SYPHILIS.
It is not possible to state how often the vagina is the seat of syphilis, since often in the recorded cases the presence of the disease in the vagina and on the cervix are confounded. For both together E. Klink, from his personal observation and from a search through French and German literature, concludes that the ratio of chancre is here to that in other lomlities as 8:322. According to Kaposi soft chancre is rarely met with, although more frequently tlaan hard; Kaposi saw two cases within three months. Of 249 hard chancres of the female genitals Fournier only found one on the vaginal mucous membrane. Klebs also states that the primary lesions in the vagina often lack induration.
Heitzmann gives an excellent description of the specular appearances. The peculiarities of the soft chancre he states to be the following: Sharply reddened, slightly elevated borders, sinuated and uneven base, and speckled purulent layer. The peculiarities of these ulcers in the vagina are: the destructive process extends more on the surface than in the depths, whence the shallow base, great tendency to unite with others, and hence there results an extensive ulceration surface with sinuous indented edges, the surface being covered with profuse secretion and necrosed masses. In this locality their progress is slow. The usual seat of the chancre is at the introitus: in the vagina, it is almost always found in the anterior third and most frequently in the anterior wall. Exceptionally, Heitz mann found it in the posterior fornix, whence it had extended on to the posterior lip. In healing, the slough separates from the borders and is shed after profuse suppuration; the epithelium is regenerated from the periphery towards the centre. When the process has not extended deeply, no cicatrix remains, and when one does, it is pale, smooth, shiny. Hard chancres, according to Heitzmann, are ordinarily found at the introitus, next to the posterior commissure. He was never able to detect charac teristic induration higher up.
Secondary syphilitic changes are relatively more frequent, although, as regards the vagina, there are but few recorded instances. Heitzmann de scribes erythema syphilitica, and also a form analogous to psoriasis, and the mucous papules (broad condylomata.) In case of erythema there exists a more or less circumscribed catarrhal inflammation of peculiar nature and eonrse. At first the mucous membrane is only diffusely reddened, with out marked swelling; soon at certain portions a more intense redness appears. Ordinarily the anterior third of the vagina is the seat of such circular erythema. At the same time a similar change is sometimes seen on the cervix. These reddened portions, in certain instances a few small, separate spots, are very sensitive and vulnerable, slight touch causing them to bleed.
Either the erythema disappears in a short time (8 t,o 10 days) sponta neously, or else a peculiar cloudiness affects the diseased portions, or finally papules form on the erythematous base. The erythema recurs rapidly, and the secretion is not purulent like that of gonorrhea, but more watery and milky; complication with virulent c,atarrh is, however, met with. With regeneration of the epithelium, young fungous epithelial
cells are sometimes formed, which, arranged in thick layers, cause the red spots to look white and opaque, as though they had. beau touched with lunar caustic. The process, according to Heitzmann, is analogous to psoriasis lingu and psoriasis syph. cut., only that, in consequence of the bathing of the parts by the increased secretion, the upper layers do not become dry, and therefore no desquamation is noticeable.
Of French authors Courty speaks of changes which belong here. " Es pecially under the influence of syphilis, we see in the vagina (particularly on the cervix) circumscribed, round, coin-like thickenings of the epithe lium, which look like drops of wax, and which are differentiated by their pale white color from the red surrounding parts. These are a species of psoriasis, plaques, which are surrounded by a red surfac,e, occasionally ulcerate, yield to specific agents, and yet may remain unchanged for a long time. In other instances they increase in thickness and consistency, and form either broad condylomata, or else small hard elevations." The mucous papules, described by Heitzmann as generally rising from the erythema, are always markedly elevated, although in comparison with the same efflorescence on the external skin of the genitals they do not form such characteristic nodules. According to Zeissl they only are typically papillar when they are seated on mucous papillte. They are ordinarily more characteristic on the cervix than in the vagina.
At the outset we see red, slightly elevated, flat surfaces the size of a pea, generally arranged in groups and quickly running together, thus making large plaques. In case of accompanying virulent catarrh, the papules swell quickly. The surface becomes eroded and bleeds readily. Occasionally, from changes in the epithelial layers, they become cloudy and look like mother of pearl (plaques opaltnes of the French). The papules do not then disappear as quickly, and after atrophy there remain milk-white patches. If instead of thickening there has occurred shedding of the epithelium, then the denuded papilla! swell int,o papillary nodules.
A second metamorphosis of the papules consists in their molecular de generation. In the beginning the condylomata seem to be covered with a thin diphtheritic membrane. They are dirty gray, their convexity is rough. The breaking down begins in the centre and is there far ad vanced, whilst the periphery is still intact. The papules then resemble very much specific ulcers, especially when the borders are not very elevated.
In the diagnosis of syphilitic affections of the vagina, the characteristic marks will answer in the majority of cases, particularly since ordinarily there are present at the same time changes due to the same disease on the external genitals, skin, etc. Still, in case of isolated ulcers, the diag nosis may be so difficult that it is only reached on the appearance of secondary symptoms.
The local treatment is similar to that which we have laid stress upon under the subject of catarrh. The general treatment is the usual one.