Bacterial flora in vaginitis

Bacterial flora in vaginitis A study

before

and after

treatment

with

I s 1 8 9 2, lXider!ein’ discovered the vaginal bacillus in his study of puerpcral sepsis. Later, however, tli? clinical importance of thv bacillus of Diiderlcin in patknts with vaginitis was demons’trated by Schriidvr. After studying the vaginal flora of 288 nonprrgnant women, he was ahlv to divide his rases into 3 grades. Grade I, 1-O lx’r writ of the cases, had only the gram-positive \:aginal bacillus. The I-aginal sccwtions in tbew patients wvrc‘ al~~ays acid. and on vxaminaSon of the \-aginal wet sItwar:, only c.pithclial wlls wrw found. In C;rade II. 19 1x3 writ of the, cases. a miscd flora of Diiderkin bacilltts and \,ariorts othtar organisms KIS found. In Gra& III, 12 1x7‘ cent d t11r cases, DGderlein bacillus was absent and there was a lxvponderancc of micrococci, diphthwoids. and streptococci. and most 01 tllew cast5 had an alkaline, discharge witIt tnany 11~1s crlls. Thv fact that Gradt: I is consistrrntl) LSsociatvd wth normalcy of the caxina 1~15 txxw furtl1c.r cstablishc~tl t,c,c.vntly by tltr, carciul study of Lock and associactx” ‘I’hw inwstigatr~d thv x~aginal flora of 7.5 stt~dcrit nrtrsrs who \vtw unmat~tkl. bctwwi lhv as-c’s of 1 i and 2.5. and appart’ri11y witliortt si,ynificsnt gync~cological cliwaw. Hv canthining c:vitlcnw frottt hotlt cwltitrks ;rtitl snit~arb. the\. found Diidct kin bacillus it1 100 per cf-nt of tlicir caws. 13~ culture aloni~ it was found in 83 per cwt. A purr growth or Diiderlcin bacillus. or Grade 1. occurtt~i

432

pure cultures

of Db’derlein

bacillus

in 49 ptar cc‘nt. 3x1 in these palif*nts the PI-1 of the vaginal swrction was always 4.3. Hecauscb oi t1te.x: findings, it is not swprisinc tJlat ;tttcmpts have hrv:n made to wstorf~ tltc \q$nal flora to normal by apIJication of biological prt’pa rat ions. Liiscr, t in 1920, iiwd 3 lartohacilltis prc’paratioti. \\-hilt, in 19:il;. Orlowa’ claimtd SLIC~S.S lvith a cultttrv of Bacillur hzt1,qnricu.c in skim milk. In this cottntry. Molder ancl Brown” !rcatrd 2 I patients lcitli s(*vtw vaginitis: with onl) pttt.t cw1tr1rc.s of 1Xdvrlcin hacilIns. Six of their patients who were adecluatc~l\~ follow cd wtw c.ompletcl~ curvtl. ‘I’lletr~ has bc.tsri rcnclvcxl intt~rest. in tliis problt~ni 1wt’tt tlv in E~li-01x3. Gcdinho clt~ C)li\3~ira~’ in 3 stncly 0i 19 casvs of \-aginitis ttvatt~tl only \t itll daily applications of 3 pttrv cultttrc of IEdcrlrin harillu~, reported itnrric~diatc~ rc.1ic.l‘ of 5vrnptonis. a rrplacc*ttlc‘ni of staphylocows. diplococrrrs. stqand other hacwtk with the, iococrtt~. Diiderlein bacillus, and a shift in vaginal I)tI frotn n.0 ,,t 6.0 to as lo\v iklt~rleirt hacilltt5 ti;l\~t. t)fbtsri rt.portrcl t>), Rindi. Methods

and

Material

SC’\wal \.;tginal ritlLrtrc3 talwn ft.orit not,nial women. one from a 1 6-)carold girl grew out a pure strain of DGderlein bacillus. This strain grew best in the culture tttcdia and MXS found to persist. hettcr than t hr ctthtv strains when implanted into a tw-ipit>nt vagina. In this study it was called i~nlorl,!!

