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JUN 23 1899

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The Physician and Surgeon

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[PÚBLISHED IN The Physician and Surgeon EXCLUSIVELY) RECENT developments in the field of serum therapy are making imperative the necessity for positive and accurate diagnosis in all forms of septic infection. The old term “puerperal fever" has given way to the more scientific term, "puerperal infection,” and this in its turn is subdivided according to certain clinical manifestations depending upon the principal seat of inflammation. Bacteriologic research has now made possible, and the coming demand for specific treatment is making imperative, the differentiation between the different varieties of infection that attack puerperal women. Some recent observations of mine have led me to believe that the near future will find us also carrying the system of bacteriologic research for diagnostic purposes more and more into the field of ordinary gynecologic practice. The pathology of many diseases attacking the pelvic organs of the female may in this way be made much clearer, and the treatment of them in consequence simplified and made more specific. It may be possible that, with the culture tube and the microscope in one hand and serum therapy in the other, the coming physician will succeed in accomplishing much that is now relegated to the abdominal surgeon.

The present quite prevalent routine practice of curetting the uterus in all cases of puerperal infection is one that must be severely condemned. Curettage of the puerperal uterus, with the abraided surface of its cavity covered with diphtheritic membrane, the result of the presence of certain different forms of cocci and bacilli, or, if simply bathed in the pus formed by the presence of organisms like the gonococci, results simply in adding more fuel to the fire, as the old raw surfaces are quickly recovered, as well as many new ones made by

*An address delivered at the annual meeting of the Detroit MEDICAL AND LIBRARY Associatiox, October 4, 1897.

the curette, the latter becoming new foci for the development of the toxin. Accurate bacteriologic diagnosis will do much toward preventing this dangerous practice. The impulse to "do something," and to have an operation, will then give way to rational deduction with specific treatment applied to the known cause, and the curette will be relegated to its proper place, to be used only in cases of retained secundines.

In quite recent articles, as well as in society discussions on this subject, there is promulgated the idea—not always specifically expressed, but at least implied—that the streptococcus is the principal factor in puerperal infection. While this may be true in the majority of cases, or in certain localities, yet the staphylococcus will be found to play a very important part, the colon bacillus, will occasionally be found, and the KLEBS-LOEFFLER bacillus, in localities in which diphtheria is prevalent, will be found to be a very important factor in the etiology of puerperal infection. Often the infection will be found to be a mixture of two or more of these, and other bacilli and cocci, such as the bacillus pyogenes fetidus, gonococci, et cetera, may be present. The gonococcus often acts as the primary cause of infection when, if the case be neglected, the natural secretions of the vagina and uterus will become so altered as to permit of the easy access of other germs which destroy the gonococcus, when the case may then appear to be one of primary infection from the germs which entered last. This condition may take place even in the nonpuerperal uterus and vagina. I have seen one case of this kind in which an extensive development of diphtheritic membrane took place as the result of a mixed infection of streptococcus and staphylococcus. The case was so anomalous in my experience, and as it doubtless illustrates an important principle in the etiology of gynesic disease, I will report it in full.

The case, which was referred to me by Doctor DEVENDORF on the 24th of last July, presented herself at my office with the following history: Age twentysix years, married six years, no children, one miscarriage at two months five years ago, menstruation normal, has no pain and has always enjoyed good health up to the beginning of present trouble, which began six months ago. She first noticed a leucorrheal discharge which became watery in character after several weeks, and for the last two or three months has had a bad odor, which has been becoming more and more fetid. Micturition frequent, but not painful. Walking or standing causes a feeling of weakness, but no pain. Bowels regular. Patient complains of sleeplessness and says she feels foverish at night. Pulse 90; temperature 99.8° Fahrenheit. Vulva normal; on retraction of the perineum quite a quantity of extremely fetid, watery fluid gushed out. The finger, when introduced into the vagina, came in contact with a shreddy, friable mass, which gave way to touch with the use of very little force, and through which the outlines of the cervix could be only very indistinctly made out. The sensation to the examining finger was so exactly like that produced by contact with papillary cancer—the so-called cauliflower excrescence—that, on the withdrawal of my finger I was surprised to see it was not covered with blood, there being not even a trace of color on it. On introducing the speculum the entire field was seen to be filled with strips and patches of partly loose and partly adherent diphthertic membrane, which was as thick as heavy buckskin. The entire cervix and surrounding wall of the vagina were covered with this mass of mem

