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INVESTIGATIONS ON PUERPERAL FEVER.
561
hygiene. It is therefore peculiarly fitting for his specific organism, better results may ensue. Various. colleagues in the public health service to perpetuate samples of serum from different laboratories have been Wheatley’s memory by the provision of a floating tested. The result of this work is largely negative ; swimming-bath on the river Severn near to the town very little increase in the bactericidal properties. of Shrewsbury, whose health was his lifelong care. of human blood against heemolytic streptococci was
found. Mercurochrome was found to have no effect on the bactericidal power of the blood. Arsenical drugs cause a marked increase in the there will be, pace Wheatley’s gospel of living dangerously, a safe and sheltered bath for non-swimmers and bactericidal powers of the blood, and Dr. Colebrook children, with two screened lawns on the adjoining considers this to be a most hopeful line for further shore where men and women respectively can enjoy investigation. Unfortunately the results obtained sun-bathing before and after entering the water. No clinically do not confirm this optimism, since elsewhere charge will be made for admission to the lawns or in the report Mr. James Wyatt declares that the dressing sheds, but a special pavilion is to be provided various organic arsenical preparations have had for those who can afford to make payment towards the little or no effect on the course of the disease in cases upkeep of the bath. It is hoped by the promoters of of septicaemia. It is interesting to note that in the Wheatley Memorial that this bathing-place may 6 out of 22 cases operated upon for general peritonitis become a model of its kind and extend further the no vaginal examination had been made. influence of this great sanitarian in bettering the health of the people. The estimated cost is .62000, of which an anonymous donor has given JE250 ; contributions may OBVIOUS AND OBSCURE INFECTIONS OF THE be sent to Dr. A. D. Symons, at 74, Wyle Cop, CENTRAL NERVOUS SYSTEM.
From the further side of the raft swimmers will have direct access to the river, while on the hither side
I
Shrewsbury.
____
INVESTIGATIONS ON PUERPERAL FEVER. THE annual report of the Metropolitan Asylums Board for 1927-28 contains a valuable section on the investigations carried out on cases of puerperal fever admitted to their hospitals. The pathological side of this work is under the care of Dr. Leonard Colebrook. His report is in agreement with the views now generally held with regard to the causative organism of this disease—i.e., that nearly all severe cases of puerperal fever are due to infection by a haemolytic streptococcus. In every fatal case investigated by him this organism was found and appeared to be the cause of death. A technique has been evolved of organisms present in the be estimated quantitatively. In fatal cases the number of streptococci per c.cm. of blood was found to increase in a more or less regular fashion until death, the number of organisms found in the blood varying between 5 and 5000 per c.cm. Only one patient survived in whom the number of streptococci exceeded 30 ; of those in whom the number was below 30, one-quarter lived. Contrarv to the general views on the causation of rigors. the blood was often found to be sterile when rigois occur, repeated blood cultures proving negative. At the present time much attention is being directed to the association between the streptococcus of scarlet fever and the streptococcus of puerperal fever. Dr. Colebrook points out that there is one great difference between these two diseases. In scarlet fever the symptoms are the result of the action of an exo-toxin, whereas in pueiperal fever the cause of the symptoms is the presence and proliferation of streptococci in the tissues and in the blood. He considers, therefore, that treatment of the two diseases should be on fundamentally different lines. In scarlet fever an antitoxin is required, whilst in puerperal fever antibacterial measures are called for. Post-mortem examinations revealed the fact that in most fatal cases gross septic foci were to be found in the uterine wall, broad liyaments, or pelvic cellular tissues, as well as infected clots in veins. It is difficult to see how any drug could reach such sites in sufficient concentration to be effective. Hope for the future appears to rest in early treatment by some efficient bactericidal agent. Four lines of treatment havebeen investigated: immuno-transfusion, passive immunisation by serums, intravenous administration of mercurochrome, and intravenous administration of organic arsenical preparations. In some of the patients who survived no specific treatment was carried out. Immuno-transfusion is now performed with whole blood. A preliminary leucocytosis is induced in the donor by the injection of nuclein. On the whole, the results have not been as good as had been hoped. If a high degree of immunity can be induced in the donor against the
by which the number circulating blood can