Vthme Nlmher

79 3

M-l. These Diiderlein bacilli were cultured on peptonized milk fortified with V-8 vegetable juice, were incubated at 35’ C., and were transferred to new media every 48 hours to maintain growth. Otherwise, exccssive lactic acid formed which reduced further bacterial multiplication. For clinical use, cultures grown in screwcapped bottles were centrifuged, the supernatant was decanted off, and the bacteria resuspended in 7 ml. of sterile skim milk. Clontrol counts were made with bacteriotrypsin digest agar, and the number of D6derlein bacilli was maintained at approximately l,OOO,OOO per milliliter. These culture tubes were refrigerated until used. Batches were kept small enough to supply only 3 to 4 days of therapy. Three methods of laboratory study were used in diagnosis and evaluation of therapy. They were wet smears, Gram-stained slides and agar plates. Wet smears were prepared by adding a drop of physiological saline to a drop of vaginal secretion taken from the upper third of the \ragina with a wooden applicator after a vaginal speculum had been fully inserted. The preparation was mixed, covered with a coverslip, and examined :immediately under x450 magnification. A sterile cotton-tipped applicator was used to collect material similarly for culture and Gram-stained smears. For culture, Petri dishes containing bacteriotrypsin digest agar were used. These were inoculated immediately, streaked for isolation, and incubated at 35’ C. for 48 hours under increased carbon dioxide tension. To accomplish this, most of the air in the closed culture plate containers was replaced with pure carbon dioxide from a cylinder. When identified on the agar plates, the DGderlein bacillus colonies were 1 to 2 mm. in diameter, colorlrss, translucent, slightly raised, and showed a very characteristic roughness or “cording.” Gram stains of these colonies always Gram-indifferI cvealed long, pleomorphic ent rods. Likewise, other bacteria were identified by colony and microscopic morphology. Throughout the study the Kopeloff-Beerman modification of the Gram

Bacterial

Flora

in Vaginitis

433

stain was used. This modification utilizes an alkaline stain and an alkaline mordant. In part of the study, a lyophilized preparation of the original M-l strain of DiSderlein bacillus was used instead of the skimmilk form. In the process of lyophilization, bacterial suspensions in sterile fat-free milk were prepared in 30 ml. quantities on a small laboratory freeze-drying unit. The bottles were shell frozen in a CO, iceacetone bath and immediately placed under high vacuum. After drying was complete the vials were sealed. Control counts after reconstitution of this material were performed which indicated nearly complete viability of the original DGderlrin bacilli. Clinical

study

The experimental group consisted of 165 patients with vaginitis seen in the pri\.ate gynecological practice of one of the authors during the year 1958. The study was divided into the first half of 1958, Plan A, and the last half, Plan B. In Plan A, at each office visit, besides the usual gynecological history, physical and pelvic examination, wet smears, slides for Gram stain, and agar plates for culture were taken. With the speculum still in place, the entire contents of a culture tube, approximately 7 million DSderlein bacilli, were poured into the vagina. An ordinary tampon was inserted and when the liquid was absorbed, the speculum was removed, leaving the tampon in place. The patient was instructed to remove it 5 to 6 hours later. In Plan B, Gram-stained slides and wet preparations were relied upon to indicate the presence of Dijderlein bacillus and to estimate their proportion in relation to other bacteria. Agar plates and colony identification were not used. Also, in the treatment of this group of patients, the lyophilized preparations were used instead of the earlier skim milk. The dry powder in the vials was reconstituted with 5 per cent glucose in water and 5 ml. of the preparation was used for each treatment. Again, the solution was instilled into the vagina with a syringe and held in place with a tampon.

