1
N. Friedman, “Everything They Didn't Tell You About Tampons,”
New West
, October 20, 1980: 33â42; and R. E. Wheatley, M. F. Menkin, E. D. Bardes, and J. Rock, “Tampons in Menstrual Hygiene,”
Journal of the American Medical Association
192 (1965): 113â16.
2
In 1977 a medical team from the University of Colorado Medical Center in Denver reported treating four young women (two of whom were teenagers) for vaginal ulcers, apparently caused by tampons. Two of the cases involved the so-called deodorant products (actually perfumed, rather than deodorized). All four women healed with cessation of tampon use. See K. F. Barrett, S. Bledsoe, B. E. Greer, and W. Droegemueller, “Tampon-Induced Vaginal or Cervical Ulceration,”
American Journal of Obstetrics and Gynecology
127 (1977): 332â33.
3
The industry denied allegations that asbestos was ever used in their products, but also consistently refused to list the stabilizing fibers that were used to prevent the cotton tampons from falling apart.
4
D. E. Marlowe, R. M. Weigle, and R. W. Stauffenberg, “Measurement of Tampon Absorbency: Evaluation of Tampon Brands,” Bureau of Medical Devices, U.S. Food and Drug Administration, Rockville, MD, 1981.
5
In her outstanding piece of investigative journalism, Nancy Friedman notes: “The range of blood loss during menstruation is two to six ounces. A single superabsorbent tampon is capable of soaking up an ounce or more of fluid. Since menstruation is a gradual process lasting three to seven days, the question arises: If the tampon has absorbed all the blood leaving the uterus and still hasn't reached saturation, what will it absorb? The answer: the normal secretions of the healthy vaginal walls.” Friedman (1980), op. cit.
6
M. Chrapil et al., “Reaction of the Vagina to Cellulose Sponges,”
Journal of Biomedical Materials Research
13 (1979): 1.
7
A. Johnson, “Used Carboxymethyl Cellulose as Chromatographic Purifier for
Staphylococcal
Toxins,”
Infection and Immunology
25 (1979): 1080â85.
8
K. F. Barrett, “Tampon-Induced Ulceration,”
American Journal of Obstetrics and Gynecology
127 (1977): 332; R. K. Collins, “Tampon Induced Vaginal Laceration,”
Journal of Family Practice
9 (1979): 127; and F. K. Beller, “Vaginal Tampon as Drug Carrier,”
Medical World
30 (1979): 709.
9
J. P. Davis, J. Chesney, P. J. Wand, et al., “Toxic-Shock Syndrome,”
New England Journal of Medicine
303 (1980): 1429â35.
10
J. Todd, M. Fishaut, F. Kapral, and T. Welch, “Toxic-Shock Syndrome Associated with Phage-Group-I Staphylococci,”
Lancet
II (1978): 1116â18.
11
F. Stevens, “The Occurrence of
Staphylococcus aureus
Infection with a Scarlatiniform Rash,”
Journal of the American Medical Association
88 (1927): 1957.
12
H. Aranow and W. B. Wood, “Staphylococcal Infection Stimulating Scarlet Fever,”
Journal of the American Medical Association
119 (1942): 1491.
13
T. Kawasaki, “Acute Febrile Mucocutaneous Syndrome with Lymphoid Involvement with Specific Desquamation of the Fingers and Toes in Children,”
Japanese Journal of Allergology
16 (1967): 178â222.
14
Between 1975 and 1980 over 10,000 cases of Kawasaki syndrome were diagnosed in Japan.
15
Centers for Disease Control, “Toxic-Shock SyndromeâUnited States,”
Morbidity and Mortality Weekly Report
29 (1980): 229â30.
16
See Table 1 in K. N. Shands, G. P. Schmid, B. B. Dan, et al., “Toxic-Shock Syndrome in Menstruating Women,”
New England Journal of Medicine
303 (1980): 1436â42.
17
Centers for Disease Control, “Follow-up on Toxic-Shock Syndrome,”
Morbidity and Mortality Weekly Report
29 (1980): 441â45.
18
The CDC's results were:
Cases
| Controls
|
---|
Tampon Brand
| (N = 42)
| ( N = 114)
|
---|
Rely
| 71%
| 26%
|
Playtex
| 19%
| 25%
|
Tampax
| 5%
| 25%
|
Kotex
| 2%
| 12%
|
OB
| 2%
| 11%
|
19
Food and Drug Administration, News Release PBD-42, September 25, 1980.
20
Centers for Disease Control, “Toxic-Shock SyndromeâUtah,”
Morbidity and Mortality Weekly Report
29 (1980): 495â96.
21
D. B. Petitti, A. Reingold, and J. Chin, “The Incidence of Toxic Shock in Northern California,”
Journal of the American Medical Association
255 (1986): 368â72.
22
According to the manufacturers, prior to 1977 all tampons were made primarily of rayon and cotton. After 1977, however, 65 percent of all tampons sold in the United States contained polyacrylate fibers, carboxymethyl cellulose, higher-absorbency rayon-cellulose, polyester, or other synthetics.
23
R. W. Tofte, K. B. Crossley, and D. N. Williams, “Clinical Experience with Toxic-Shock Syndrome,”
New England Journal of Medicine
303 (1980): 1417.
24
“Report Rise in Toxic Shock Cases Unrelated to Tampon Use,”
Hospital Practice,
July 1982: 197â200;
“S. aureus
Bacteriophage May Be Implicated in Toxic Shock,”
Hospital Practice,
May 1983: 36â38; and B. Hanna and P. Tierno, “Staphylococcal Growth on Carboxymethyl Cellulose,” presentation to the Annual Meeting of the American Society of Microbiology, 1981.