THE existence of epidemic diseases of the central system is now well established, and the epidemic incidence of cerebro-spinal fever, poliomyelitis, and encephalitis has been memorable in the records of the first quarter of the twentieth century. In the George M. Kober Lecture, delivered on March 27th, 1928, at Georgetown University, Washington, Dr. Simon Flexner reviews the history of these diseases and offers interesting comments on their aetiology and epidemiology. The large epidemic wave of cerebrospinal fever which broke over Europe and America in 1904-05 and culminated in the pandemic of the war-period, appears to havespent its force and since 1920 the incidence of the disease has been endemic rather than epidemic. It is possible that emigrants from Germany and Austria conveyed the infection to The origin of epidemic poliothe United States. myelitis may be traced to north-western Europeespecially Sweden and Norway-and here again Dr. Flexner believes immigration to be responsible for the conveyance of infection. The first two outbreaks of in the United States occurred on the eastern coast and in the States adjoining Minnesota,. the western homeland of the Scandinavian emigrants. The outlook for this disease is less favourable than for epidemic meningitis. It arose in pandemic form in 1906-07 ; with many fluctuations epidemics have since recurred in Europe and the United States in late summer and autumn. In 1916 an unprecedented wave of poliomyelitis swept over New York State in which more than 20,000 cases were reported and many more cases, paralytic and non-paralytic, probably In 1926 outbreaks of some magnitude occurred. occurred in England and France, and in 1927 German Saxony, Roumania, and the United States were attacked. Epidemic encephalitis, the third disease which has reached epidemic proportions in the present century, can be traced back to two relatively small outbreaks during the war, one at Bar le Due, in France, in 1916, the other in Vienna in 1917, which was. well described by Economo. The extension of the disease was rapid. It appeared in England and Wales in 1918 and affected much of Europe. In 1919 cases were seen in the United States, and by 1920 the disease had become pandemic, whether permanently or not, Dr. Flexner is unprepared to say. He inclines to the view that epidemic encephalitis is of recent origin. The theory that it was confused in the past with other maladies does not appeal to him, not only because the clinical manifestations are very impressive, but because he considers that the after-effects are too severe and serious to have escaped incorporation into medical history. Dr. Flexner holds that meningitis and poliomyelitis may be dismissed from connexion with infiuenza since their epidemics arose independently. The epidemics of intluenza and encephalitis certainly overlapped, but the height of the wave of encephalitis
nervous
poliomyelitis
1
Jour. Amer. Med. Assoc., July 7th, 1928.
hygiene. It is therefore peculiarly fitting for his specific organism, better results may ensue. Various. colleagues in the public health service to perpetuate samples of serum from different laboratories have been Wheatley’s memory by the provision of a floating tested. The result of this work is largely negative ; swimming-bath on the river Severn near to the town very little increase in the bactericidal properties. of Shrewsbury, whose health was his lifelong care. of human blood against heemolytic streptococci was
found. Mercurochrome was found to have no effect on the bactericidal power of the blood. Arsenical drugs cause a marked increase in the there will be, pace Wheatley’s gospel of living dangerously, a safe and sheltered bath for non-swimmers and bactericidal powers of the blood, and Dr. Colebrook children, with two screened lawns on the adjoining considers this to be a most hopeful line for further shore where men and women respectively can enjoy investigation. Unfortunately the results obtained sun-bathing before and after entering the water. No clinically do not confirm this optimism, since elsewhere charge will be made for admission to the lawns or in the report Mr. James Wyatt declares that the dressing sheds, but a special pavilion is to be provided various organic arsenical preparations have had for those who can afford to make payment towards the little or no effect on the course of the disease in cases upkeep of the bath. It is hoped by the promoters of of septicaemia. It is interesting to note that in the Wheatley Memorial that this bathing-place may 6 out of 22 cases operated upon for general peritonitis become a model of its kind and extend further the no vaginal examination had been made. influence of this great sanitarian in bettering the health of the people. The estimated cost is .62000, of which an anonymous donor has given JE250 ; contributions may OBVIOUS AND OBSCURE INFECTIONS OF THE be sent to Dr. A. D. Symons, at 74, Wyle Cop, CENTRAL NERVOUS SYSTEM.
From the further side of the raft swimmers will have direct access to the river, while on the hither side
I
Shrewsbury.
