Forty Cases of Fever in theFuerperium, with Bacterio-logical Examination of theUterine Contents

BY

J. WHITRIDGE WILLIAMSAssociate Professor of Obstetrics, Johns

Hopkins University

• REPRINTED FROM

The American Journal of ObstetricsVol. XXXVIII. No. 3,1898.

NEWYORK

WILLIAM WOOD & COMPANY, PUBLISHERS1898

FORTY CASES OF FEVER IN THE PUERPERIUM, WITHBACTERIOLOGICAL EXAMINATION OF THE

UTERINE CONTENTS. 1

For the past two years it has been my routine custom toexamine the uterine lochia bacteriologically in every case offever during the puerperal period, whether occurring in theObstetrical Department of the Johns Hopkins Hospital or inmy private or consultation practice.

I wish to consider this evening the results of the examinationof 40 such cases which have come under my observation withinthe past two years.

This work has possessed a double interest for me. For it isnot only of importance from a theoretical and scientific pointof view, in confirming in great part the observations of themany investigators who have busied themselves with the con-ideration of the etiology of puerperal infection, but it has alsoled to the discovery of thepart which may be played by severalorganisms which up to this time have not been observed inconnection with puerperal infection.

In addition to its purely scientific aspects, the work is ofequal, if not greater, importance in its practical applications;for it enables us to make a positive diagnosis as to the presenceor absence of puerperal infectionand of the species of organismor organisms which stand in a causal relation to it, and inmany instances determines the prognosis and treatment of thecase.

In our work we have adopted the usual arbitrary standard ofconsidering as abnormal every case in which the temperatureexceeds 100.4° F. (38° C.) at any time during the puerperium.As single rises of temperature slightly above this point occur

1 Abstract of remarks before the Baltii lore uJlts^tri-cal Society, March 8, 1898.

2 WILLIAMS: FORTY CASES OF FEVER

in a considerable number of cases, we have adopted the ruleof taking cultures from the uterus only in those cases in whichthe temperature rises to 101°F, (38.3° C.) or higher. When-ever the temperature reaches that point in a case in the ob-stetrical wards of the Johns Hopkins Hospital, no matter whatmay be supposed to be its cause, the head nurse at once notifiesthe resident obstetrician, and cultures are promptly made fromthe uterine cavity, by myself if possible, or by the resident inmy absence. In the out-patient department and in my ownpractice the limit is placed at 102° F. (39° C.) on account ofthe technical difficulties which surround taking cultures out-side of the hospital. With a few exceptions, in which therewas a single rise of temperature, which fell before culturescould be made, the 40 cases under consideration representevery case coming under my observation during the past twoyears in which the above-mentioned temperature has beenreached.

Before taking up the consideration of our cases in detail Ithink it will be well to describe the method by which weobtain the uterine lochia for examination. For this purposewe use the method which was first introduced by Doderlein:A glass tube, 25 centimetres long and 3 to 4 millimetres indiameter, is curved at one end like a uterine sound. It isthen placed in a long, thick glass test tube, especially madefor the purpose, whose open end is plugged with cotton, andsterilized by dry heat at 150° C. for one hour. The large testtube is simply intended to enable us to carry the smaller tubearound with us in a sterile condition.

When a culture is to be taken the external genitals of thepatient are carefully washed with soap and hot water, andlater with a 1 : 1000 bichloride solution, while the hands of theoperator are carefully disinfected by soap, nail brush and hotwater, permanganate of potash, oxalic acid, and bichloride.The patient is then placed in Sims’ position, the thighs andbuttocks being covered with sterilized towels, and a Simsspeculum introduced. The anterior lip of the cervix is seizedwith bullet forceps and the cervix brought down as far as pos-sible. The exterior of the cervix and external os are then care-fully wiped off with sterile absorbent cotton, when everythingis ready for the introduction of the tube, which is then takenfrom its containing tube, grasped at its straight end by twofingers, and its curved end carefully introduced into the cervixand then up to the fundus of the uterus, care being taken to

i * , ~ ■ .

IN THE PUERPERIUM. 3

avoid contact with anything until the os externum is passed,A large syringe is then attached to the free end of the tube,suction made, and a greater or less quantity of uterine lochiais aspirated into the tube. The syringe is then taken off, thetube removed from the uterus and both its ends sealed withsealing wax. It is now replaced in the containing tube andtaken to the laboratory for examination, where it is nicked witha file and broken at that point when cultures and cover glassesare made from its contents. As the tube is hermetically sealed,it is not necessary to make the culture at once, but it may belaid aside for several hours until perfectly convenient.

