Genital Organs" for gonorrhoea. He objects to "Urethral Pyorrhoa," because "in the greater number of cases it does not hold good for the analogous disease in the female."

Bumstead and Taylor, page 193, say: "Vaginitis is more common than any other form of gonorrhoea in women." At page 197, they say: "Gonorrhoea of the urethra usually coexists with that of the vulva and vagina, and sometimes with that of the uterus alone. Cases, however, are reported in which this was the only part of the genital organs affected." Gilbert met with. three such instances, Ricord with two and Cullerier with one. At page 186 they quote Zeissl's statement that "only about five cases of urethritis are met with to 100 of vaginitis."

Morrow, in his System of Genito-Urinary Diseases, 1893, vol. I, page 1,050, says: "vaginitis, so far as symptoms is concerned, is the form of gonorrhoea which has most frequently brought women to me for relief." He quotes Bumm's statement, and thinks that we are justified in making our diagnosis on clinical phenomena alone. It is only necessary to quote such names as Noeggerath, Sanger, and Wellander in support of the statement that clinical facts are sufficient to determine a diagnosis. On page 1,053, se says: "the greater frequency of urethritis met with by some authors has been referred to. I have not found it thus frequent. Forty per cent. would be a liberal estimate for those who have suffered with urethritis in my experience." It would thus appear that, clinically, vaginitis is more commonly complained of by women than is urethritis, and it is from that they suffer first in a degree to cause them to apply for relief. On the other hand, Bumm, in 1884, published the results of elaborate experiments, tending to show that the vagina was never the site of original infection, but that this always occurred either in the urethra or in the cervical canal-generally the latter. He claimed first, that, according to his microscopical examinations, gonococci enter only cylindrical epithelium, that they cannot pass through pavement epithelium, and whenever pavement and cylindrical epithelium come in contact, the gonococci disappear where the latter begins. The vagina is covered with firm pavement epithelium, which resists the effort of gonococci. He also examined portions of the inflamed mucous membrane of the vagina and never discovered a gonococcus therein and finally he kept blennorrhagic secretion in direct contact with the vaginal mucous

membrane for twelve hours, and could never produce vaginitis in this way.

It is evident then that he admits of a vaginitis which is associated with blennorrhoea of the urethra and of the cervix and uterus, but contends that the cervical or uterine blennorrhea is produced by the primary infection and the secretion stagnates in the vaginal canal and produces vaginitis. Steinschneider supports this view. They all admit that vaginitis may communicate blennorrhoea, but explain it by the fact that what they call a catarrhal vaginitis contains abundance of gonococci, which proliferate in the vaginal secretions as in an incubator and may even cover the vaginal epithelium, though they do not penetrate it. It appears in addition that the gonococci prepare the field for the invasion of a considerable number of other cocci and bacteria, which it is admitted do then proliferate freely in the vaginal secretion.

These views are opposed by Schwarz in every detail. He states that in many recent cases vaginitis may be demonstrated, although the uterus is entirely intact; that the obstinacy of the vaginitis proves its specific character; and that the presence of gonococci in the deepest layers of epithelium can be proven by scraping the vaginal walls with a curette after previous irrigation of the vagina.

Sanger (1899) also states that the vagina remains free from gonorrhoeal disease when its epithelium is firm and contains many layers, but also states that true gonorrhoeal vaginitis does occur even in adults, in young people, in pregnancy, in many women with delicate skin and blonde hair, and when the entire mucous membrane is succulent. These opinions are confirmed by Tuton's investigations. Finger, in his book on Gonorrhoea and its Complications, page 283, discusses this whole question fully, and closes the dissertation by saying: "I am convinced from my own experience that acute vaginitis may develop without disease of the cervical canal."

Steinschneider (1887) stated that "the urethra was affected only in recent cases." Fabry, Wellander and many others regard the urethra as the favorite site of the gonococci. On the other hand, Schwediaur states that "he never observed a case of urethritis in the female." Recent writers agree almost unanimously concerning the frequency of blennorrhagic urethritis and that it

is never absent in cases of recent infection. Zeissl appears to be al:nost alone in maintaining that "only five per cent. of acute cases have the urethra affected."

G. Frank Lydston, in his Surgical Diseases of the GenitoUrinary Tract (1899) says, on page 163, "Vaginitis of venereal origin is exceptional, and urethritis is exceedingly rare and does not always occur when virulent vaginitis exists." On page 169 he says: "Most cases of gonorrhœal infection in women are not only uncomplicated by urethritis, but exceptionally by vaginitis." He appears to adopt the view that the cervix uteri and the uterus itself are the most frequent sites of primary infection.

