For the affection shows a number of peculiar and characteristic symp toms.
a. It occurs most frequently during gravidity, and often disappears spontaneously during the puerperium, even during pregnancy if antisep sis is thoroughly carried out. It has only been observed in non-pregnant women in extremely rare cases, so far as I know, and then solely in per sons of middle or advanced life.
b. Its tumal seat is at the fornix vaginre and the adjacent mucous mem brane, especially of the posterior wall; only exceptionally does it affect the greater part of the vagina.
c. The granule or noduli itself may be distinguished by the touch from the ordinary papillary hypertrophies. Whilst the latter feel hard and rough, the former are smooth, round, soft, lentil-shaped prominences. Where closely aggregated in the fornix, the mucous membrane may feel sa if it were filled with closely-packed. small varices. Through the speculum they appear as round, smooth, isolated or grouped, broad-based protuberances, of a bright reddish or paler grayish color, which show very distinctly upon the swollen and vascular membrane. Occasionally they are surrounded by a vividly injected, red, seam-like border, and show here and there a central groove or opening. Whilst the other catarrhal changes of the mucous membrane are never absent, the com plication of extensive papillary hypertrophy may often be absent.
d. We cannot deny that this affection stands in relationship to the de velopment of vaginal gas-cysts. We regularly find in kolpohyperplasia cystica transition forms between grannlis with the central depression and the gas-containing prominences. The common location at the fornix, and the common chronically inflamed base, also point in the same direction.
e. Finally, as Eppinger has proved, where disintegration of the cir cumscribed cellular infiltrate which forms the granula or milia occurs, a central opening appears; and with the retrogressive changes at the in flamed spot there begins the floccular pigmentation of the mucous mem brane so frequently seen in elderly individuals, though sometimes observed in young persons. We must therefore regard the rounder, sharply limited and grouped spots of pigmentary deposit, even when no infiltration or loss of substance is discoverable, as the remains left by this form of vaginitis.
f. Though papillary hypertrophy is chiefly caused by virulent catarrh, we cannot prove any e,ausal relationship between the granular form and gonorrhcea.
Heitzmann,' who gives a good specular picture of a follicular vaginitis, recently claims that he has observed it not only in pregnant women, but also in young girls suffering from virulent and non-virulent catarrhs. But he refers this form to the participation of glands in the inflammation, which are not regularly found there; and he gives a drawing of a micro scopical preparation, which does show marked and partly dilated gland like depressions.2 His id.ea is that the central cavities of the granulis in vaginitis follicu laris are nothing more than the dilated excretory ducts of the swollen and inflamed glands. Only after the glands have been destroyed by suppura tion are their places taken by the lymph-follicle-like arrangements which Birch-Hirschfeld mentions.
Although the concensus of opinion of other investigators is that the relation claimed by Heitzmann between true vaginal glands and the nodules with disintegrating centres of follicular vaginitis is not proven, his drawings show that he has really seen ectatic glandular structures in catarrhal vaginitis, and that in cases where glands are present, true re tention follicles may occur.
We will accordingly entirely discard the term granular vaginitis, since both the papillary and the above-mentioned form are included under it; and we will call the latter follicular vaginitis, for the analogy between the circumscribed small-celled accumulations in the superficial layers of the mucosa, and lymphatic follicles, has been dwelt upon by several ob servers, and is supported most recently by H. Chiari's observations.' I intend to consider here two changes of the catarrhally inflamed mucous membrane, for I believe them to be only modifications of follicular vagi nitis; I refer to the formation of vesicles containing serum and gas.