The vaginal erosion, which was the only constant pathological local finding, re,sisted all treatment, antiseptics, astringents, aromatics, caustics, alterants, heat and cold, dry, wet, and ointment tampons, permanent ir rigation, without more than transient effect. At the same time, the in terior of the uterus was treated. The white erosion simply extended. The general hysterical treatment, which Cohnstein advocated in case of exfoliative vaginitis, was not neglected, with the precaution, during its administration, to intermit the local treatment. All sorts of cures, baths, electricity, etc., were without effect. Frequently carcinoma and rodent ulcer were suggested by my consultants, but I could never detect any thing but superficial changes, there being no infiltration or deep exten sion of the process. I am able to explain the case purely on the associa tion of changes in the circulation and local nourishment accompanying hysteria.
Owing to the great tendency and the ability of the hysterical to simu late everything, it is very difficult to explain marked symptoms from the side of the circulatory and secretory organs, such as luemoptysis, rapid discharge of unchanged fluids, as milk, per rectum, and the like, on the score of perverted innervation, although there is no ground for doubting the action of abnormal innervation on the secretions, and on the contrac tion of the blood-vessels: The protracted constipation which is witnessed in the hysterical without appreciable disease of organs, the marked de crease in the amount of urine secreted and in its concentration, these must be accounted as sequelte of the hysterical neurosis. In our case the conditions find their explanation in chronic hysteria of high grade which had existed for a number of years.
A peculiar membranous exfoliation of the superficial layer of the mu cous membrane has been described by Winckel under the name colpitis gummosa. In a twenty-eight year old nullipara, who since her six teenth year had had molimena every four weeks, and since her seventeenth had suffered from leucorrhcea, who at twenty-two began to menstruate every six months, and had never had any ulceration on her genitals, Winckel found the following: The vulva was reddened to the mon,g yowls, the labia not swollen and dry, the rima closed. On separating the nym plate, a gmy, partially adherent, partially desquamating membranous layer was seen, which began above the urethra, and spread over the anterior vaginal wall, along the inner surface of the nymphie, down to the pos terior commissure and thence over the entire vagina. Externally it
terminated sharply at the frenulum, and above at the vaginal vault; on one occasion alone, a portion the size of a pea was found adherent to the postelior lip of the cervix. The external os was entirely smooth; there was no cervical discharge. The membmnous layer, a number of lines thick, could be removed with the forceps, and the mucous membmne beneath it was pale red. The insertion of the finger and the speculum was difficult and painful, although there was no hemorrhage. The con dition had lasted for about three months. A year previously she had been treated for the leucorrhcea and for pain in the back and abdomen. The patient had no fever.
The reaction of the secretion was highly acid. On microscopic exami nation the layer was found to consist in numerous fat corpuscles, like cells, partially containing crystals in the shape of needles; these bodies dissolved in ether. There existed also a thick layer of partially cornified epithelium.
Birch-Hirschfeld examined a portion excised from the neighborhood of the introitus and reported that the epithelium was markedly thickened, the upper layers being partially converted into membmnous lamelhe; the rete malpighi contained large cells, and was much thickened; the papilla) were hypertrophied, the sub-mucosa greatly thickened and filled with many thick-walled vessels; the tissue was infiltrated with round and spindle form cells, so that the appearance was similar to that obtained from fresh sections of a gumma.
Winckel watched the patient for four and a half weeks. Within two to three days, on the-parts whence large pieces of membrane had been removed, nodules the size of a pin's head formed anew, grayish in color, which quickly coalesced into membrane. For two days she lost a slight amount of blood (menses), and on the third day Winckel found the en tire vagina filled with a boggy, black mass which was shed, and then the previous membranous formation recurred.
It is interesting to note that the case was complicated with a chronic affection of the left eye, which had existed since her nineteenth year, and had been repeatedly treated. At the time Winckel examined her, the conjunctiva was covered by a layer very similar to that in the vagina, the cornea being partially cloudy and the pupils prominent In addition the patient had had an eruption on the face and arms, which had yielded to inunction with some ointment. She did not cohabit till afterwards. Examination revealed no sign of syphilis, and the affection was neither cured nor bettered by protracted use of anti-syphilitic remedies.