VULVOVAGINITIS Practically the most important clisease of the female genital appa ratus is the inflammation of the mucous membrane of the vulva and vagina. It is only in the last two decades that we have come to realize their terrible frequency. But the experience of the last few years has also taught us that the great majority of the cases are infectious, and are due to the same organism that causes the urog,enital gonorrhma of the adult: namely, the gonococcus of Neisser. In the following remarks therefore we shall speak of the gonorrhota of girls, and only incidentally will mention be made of inflammations due to other causes, ancl of their terminations.
(a) GONORRACEAL VISLVOVAGINITIs This affection, according to Pott, is to found most frequently in the newborn and during the first five years. Later on it increases again in frequency at the age of puberty. In Pott's statistics there were 3,921 girls, of whom 44 were infected with the gonococci, and of these 27 were less than five years olcl. Epstein does not believe that there is any special predisposition between the second and fourth years, but that in numerous cases brought to the physician for examination the infection occurred at the very beginning of life, and only attracted attention when the chilct began to walk.
Etiology.—The exciting cause is the gonococcus discovered by Neisser. Even during delivery the infection may enter the child's geni tals from the vagina of the mother affected by gonorrhoea, but later on in life, too, there are a whole chain of circumstances which may render the infection possible. For instance, sleeping with the infected mother in the same bed; the use of the same wash-basin, the same chamber, the same bath water, the same towels; contact with hands soiled by the gonorrhceal poison; taking the temperature with a thermometer dirtied by a previous record. Moreover, especially in large cities, coitus practiced from perversity or for superstitious reasons, is a deplorable cause of the disease.
In this place it is necessary to consider why it is that more girls than boys become infected. Poet explains this difference by the fact that, in boys owing to the firm adhesion of the prepuce to the glans, the mouth of the urethra, funnel shaped as it, is, is so small that it will only permit the entrance of a very small sound, whereas in girls the genital orifice is free and open.
many cases the infection will not, be be trayed by; a single subjective symptom. The mother as a rule brings
the child to the doctor because the clothing is stained with yellow spots.
Examination shows the vaginal orifice to be more or less irritated, swollen and reddened, and in more advanced eases there are found small ulcerations and erosions upon the labia majora and minora. From the vulva a discharge escapes which is sometimes chiefly mucous, sometimes chiefly purulent.
When stained with aniline clye, we find un der t,he microscope, in addition to leucoeytes, great numbers of typically located gonoccoci (Fig. 20).
If there are subjective symptoms, they present themselves in the form of dysuria, itching of the genitals, associated with more or less extensive eczema, due to the secretion, and eventually considerable pain in walking. In cases of long duration the general health suffers, the appetite fails, the temper is irritable, and the child loses its freshness and becomes pale. An elevation of temperature is not rare.
most striking thing is the extraordinary ease with which the gonococci can be demonstrated. Their form, intracellular location, and the negative result of Grarn's method permit them to be recognized without even the necessity of a culture.
Sometimes upon inspection are seen injuries of the genitals which point to the commission of a "coitus." 'Unless there are e.vidences of violence one must be exceedingly cautious in surmising a crime, since there are many other possible ways of infection.
Course and course of the disease is eminently chronic. Only under unusually favorable circumstances will the disease disappear in six weeks. Generally it lasts considerably longer, even for years, during which latent periods alternate with periods of acute ex acerbation. The complications consist in the first place in an extensive participation of the genito-minary mucous membrane in the inflamma tory proces.s. In this way there will develop inflammation of the mem brane of the urethra and bladder, which will be attended by severe urinary distress. Less frequently an infection of the cervical and cor poreal uterine membrane results, which may lead to hmmorrhage. Bar tholinitis is rare, as is the spreading of the gonorrhma to the peritoneum, the gonorrhceal peritonitis which may lead to death by sepsis and pysentia, but in which there have also been a few recoveries.