H. Close Hesseltine

A study of the bacterial flora of the normal and pathologic vagina and uterus.

Abstract The results of a bacteriologic investigation of 250 cultures from the vagina and uterus of 248 patients are reported, and the significance of the findings is discussed. The study included vaginal cultures from normal prenatal patients, cases of trichomoniasis, moniliasis, and nonspecific vaginal infections, intrauterine cultures from normal and febrile postpartum patients, and from a few postabortal puerperae. The results are tabulated to show percentages of isolations, the isolation of anaerobic bacteria, and the predominant micro-organisms. In general, the bacterial flora of the vagina of normal prenatal patients was similar to that of patients with mycotic and nonspecific vaginitis. A variety of bacteria was isolated from the postpartum uterine cavity of normal and endometritis patients and from the vagina of trichomoniasis patients. The bacterial flora in the latter groups was similar. The significance of these findings to the problem of puerperal infection is discussed.

Histopathology and Treatment Of Vaginitis

Summary 1. Vaginal trichomoniasis and senile vaginitis have been cured by using lactose (95 per cent) and citric acid (5 per cent) therapy. Focal infections have been treated simultaneously by appropriate means. Although recurrences have developed there have, as yet, been no failures. 2. Generally, vaginal trichomoniasis and senile vaginitis respond slowly to treatment. The maximum period of treatment and observation was ten months in one instance, while the minimum was two months. 3. The average number of clinic visits in the “cured” group was 6.2, 9.2, and 8.3 far the pregnant trichomoniasis, nonpregnant trichomoniasis, and senile vaginitis patients, respectively. The respective average time intervals for treatment and observation were 2.7, 4.4, and 4.5 months. Perhaps these averages are higher than are necessary, especially since several of these were severe and extremely chronic cases which had not responded to other procedures. 4. Some recurrence of vaginal trichomoniasis and probably some exacerbations are due to reinfection and reinfestation from sexual partners. 5. The principle of this therapy is to supply directly nutritive substances which are necessary for a normal vaginal flora. This nutritive material may be supplied indirectly as a result of hormonal stimulation after the menopause. 6. The histopathologic pictures obtained by biopsy from the vaginal wall in tricllomoniasis, mycoses and senile vac initis are not distinguishable. 7. Biopsies from the vagina have revealed that even though the clinical appearance and smears are normal, inflammation may continue to exist in the epithelial and subepithelial. layer for varying periods. 8. The microscopic examination indicates an increased number of glycogenic granules in the epithelial cells of the treated cases, the deposition of which may be a factor in producing the beneficial effects of this treatment. 9. As yet, no conclusions can be drawn as to the modus operandi of this treatment. It may be from the creation of conditions which favor the development of a normal vaginal flora or from factors which permit or stimulate normal epithelial growths, or it may be a combination of both. 10. A biochemical approach to the treatment o.r some of the lower genital tract infections has been reported. 11. At the University of Chicago Clinic (Max Epstein Clinic) the most favorable results in trichomoniasis therapy have been achieved through the use of lactose (95 per cent) and citric acid (5 per cent) therapy, and the elimination of foci of infection end infestation.

Pyridoxine failure in nausea and vomiting of pregnancy

Abstract Every one of these sixteen patients was cured and the pregnancy carried on. It has not been necessary to perform a therapeutic abortion for hyperemesis in the Chicago Lying-in Hospital during the last few years. All staff cases and most of the private patients are treated by the routines outlined by Dieckmann. 7 These observations reaffirm the need for proper controls in all clinical and therapeutic research just as it is necessary in the basic sciences. Since many factors can be involved in clinical studies, it does not become research until adequate and suffcient controls have been established. A serious and earnest plea is advanced for critically controlled studies of all procedures and that publication be withheld until such controls are obtained. Fortunately, pyridoxine can be given safely in these dosages (as far as we know now). Aside from the expense to the patient and delay in instituting therapy where cures did not follow, no particular damage can be claimed. Another plea is offered for the retraction of prior recommendations when and as such corrections become evident to the original proponents.

Limitation of human reproduction

Abstract In retrospect, it appears that all of the terminations were undertaken after adequate observation and thorough consideration. In spite of this caution, certain of the abortions failed to give the expected benefit, and did not relieve the underlying disorder. In a few cases the interruptions were probably delayed too long. On the whole, it seems clear that considerably more good was accomplished than is indicated by the arbitrary designations in the result columns. A number of conclusions may be drawn: 1. 1. Therapeutic abortion is a necessary, but relatively infrequent, obstetric procedure. 2. 2. It should be done only to save or to prolong significantly the life of the mother, or to prevent the transmission of serious hereditary defects. 3. 3. It should be attempted only after adequate consultation, only in reputable hospitals, only by competent operators, and only after both the husband and wife (or legal guardian) consent. 4. 4. It is rarely, if ever, an emergency procedure, and should not be undertaken until the patient is in the best possible condition for it. 5. 5. It is not without some risk of operative complications, and even fatality. 6. 6. Sterilization is indicated whenever the same problem would arise in a subsequent pregnancy.

Acute appendicitis in the obstetric patient

Abstract 1. 1. A review of 51 cases in which a clinical diagnosis of acute appendicitis was made during pregnancy or the early puerperium with one maternal death and two fetal deaths is reported. The signs, symptoms, and physical findings were discussed. 2. 2. The obstetrician must always be alert to the signs and symptoms of acute appendicitis in pregnancy and when in doubt it is best to operate no matter what the duration of the pregnancy. 3. 3. Laparotrachelotomy at the time of removal of an appendix, with but very few exceptions, is violation of good surgical procedure, and should not be performed. 4. 4. It is an acknowledged principle that elective appendectomy at the time of cesarean section or removal of an ectopic pregnancy increases the hazard of appendectomy.