434

Butler and Beakley

The 135 paticxnts in Plan .4 were seen al Ml officr \risits. To identify this group further. tht> a\-erag~ ;I~IX \\.a~ X.5. Ttsn were single, !I di\,orctYl. and tllc. rcmaintlt~r. 115 married. Of thc.scs patients. 1 I1 had been undo Jx,riodic c1hst.r \,ation for :\n average of 15 Irionths Jxior. during. and rafter the study. Durirlg thus 6 months of the Plan i\ investigation. 89 patic*nts w(‘re carefully ohscrvcd an avcra~cb of 2.6 months. These J)aticnts \vc~ iurthttr divided into gI’OllJ1S: controls, pregnant: adequately. alld initially sauditxl cax~. Tllc first ~WW groups “Initially st,idied” arc! self-~splan;ltor~,. means that 3 diagnosis as to llic cause of the vaginitis 1~;~s madr by cultures and smears. but these patients rclcrived only one or two applications of Xderlcin bacillus and were: not followed over a long enough period to evaluate what caffect these frw treatments might have; ‘I’he “adequately studied” cases were treated, studied, and followed o\-t:l- a sufficient time so that the Wsdts of therapy could bc dt~tt~rminetl. In Plan 4, 96 patients M’~w~ given 380 seJ>arate vaginal aJ)plications of tlicx skim-milk IXderIein bacillus preparation. In 106 patients, 228 wet-mount slides tvcre studied and in the entire group of 13% patients, .I-79 Gram-stained smears and ,479 agar plates were studied. The 69 patients in Plan I< wcrt‘ trcat(d with 124 vaginal applications of the rcconstituted lyophilizcd Diidrrlein preparation. At each office visit Gram-stained smears and Wet mount slicl(,s ww txa~rlinc~d.

Table I. Presence

of JXdcrtcin

bacillus

In order to group and compare patients. it was nccrssar) to classify them into one oi I o,rarlrs tlt~prndent 11po11 thr \+$nal Jxtpulation d the Diidcrleiu bacillus. This LZ’;LSdone brfort~. dririrl~. and after therajx. ;i nd \vas der~~rrrtinrtl 1)). agar-plates r.ult ures iti Pla11 .4 and by (iram-stained slides in Plan 1% The wws \VVIX~ c*asily, divisiblr into ,I grades. ‘I‘lic~sc~ wcrt’: C;racltx 1. a purfe ~rowtli of LGdt~rlcin bacillus by cirltui-fl: Gradcx II: a Jm~dominatt~ grob$.th of DGdcrIt+1 bacillus with only a t’art. colonv of other organisms: (;~,~~lc* IlI. a mistuix. d [)I’,~arllsnls \vi th IXdcrlcin bacillus Jxcsen t ; and Grade IV. ‘my of the organisms consmanly found in t tic v:tgina. hut a complete absrncx~ oi’ ttrt* l>iidt~rlcin hacillu~. .Iclllally. thi, (.lassific;rtion was i hc sani(’ Cl> the original SchrGdcr, except that S&r& dcr Oradr IT has bcerl divided into Gradrs If and III. Grads I ix the same as Schriid(~r Grade I nncl GracltL I11 of Schriider is identical lvitlt Gra& IL7 ill this study. ‘I’hci 1~ quantitative i!Ild objyc,ti\-c* aspr,cts of each :rad(b tttw stlldied hut w(‘r(’ uot ustd in llit~ statistical J)art ol this rtaport. ~l’lius. in (:I,acle I there was usually no dischal.gc. the l,axinal sccrctious were acid, and 011 ltlicroxopic rsaminaticm thtsrt, wer(* oniy rpithelial cells and l)iiclt~rlein bacilli. On th(s otltt‘r t’nd of I tic, ~pectrtun. Gr;& I\‘. tlic~w \vas oftt’n cliscllargc: ;lnd annovirig svlnllmoms, ant1 the \,a+~aJ scc.rctioIl \v;lr; nc*lltrnl or allialinct. On rilictx)scoJ>ic rxartiinaticxi 01w \.trould find pus cc*lls and ,I 1 arirrv of batlt*r.ia. Frcx~rlc~ritl!~ th(*sc* patients Ilad vt’;lst,

as determined

by vaginal

culture

in 12,-l

cases of vaginitis I

Per~c:Lnder~cent Of CaSeS ~. ..,-.-~~~I

I Cases 75 15 9 44 47 17 7

normal unmarried young adults3 normal controls (this study) pregnant monilia vaginitis nonspecific vaginitis trichomonas vaginitis trichomonas and monilia ____---._~ vaginitis

; Grades I, II, III I (with Diiderlein) 83 73 5b 33 19 (i -.. 0 .

