Louis G. Feo

The Biologic Characteristics of the Normal Vagina

Summary 1. Extensive studies were made on the vaginal tract of more than 500 patients; included in this number were 37 normal patients in whom the studies were made three times weekly through one to three menstrual cycles. The special studies made included determinations of the pH of the vaginal mucosa, cytologic studies of vaginal. smears, examination of smears stained for glycogen content, determination of the bacterial flora, and the study of vaginal biopsies. 2. The role of the estrogens as the major factor in controlling the histologic and cytologic features of the vaginal epithelium is reviewed, but evidence indicating that progesterone and perhaps other steroid hormones have an important influence is presented. Certain cyclic histologic changes were frequently noted on the biopsies, but in the main these were not nearly so clear-cat as the changes noted from cytologic study of vaginal smears. 3. Present evidence indicates that the estrogens are the dominant factor in causing the mobilization of glycogen in the vaginal epithelium; progesterone may aid in this process. Androgens appear to be an inhibiting factor in glyconeogenesis. Glycogen is abundantly present in vaginal biopsies. A concentration of 2.5 to 3.0 mg. per cent was encountered in the upper part of the vagina and smaller concentrations in the lower part of the vagina. The metabolism of vaginal glycogen is not known, but various theories are discussed. Vaginal biopsies prepared with Bests carmine stain were found to be highly suitable for demonstrating distribution of vaginal mucosa. Cyclic changes in glycogen content were far more easily noted in vaginal smears stained by an iodine method. It was found that the glycogen content of the superficial vaginal epithelium showed a tendency to increase throughout the cycle and then to fall in the late premenstrual phase, thus roughly approximating the estrogen excretion through the cycle. 4. The various methods for determining the pH of the vaginal secretion and mucosa are reviewed. Direct determination of the pH of the vaginal mucosa by the glass electrode method was chosen as most accurate and reliable. A special glass electrode is described which has been found to be highly satisfactory for this purpose. In making 632 readings on 100 normal women, it was found that the pH varied from 4.0 to 5.0 in all except 3 per cent of the determinations. A pH gradient was found to exist in the vagina in most patients. The highest acidity was generally encountered in the anterior fornix. The next highest readings were obtained in the middle third of the vagina; these were generally quite constant and most nearly approximated the pH of the vaginal secretion. Lower values were obtained in the lower third of the vagina, while determinations made in the posterior fornix usually varied considerably. In the 37 cases studied at frequent intervals, a periodic variation in pH was observed in many instances. The average readings indicate that pH gradually falls to reach its lowest point at the midcycle and then gradually rises to meet the highest values at the premenstrual stage. 5. The factors which influence the character of the vaginal flora are discussed. From available evidence it would appear that the vaginal pH is the strongest immediate factor determining the type of organisms present in the vaginal tract. The vaginal pH and flora were correlated for a large series of patients and indicated that most of the patients with Grade I flora had a vaginal pH of 3.9 to 5.0 (range 3.9 to 6.0, average 4.56). Majority of patients with a Grade II flora-fell in the pH interval 4.6 to 5.5 (range 4.0 to 7.0, average 5.09). In Grade III type the majority of the patients had a pH of 5.1 to 6.0 (range 4.0 to 9.0, average 5.54).

The pH of the human uterine cavity in situ

Abstract A method is presented for the study of the pH of the human uterine fluids and/or mucosa in situ. The hydrogen-ion concentration of the uterine cavity varies during the normal menstrual cycle. A decrease in the alkalinity of the uterine fluids and/or mucosa is associated with a corresponding secretory endometrium. The occurrence of ovulation appears to be accompanied by a period of relative acidity of the uterine fluids and/or mucosa.

Trichomonas vaginalis infection in postmenopausal women

Abstract 1. 1. In a series of 504 patients aged 50 to 91 years attending a routine medical clinic, 65 women were positive for Trichomonas vaginalis. 2. 2. In the age groups 60 years and beyond Trichomonas vaginalis was found in 2 of 227 white women and 22 of 106 Negro patients examined. 3. 3. Attention was drawn to the comparatively mild symptomatology. 4. 4. The relation between Trichomonas vaginalis infection, postmenopausal age, and deficiency of estrogen effect was discussed. 5. 5. Some evidence was presented in support of a theory that the implatation and survival of Trichomonas vaginalis in the vagina are the result of the serum present.