____
INVESTIGATIONS ON PUERPERAL FEVER. THE annual report of the Metropolitan Asylums Board for 1927-28 contains a valuable section on the investigations carried out on cases of puerperal fever admitted to their hospitals. The pathological side of this work is under the care of Dr. Leonard Colebrook. His report is in agreement with the views now generally held with regard to the causative organism of this disease—i.e., that nearly all severe cases of puerperal fever are due to infection by a haemolytic streptococcus. In every fatal case investigated by him this organism was found and appeared to be the cause of death. A technique has been evolved of organisms present in the be estimated quantitatively. In fatal cases the number of streptococci per c.cm. of blood was found to increase in a more or less regular fashion until death, the number of organisms found in the blood varying between 5 and 5000 per c.cm. Only one patient survived in whom the number of streptococci exceeded 30 ; of those in whom the number was below 30, one-quarter lived. Contrarv to the general views on the causation of rigors. the blood was often found to be sterile when rigois occur, repeated blood cultures proving negative. At the present time much attention is being directed to the association between the streptococcus of scarlet fever and the streptococcus of puerperal fever. Dr. Colebrook points out that there is one great difference between these two diseases. In scarlet fever the symptoms are the result of the action of an exo-toxin, whereas in pueiperal fever the cause of the symptoms is the presence and proliferation of streptococci in the tissues and in the blood. He considers, therefore, that treatment of the two diseases should be on fundamentally different lines. In scarlet fever an antitoxin is required, whilst in puerperal fever antibacterial measures are called for. Post-mortem examinations revealed the fact that in most fatal cases gross septic foci were to be found in the uterine wall, broad liyaments, or pelvic cellular tissues, as well as infected clots in veins. It is difficult to see how any drug could reach such sites in sufficient concentration to be effective. Hope for the future appears to rest in early treatment by some efficient bactericidal agent. Four lines of treatment havebeen investigated: immuno-transfusion, passive immunisation by serums, intravenous administration of mercurochrome, and intravenous administration of organic arsenical preparations. In some of the patients who survived no specific treatment was carried out. Immuno-transfusion is now performed with whole blood. A preliminary leucocytosis is induced in the donor by the injection of nuclein. On the whole, the results have not been as good as had been hoped. If a high degree of immunity can be induced in the donor against the
by which the number circulating blood can
THE existence of epidemic diseases of the central system is now well established, and the epidemic incidence of cerebro-spinal fever, poliomyelitis, and encephalitis has been memorable in the records of the first quarter of the twentieth century. In the George M. Kober Lecture, delivered on March 27th, 1928, at Georgetown University, Washington, Dr. Simon Flexner reviews the history of these diseases and offers interesting comments on their aetiology and epidemiology. The large epidemic wave of cerebrospinal fever which broke over Europe and America in 1904-05 and culminated in the pandemic of the war-period, appears to havespent its force and since 1920 the incidence of the disease has been endemic rather than epidemic. It is possible that emigrants from Germany and Austria conveyed the infection to The origin of epidemic poliothe United States. myelitis may be traced to north-western Europeespecially Sweden and Norway-and here again Dr. Flexner believes immigration to be responsible for the conveyance of infection. The first two outbreaks of in the United States occurred on the eastern coast and in the States adjoining Minnesota,. the western homeland of the Scandinavian emigrants. The outlook for this disease is less favourable than for epidemic meningitis. It arose in pandemic form in 1906-07 ; with many fluctuations epidemics have since recurred in Europe and the United States in late summer and autumn. In 1916 an unprecedented wave of poliomyelitis swept over New York State in which more than 20,000 cases were reported and many more cases, paralytic and non-paralytic, probably In 1926 outbreaks of some magnitude occurred. occurred in England and France, and in 1927 German Saxony, Roumania, and the United States were attacked. Epidemic encephalitis, the third disease which has reached epidemic proportions in the present century, can be traced back to two relatively small outbreaks during the war, one at Bar le Due, in France, in 1916, the other in Vienna in 1917, which was. well described by Economo. The extension of the disease was rapid. It appeared in England and Wales in 1918 and affected much of Europe. In 1919 cases were seen in the United States, and by 1920 the disease had become pandemic, whether permanently or not, Dr. Flexner is unprepared to say. He inclines to the view that epidemic encephalitis is of recent origin. The theory that it was confused in the past with other maladies does not appeal to him, not only because the clinical manifestations are very impressive, but because he considers that the after-effects are too severe and serious to have escaped incorporation into medical history. Dr. Flexner holds that meningitis and poliomyelitis may be dismissed from connexion with infiuenza since their epidemics arose independently. The epidemics of intluenza and encephalitis certainly overlapped, but the height of the wave of encephalitis
nervous
poliomyelitis
1
Jour. Amer. Med. Assoc., July 7th, 1928.