The 40 cases which we have under consideration were fromthe following sources: 22 women delivered in the obstetricalwards of the Johns Hopkins Hospital, 8 women delivered inthe out-patient department of the hospital, and 10 cases seenin consultation. I have included among the consultation casesseveral which were delivered outside the hospital by personsnot connected with it, and sent to the hospital after symptomsof infection had appeared.

It therefore appears that 30 of the cases occurred among the600 women who have thus far been delivered by the in- andout-patient departments of the hospital, while the remaining10 were delivered by persons not connected with it.

In every case cover slips were made and the uterine lochiawere plated upon ordinary agar, acid agar, and glucose-agar,and blood serum or blood serum and agar slants were inocu-lated, and anaerobic cultures made upon glucose-agar by inocu-lating a melted tube, allowing it to solidify, and then pouringthe contents of a second tube upon it. With a few exceptions,the blood was examined in every case for malarial plasmo-dia.

By these methods we found streptococci in 8 cases; staphylo-cocci in 3 cases; colon bacilli in 6 cases; gonococci in 2 cases;anaerobic bacteria in 4 cases; unidentified aerobic bacteria in3 cases; bacteria in cover glass, but cultures sterile, in 4 cases;diphtheria bacilli in 1 case; gas bacilli (bacillus aerogenes cap-sulatus) in 1 case; typhoid bacilli in 1 case; cover glass, cul-tures, and blood sterile in 11 cases; cover glass and culturessterile, with malarial plasmodia in blood, in 1 case—making atotal of 44 cases.

This apparent discrepancy is due to the fact that we had todeal with a mixed infection in several instances: thus, we hadone case with streptococci and colon bacilli, a second with

4 WILLIAMS: FORTY CASES OF FEVER

staphylococci and colon bacilli, and a third with typhoidbacilli, streptococci, staphylococci, and an unidentified anaero-bic gas-producing bacillus.

When we consider our work more in detail we find that itconfirms the results obtained by most observers, and also addsseveral organisms to the already long list of bacteria whichmay lead to puerperal infection.

This will be rendered more apparent if we consider brieflyand separately each group of cases. Streptococci were firstcultivated from a case of puerperal infection by Pasteur in1880, and since then have been demonstrated by an almostcountless number of observers. Indeed, they are found so fre-quently, especially in fatal cases, that until very recently manyauthors considered them to be the sole organism concerned inthe production of the affection. Recent work has, however,demonstrated that such is not the case, which, as already indi-cated above, is amply borne out b} r our own observations; butthey are, nevertheless, the most important etiological factor inthe production of puerperal infection, especially in its fatalforms. In the 40 cases, we demonstrated streptococci morefrequently than any other organism, and found them in 8 cases(30 per cent), none of which, however, ended fatally. It isinteresting to note that streptococcic infection has not yetoccurred in any of our house cases, but was present in 3 out ofthe 8 out-door fever cases and in 5 out of the 10 consultationcases. In 6 cases the streptococci were demonstrated in pureculture, while in the other 3 cases we had to deal with ainfection. In one case they ■were associated with colon bacilli,and in the other with typhoid bacilli, the staphylococcus aureus,and an anaerobic gas-producing bacillus.

It was not until 1888 that Brieger demonstrated that staphy-lococci might cause puerperal infection, and his results weresoon confirmed by Doderlein, Hagler, and others. It was gen-erally believed that this variety of infection occurred but rarely,and, when it did, usually gave rise to mild forms of disease.Striinckmann, however, in a very recent article, combats thisview, and, from his own experience and a very exhaustive reviewof the literature, concludes that staphylococcic infection occursmore frequently than is usually supposed and frequently resultsin serious and sometimes in fatal illness. We have demon-strated staphylococci in 3 cases: once alone, and twice associatedwith other organisms. In one case we found the staphylococcus©pidermidis albus alone and are inclined to consider it a con-

5IN THE PUERPERIUM.

tamination ; in the second case we found the albus and colontogether, while in the third case we found the aureus in com-bination with the streptococcus and typhoid bacillus. None ofthese cases died, and it is apparent that it is difficult to statewhat part, if any, the staphylococci played in the productionof the symptoms observed.

