Symptoms.—In each of the forms of venereal vulvitis it must be remembered that we have, as a rule, a section or frag ment of a more extensive disease. The symptoms may be limited to the vulva during the initial period, but they are not likely to remain thus limited.
Gonorrhma in its relation to the vulva presents acute inflammatory symptoms, the tissues being hot, dry, and swollen from three to seven days, after which they are soiled with a more or less puru lent secretion. There may be no erup tion upon the skin or there may be a crop of warty growths sometimes few in number, sometimes abundant, not limited to any particular spot or area, but often more abundant near the pos terior commissure than elsewhere. They are painless, and vary in size from a pin's head to that of a small cherry. Other developments are the soft chancroidal sores sometimes limited to the fourchette or the mucous membrane of the vulva, and sometimes covering the whole vulva with a disgusting accumulation of dis charging ulcers. Like the venereal warts, these are seldom painful except as the ulcerated surfaces on opposite sides are rubbed against each other as the patient moves about.
A very common accompaniment of gonorrhoeal vulvitis is the inflammation of the vulvo-vaginal glands. The infect ive process extends from the duct to the structure of the gland, the duct being occluded in some instances, while in others it is the avenue for the escape of exuberant secretion. Suppurative in flammation, as already observed, is not unusual.
In syphilitic vulvitis the initial lesion may be on any portion of the skin or mucous membrane. It is not always easy to find it, for it (the Ilunterian chancre) may be very small and without well marked distinguishing characteristics. It is often hidden within the navicular fossa or on the inner side of the vulva, and may be overlooked without a very careful search. Acute inflammatory symptoms apart from those which pro ceed directly in connection with the sore or sores are not frequent, and may not appear in the vulva at all. The neigh boring inguinal glands may be enlarged and painful, but they are not thus af fected invariably. The ervthematous eruption of syphilis is often seen upon the skin of the vulva. while the ulcera tive lesions of the late periods of the dis ease are relatively rare.
Etiology.—The cause of this disease is, of course, the specific poison of one or the other infectious condition alluded to in the table. Chancroids and gonor rhoea are very frequently associated, as already observed, if, in fact, they are not identical. Syphilis and gonorrhoea are
less frequently associated, but the com bination is not very rare. This disease results almost solely from coitus. I have heard the usual stories of communi cation by means of towels and water closet seats, but such a method of inocu lation is apt to be questionable. The dis ease may occur at any age. I have seen it in the little child and in the toothless dame of three score and ten. The tis sues of women between the ages of 20 and 30 are the most susceptible to its influence. In very young children the poisonous agent is often conveyed by the hand of the infected mother when the child is washed or dressed, or it may come from contact with an infected father or mother while in bed at night.
Pathology.—The pathology of gonor and syphilitic vulvitis is that of gonorrhoea and syphilis, in which an in tensely infectious agent is communicated directly to the skin or mucous mem brane. It is not necessary that the tis sue be abraded to insure inoculation, though it occurs more readily, of course, through a broken than through an un broken surface. The active agent of in fection in gonorrhoea is the gonococcus • of Neisser: a diplococcus, or biscuit shaped microbe, of considerable vitality and good powers of reproduction and found upon the exterior as well as the interior of epithelial cells.
The essential bacterium of syphilis has not yet been isolated.
Treatment.—The treatment of these diseases consists, first of all, in cleanli ness, frequent ablutions or douchings with hot water (100° to 110° F.) being desirable. For local applications noth ing will surpass the frequent and liberal use of a 10- to 20-per-cent. solution of nitrate of silver, the entire affected sur face being freely covered with it. Quite recently protargol has been introduced as a substitute for the silver salt, but it is doubtful whether anything will en tirely supersede a remedy of such tried efficacy. For internal treatment a ferru ginous tonic may be given or a combina tion of quinine, strychnine, and gentian. The well-known elixir of iron, quinine, and strychnine is very efficient, and the proportions of the different drugs may be varied to suit individual requirements. If syphilis is present, the mercurial treat ment will be indicated. I know of noth ing better than the protiodide in grain pills, given three or four times daily until the limit of tolerance has been reached. Local lesions must be kept clean and treated daily with the nitrate-of-silver solution.