White and Martin, in their work on Genito-Urinary and Venereal Diseases (1897), page 153, say: "Vaginitis, at one time regarded as the most characteristic manifestation of gonorrhoea in the female, is now recognized as occurring much less frequently than urethritis or endometritis."

Finger, on page 277, explains these differences of opinion as "owing to the rapid and mild course of the acute stage, and the readiness with which chronic urethritis in the female is overlooked."

Summing up the above evidence on both sides one would seem justified in concluding that in acute cases in the female the gonococcus can be more frequently found lodged in the urethra and the cervical canal than in the depths of the mucous membrane of the vagina. But that in these localities they give rise to very little annoyance to the patient-to very little acute inflammation. And that vaginitis is the condition for which many women acutely infected with gonorrhoea apply for relief, whether the gonococcus be found in the vaginal mucous membrane or not.

OPACITIES OF THE VITREOUS.*

BY WILLIAM B. SABIN, M. D.,

Watervliet, N. Y.

S. B. W.]

Opacity of the vitreous is that variety of inflammation of the vitreous characterized by the formation of fixed or movable opacities which may be either acute or chronic.

*Read before the Medical Society of the County of Albany, March 14, 1900.

These opacities are usually the result of some pre-existing disease of some other part of the eye, although there may be a primary inflammation of this body to which they owe their origin. Exhaustion of the general system from long continued fevers, gout, constipation, anaemia, interference with the function of the liver by congestion, irregular menstruation, syphilis and the action of drugs may and sometimes do produce opacities of the vitreous. Injuries to the eye causing chorioidal haemorrhage will also result in their formation, and if extensive may lead to suppuration. Eye strain may be manifested by opacities; and late in the course of extreme myopia associated with posterior staphyloma they are liable to occur. They are also one of the changes which have been observed in glaucomatous eyes. Patients readily see opacities of the vitreous either as fixed or movable black spots and are able to describe their size, shape and situation. There may be no diminution of vision, although central vision may be entirely lost if there is a large centrally situated fixed opacity. There is usually no pain associated with them and if there is it is pretty certain to be complicated by some other affection and probably the result of it.

The treatment of opacities of the vitreous is of course dependent upon the cause of the disease. If due to refractive errors they must be corrected. Irregularities of the menstrual function, disorders of the liver or exhaustion from protracted illness must also receive due attention. If from syphilis, the mercurial preparations, iodide of potassium and iron compounds give the best results. Gout, constipation and anaemia must receive treatment for their share in the production of the disease. The soluble mercurial salts, iodide of potassium and carbolic acid have been injected into the vitreous chamber where the opacities were so dense that if they accomplished no good, they could not increase the blindness; but this is a dangerous procedure and very apt to cause panophthalmitis. A large fixed and more or less central membranous opacity may be divided by passing a discission needle into the vitreous in front of the equator of the eye, entering it just below the lower border of the external rectus muscle, care being exercised to watch the movements of the instrument with the ophthalmoscope. There are lesser forms

of opacities of the vitreous which are called muscæ volitantes and while they are annoying, they do not interfere with vision; they are usually due to errors of refraction, and cease to be troublesome by correction with suitable lenses. There are also cholesterine crystals sometimes met with in the eyes of the aged, but of rare occurrence, appearing as small luminous bodies which reflect the light from the ophthalmoscope in the form of a shower of sparks, but they do not yield to treatment.

I have a case I wish to report, of a young woman, 32 years of age, who consulted me in July, 1898, complaining of dimness of vision and sore mouth and throat. Upon examining the mouth and throat I found the surfaces covered with a very large number of mucous patches. She gave a history of infection dating back three or four months and of having been under treatment for some time for specific disease. Upon examining the eyes I found her vision in the right equal to, Snellen's, and in the left equal to Upon ophthalmoscopic examination I found a thick membrane floating about in the vitreous of the right eye, while in the left I found slight evidences of beginning trouble, there being a hazy condition of the media. I at once put her on increasing doses of potassium iodide, beginning with fifteen grains three times a day and increasing three grains daily until she took seventy grains three times a day. I also gave her one-thirtieth grain of bichloride of mercury three times a day and daily inunctions of mercurial ointment. I discontinued the mercurials in about two months keeping on with the iodide of potassium. About the first of August the vision of the right eye was about the same, %, while the left was, being slightly improved, but from this time the vision steadily failed in the left, so that by September Ist it was; September 5th, 1, and September 27th, %, the right remaining the same as before.

At this time ophthalmoscopic examination showed thick membranes in the vitreous of each eye so that the fundus. was entirely occluded, and she found it necessary to be led to my office, as she could not discern where she was stepping. During the month of October she began to show some signs of improvement in regard to vision, the vision improving in