25
It is likely that true
Staphylococcus
rates were 100 percent. As physicians became more familiar with TSS and recognized the speed with which the ailment could dangerously escalate, it became routine to give symptomatic menstruating females high doses of non-penicillinase antibiotics before taking vaginal samples and awaiting staph culture results.
26
Davis et al. (1980), op. cit.
27
These and many other comments in this chapter were made to the author during interviews conducted over the course of the TSS investigation.
28
J. Langone, “Riddle of the Tampon,”
Discover
, December 1989: 26â28.
29
P. M. Schlievert, K. M. Bettin, and D. W. Watson, “Purification and Characterization of Group A Streptococcal Pyrogenic Exotoxin Type C,”
Infection and Immunology
16 (1977): 673â79.
30
P. Schlievert, “Activation of Murine T-Suppressor Lymphocytes by Group A Streptococcal and Staphylococcal Pyrogenic Exotoxins,”
Infection and Immunology
28 (1980): 876â80.
31
Institute of Medicine, “Toxic Shock Syndrome: Assessment of Current Information and Future Research Needs” (Washington, D.C.: National Academy Press, 1982).
32
By that time Schlievert and his collaborators in Minnesota, Wisconsin, Colorado, and California were seeing clear autoimmune disorders in the women who had survived TSS bouts months earlier. Eleven of 123 women surveyed had developed lupus, and 40 percent had early symptoms of arthritisâa striking finding given that most TSS sufferers were under thirty-five years of age.
P. M. Schlievert, K. M. Shands, B. B. Dan, et al., “Identification and Characterization of an Exotoxin from
Staphylococcus aureus
Associated with Toxic-Shock Syndrome,”
Journal of Infectious Diseases
143 (1981): 509â16; and P. M. Schlievert and J. A. Kelly, “Staphylococcal Pyrogenic Exotoxin Type C: Further Characterization,”
Annals of Internal Medicine
96 (1982): 982â86.
33
Centers for Disease Control, “Toxic Shock Syndrome, United States, 1970â1982,”
Morbidity and Mortality Weekly Report
31 (1982): 201â4.
34
Centers for Disease Control, “Update: Toxic-Shock SyndromeâUnited States,”
Journal of the American Medical Association
250 (1983): 1017.
35
A. L. Reingold, “Epidemiology of Toxic-Shock Syndrome, United States, 1960â1984,”
Morbidity and Mortality Weekly Report
33 (1982): 19ssâ22ss.
36
When averaged over the population as a whole for the various states, acute TSS cases occurred, for example, in:
State
| Per capita (all ages , both genders )
|
---|
Utah
| 1:10,288
|
Minnesota
| 1:14,201
|
Wisconsin
| 1:17,363
|
Colorado
| 1:22,228
|
Oregon
| 1:30,978
|
Ohio
| 1:73,956
|
Washington
| 1:93,917
|
Indiana
| 1:99,368
|
California
| 1:100,713
|
Michigan
| 1:110,262
|
Texas
| 1:122,633
|
New York
| 1:532,065
|
Based on cumulative reports, 1975â83, to the CDC.
|
See Petitti, Reingold, and Chin (1986), op. cit.
37
S. F. Berkley, A. W. Hightower, C. V. Broome, and A. L. Reingold, “The Relationship of Tampon Characteristics to Menstrual Toxic Shock Syndrome,”
Journal of the American Medical Association
258 (1987): 917â20.
38
G. Faich, K. Pearson, D. Fleming, et al., “Toxic Shock Syndrome and the Vaginal Contraceptive Sponge,”
Journal of the American Medical Association
255 (1986): 216â18; and A. L. Reingold, “Toxic Shock Syndrome and the Vaginal Sponge,”
Journal of the American Medical Association
255 (1986): 242â43.
39
S. M. Wolfe, “Dangerous Delays in Tampon Absorbency Warnings,”
Journal of the American Medical Association
258 (1987): 949â51.
40
The chart was as follows:
Absorbency
| Ranges of Absorbency in Grams
|
---|
Tampons come in the following standardized industry-size absorbencies.
| Junior absorbency
| Less than 6
|
Regular absorbency
| 6 to 9
|
Super absorbency
| 9 to 12
|
Super Plus absorbency
| 12 to 15
|
41
L. E. Markowitz, A. W. Hightower, C. V. Broome, and A. L. Reingold, “Toxic Shock Syndrome: Evaluation of National Surveillance Data Using a Hospital Discharge Survey,”
Journal of the American Medical Association
258 (1987): 75â78.
42
K. L. MacDonald, M. T. Osterholm, C. W. Hedberg, et al., “Toxic Shock Syndrome: A Newly Recognized Complication of Influenza and Influenzalike Illness,”
Journal of the American Medical Association
257 (1987): 1053â58; and Centers for Disease Control, “Toxic Shock Syndrome Associated with Influenza,”
Morbidity and Mortality Weekly Report
35 (1986): 143â44.
43
S. J. Sperber and J. B. Francis, “Toxic Shock Syndrome During an Influenza Outbreak,”
Journal of the American Medical Association
257 (1987): 1086â87.
Langmuir and his colleagues hypothesized the existence of such a scourge, combining TSS and influenza, which they dubbed Thucydides syndrome after the great Greek chronicler, and said might have been the cause of the 430â427 B.C. plague of Athens. See A. D. Langmuir, T. D. Worthen, J. Solomon, et al., “The Thucydides Syndrome: A New Hypothesis for the Cause of the Plague in Athens,”
New England Journal of Medicine
313 (1985): 1027â39; and B. B. Dan, “Toxic Shock Syndrome: Back to the Future,”
Journal of the American Medical Association
257 (1987): 1094â95.