/ i

.__~~~ __..

(without Dijderlein) 4 ,‘7 Y-1 6R 81 100 -. 100 ..~

i (pure

Grade I D6derlein)

. .__

49 20 22 6 2 0 0 ..~~_

~- ~~--

Volume Nlunber

79 3

Trichomonas

Bacterial

vaginalis,

or Hemophilis vagillal& present, but Doderlein bacilli were absent. Grades II and III were found in more of the normal patients.

Flora

in Vaginitis

435

s -I

AVERAGE

OF ALL

I5 CASES

2.5

Results The premise of this study is that normally the Dijderlein bacillus should be present in the vagina to the exclusion of almost all other bacteria and all pathogenic agents. Referring again to the work of Lock and associates,3 Diiderlein bacillus was found in 83 per cent of normal young unmarried women when the vaginal secretions were cultured. In the present study, by culture alone, Dijderlein bacillus was found in 73 per cent of the 15 nonpregnant controls and in 56 per cent of 9 pregnant patients. In 44 patients with monilia vaginitis, 32 per cent had Dijderlein bacillus, but it was found in only 19 per cent of the 47 patients with nonspecific vaginitis. Doderlein bacillus was not isolated from any of the 11 patients with trichomonas or the 7 patients who had both monilia and trichomonas in the vagina. These results have been presented graphically in Table I. It emphasizes the correlation of absence of Diiderlein bacillus and increasing severity of the infection. Another correlation was found when the incidence of Grade I was compared (Table I). Thus, 4.9 per cent of Lock’s normal controls had a. pure growth of Dijderlein bacillus while in the married controls of this study a pure growth was found in 20 per cent. Among the cases of vaginitis there was a marked r,eduction in the incidence of Grade I cases. These were as follows: monilia vaginitis, 6 per cent; nonspecific vaginitis, 2 per cent; trichomonas, 0 per cent; and trichomonas combined with monilia, 0 per cent. In Plan A, because of the culture methods used, H. vaginalis was not found; however, in both Plan A and Plan B, several patients who had the typical “clue-cells” as found by Gardner and Dukes” and collaboratecl by l3rewer and associates,lO when culture was done by the method used in this study, did not have Doderlein bacillus. These cases of suspected H. vaginalis were included among

Fig. 1. Diiderlein

bacillus in 15 normal

controls.

the cases of nonspecific vaginitis. A further study of the specific problem of H. uaginalis in relation to Dijderlein bacillus will be published later. To facilitate compilation and comparison of the data resulting from this study, the various grades were given an identical numerical rating. Thus Grade I was equivalent to 1, Grade II, 2, Grade III, 3, and Grade IV, 4. Thereby, an average grade for a group of cases couId be found after each case had been allotted the proper rating. For example, the average grade of the 15 controls was 2.5 or halfway between Grade II and Grade III, indicating the presence of Diiderlein bacilli in most cases (Fig. 1). An average of the 9 pregnant cases was 2.9, close to Grade III. The 47 cases of nonspecific vaginitis averaged 3.7, the 44 cases of yeast vaginitis, 3.9, the 17 cases of trichomonas, 4, and the 7 cases with both yeast and trichomonas, 4. Thus, all of the cases of vaginitis averaged 4 or Grade IV. When patients with Grade IV flora were treated with the DSderlein bacillus preparation, the studies made on the next visit would indicate if there had been a change. Thus. for example, if 5 cases of nonspecific vaginitis were all Grade IV initially but after one treatment with Diiderlein bacillus became Grade I, the average grade for these cases would be 1 and the result could be so graphed as a change in grade from 4 to 1. In Figs. 2 and 3, the actual changes in aver-

436

Butler

and

Beakiey

age grade in the cases oi this study were reprcsrnted paphically in this manner. The number of cases comprising each sum is in parrnthcsea.

