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examining bodies, I think that it could be done if there were only some means of supplying maternity clerks for the year or two of the interregnum.
Before concluding this part of my paper, let me draw your attention once more to the iniquity of the Conjoint Board by asking you to look at the schedule to be filled in for its midwifery examination; and do not forget that this examination is meant above all for those who are going in for general practice. Leaving out of account the certificate "of being 21 years of age," and the certificate of instruction in gynecology, the candidate is required to be signed up for four things. That he has spent four winter and four summer sessions at his professional studies, that he has attended a three months' course of lectures, that he has had systematic practical instruction, and that he has attended 20 labours. The various sins of omission and commission in this well known bit of red paper are easily recognised. It requires that four winter and four summer sessions be spent in professional studies-how, it matters little so long as it includes a three months' course, an indeterminate amount of practical instruction, and the regulation 20 cases. No medical or surgical training is thought necessary for a man who wishes to practice modern-day midwifery, so that, except that his lectures cover a little more ground, his instruction is little different to that of the well trained midwife whom he may be called on to assist. He may have spent four winter and three summer sessions in getting through the anatomy and physiology of his second examination, and yet if he can cram three months' lectures, and his cases into his fourth summer session, the Board is quite prepared to take his fee and pass or reject him as its examiners may think fit. He think fit. He may know nothing of the ordinary heart sounds, but he will be expected to have heard the foetal heart through the mother's abdomen. He may never have seen a case of renal disease, or been taught the clinical testing of urine, but he will be expected to know all about the urinary and renal and hepatic conditions found in eclamptic and other toxic diseases of pregnancy and the puerperium. He may never have had any drilling in surgical methods, but he must learn-most probably parrot-like-how the puerperal infections ought to be prevented. There is no need to labour this point further. One can only wonder that the Gilbertian character of these regulations has not yet dawned on the Solons of the Conjoint Board and the General Medical Council, especially as the latter are supposed to guard the paths into the profession on behalf of the British Public. When our methods are what they are, is it surprising that the puerperal mortality outside the lying-in hospitals has remained unaffected by Listerian principles? The blame does not rest with the teachers and examiners in midwifery, for they have made representations without number and without effect.
(To be continued.)
The Present Status of Serotherapy in Relation to Surgery.
Whatever bacteriologists may ultimately decide with regard to the specific nature of its streptococcus, there can be little doubt that, clinically, cutaneous erysipelas, the variety to which alone the term is properly applied, is a disease sui generis-a distinct pathological entity comparable in many respects with other specific fevers. Its contagious character, its tendency to occur in epidemics, and the distinctive character of its course and termination in ordinary cases, all point to the specific nature of the infection. It is strictly speaking not a pyogenic infection, because in the ordinary uncomplicated form no pus is produced.
I deal, therefore, with this disease separately from other streptococcic infections.
Erysipelas is, except in those suffering from severe constitutional affections and in patients at the extremes of life, a disease with a low mortality. Lockwood gives the death rate as only 3.5 per cent.
There would, therefore, seem to be little room for the extensive employment of a specific antiserum. Yet there is a certain number of cases in which very severe symptoms occur; and a small proportion in which the organisms, entering the blood, produce a true septicemia; and for the treatment of such cases a specific serum is the only means which holds out any prospect of ameliorating or curing the disease. Such a serum is now supplied by a well known firm and is multivalent, being prepared by immunising animals with six different strains of streptococci obtained from cases of erysipelas. It is antitoxic as well as antibacterial-possibly the former more strongly than the latter, a property which will account for the immediate relief obtained in some of the cases for which it has been tried. I have found notes of eleven cases of erysipelas which have been treated at St. Thomas's Hospital with this multivalent seruma number of course which is far too small to dogmatise upon, but which is sufficiently large to give some idea as to the possibilities of the specific treatment.
The first case was that of a nurse with a very severe attack of erysipelas, accompanied by persistent high fever, delirium and albuminuria. The rash commenced upon the face and rapidly spread over the scalp, neck and back. On the seventh day a dose of 10 c. c. of
the multivalent serum was given, at a time when the temperature was 103.2°. Within twelve hours the temperature was normal, and although the rash continued to spread great relief of the symptoms was experienced. The temperature again rose to 102.8°, when a second dose of 15 c. c. was given, and the temperature again fell to normal, after which there was no further rise.
Other cases have shewn equally striking results. A man aged 42, with a bad attack of facial erysipelas, complicating alveolar abscess, was treated with the serum, commencing on the eighth day. He received 100 c. c. in 36 hours. The temperature, which had ranged from 103-104° the whole time, at once dropped and recovery ensued.
Another case, a boy of 16, with facial erysipelas, had the treatment commenced on the fifth day, and received 25 c. c. in 48 hours. A crisis occurred 24 hours after the second dose, but the temperature fell temporarily after the first, and the symptoms began to subside immediately.
Two fatal cases occurred in this series-both men of middle age, and both extremely ill when treatment was commenced. They received respectively 120 and 180 c. c. within periods of 36 and 72 hours, but without effect.