The colon bacillus was not mentioned as a cause of puerperalinfection until 1893, when Von Franque demonstrated its pres-ence in pure culture in one of his cases. The same year, in anarticle entitled £ - Puerperal Infection considered from a Bac-teriological Point of View,” I referred to Von Franque’s caseand stated that it was remarkable that colon infections had notbeen observed more frequently, and predicted, attention havingbeen directed to them, that they would probably soon bedemonstrated in a considerable number of cases. This predic-tion has been amply fulfilled and a very large number of suchcases reported—so many, indeed, that their mere enumerationwould no doubt prove wearisome to you, and I shall thereforeonly mention the cases which have been reported by Gebhard,Kronig, and Marmorek. We have demonstrated colonbacilli in6 of our cases: in pure culture in 4 cases, and combined with thestreptococcus in one and with the staphylococcus albus in an-other case. Two of the pure colon cases were observed in thein-door hospital work, and the other 2 in consultation; whilethe mixed infection with the staphylococcus was observed inthe out-patient department, and the one with the streptococcuswas seen in consultation.

It is of interest to note that both of the hospital cases oc-curred in patients with eclampsia, in whom it was necessaryto dilate the cervix manually and extract the child. In boththese cases croton oil had been given before the operation, caus-ing profuse watery stools during its performance, by which thehands were unavoidably soiled and therefore readily affordeda satisfactory explanation for the infection. In the streptococ-cus and colon case there was a complete tear into the rectum,through which colon bacilli gained access to the generativetract. The mode of infection in the other 3 cases was not soevident, but, when we consider the marked proximity of therectum to the vagina, the cause is probably not far to seek.

Kronig in 1893 was the first to cultivate the gonococcus fromcases of puerperal infection, and since then has abundantlyconfirmed his original observations, and in his recent workwas able to refer to 50 such cases which he had observed him-

6 WILLIAMS; FORTY CASES OF FEYER

self. In 2of our cases we were likewise able to demonstrategonococci as the cause of the fever.

Thus far our work is perfectly in accord with that of thegreat majority of observers, and only serves to substantiatethe doctrine that puerperal infection is wound infection, andlike it may be due to a number of differentbacteria which havebeen introduced into the patient from without.

We shall now turn to the consideration of 11 cases in whichthe relation between the clinical symptoms and the bacteriaobserved in the uterus is not so clear. In some of them wedoubtless had to deal with sapremia in the sense of MatthewsDuncan, while in several others it is doubtful whether thebacteria observed played any part in the production of thesymptoms.

This aspect of puerperal infection has been studied by Bumm,Yon Franque, and especially by Kronig, who have demon-strated in a certain number of fever cases that the uterus didnot contain the usual pathogenic organisms with which weare all so well acquainted, but various cocci and bacilli, whichfor the greater part could not be cultivated at all, or onlyanaerobically, and which could not be identified with well-known organisms.

In 4 of our cases we were able to cultivate strictly anaerobicorganisms from the uterine lochia. In 2of these cases we hadto deal with short, thick bacilli, and in a third with a thickbacillus which was from three to five times as long as broad.Hone of these organisms appeared to possess a great degree ofvirulence, as the highest temperature in these cases was 101.6°F. (38.8° C.). The fourth case, on the contrary, ended fatally,and in it we were able to demonstrate the gas bacillus (bacillusaerogenes capsulatus) and the streptococcus, which has alreadybeen reported by Dr. George W. Dobbin in the Johns HopkinsHospital Bulletin.

In 3 other cases we were able to cultivate aerobic bacteriawhich we were unable to identify. From 2 of these we culti-vated a non-pathogenic streptobacillus, which grew upon allmedia and stained by Gram’s method.

Before labor we cultivated from the vaginal secretion of oneof these cases an organism which was apparently identicalwith the one found during the puerperium, and it is a questionwhether it was a case of autoiufection or not. However thatmay be—and we are unwilling at present to express a definiteopinion concerning it—it is the only case among the 40 which

IN THE PUERPERIUM.

offers the slightest evidence in support of the doctrine of auto-infection. From the third of these cases, a woman who hadaborted at the fourth month and who was not examined inter-nally, and in whom the temperature rose to 103.5° F. (39.8° C.)on the eighth day, which, however, fell promptly after briskpurgation, we cultivated a non-pathogenic bacillus which hadall the characteristics of the colon bacillus, except that it didnot decolorize with Gram’s stain and did not produce gas inglucose-agar.