Aritxg tlic 9 pregnant patients, 1 liatl nonspecific \-aginitis. 4 had monilia vaginitis. and ontr had trichomonas and monilia vaginitis. Of the .5 cases of monilia and trichomonas, 4 wcrf: Gt,ade IV and 1. Graclv III. Of the L cast5 of nonsp~cilic vaginitis. 2 LL-CW Grade 1, I \$‘;I\ Ciradv II, and I. Graclr III. Ah an t:ntire group lX5derlein bacillus was found itt 5ti l)vr cl.rtt on c,i11turn; in $1, l)vt‘ cent llic:tx. bxs none, wltik was present in in 22 per cent IXderlcin pure culture Table I ‘.

GRADE

I NUMBER

Fig.

2 OFVAGINAL

3 APPLICATIONSOF

, 5

4 PURE

6 CULTURES

Of

7

e

VIABLE

D6DERLElN

9

2. Results of therapy with application of pure cultures of DGderlein bacillus with monilia vaginitis and in 8 patients with trichomonas va,ginitis who quately stndird.”

tirnts

IO

BACILLUS

ill 2.5 pt.werr “ade-

Volume Number

79 3

Bacterial

Flora in Vaginitis

437

GRADE

NUMBER

Fig.

3. Results

OF VAGINAL

of therapy

with

APPLICATIONS

application

OF PURE CULTURES

of pure

tients with nonspecific vaginitis and in 6 patients vaginitis who were “adequately studied.”

pletely free of symptoms, their cultures were negative for yeast, and there was a predominate growth of DGderlein bacillus. Only 7 patients continued to the end of the study although free of symptoms. In this smaller group with further Diiderlein bacillus treatments the degree of purity of Daderlein bacillus in the vagina increased further to a final numerical grade of 1.5. The 47 cases of nonspecific vaginitis were divided into grades and cases as follows: Grade I, 3; Grade II, 1; Grade III, 5; and Grade IV, 38. The grade average for the entire 47 cases before therapy was 3.7. From another point of view, 81 per cent of the patients had no DGderlein bacillus on culture and of the 19 per cent who did, only 6 per cent had a pure growth or Grad.e I (Table I). Of these patients, 19 were in the adequately studied group and among these before onset of therapy the division into grades was as follows: Grade I, 0; Grade 11, 0; Grade III, 1; Grade IV, 18; or an average of 4. Thus, as represented in .Fig. 3, after one treatment with DGderlein bacillus, one week later the average grade was

cultures

with

0

of Diiderlein

combined

bacillus

trichomonas

in

19 pa-

and yeast

between II and III, or 2.5, and with subsequent treatments a greater preponderance of DSderlein bacillus was obtained. All of these patients were treated with only cultures of Dijderlein bacillus. Treatments were at first at weekly intervals and then at 2 week and finally at monthly intervals. As seen in Fig. 2, in spite of the long period of the study, once introduced into the vagina, the Daderlein bacilli persist. Of course, as the patients were relieved of symptoms, fewer returned for further treatments. Of these 19 patients (Table II), 18, or 95 per cent, were completely cured. One had no symptoms but, in spite of 4 applications of Diiderlein bacillus, on subsequent examination DGderlein bacillus could not be recovered. This patient was, therefore, considered only symptomatically cured. The 17 cases of trichomonas vaginitis were all initially Grade IV. Thus, DBderlein bacillus was absent in all. Of the 8 cases studied adequately all were cured except one which was a failure; in 2 of the cured patients there was a recurrence of the trichomonas vaginitis weeks later. These patients were treated with DGder-

