These investigations of Chiari show the connection between the lymph follicle-like round cell ae,cumnlation and the gas-cysts, and the relations of both of them t,o dilated lymphatic vessels.
Hence it is very probable that the not papillary but follicular nodules seen in catarrhal vagina.1 inflammation really are connected with the lym phatic follicles; and that the formation of gas is simply a change which occurs under certain circumstances in the lymph follicles and the neigh boring canals. Hence the extent of gas accumulation in the deeper layers of the vaginal walls, though the original follicular chan,ge affected only the mucosa, and chiefly its more superficial layer Chiari is inclined to believe that the development of gas and of the giant cells may have a common cause in some bacterial activity. It is true that we only have a somewhat far-fetched experimental proof of this connection. L. A. Nageli I found, when experimenting upon the formation of extravasations in doves, that out Of seventeen cases where infection occurred with the wound, eleven had micrococci in the extrava sation and giant cells upon the outer surface of the clot. The giant cells were absent in twenty out of twenty-one cases in which the process was carried on with perfect antisepsis.
It is true that cocci have not yet been demonstrated m the gas-cysts, and Lebedeff is the only one who has as yet brought the extravasation formation into connection with the formation of gas-cysts. Nevertheless Niigeli's observation deserves further investigation in its relation to gas cysts, especially as venous stasis has been proven by Lebedeff, Chiari, and Eppinger to be the usual predisposing moment for the condition.
Nor has the question as to the origin of the gas in the cysts found a decisive answer. Schroder first demonstrated its nature by puncturing the cysts under water; but its composition has not been ascertained. Eppinger concludes from a case which Lerch examined, that it is atmos pheric air; and this seems to be confirmed by a case of Klauser and Wel poner. Zweifel believes it to be trimethylamin, and finds confirmatory evidence in the fact that Hilger has lately proved that trimethylamin is present in the vaginal se,cretions of healthy pregnant women. At all events it is very probable that it is not simply atmospheric air; and Klebs is I think right when he says that germs present in the vaginal secretions get into the affected cavities, and give rise to the development of gas.
The constant presence of swelling and hypersecretion, as also the micro scopic appearances which most observers have found, entitle us to place the affection among the chronic inflammatory ones of the vagina, and have led to the designations kolpohyperplasia cystica (Winckel), kolpitis vesi culosa (Schmolling), or k. emphysematosa (Ruge, Zweifel). It certainly occurs less frequently in non-pregnant women. I have seen it over twenty times developed to a varying degree in gravid women, and only twice in others. I can sustain Winckel's assertion that kolpohyperplasia cystica causes no serious symptoms, and has in most cases disappeared by the ninth or tenth day of the puerperium.
It is evident that since most of the cysts are superficially located in the sub-epithelial connective tissue, their disappearance is due to the stretch ing and compression of the vaginal wall daring labor, and the abundant secretion and desquamation during childbed. Air-cysts which are deeper setsted persist much longer. Schroder saw them well-marked upon the tenth day; and in a case described by Cheneviere and which we ob served, the cysts were most developed on the thirtieth day post partum, and some were still present even upon the forty-sixth day.
Special treatment would hardly be required did not the affection always occur in connection with a catarrhal vaginal flow. Disinfecting injec tions are indicated; carbolic acid or corrosive sublimate may be used, or, as Zweifel recommends, water acidified with hydrochloric a,cid.
Gravidity exercises an influence upon the catarrhally diseased mucous membrane on account of the increased vascularization and hyperplastic tissue increase which occurs in the vagina of pregnant women; and also by the venous stasis which is so early caused by phlebectasus in multiparre. Hence the swelling, relaxation, and diffuse injection of the mucous mem brane, as well as the papillary hypertrophy, reach a high grade in the vaginal catarrh of gravid women. It occurs in them more often than in non-pregnant wornen without any gonorrhcea being present. As we have already said, gravidity offers the most favorable conditions for the de velopment of the nodular hyperplasias. And for the same reasons the secretion is more abundant, and the whole course of the disease a more obstinate one.