brane. Before applying anything or disturbing it any further, I sterilized a test-tube, and with sterilized forceps placed a good sized piece of the membrane within and sealed it with cotton. The vagina was then dried with cotton, and without attempting to remove any more of the membrane a good-sized tampon of cotton and lamb's wool, saturated with fifty per cent. boroglyceride, was introduced, and the patient directed to return at the end of forty-eight hours, and to allow the tanpon to remain until she did so, as I desired to observe its effect on the membrane.

The specimen in the test-tube was submitted to MR. TIBBALS, the bacteriologist of the Health Office, who reported on the following day that it contained a mixture of streptococci and staphylococci, but no gonococci or KLEBS-LOEFFLER bacilli.

July 26: Temperature 99o. The tampon was removed with the entire mass of membrane adhering to it. Odor extremely offensive. Digital examination showed a normal condition of vagina and cervix, although the latter was considerably enlarged and very sensitive to touch. By the speculum many superficial abrasions, covered with a very thin grayish white adherent membrane, were observed. The appearance of these patches was much the same as is presented by the well known appearance of the seats of recently detached diphtheria membrane in the throat. The vagina was thoroughly washed with 1-2000 sublimate solution, dried with absorbent cotton, a concentrated solution of iodine and carbolic acid applied to all of the abraided surfaces, this also dried off after a few minutes, and the vagina again packed with wool and boroglyceride.

July 28: Temperature normal. Patient noticed no oder from the discharge, and only a very slight odor was observed on the removal of the tampon. She complained of some pain after the last treatment. The abrasions presented a clean, healthy appearance. I dusted with stearate of zinc and packed the vagina with iodoform gauze, which patient was directed to remove in forty-eight hours.

July 30: No odor. Abrasions much smaller and less inflamed. Repeated previous treatment.

August 1, 5 and 8: Applied tampon with acetate of lead and glycerine, with directions to use an astringent wash daily after the last treatment.

August 21 and 31: I made an intrauterine application of iodine and carbolic acid, as evidence of uterine catarrh was observed. There still remains some uterine catarrh, but the patient feels perfectly well and has no leucorrheal discharge.

The especial points of interest in this case are, first, the presence of pseudodiphtheria in the nonpuerperal vagina; second, the apparent long duration of the microbic action in the vagina, without infection of the uterine cavity or Fallopian tubes, and without producing more symptoms of systemic toxemia. The presence of the cocci in this nonpuerperal vagina, along with the membrane-the product of their activity-would indicate that the natural secretion of the vagina had been changed in some manner so as to permit their growth, while the fact that the invasion of the uterus did not, apparently, take place even after the long continuation of the microbic activity in the vagina and on the cervix, even up to the external os, may doubtless be explained by the theory


that the secretion from this organ had not been changed by previous disease, and so still retained its natural germicidal properties, and was enabled to act its part in repelling the invader. The fact that the varina offers natural facilities for good drainage, is doubtless the reason why the toxins resulting from the microbic growth were not absorbed in quantity sufficient to produce active systemic disturbance.

At the last meeting of the Association of Obstetricians and Gynecologists, held recently at Niagara Falls, the writer reported six cases of puerperal infection in which the KLEBS-LOEFFLER bacillus was found, cultures in each case being made and submitted to the bacteriologist of the Health Board. Two of them were cases of mixed infection, having besides the diphtheria bacilli, streptococci also. Five of the cases were treated with antidiphtheritic serum, and they all recovered, although the cases of mixed infection did so slowly, showing by a continuation of febrile symptoms after the diphtheritic manifestations had entirely disappeared, the necessity for making careful differentiation in diagnosis so as to be able to make the necessary differentiation in treatment. The fatal case was one of the most virulent in its manifestations that I have ever seen, and died on the morning that the report of "pure KLEBS-LOEFFLER" came from the Health Office. The symptoms indicated such profound infection that, at the time of making the culture, I believed the source to be of streptococcic origin, and, in order to loose no time, the antistreptococcic serum was used at

If the antidiphtheritic serum had been used when she was first seen by me, I feel certain that this woman would have recovered.