In 4 other cases of this group we were able to demonstratethe presence of bacteria in the uterine lochia in cover-slip prep-arations, but were unable to cultivate them either aerobicallyor anaerobically. In 3of these cases we found cocci and short,thick bacilli, while in the fourth case we had to deal with alarge, thick bacillus. In this case the temperature rose sud-denly to 104.4° F. (40.3° C.) on the fourth day, and fell withintwenty-four hours after a brisk purgation, never to rise again.

It is apparent, leaving out of consideration the case of gas-bacillus infection, that we must be cautious in attributing theclinical symptoms observed in this group of cases to the bac-teria which were demonstrated in the uterus; for it is morethan likely, in several cases at least, that no causal relationexisted between them and the symptoms observed, but that thesymptoms were probably due to intestinal autointoxicationand that the bacterial find was purely accidental.

On the other hand, it is probable that the bacteria whichwere demonstrated in several cases of this group did give riseto the symptoms. But whether they were due to the directinvasion of the tissues by the bacteria, or to the absorption ofpoisonous substances, produced by bacteria, which were presentin the necrotic material lining the interior of the uterus, arequestions which we must leave unanswered until further studyof this class of cases affords us data upon which we can basedefinite assertions.

The practical value of the bacteriological examination of theuterine lochia is clearly demonstrated by the study of thisgroup of 11 cases, for by no other means could we so promptlyarrive at a definite diagnosis and thereby exclude infection bythe more dangerous pyogenic bacteria. Its practical value,however, is even still more strikingly illustrated bjr the groupof cases which we shall now consider.

In 11 other cases, in which there was a more or less markedrise of temperature, the bacteriological examination was abso-

8 Williams: forty cases of fever

lutely negative. In none of these cases were we able to dem-onstrate the presence ©f bacteria upon cover-glass preparationsor by cultural methods, and in every case the examination ofthe blood was negative. We were therefore able in each caseto exclude positively the presence of puerperal infection on theone hand and malaria on the other.

How great a gain this is can only be appreciated by thosewho have experienced the immense relief of finding that theuterus is absolutely sterile in a patient whose temperature hassuddenly shot up to 103° or 104° on the third or fourth day ofthe puerperium, and in whom we suspect the possibility of aninfection. This has happened to us upon a number of occa-sions, and the relief afforded by the negative result of theexamination has more than repaid us for the labor expendedupon the entire series of cases under consideration.

Further observation of this group of cases has shown that inmany instances the temperature was probably due to an auto-intoxication from the intestines, as was indicated by the rapidfall of temperature after brisk purgation. In other cases therise of temperature was undoubtedly due to disturbances aboutthe breasts, while in a few cases we were absolutely unable tofind any cause for the temperature.

In a case of quartan malarial infection occurring during thepuerperium, the examination of the lochia enabled us to ex-clude positively the possibility of its being associated with apuerperal infection. And we do not consider that in futureone will be justified in treating as malarial a rise of temperatureoccurring during the puerperium, unless the examination ofthe blood reveals the presence of the characteristic plasmodiaand the examination of the uterine lochia demonstrates theabsence of bacteria.

In addition to the results already referred to, our work hasled to the discovery of puerperal infection by several organ-isms which have not been previously described in this connec-tion, or which, if described, occur but rarely. Thus, in onecase we found the gas bacillus (bacillus aerogenes capsulatus),which has already been described by Dr. George W. Dobbin inthe Johns Hopkins Hospital Bulletin and Die Monatschriftfur Geburtshillfe und Gyndkologie; in a second case thediphtheria bacillus, described by me in The American Jour-nal of Obstetrics *; and in a third case the typhoid bacillus,which will be published by me in the Centralblatt filr Gynd-

JSee the August number, p. 180,

9IN THE PUERPERIUM.

kologie l and which has already been described by Dr. Dobbinin this Journal.2

I have attempted this evening to give an idea of the work whichwe are doing, without going into details, as we expect to pub-lish our results more fully at a later period, when we shall basethem upon a larger number of cases, giving more detailed information about the bacteria observed, and accompanying itwith illustrative charts and histories of cases. But we hopethat what we have said will be sufficient to convince you of theImportance and practicability of this character of work, and ofthe value as a means of diagnosis and as a guide for treatment.

In conclusion I might add that this work was done either bymyself, or under my supervision by Dr. George W. Dobbin,resident obstetrician, Johns Hopkins Hospital.

1 See the August number, p. 185.

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