438

Butler

and

Beakley

Table II. Results bacillus

of therapy with vaginal in 58 adequately studied cases

application

of pure

cultures

of Diiderlcin

Per cen,t of cases I SymPtomatic Cases

19 25 8 -6

nonspecific vaginitis monilia vaginitis trichomonas vaginitis trichomonas --and monilia vaginitis

Cured

i

cure

Failure

I

Kecurreuce

95 88 8i

100

lein bacillus at each visit. Each patient was given initially one or two treatments with a cinquarsen compound (No. 21 Powdex, Greenspun Laboratories), and those with persistent cases were given Devcgan vaginal tablets (Winthrop) to use twice a day for one week at home. With Dijderlein bacillus treatments first at weekly and then’ monthly intervals. thrre was a slog development of residual Diiderlrin g-rowth. but, as the trichomonas disappeared and the use of arsrnicals and Dc\.egan finished. Dijderlein bacilli became prominent and most casts became Gradr, II {Fig. 2:. The low average tobvard the vnd of the study \vas due to the one failure. In this patient Dijderlein bacilli would not grow. ‘I’hercs was nlscl a return to Grade IV of’ a cask’ t tlat waa “cured” but later recurred. Of these 8 cases, 7 \vcrc cured, 87 l>cr writ; one \\‘ax a failure, 13 per cent; and in 2. reinfection or recurrence ocrurred htcr, 25 per crnt (Table I j. Seven patients had a combined \,aginitis duca to trichomonas and monilia. ,411 these casts were GradI, IV and. thctrrfore. there Teas no Dijclerlein bacilltrs in the vagina initially. Six wcrc‘ adequately studi& and treated. Pow&s, Mycostatin vqinal suppositories, and Dijderlein bacilli were used initially, and then only Dijderlein. Surprisingly, all of thesr patients were cured and a Grade II vaginal flora obtained [Table I and Fig. 3). There bbc’re no rrcurrenc-c‘s, The plan B cases demonstrated that the lyophilized DijderIein bacillus preparation gave similar results in subsequent growth of Dijderlein bacillus and in therapy in the treatment of the various types of vaginitis

as did the skim-milk preparation us?d in Plan A. It had the advantages of more uniform bacttariai count, preservation witholtt refrigeration, permanence withorlt ttetcr,ioration, accessibility, and ease of USC. A critical analysis of these cases i\ not prcscnted because cultures wcrf’ not taken in this group and Gram smears and study of wet-mount slides l,verc: not considered sufficientlv reliable to warrant conclusioIls hased upon thrsc 5tlltliry alone. Comment When r.ultural metltods arc used which are especially df5ipecl to favor growth of DSderlcin bacillus. positive cultures u ill br found in a high percentage of normal \\;omen. But thp normal vaginal flora, that is, a pure’ or prtldominate growth of D&rlein bacillus. can 1~: easily altered since this microorganism i:, sensitive to rnan\~ antibiotics” used today. Then, too. the efiect of contraceptive jellies, douches. and various vaginal mctlicirics upon llic normal vaginal flora needs study in light of this inlcstigation. C~rrt;tinly. from this study tllrre is one positive conclusion. that is. thcrtx is a lack of Dijderlein bacillus in most patients with vaginitis. Does thr Diiderlein bacillus disappear first and tt1c.n the vagina become in\-aded with pathogenic organism? Or do the pathogens, by their invasion. destroy the IXderlein baciltlls? CzThictl is the cart and which is tht. hors(~ is theoretical, but> either way, re-estahlisllrncllt of normal flora shotlId be strived for in tht‘sc womfn. Our findings art’ not in agrccmcnr with rccent artkks \vllicll repot-t no significant aiteration in the xxginal flora of “ahnormal”