Leptotrichia (Leptothrix) vaginalis

Abstract In 76, or 15.2 per cent, of vaginal discharges from 500 pregnant Negro women examined, a filamentous strain of the bacillus of Doderlein was found. In forty patients, or 8 per cent, it occurred in maximum numbers and produced in twelve patients (30 per cent) the following vaginal picture. A diffuse mild erythema was observed of the introital and vaginal mucosa upon the surface of which were scattered numerous discrete, pin-head sized white areas. These lightly adherent flecks were, microscopically, colonies of tangled bacterial filaments and epithelial cells. Superficial ulcers of the mucosa were beneath some of these masses, usually in association with a Candida infection. However, of 200 pregnant white patients examined, this filamentous strain was found in only one individual. The strain survived in the same patients for periods of one to three years. The morphology of the bacillus was similar to the descriptions of that of Leptotrichia (Leptothrix) reported in the literature and was identified with the Lactobacillus group of organisms, especially L. acidophilus , in its microaerophilic characteristic and biochemic properties.

Trichomonas vaginalis in urethritis of the male.

The effectiveness of penicillin in the rapid elimination of the gonococcus has served to focus attention on a group of diseases under the name of nonspecific or non-gonococcal urethritis. It is a not infrequent diagnosis: published reports give the incidence of this group as varying from 12 4 per cent. to a maximum of 70 per cent. of urethritides (Bull. U.S. Army med. Dep., 1947; Crouch, Reese, and Boudreau, 1953; Parrino, 1954; Babione and Graham, 1952; Durel and Siboulet, 1954; Harkness, 1950). The causes of the condition are not clearly defined. For many years speculation has centred in the possibilities of bacterial infection. Evidence has been based on the culturing of a predominant bacterium. In more recent times a virus and organisms of the pleuro-pneumonia group have been incriminated. But these same organisms have been reported in the urogenital tracts of men who gave no history of infection and were clinically well (Garvin, 1950; Wagner, Morse, and Kuhns, 1953; Ambrose and Taylor, 1953; Willcox, Howard, and Findlay, 1954; Willcox, 1955; Day and Arm, 1955; Feo, Fetter, Peoples, and Morton, 1956; Nicol and Edward, 1953; Shepard, 1954). Although Trichomonas vaginalis has been found in such cases, the idea that this organism might be responsible has stimulated little interest. This lack of interest is the more remarkable because of the incidence of this parasite in the general male population and in male patients with non-gonococcal urethritis in particular (Bauer, 1942; Feo, 1944; Seneca and Ides, 1953; Leca, 1951; Kozlowski, 1951; Sorel, 1952; Lanceley, 1953; Jira, Rossler, and Svejcar, 1955). Notwithstanding the fact that many men harbouring the flagellate are symptom-free, there are cases that attract attention. It is the purpose of this paper to emphasize the role of Trichomonas vaginalis as an aetiologic agent in cases of non-gonococcal urethritis.

Maintenance of trichomonas vaginalis in simplified trypticase serum medium without maltose

Abstract These data show that Trichomonas vaginalis will survive and grow in simplified trypticase serum medium without maltose. This experimental evidence supports the clinical observation of the survival of this flagellate in a vaginal environment lacking in epithelial glycogen. The metabolic requirements of the organism are met by the presence of serum and the nutritional stimulation of bacteria. The resulting metabolism and rate of division of Trichomonas vaginalis in this medium afford a method of conserving the flagellates with a minium expenditure of material and time.

Concurrent association of Trichomonas vaginalis, the filiform bacillus of Döderlein and Syringospora in pregnancy