FACTORS RELATING TO MYCOTIC AND TRICHOMONAL INFECTIONS

A number of infections and inflammatory lesions may involve the vagina. Two unrelated frequent clinical entities, vaginal mycosis and trichomoniasis, are considered here. Each disease will be discussed separately for clarity and because of dissimilarities in pathogenesis. Limitations make review of even the pertinent literature impossible, but other presentations in this monograph supplement this deficiency in references. To the scientifically oriented student it is obvious that certain reports dealing with therapies have been inadequately controlled; for example, a number of microbiological studies have been essentially aerobic in nature. In order to give consideration to factors related to vaginal trichomoniasis and mycosis, statistics on and details of therapy for these conditions have been intentionally omitted. Since the lay public no longer accept? vaginal discharges and irritation as woman’s natural burden, pressure has been exerted for rapid and permanent relief of these conditions. The glamor of the many phenomenal medical advances in other areas in recent years may have contributed to premature reporting, especially in aspects of trichomoniasis. Thus, as the months pass the older of the widely heralded cures tend to disappear. Two questions arise: Is the problem of vaginal mycosis fundamentally one of reinfection? Is failure of trichomoniasis therapy related to the establishment of a normal vaginal flora?

The specific treatment of vaginal mycosis.

Abstract 1. 1. A new and specific therapy for vaginal mycosis is described, namely, the use of ricinoleic acid 3 per cent in a buffered acid jelly. 2. 2. This course of therapy in an uncorrected series produced 74 per cent of cures in the pregnant group and 90 per cent of cures in the nonpregnant group. 3. 3. This method of therapy is characterized by prompt relief of the pruritus, disappearance of the causative organism, and prevention of spread of infection to other skin surfaces. 4. 4. No ill effects or accidents have occurred over extended periods of treatment to either the mother or newborn. 5. 5. Use of this preparation affords a convenient and most satisfactory method of self-treatment for the patient. 6. 6. It is believed that the 3 per cent ricinoleic acid could be carried in suppositories or other suitable vehicles. 7. 7. The skin, mouth, and intestinal tract serve as ready foci for reinfection of the vagina.

Effect of lymphogranuloma venereum on pregnancy, labor, and the fetus☆

W HENEVER an infectious process occurs in a gravid patient, an understanding of the effect of the disease upon the product of conception and parturition, of the alteration of the course of the disease because of the pregnant state, and of the possibilit,y of transmission to the fetus and newborn is apropos. Lymphogranuloma venereum is rare in private patients, but more common in the charity services, especially among the colored race. The concomitant presence of lymphogranuloma venereum and pregnancy is striking because of its infrequency. Perhaps a few cases with minimal or no residual change remain undiagnosed. Within the past four and one-half years (Dec. 24, 1936, to June 30, 1941): 17 such patients have been observed at the Provident Hospital, whereas within the past ten years (May 25, 1931, to June 30, 1941) only one such patient has been diagnosed at the Chicago Lying-in Hospital. This rarity along with the infrequency of other pelvic neoplasms emphasizes the need for evaluation of the pelvis on prenatal examination, particularly in view of a few isolated reports which stress the possibility of tragedy at delivery both to the mother and the newborn. Nevertheless, the observations listed below do not agree with some references that termination before viahilit,y or in stillbirth is problematic merely because of this venereal disease damage. Perhaps during the active infection such hazards confront the fetus. More likely a relative sterility persists either because of pathologic alteration from an extensive inflammatory process of the disease or perhaps from other disease processes. It is not the rectal stricture as such that produces dystocia, but the associated perirectal hyperplastic or inflammatory reaction which obstructs the passage. The parturient uterus probably functions normally. Repeated examinations before conception, during pregnancy, and after delivery have shown no not,iceable alteration in the course of the disease or a change in the inflammatory tissue mass as a result of the pregnancy. All in this series were in the chronic or latent stages. Not one patient came t,o the prenatal clinic in the active state or developed an active process while under prenatal care. Possibly such stages did exist,, but in any event the active stage went unnoticed.

Vulval and vaginal mycosis and trichomoniasis

Abstract Twenty years ago gross ignorance prevailed on vaginal trichomoniasis and vulvar and vaginal mycoses. Today these conditions are usually recognized and adequately treated although improvement in therapy should and will likely take place. To the physicians of the United States goes priority for most of the important contributions in the understanding of these entities and credit for resourcefulness in the development and improvement of therapies.

Therapeutic abortion at the Chicago Lying-in Hospital

Abstract A statistical analysis has been made of 301 therapeutic abortions performed at the Chicago Lying-in Hospital over a fifteen-year period. These data were compared with similar data from the preceding eight years. The total time is from the opening of the present Chicago Lying-in Hospital on May 25, 1931, up to June 30, 1954. Comments on the indications and technical methods have been given. An attempt has been made to designate changes in the indications as well as in the procedures. In 69 per cent of the cases the results have been adjudged satisfactory. Only 12.6 per cent of the group had an unsatisfactory outcome. The remaining percentage of patients did not return. Thus the procedures were properly chosen, for by critical appraisal the outstandingly favorable results speak for themselves. It is obvious that the future will witness changes in indications and management as medical science advances.