Volume Number

79 3

as compared to “normal” patientsI Even in trichomonas, Lash13 reports a similar incidence of Dijderlein bacillus in controls and in infected patients. However, Weinstein and co-workers’4 and FreedI are in complete agreement with our findings. They have also found that Doderlein bacillus is rarely, if ever, present in patients with trichomonas vaginitis. The increasing incidence of monilia vaginitis following systemic and vaginal therapy with some antibiotics is widely recognized. In these cases, possibly, the destruction of the Dijderlein bacillus by the antibiotic may be important. The upset in the vaginal flora balance certainly allows yeast cells to multiply. To counteract these changes rational therapy requires prophylactic and therapeutic suppression of the monilia and preservation or restoration of the normal vaginal flora by vaginal treatments with pure cultures of Doderlein bacillus. Unfortunately, the diagnosis of nonspecific vaginitis has become one of exclusion. That is, if a case of vaginitis is not due to monilia or trichomonas, it is considered nonspecific. The recent elucidation that some of these cases are due to H. vaginalis is a step in the right direction. With further study possibly a specific cause will be found to clarify all of these cases. Nevertheless, nonspecific vaginitis encompasses a broad group which constitutes a large percentage of the total cases of va,ginitis. Many of these cases may have resulted from the use of antibiotic drugs, contraceptive jellies, medicated douches, and some drugs used to treat vaginitis. A common factor in these cases may be the destruction of the vaginal Dijderlein bacillus and the subsequent disturbance of the vaginal flora and an alteration of the vaginal pH. Significantly, treatment of these patients with only vaginal applications of pure culturezs of Doderlein bacillus was found to be practical, rapid, and successful. Sixty-six years after DSderlein’s original discovery, the bacillus named for him still remains an important factor in the preserva-

Bacterial

Flora

in Vaginitis

439

tion of a normal vagina. These bacteria are also, possibly, a protective mechanism against vaginal invasion by pathogens. Probably the widespread use of many systemic antibiotics and vaginally applied drugs reduces a normal woman’s protective mechanism, a pure or predominate growth of Doderlein bacillus, and thus vaginitis may develop more easily. Thirty-seven years after Schrijder’s original classification of vaginitis into grades, his method has been found to be of practical value. This method helps, as demonstrated in this study, in the classification of and comparison of therapeutic changes. Ry substitution of a numerical rating, large groups of cases can be considered statistically and the results plotted on graph paper. In the cases of vaginitis studied in this report, Diiderlein bacillus was rare or absent initially and replacement was, therefore, an obvious and rational consequence. To save time and amount of biological used the initial use of “specific” drugs was justifiable; for example, Mycostatin for monilia vaginitis, Devegan for trichomonas vaginitis, and Terramycin vaginal suppositories for H. vaginalis vaginitis. It is an impression gained from this study that concomitant and subsequent use of the Diiderlein bacillus with these drugs alleviates symptoms more rapidly, increases the cure rate, and helps to prevent recurrences. In most instances of nonspecific vaginitis, the applications of pure culture of Diiderlein bacillus alone were effective. Today, with ever-increasing drug usage, factors which enhance or destroy the normal vaginal flora must be understood. Summary

and conclusions

1. The Dijderlein bacillus is usually present in the normal vagina and absent when there is vaginitis. 2. Pure cultures of certain strains of Daderlein bacillus isolated from the vagina of normal women can be cultured and successfully reimplanted in the vagina of patients lacking the bacillus. 3. Lyophilized Doderlein bacillus gave re-