To still further illustrate the variety of specific causes of puerperal infection I will mention in brief two cases that occurred recently at the Woman's Hospital

Both women were confined on the same day, and both exhibited similar symptoms of infection on the third day afterward. Vaginal examination revealed an abundance of white membranous exudate covering abrasions of vagina and cervix in both cases. Cultures from the cervical canal were carefully made and the infection in each case found to be due to the staphylococcus pyo

As no antistaphylococcic serum could be obtained they were treated on general principles, and both have recovered. As I expect to report these cases in detail in a future paper, I will not enter further into their symptoms or treatment here.

Reliable antidiphtheritic and antistreptococcic serum can now be obtained, and I understand through Doctor McClintock that Parke, Davis & Company will be glad to make the antistaphylococcic serum if it is wanted.

Quite an extensive article on “Streptococcic Infection and MORMOREK'S Serum," by Doctor GEORGE W. Cox, appeared in The Journal of the American Medical Association, of September 11, 1897, in which the author speaks in the most positive terms of the efficiency of the serum. He also warns against its use when it contains any chemical which has been added for the purpose of preserving the serum, and says the serum made by MORMOREK contains nothing of that kind, and from his experience and observation he knows that it can be used in any quantity without producing any toward effects. understand that Parke, Davis & Company keep this serum in stock, prepared both with and without the preservative, so that it can be obtained in either

genes albus.

condition desired, and on very short notice. The antidiphtheritic serum is now eo generally used and is in such universal demand that it can be quickly procured from many of the druggists, not only of this city but of the state generally.

With these facilities for obtaining these two reliable serums whose usefulness has passed beyond experiment, and which are now proven to be so powerful in controlling the two forms of infectiom, and with the equal facilities for obtaining the culture tubes necessary for making the cultures, no case should be left to the fate consequent on haphazard diagnosis and consequent faulty treatment. It takes but little time and trouble to make the culture, and if the physician making it has not the time, instruments or experience to make microscopic examination himself, there are a number of reliable microscopists here in this city that can do it for 'him, and bacteriology is now so generally taught in our colleges that almost every community has one or more physicians competent to make these microscopic examinations. Culture tubes for this purpose can be obtained at the Health Office by physicians of Detroit, and MR. TIBBALS, the bacteriologist of the Board, will make the necessary microscopic examinations and report on them in the same manner as is customary in cultures taken from the throat.





[PUBLISHED In The Physician and Surgeon Exclusively.] DEEPLY sensible of the privilege of addressing you this evening, I will endeavor to comply with the request of your secretary and bring my paper within the ten minutes allotted me.

The majority of gynecologists within a comparatively short time, would have judged one advocating vaginal incision and drainage as a cure for pelvic abscess, either lacking in courage or sadly deficient in his knowledge of pelvic pathology. Lawson Tait and his followers by their brilliant abdominal work had demonstrated that pelvic cellulitis was only an accompaniment and that the real seat of the trouble lay in the diseased appendages. As each one took up his abdominal work he learned to distinguish, amidst the dense adhesions uniting the omentum, bowels and pelvic organs, the tube or ovary distended with pus and removed it forthwith. As his fingers became more educated the damage from this “cleaning out” of the pelvis became correspondingly diminished. The operations were oftentimes extremely difficult and the mortality quite high. When a case was lost through shock or sepsis, the surgeon would console himself with the thought that the pus tubes demanded enucleation and had he only secured the case sooner, before the strength of the patient had been exhausted, all might have been well. Not infrequently after working through

*Read by invitation at the annual meeting of the DETROIT MEDICAL AND LIBRARY AssociATION.

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