In judging the effect of the serum in these eleven cases, one must not take into account the temperature alone. In some the fall in temperature was immediate and striking, in others slight and temporary. But in most cases there was also a marked improvement in the general condition, and the patients usually expressed themselves as feeling much relieved. The effect upon the rash does not appear to be rapid; it has usually continued to spread for a day or two after the general symptoms have begun to subside, which in an ordinary case that recovers without specific treatment is not the usual order of events.
It seems, therefore, that as far as we can at present judge, the specific treatment of erysipelas promises to be of decided value. But it is not the treatment which ought to be adopted in all cases, and unless a judicious selection is made it is likely that the real value will be masked and discredit brought upon it.
Under this heading, which should properly embrace organisms such as the pneumococcus and the bacillus pyocyaneus, I propose to deal only with those which occur with the greatest frequency in Surgery, namely the streptococci, the staphylococci, and the colon bacillus,
The case of such pyogenic diseases is totally different from that of tetanus. In the latter we have a specific and definite disease, due to a well known specific micro-organism; and against it we have a specific antitoxin. And we may fairly say that every case of tetanus should be treated, at the outset with the antitoxin, for its tendency is towards a fatal issue, and none can foreshadow the progress of a case at its commencement.
But in pyogenic infections, we have a number of different organisms producing a number of totally different diseases and in by far the larger number of cases, the tendency is by no means towards a fatal issue if the focus of infection can be effectively dealt with on surgical lines. It is, therefore, only a few cases of pyogenic infection that require a specific serum treatment.
The time-honoured classification of septic cases into sapræmia, septicemia, and pyæmia has served its day and generation, but to the older surgeons these three terms conveyed a very definite distinction. In sapræmia the blood was said to be free from organisms, which remained localised at the site of infection; in septicemia the organisms were regarded as truly parasitic and multiplying in the blood; in pyæmia it was supposed that the organisms were in the blood merely as passengers from one spot to another, and only resumed work when the thrombus conveying them became arrested as an embolism. And one of the most distinguished pathologists of ten years ago, Professor Kanthack, used to teach that recovery from a true septicemia had yet to be recorded. But the distinction between septicemia and pyæmia, although useful clinically, will not stand the essential test of bacteriological investigation, and must not be pressed too closely. Many cases are now known where recovery has followed even after bacteriological examination has demonstrated the presence of parasitic pyogenic organisms in the blood. Moreover, the term septicemia has now a wider meaning, embracing diseases other than those due to blood infection with pyogenic organisms.
For our present purpose, however, we may draw a concise distinction between two great groups of pyogenic diseases, septic intoxication, or sapræmia, in which the organisms remain strictly localised to the site of infection, and septic infection, in which they enter the blood stream, remembering of course that a case of septic intoxication may at any moment become one of septic infection by the entrance of the organisms into the blood, and that the distinction can only be made by a bacteriological examination of the blood. The great majority of cases of sapræmia will recover if the focus of infection can be effectively dealt with, and therefore require no specific antiserum. Recovery would doubtless be accelerated by a specific antitoxin administered at the same time, but as a rule, so
rapid is the subsidence of symptoms as soon as the focus of infection is properly dealt with, that in the great majority of cases there is no need for the use of a specific anti-serum. In this connection it is as well to repeat that an anti-toxin whilst capable of dealing with the free poisons present, is incapable of affecting the results of their action upon the tissues.
In considering the pyogenic cocci which are grouped under the general headings of streptococci and staphylococci, we at once find ourselves confronted with a great difficulty. There are many varieties both of streptococci and of staphylococci. Dr. Foulerton, in a recent paper dealing with streptococci infections, inclines to the view that they should be regarded actually as different species, rather than merely as varieties of the same species. More recently still, Dr. M. H. Gordon has published a most interesting paper, dealing with the differentiation of the streptococci. He distinguishes them according to their power of decomposing, with an acid reaction, a number of chemical compounds belonging to the carbohydrate, glucoside, and alcohol groups, and in this manner has recognised no less than 48 different types from normal saliva, and 40 types from normal fæces; and goes so far as to utilise these distinctive reactions as a test for oral or fæcal contamination of air or water. Dr. Gordon also, on the same lines, finds a considerable diversity among the streptococci obtained from the human body in disease. He insists that the old impression that streptococci are still incapable of being differentiated is erroneous, and that their individuality is real and not only apparent. The staphylococci shew as great or even greater differences amongst themselves, both culturally and in their pathogenicity. Hence there must be a considerable number of different diseases due to the pyogenic cocci. Moreover, the same coccus is capable of producing, according to its degree of virulence and other circumstances, very different effects upon different individuals; a strain of a staphylococcus aureus for example, may in one individual produce a boil, in another a rapidly fatal septicemia.
Again, it cannot be denied that septicemia may be due to a mixed infection with two or more pyogenic cocci. For example, in one case of fatal post-operative peritonitis, Dr. Dudgeon isolated from the blood both a streptococcus and a white staphylococcus.
When Marmorek produced the first antistreptococcic serum, he maintained that it was powerful against any form of streptococcus. Moreover, his serum was actually produced from an organism not obtained even from a human source. It is true that Calmette proved the antitoxic serum produced against one kind of snake poison to be powerful, though in varying degrees, against other varieties of snake poison, but the same has not been shown to be the case with anti