hematoma of the vulva is due to the subcutaneous rupture of a vein. Blows, kicks, or falls cause this condition. It is usually produced by rupture of a varicose vein during pregnancy or

labor.

The affected labium is purple in color and may reach the size of a fetal head. When the hematoma is small the vagina should be kept as clean and aseptic as possible, and a light compress should be applied. Absorption usually takes place. If the collection of blood is large or if it has become infected, a free incision should be made into the labium, the clots should be turned out, and the cavity thoroughly washed and packed with gauze.

Papilloma. Papillomata or warts of the vulva are not uncommon. They may occur singly, scattered over the vulva and the neighboring skin, and extending up the vagina as far as the cervix uteri, or they may occur in large cauliflower-like masses, forming tumors the size of the fetal head. They are pink or purplish in color. They often exude a bloody, offensive discharge, which is capable of exciting a similar condition by contact. Papilloma is usually the result of gonorrhea or syphilis. It may, however, be caused by irritation from filth or by the leucorrhea of pregnancy.

The treatment of papilloma is by excision. The small warts should be picked up with forceps and clipped off with curved scissors. Every one should be removed or

the condition may recur. In the case of large papil

lomatous tumors the wound of excision should be closed with continuous sutures. Pregnancy is no contraindication to excision of papillomata.

The vulva may be the seat of epithelioma, lupus, sarcoma, fibroma, fibromyoma, myxoma, lipoma, or enchondroma. These tumors present the same characteristics and demand the same surgical treatment as in other parts of the body.

Small cysts have been found in the labia majora, the vestibule, and the hymen.

Elephantiasis.—True elephantiasis of the vulva (elephantiasis Arabum) is a rare disease in this climate. The disease occurs especially in Barbadoes. It may affect the labia and the clitoris. The hypertrophied labia may attain the size of the adult head.

The treatment of this condition is excision of the affected structures.

There is a syphilitic form of hypertrophy or elephantiasis of the vulva which is not uncommon in this country. The labia minora and majora may be transformed into enormous flap-like folds. Though at first free from ulceration, this may subsequently result from chafing. Warty growths may cover the hypertrophied labia, the perineum, and the buttocks. The disease usually affects both labia, though it may be confined

to one.

This manifestation of syphilis does not yield readily to constitutional or local medicinal treatment. Many cases prove to be incurable by medicine. Antisyphilitic treatment should always be tried at first, and if this fails, the hypertrophied structures should be excised with the knife.

If, in such cases, there is any doubt in regard to diagnosis between syphilis and cancer, a small portion of tissue should be excised and submitted to microscopic examination.

Adhesions of the Clitoris.-Adhesions between the glans of the clitoris and the prepuce or hood which

covers it are exceedingly common.

Usually no trouble whatever is caused by these adhesions, unless an accumulation of smegma takes place, or irritation is produced by the presence of a concretion.

In case of any irritation about the genitals, the prepuce and clitoris should always be carefully examined. In fact, a careful examination of the clitoris should form a routine part of all examinations of the external genitals.

When trouble arises from the presence of adhesions, the prepuce should be drawn back and the adhesions freed with a blunt probe. A 20 per cent. solution of cocaine should be applied to the clitoris for ten minutes previous to the operation. The whole corona and the sulcus back of the corona should be exposed. The raw surface should be covered with vaseline, and the patient. should abstain from walking as long as pain is caused by it. The prepuce should be drawn back and vaseline applied every day for two weeks, to prevent the formation of adhesions.