certain influence is also exerted by age. The mucous membrane at the time of senile involution, possesses anatomical peculiarities so marked as to give a different picture when attacked by catarrh than does the mucous membrane of the adult vagina. Hence there occur changes rather in spots than diffuse; and hence also the tendency of circumscribed sub-epithelial extravasations to undergo ulcerative degeneration with consecutive adhesion, which Ruge has so well described. Sharply cir cumscribed purulent and easily bleeding erosions of the vaginal mucous membrane often occur in senile vaginitis; but papillary swellings are not so common. On account of the frequency of adhesions, especially in the atrophied immix, Hildebrandt ' has been led to erect this into a separate form, which he calls vaginitis chronica adhesive.. They can usually be easily broken down with the finger; bat where they cannot some caution is necessary, since from the friability of the atrophic' mucosa false pas sages into the peri-vaginal connective tissue may readily be made by attempts at division.
Much more rarely the infantile vaginal mucous membrane is said to be disposed to form adhesions when attacked by vaginiti& Such cases have been described by J. Y. Simpson.' They are said to cause close of the introitus by the union of excoriated surfaces without suppuration. Simpson remarks that want of cleanliness cannot be the cause of these inflammations, since he has seen it in two children in spite of the most careful attention. It is difficult to prevent adhesion, which we must ende,avor to do by means of pledgets soaked in oil or glycerine. Save for a little pain in urination, there are no symptoms. Inspection reveals the fact that the vaginal entrance is closed by a grayish, non-vascular membrane, which does not bleed when torn. Simpson considers the affection to be a special form of adhesive inflammation. I cannot decide from Simpson's short and indefinite description whether we are not deal ing with retro-hymenal epithelial adhesions, and not with any inflamma tions at all. Or there might have been simple adhesion of the labia. For the former speaks the non-vascular membrane at the introitus, for the latter the treatment which Simpson recommends.
Subjective symptoms are never absent in acute catarrhs, and depend upon the cause and the seat of the affection. Most commonly there is a feeling of he,at and burning in the pelvis with difficulty in urination. This latter may consist in difficulty in voiding water, but is more coin monly seen, especially in catarrhs affecting the introitus, as a feeling of burning on micturition, even when no urethritis can be proven. Often
the patient complains of troublesome itching around the genitals arid of burning of the portions of skin which are bathed by the secretions. More rarely disturbances of the general health appear; there is anorexia, lassitude, nausea, or nervous excitation. Acute gonorrhceal catarrh, affecting the introitus, causes the most violent symptoms. We hardly ever see fever. In chronic cases we get very varied symptoms.
As a rule, complaints of illness, weakness, want of appetite, and ner vousness predominate, which we can easily understand from the long continued loss of fluid. But, as Schroder remarks, there are women who have no trouble at all. The local difficulties also are not so marked as in acute catarrhs, and are chiefly confined to burning and itching sensations about the genital& The prognosis of catarrhal inflammation, if left to itself, is not a good one. If treated, it is usually good, though relapses often occur. Acute catarrh has a great tendency to become chronic, since the causes which originate it, do not tend to subside of themselves. The continua,nce or recrudescence of the catarrh is favored by the unevenness of the surface of the mucous meinbrane, which lead to the retention of secretion in its furrows and in the crypts of the introitus; and also by the periodic ftnxions of menstruation, and those of gravidity and the puerperal period. In children and virgins the hymenal ring hinders the outflow of secre tions; and in old women there is the tendency to ulceration of the inflam matory focus. And although the catarrh does not cause any danger to life, it does depress the general health both by the albuminous waste, the changes in the vaginal mucosa itself, and the abnormal nervous excita tion caused by extension of the process to neighboring organs. Besides, in its acute stages it prevents coitus, even if in general it does not influ ence the capability of conception. Daring childbirth it may easily cause infection of traumata; and the gonorrhceal form is always liable to cause infection in wounded surfaces or predisposed mucous membranes which come 'in contact with the secretion.
The treatment of catarrhal inflammation of the vagina demands above all things the removal of its cause. Then we must reestablish favorable conditions for the relief of the circulatory disturbances, thus limiting the secretion and promoting retrogression of the inflammatory changes. The local is therefore the most important part of the treatment, which may be helped by a suitable general treatment. The latter consists essentially of a suitable regimen dieteticum, rest, care of the bowels, etc.