the vaginal entrance in an inflamed condition. Hence the opinion was given that the condition of the child was due to an attempted, but not completed, coition by a man affected with gonorrhea. Eight other similar cases are given. Another instructive case is the following: The girl was fourteen years of age. The labia majora were relaxed and inelastic, and did not cover the vaginal entrance as they do in the virgin state. The orifice of the vagina was dilated, particularly in the lower portion. The opening of the hymen, which was itself not destroyed, was unusually large, and the vaginal mucous membrane very red and inflamed. The hymen and clitoris were swollen, and there was also gonorrhea. The defendant, a bookbinder, who was charged with having frequently had connection with the young girl, as well as others who visited his shop to buy writing materials, represented that he had merely used manipulations with his hand. Dr. Casper, in reply to the question put by the judge, stated that "it was improbable that the defendant had merely manipulated with the 'hand, since the dilation of the vagina was adverse to this opinion, and that masturbation merely could not induce so much inflammation, nor the urethral gonorrhea which was present. Hence it was to be presumed that the defendant had at least endeavored to introduce his organ into the vagina." A case happened in London, in 1858, and is related by Dr. Taylor,26 of a girl of seven years, violated by a boy under seventeen years of age. There was complete destruction of the hymen, and slight laceration of the perineum, but no other marks of violation. Very profuse bleeding had saturated the girl's clothing, but no trace of blood was found on the boy's clothes or person; and it was inferred, therefore, that the bleeding was an after effect, and a result of oozing from small blood-vessels. Had not the proof of the crime been complete on other grounds, this circumstance would have rendered its commission by the accused improbable. Hascher27 relates a sickening case of a child eight months of age, violated by a boy eighteen years old. Upon examination there were found redness, swelling, and great tenderness of the labia minora and parts in the neighborhood of the urethra, with rupture of the hymen, frenum, and perineum, together with laceration of the posterior wall of the vagina. A case of genuine rape, with syphilitic infection, gave rise to an indictment against a journeyman hatter, who had abused his master's daughter in the most shameful manner. "The girl was only eight years of age, her private parts were very much dilated, and the mu

697.

Taylor, Med. Jurispr., 6th ed., p.

"Hascher, Oestr. Zeitschr., Vol. XXXII., p. 33.

cous membrane, particularly at the entrance, very red and painful to the touch. The hymen was destroyed, and she had a virulent gonorrhea." Dr. Casper gave his opinion, "that there was no room for doubt that an impure coition had taken place, and been really consummated." It was afterwards discovered that the accused was affected with gonorrhea. But on account of his obstinate denial of the charge, and his endeavor to escape conviction by assigning other reasons for the infection, the judge proposed the question, if the common use of an unclean chamber utensil could possibly be the means of conveying the gonorrheal disease. The answer was, that this was possible, but that such an origin of the disease could not properly be assumed in this case, on account of the destruction of the hymen, and the dilatation of the vaginal canal.

There can be no doubt of the occasional transmission of venereal disease by other means than sexual intercourse. Dr. Ryan28 examined two children who were infected with gonorrhea by using a sponge belonging to a servant girl who had the disease. Mr. Hamilton29 has published a case, in which a girl of six years of age was infected with syphilis by a boy of nineteen. The contagious matter was carried by the fingers. In Henke's Zeitschrift for 1850,30 the details of a judicial examination of a somewhat similar case, where, also, the virus was conveyed by the finger, are given by Dr. Henrich, of Mayence.

To be distinguished from the venereal diseases of children, acquired by intercourse and indirect infection, are the cases of simple vulvo-vaginitis, which simulates gonorrhea, and hereditary spyhilis; and the two less closely simulating conditions,-herpes of the vulva and gangrenous vulvitis. In the minds of anxious relatives they may awaken suspicions of violence with intent to commit rape, and sometimes form the occasion for criminal prosecutions against innocent persons, for the sake of gain. The following descriptions are taken from L. Emmett Holt's Diseases of Infancy and Childhood, 2d ed., 1902.

187a. Simple vulvo-vaginitis.—Simple vulvo-vaginal catarrh may be seen at any age, even in infancy. It is, however, most frequent after the second year. It more often occurs in girls who are anemic or suffering from malnutrition than in those whose general health is good, being especially common in those who live in unhygienic surroundings, or where personal cleanliness is neglected. It may follow

"Ryan, Lond. Med. Gaz., Vol. XLVII., 30 Erg. Heft. 41.

p. 744.

2 Hamilton, Dublin Med. Press, Vol.

XX., No. 511, p. 1848.

any of the infectious diseases, especially measles. There seems to be little doubt that even this form may be spread by contagion. It is common in children in institutions where small epidemics are seen. It may be communicated by direct contact, or by handling the parts, or through clothing, diapers, sponges, towels, etc. The disease may be traumatic, as from attempted rape, or the introduction of foreign bodies. It may be secondary to the presence of pinworms, or the itch, and is sometimes the cause, sometimes the result, of masturbation.

"The disease generally begins as a subacute catarrhal inflammation, the discharge being the first thing noticed. In the milder cases this is thin and yellowish-white, giving some pain on walking, itching, and burning on urination. In the more severe form it is abundant, and of a yellowish-green color, causing the labia to adhere, and the secretion drying forms crusts. The odor is sometimes extremely fetid, and the skin of the thighs may be excoriated. The local examination shows the mucous membrane to be red, swollen, edematous, and bathed in pus. All the visible parts-urethra, hymen, vagina, etc.are involved. By using an ordinary urethral speculum in the vagina, pus may be seen, in most of the severe cases, to come from the cervix uteri. There are no constitutional symptoms. There may be swelling and even suppuration of the glands in the groin. The disease has no definite course, but usually, with proper treatment, lasts from one to three weeks, when there may be complete recovery, or there may persist for a long time a leucorrheal discharge. In children who are in poor general condition, and where the proper means of treatment are neglected, vulvo-vaginitis may last for months."

