Vesicular Vaginitis.—Eppinger first investigated this form of the mal ady, which he called vaginitis vesiculosa or herpetiformis. It is formed by the epithelium of the infiltrated area being raised over a vesicle by the serous exudation. If the vesicles rupture, they have superficial, circular, sharp-edged erosions behind, which when large much resemble ruptured pemphigus blebs. Kleinwachter,' however, is the only one who has ob served these erosions in connection with pemphigus, his patient being thirty years old, and having had pemphigns of the lower limbs for three years. Apart from the vesiculation, all the other appearances, as well as the termination in the Hallerian pigment spots, are in exact accordance with the variety called miliaris by Eppinger, here termed foilicularis; and we can only regard it as a modification of that form.
Emphysematous Vayinitis.—This second modification appears as mul tiple cysts of the vaginal mucous membrane with gaseous contents. To F. Winckel belongs the credit of having first minutely investigated it in the cases of some pregnant women. He called it kolpohyperplasia cystica.2 In his communication he reviewed the observations of Eppinger,' Schro der,' myself,' Nacke," Schmolling," Cheneviere,' Zweifel,' and Ruge." Since that time there have appeared researches upon the subject by Klauser and Welponer," Eppinger," Lebedeff,'' Zweifel," Hiickel " and H. Chiari." It is true that occasional and very excellent observations upon such cases had been made by Ritgen and C. Braun before Winckel; but the latter was the first to thoroughly investigate the subject.
In the vagime of pregnant women, exceptionally in those of puerperal and non-pregnant women, there are found hemispherical prominences with soft smooth surfaces, in some few cases of which an emphysematous crackling can be recognized even with the finger. They usually occur in the upper third of the vagina, and may affect the portio vag. Through the speculum they appear as grayish translucent vesicles of from corn grain to grape size, occurring in irregular and often crowded groups.
Many vesicles appear sunken, or have a central depression. They all spring from a swollen, bright-red surface; when pricked they collapse without any fluid exuding, and we can often hear the noise made by the escaping gas. At the utmost they may exceptionally contain a few drops of serous fluid.
There is usually also an abundant dirty-yellow mucoid discharge. A very correct picture of the portio vag. and tbe neighboring tissues in this condition accompanies Cheneviere's communication.
Microscopic examination of the dead and living tissues has as yet given us no certain information as to the condition. Winckel, Zenker (in Schroder's case) and Hirckel found the inner wall of the cyst distinctly lined with epithelium. Lebedeff found it absent in part. Klebs, Eppin ger, Ruge, and Chiari could never demonstrate it. And the latter ob servers unite in asserting that they found a number of communicating cavities in each round cyst, which, being entirely devoid of epithelium, could only correspond to clefts in the tissues. Klebs believed that they
were caused by micrb-organisms in the lymphatic spaces. Eppinger sums up his six cases thus: " Emphysema of the vagina is distinguished by the appearance of very numerous grouped air vesicles in the lymphatic channels of the interstitial connective tissue, especially along the vessels; and its occurrence is greatly favored by cedematous loosening of the in terstitial connective tissue in consequence of venous stasis." In all his cases there were circulatory disturbances; but vaginal catarrh or other in flammation Eppinger does not consider necessary for the occurrence of emphysema. Lebedeff also considers passive hyperremia to be the effi cient cause, but claims that the air cysts are due to extravasations in the interstitial connective tissue. The latest monograph upon the subject is that of Chiari. Celloidin, ombedding of alcoholic preparations, and staining with alum-cochineal enabled Chiari to reach some new and re markable conclusions. He used two new cases and five of Eppinger's which had been preserved in the pathologico-anatomical museum at Prague. In both of his own and in the three best preserved of the other specimens he found " that the gas-cysts are always without a proper wall; and that their internal surfaces are characteristically lined in part by flattened or rounded giant cells. In every case these giant cells were also found in the lymphatic capillaries, being evidently derived from their epithelium; and in every case lymph-follicle-like he,aps of round cells and lymph capillaries filled with lymph cells, could be demonstrated in the mucosa vaginre." In two cases of Chiari's and two of Eppinger's the round erosions present were found to be due to the opening of gas cysts. Very commonly, as Eppinger has noted, the cysts follow the blood-vessels in their course. Nor was venous stasis absent in Chiari's cases; both patients had heart lesions. Chiari concludes that the condi tion is connected with a pathological change of the lymphatic apparatus; and that the gas-cysts develop in preformed pathological spaces in the lymphatic system, which are filled with a mass of epithelial cells, part of which have been changed to giant cells. Chiari found by careful exami nation post mortem of the vaginal mucous membrane of many subjects, that lymph-follicle-like structures are fairly frequently found both in old and young individuals. He could generally recognize them as grayish points with the naked eye, and usually found them in the upper part of the vagina, especially along the posterior wall. They appeared almost always to be combined with a catarrh, and always gave him the impression of a new growth. The small punctate central openings, into several of which a bristle could be passed, were the orifices of ectatic lymphatic spaces. These structures were histologically exactly like the gas-cysts, and were traversed and surrounded by capillary passages filled with lymphoid cells. In a small percentage of these cases Chiari found giant cells in the lymphatic capillaries.