Abstract 1.1. Saline mounts of the vaginal discharges of 500 Negro and 200 white women in their last trimester of pregnancy were examined microscopically for Trichomonas vaginalis. the filamentous strain of the bacillus of Doderlein, and the pseudomycelia of Syringospora. 2.2. In the white group the percentage incidences of the above organisms were 16.5, 12.0, and 0.5, respectively. There was one case of double infection with Trichomonas vaginalis and the bacillus of Doderlein and 6 cases showed both trichomonads and Syringospora. 3.3. In the Negro group Trichomonas vaginalis occurred in 43.6 per cent of the patients, Syringospora in 23.0 per cent, and the filaments of the bacillus of Doderlein in 15.2 per cent. The concurrent association of trichomonads with Doderleins bacillus, trichomonads with Syringospora and the bacillus of Doderlein with Syringospora was observed in 12.4 per cent, 12.2 per cent, and 5.2 per cent, respectively, of the Negro patients. Concurrent infection with the three organisms occurred in 22 patients, or 4.4 per cent. 4.4. Trichomonas vaginalis survives in an environment optimum for the growth of Syringospora or the bacillus of Doderlein (long strain). In the Negro group with a plus four (++++) Syringospora infection, Trichomonas vaginalis was present in 60.6 per cent of the patients. In a plus four (++++) environment of the filamentous bacillus of Doderlein, 92.5 per cent of the Negro patients harbored Trichomonas vaginalis.

The clinical findings in the presence of syringospora albicans and stellatoidea

Abstract 1. Of 150 pregnant Negro patients showing the presence of pseudomycelia by wet-mount examination, 44.0 per cent harboredSyringospora albicans, 54.7 per cent hadSyringospora stellatoidea, andSyringospora tropicalis was present in 2 cases. 2. Forty-three, or 29 per cent of all patients, revealed the classical picture of a mycotic vulvovaginitis. No definite correlation between the occurrence of this picture and the incidence of the species was found. 3. Pruritus vulvae was present in 55 per cent of all infected patients. Sixty-six patients were positive forS. albicans and of these 46 complained of pruritus vulvae while only 35 of 82 patients withS. stellatoidea were likewise positive. 4. Of 67 asymptomatic patients only 20 harboredS. albicans, whereas 47 showed positive cultures forS. stellatoidea. 5. It is not possible to make a clinical diagnosis of the species of Syringospora present in mycotic vulvovaginitis, with or without pruritus vulvae. However, the pruritic symptom is related significantly to the presence ofSyringospora albicans and not toSyringospora stellatoidea.

Implantation of trichomonas tenax (buccalis) into the human vagina

Abstract 1.1. Twenty-five T. vaginalis-free patients were inoculated intravaginally with T. tenax (buccalis) resulting in 6 temporary infections. There were 3 survival periods of two days each, and one each of three, seven, and eighteen days. 2.2. Twenty-five T. vaginalis-positive patients were inoculated intravaginally with T. tenax, resulting in 2 temporary infections. There were 2 survival periods of two days each. 3.3. T. tenax appeared to effect a temporary establishment in one patient, surviving for at least eighteen days. 4.4. The temporary residency of culture T. tenax and its associated bacteria caused little or no increase in local symptoms and signs. 5.5. Intravaginal survival of T. tenax was more infrequent and of less duration in those patients positive for T. vaginalis. 6.6. Three brief experiments involving the direct transfer of T. tenax from mouth to vagina gave negative results. 7.7. From the evidence presented, it is concluded that the mouth is not a source of vaginal trichomoniasis, and that the two sites are inhabited by two distinct species of trichomonas.

Flagyl in the oral treatment of trichomonal vaginitis.

Several reports may be found in the literature on the trichomonicidal properties of derivatives of Azomycin (Nakamura, 1955; Horie, 1956; Cosar and Julou, 1959). Among this group, 1-(2-hydroxyethyl)-2-methyl-5-nitroimidazole (Flagyl) was found to possess a high activity and a very low toxicity in experimentally-infected mice (Cosar and Julou, 1959). These results were confirmed by Durel, Roiron, Siboulet, and Borel (1959, 1960), and the studies were extended to include a clinical trial of the drug in -trichomonal infections. The results of the trial were encouraging and the effect was attributed to the trichomonicidal property of the serum and urine. The last-named study has been followed by others, and the success rate of cures with this drug has been very high (Sylvestre, Gallai, and Ethier, 1959; Sylvestre and Gallai, 1960; Bouziane and Desranleau, 1960). However, such results were obtained by combined local and oral administration of Flagyl. Although numerous compounds have been tested against Trichomonas vaginalis infections in man, no specific drug had yet been found which would produce a cure when given orally alone. The final test of any drug in this persistent and recurring infection should be based on its effectiveness in systemic treatment. The present communication reports the findings of orally-administered Flagyl in cases of Trichomonas vaginalis vaginitis.