187b. Gonorrheal vulvo-vaginitis.-Gonorrheal vulvo-vaginitis in young girls has been shown by recent studies of the micro-organisms in the discharge to be very much more frequent than was formerly suspected. While indirect infection is no doubt possible, and in certain cases proved, nearly all writers agree that this is very excep tional, and that the most common origin of the disease is the direct contact, either intentional or accidental, with another case of gonorrhea, sometimes sexual and sometimes with the hands. In this way the disease may be conveyed from one child to another, or from adults to children; very often from parents who occupy the same bed with the child. Pott states that in 90 per cent of his forty-four cases, the mothers were found to be suffering from leucorrhea. The mode of contagion may be difficult to trace, but this fact should cast no doubt upon the diagnosis in the case. The disease occurs in girls of all ages, but chiefly between three and eight years. Epstein has reported

cases in the newly born. The incubation in three cases in which it could be definitely traced was exactly three days (Cahen-Brach).

"The disease is believed to begin usually in the urethra, although this is, in most cases, difficult to establish, as there are generally found, on the first examination, evidences of inflammation of all the mucous membranes of this region. There is a copious secretion of thick yellow pus. There may be erosions of the vaginal mucous membrane, so that the parts bleed readily. Crusts form on the labia. When a view of the cervix can be obtained by means of a small speculum this is almost invariably seen to be involved. For the first day or two, in the more severe cases, there may be slight fever and general indisposition, but more frequently-and this is one of the most striking points of difference from the disease as seen in the adult-constitutional symptoms are entirely wanting. Urination is painful and sometimes frequent; there are also excoriation of the skin, and difficulty in walking, all these symptoms being more severe than in the simple catarrh. The duration of these cases is indefinite, being from one to six months. Under the most favorable conditions it is several weeks, largely due to the difficulties in the way of a thorough application of local treatment. It is always more obstinate than a simple

catarrh.

"A positive diagnosis between the simple and the gonorrheal catarrh can be made with certainty only by a microscopical examination of the discharge. It should be emphasized that the mere presence of a few diplococci, even though they be in the pus cells, is not sufficient to establish the diagnosis of gonorrhea, since there are varieties of diplococci found in the simple catarrh, and even in the normal vaginal secretion, which morphologically closely resemble the gonococcus of Neisser. It is the presence of these in large masses in the pus cells which is the characteristic feature. According to the very careful observation of Heiman and others, the two varieties of diplococci may be positively differentiated by staining with Gram's method. The gonococcus is decolorized, while the other form is not."

One of the possible complications of gonorrheal vulvo-vaginitisthe gonorrheal ophthalmia-is so characteristic that if it occurs it is very significant, and before the identification of the bacterial origin of the disease such evidence was considered proof of the disease. In the case referred to in Henke's Zeitschrift,31 in 1850, about thirty years before the discovery of the gonococcus, the virulent character of the vaginal discharge was settled by the unmistakable gonorrheal oph

"Erg. Heft. No. 41.

thalmia which the child brought on by touching her eyes with her soiled fingers.

187c. Hereditary syphilis.— Hereditary syphilis would scarcely be mistaken for that acquired by direct sexual infection, for in the hereditary cases, while the infant, in the majority of cases, appears healthy at birth, and does not develop syphilitic symptoms till the second to the sixth week, yet, when those symptoms appear, they are distinct from those of the acquired form. In the hereditary form there are no primary or secondary stages, but only the constitutional symptoms that show themselves most frequently in the coryza, eruption, fissures about the mouth and anus, mucous patches, and bone disease. On the other hand, in the acquired form in infants, the disease has the same primary sore and secondary eruption as in the adult.

187d. Herpes of the vulva.- "Herpes of the vulva is a simple vesicle formation on the skin or the mucous membrane. On the skin the vesicles rupture, or dry and form crusts or little ulcers, which heal in a week or ten days if the parts are kept protected. On the mucous membrane the vesicles are succeeded by small ulcers, which may coalesce and form larger ones. The symptoms are itching, burning, and a slight discharge. The herpetic ulcer may be confounded with the mucous patch of syphilis, but these herpetic ulcers heal quickly under the simplest treatment."

187e. Gangrenous vulvitis.- "Gangrenous vulvitis, or noma, usually follows one of the infectious diseases, most frequently measles, occurring in patients whose general vitality has been greatly reduced. The condition may follow a simple catarrh or a herpetic vaginitis. There is first noticed a tense, brawny induration, the skin being shiny and swollen over a circumscribed area. Day by day the gangrenous area advances, preceded by the induration. It may involve the whole labium, extending even to the mons veneris and the perineum. These cases are usually fatal. If recovery takes place it is with considerable deformity of the parts in consequence of the extreme sloughing and cicatrization." The discrimination between this condition and the results of an attempt at rape would not be at all difficult for the physician, though the parents or friends of the child might be misled so far as to attribute it to criminal violence.

Cases have arisen, however, in which both physicians and jurists found the distinction difficult, yet more from the circumstances of the patient suggesting the suspicion of violence than from the character of the disease itself. The earliest case is one often quoted from Per