Whilst the patches and the superficial erosions depended on mycotic epithelial necrosis, the process appeared to extend more deeply where the circumscribed yellowish dry scabs existed. The structure was not recog nizable, only the thrombosed vessels were prominent. At the line of demarcation the vessels were widened, and the tissue infiltrated with small cells. The micrococci were only exceptionally found. In the stage of ulceration, in one marked case, the borders were formed of overhanging epithelium the lower surface of which was covered with a thin layer .of pus in which projected stumps of vessels, filled with coloring matter. Underneath the pus layer there vras granulation tissue, and in places the Eruppuration extended into the depths.
As regards the method of infection, Eppinger concluded that the micrococci caused a loosening and a separation of the epithelial layer, even as Bumm has latterly shown occurs in case of gonococci, and that contact with the dysenteric dejecta caused extension to the vaginal mucosa. In favor of this view, the frequently observed patent vulva and site of election at the introitus speak.
Vaginitis Erysipelatosa.—Eppinger has also described an erysipelatous inflammation of the vagina: On the body of a woman of thirty-five, who had died of erysipelas on the twelfth day of the disease (which began in the face, disappeared from there, and on the tenth day, was seated on the left thigh and hip), Eppinger found reddening and swelling of the nym phte, especially on the left side, whero also on the inner surface of the labium majus, the epidermis formed bulla3 the size of a bean. The mu cous membrane of the vagina, as far as the fornix, was swollen and red. dened, and in places, wrinkled. On the posterior wall, three-quarters of an inch above the commissure and as far as the middle of the vagina, there was loss of substance for a space the breadth of the little finger, which was covered with swollen epithelium, in places elevated in blebs, and the base of which was formed by a greatly reddened, thin, whitish exudation. Similar small patches were found laterally and on the anterior wall. Where the epithelium was intact it could be readily separated. The sub-epithelial and sub-mucous tissue was softened, moist, reddened.
The fluid from one of the small blebs by the side of the ulcer contained the pale, movable, monadinencocci (Klebs). Similar cocci were found in the epithelium from the foot; in the deeper tissue-layers and in the blood they were not detected. Where the epithelium was intact, it was swollen, and the cells contained vacuoles. The papillte were broadened, and the vessels were injected. The cellular infiltration extended in por tions down to the muscular layer. The epithelial and sub-epithelial
layers intercommunicated. The deep vessels of the vagina were much widened; the muscular layer was unchanged, and the mucous membrane of the cervix and the uterus, as well.
Eppinger's case, which was seen before the appearance of Fehleisen's work, is, as far as I know, the only one in which erysipelas extended to the vaginal mucous membrane.
Vaginitis Septica.—Of the septic changes in the vagina, the slough and ulceration on infected wounds in puerperte, which Klebs has called wound diphtheria, are best known. Less attention, anatomically, as well as clinically, has been paid to the septic changes in the intact mucous membrane, although they are of not infrequent occurrence on the nym phie, in the vagina and on the cervix, as the result of the action of septic secretion. W. Fischel has often spoken of epithelial necrosis in septic puerpene, without going into a detailed description. Eppinger states in regard to the differential diagnosis between dysenteric and septic necrosis, that the former invades by preference the lower extremity of the columnse.
These changes are most frequently found in puerperx. On intact por. tions of the mucous membrane, as, for instance, on the borders of the nymplue, on the cervix, on top of the vaginal rugre, and in particular on the edge of the columnae, are found dry, yellow spots, isolated, on the level of the mucous membrane, which can only be removed with the epithelial layer. In extreme cases they may extend over the entire vagina, and resemble a diphtheritic exudation. Although these spots are not particularly injected, the mucous membrane under them is swollen and inflamed, especially on the apices of the rugm and columnte, and it is reddened. Without doubt, the inflammatory processes, as well as the epithelial necrosis are due, in general, to secretion from the uterus con taining septi cocci, and in proof of this we have seen a marked instance where there could be no question of extension from an ulcer. In a case of atresia hymenalis, to which we have referred, where, after a small per foration; there occurred purulent degeneration of the retained blood, there formed a septic colpitis which spread over the entire vagina with yellow adherent deposit on top of the thickened rugae. During the course of antiseptic treatment these deposits remained unchanged for days, and the epithelium reformed without there being at any time an erosion; in other cases, on the contrary, where antisepsis was not attended to, there remained after separation of the deposit, flat, yellowish ulcers, which spread irregularly in depth and in width. Such ulcers have been not,ed by Eppinger at the extremities of the colunune.