440

Butler and Beakley

suits comparable to the skim-milk preparation used at first and had thus advantages of’ indefinite preservation. uniformity of hacterial count, and simplicity of ust’. 4,. The study comprised 16.5 private patients with vaginitis scxm in un~: );par. 1958. 3. In Plan A. 134, patients wcrc intcnsivt,l>, studied o1.c~ a fxriocl of 6 months. The presence or absence of Dijderlein bacillus was determined hy a cultural method designed to favor its ,crowth. Patients with vaginitis, lacking the I>iiderlein bacillus. were treated by applying purr cufturc.s of’ a special strain of Diidcrlcin bacillus to the, \-agina. On il subsequent \.isit a repeat culture was taken to cletrrminf~ thr rff(73i\-cness of the therapy. 6. Of ,&1 cast’s of monilia \xginitis, 25 Lvert: treated and studied intensivclly. Fl’ith refxatcd applications, +ns and symfxoms cleared rapidflr and the \.aginal flora hvcarnc, predominantly Dijderlein bacillus. Mycostatin \.aginal supfmitorim were wvd in addition only durirq thfb first M.CC~. 7. ‘T’hcw \vrrt $7 casch of nonspecific~ vaginitis. &fore trcatmenl 8 I jxr cent 01 these patients had IW Diidtarlein bacilli in the vaginal flora. Thy NYW treated wit11

only purr cultures of Daderlein bacillus. Of the 19 cast’s intcnsivol)studied, 95 per crnt \,vert’ cured and the vaginal flora of thc:stb patients became fxedominantfy IXiderlein hacillils. 8. None of thr I7 patients with triclmnionah lraginitis had Diiderlein bacillus in the‘ vaginal flora. These patients were initially treated with pentavalent arsenical as w~li as witfl Diidcrlcin bacillus cufturtx As the. arsenical was stopfxd and the trichomonads disappeared, further applications 01 Sderlcin bacillus resulted in a nearly pidominate growth of this microorganism. !I. The fj5 fxltients in Plan R. some of \vhicf1 M‘CI‘C rontinrlcd from Plan A. p’a\‘c’ cx\-iclenct~ that sirrrilal, results could bt* c‘xpcctrcl froni t hc* II~(’ of tllcb lyophifi7c~d prep,I ra I ion. IO. Since thcsrc ih \videsprcad use of syst cmic and focal clrlqjs whicll destroy the normal \~++a1 I)iiderlein bacillus. the’ fjrofx’r biological balance sfloultl hts rnainiaintyl or rrstot~c~d. Ttlis Ina\.- 1-W a(‘cotnl)lishecl

I>>, vaginal

qq)lications

ol’ jxi1.f’

!III’C’S of a sfleciaf <\lrain of Dijdcrfcin a> rrportecf in this stud!..

rui-

hacilfu

REFERENCES

1.

Diiderlein. A.: Das Scheidensekrct und srinr Bedeutun? fiir das Puerperalfieber. Leipzig. 1892. 2. SchrGder, R.: Zentralbl. Gyn%k. 45: 1350. 1921. 3. Lock, F. R., Yaw, M. D., Griffith. ,&I. 1.. and Stout, M.: Surs:. Gynrc. s( Obst. 87: 410. 1948. 4. L&r, A.: Zentralbl. Gynsk. 44: 417, 1920. 5. Orlowa, R.. and Tomashewitsch, M.: .4rch. Gynlk. 154: 628, 1933. 6. Mohler. R. W., and Brown. C. P.: .\&I. J. OBST. & GYNEC. 25: 718, 1933. 7. Godinho de Oliveira, J.; J” Clin. Chir. di Lisbona. 7: 205. 1956. 8. Rindi, V.: Min’erva ginec. 7: 621, 1955. 9. Gardner, H. L., and Dukes, C. D.: ,4M. J. OBST. & GYNEC. 69: 962, 1955.

10,

Brewcar. .j. I., IIalperu. K.. a11d Thomas, :tM. 1. &ST. c; GYNEC. 74: 834, 1957. Lutz. A.. and Wurch, Th.: Bull. FPd. gyntc. et obst. 6: 115. 1954. Huntrr, C. H.. and Long, li. R.: AM. OBST. & GVNIX:. 75: 865. 1958. Lash, J. ,J.: ,4sr. J. ORST. & GYNEC. 138, 1954. Weinstein. I... Ijogin. M.. Howard, .I.. Finklestone, B.: A>r. J, OHST. & GYNEC. 211, 1936. Freed, L. I:.: South African M. J. 22: 1948.

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550 West Thormu Phoenix, Arizouo (Dr. Butler)

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