There is a syphilitic form of hypertrophy or elephantiasis of the vulva which is not uncommon in this country. The labia minora and majora may be transformed into enormous flap-like folds. Though at first free from ulceration, this may subsequently result from chafing. Warty growths may cover the hypertrophied labia, the perineum, and the buttocks. The disease usually affects both labia, though it may be confined to one. This manifestation of syphilis does not yield readily to constitutional or local medicinal treatment. Many cases prove to be incurable by medicine. Antisyphilitic treatment should always be tried at first, and if this fails, the hypertrophied structures should be excised with the knife. If, in such cases, there is any doubt in regard to diagnosis between syphilis and cancer, a small portion of tissue should be excised and submitted to microscopic examination. =Adhesions of the Clitoris.=--Adhesions between the glans of the clitoris and the prepuce or hood which covers it are exceedingly common. Usually no trouble whatever is caused by these adhesions, unless an accumulation of smegma takes place, or irritation is produced by the presence of a concretion. In case of any irritation about the genitals, the prepuce and clitoris should always be carefully examined. In fact, a careful examination of the clitoris should form a routine part of all examinations of the external genitals. When trouble arises from the presence of adhesions, the prepuce should be drawn back and the adhesions freed with a blunt probe. A 20 per cent. solution of cocaine should be applied to the clitoris for ten minutes previous to the operation. The whole corona and the sulcus back of the corona should be exposed. The raw surface should be covered with vaseline, and the patient should abstain from walking as long as pain is caused by it. The prepuce should be drawn back and vaseline applied every day for two weeks, to prevent the formation of adhesions. CHAPTER IV. DISEASES OF THE VAGINA. =Inflammation of the Vagina.=--Acute inflammation of the vagina is not a very common affection. Primary inflammation confined to the vagina alone is unusual. The disease in most cases is secondary to vulvitis, urethritis, or endo-cervicitis. The causes of vulvitis (which have already been considered) are also the causes of vaginitis. It is of importance to remember that the disease may occur in children as a result of the same factors which produce vulvitis. The exanthemata, as measles and scarlet fever, may cause vaginitis as part of the general involvement of the skin and mucous membrane which occurs in these diseases. The most usual cause is gonorrhea. Several varieties of acute vaginitis may be recognized--the simple, the granular, the senile, and the emphysematous. It is unusual to find the entire surface of the vagina involved. The disease is confined to areas or patches separated by healthy tissue.