Puerperal infection: with special reference to the value of blood cultures in the various stages of this condition, and to the question of 'autoinfection'

Abstract

Since the introduction of aseptic and antiseptic methods into Midwifery the incidence of Puerperal Fever has diminished enormously. But when we compare the results obtained in Midwifery, with those obtained in Surgery it must be admitted that the improvement is not proportionate. Still sepsis does occur in cases where every precaution has been taken. We have however inherited the view that sepsis is preventible in every case, that carelessness on the part of the accoucheur is responsible for its occurrence, and that, should a case become infected the essential part of the treatment is to take steps to ensure the complete emptying of the Uterus.Therefore, when new ideas are brought forward and the suggestion made that patients may carry in the Vagina organisms which may give rise spontaneously to sepsis in the Puerperium and that mole harm than good may be done by removing fragments of placenta from an already infected Uterus, it is a long time before these suggestions are seriously considered.Work has been done in the endeavour to solve the first- mentioned problem, since the end of last century, chiefly in Germany and in America. The second debatable point - that the hitherto recognised treatment of infected cases by douching, and removing remnants of placenta etc. has no sound foundation in Pathology - was brought forward in Germany in 1910. American observers then became interested and began to investigate the matter. This country, always a conservative one, has only recently begun to consider the question. At a meeting of the Obstetrical Society in Edinburgh in 1923, Professor Watson brought forward this view and raised a lively discussion.Certainly both questions, if they offer any explanation of the obstinately high mortality statistics, are well worth studying. In Scotland more than six pregnant patients in every 1000 die from diseases or accidents of childbirth and 25 -50% of these deaths are due to Puerperal Fever; i.e. about 2000 patients die annually in the United Kingdom from this disease, and there is no indication that this high mortality is decreasing.The evidence which r have endeavoured above to collect, seems to point to the following facts : -1. The Vagina frequently contains organisms, even haemolytic Streptococci, in apparently uninfected non -pregnant and pregnant patients. There is no evidence to prove that these are other than harmless saprophytes.2. It is only in exceptional cases that these organisms are likely to cause Puerperal Fever.3. Infection in the puerperium is therefore probably due to a recently introduced virulent organism or to one which has ascended from the Vulva after delivery.4. The Vagina and Uterus always contain organisms, frequently Streptococci, in cases of incomplete abortion. These organisms can cause putrefaction in the Uterine contents without a rise of temperature if drainage is sufficient.5. During contractions any or all of the organisms in the Uterus can and do reach the circulation. They cause rigors, but are soon destroyed by the blood. This type of bacteraemia is not a serious one.6. Even when Streptococci appear in the blood under these circumstances, they are probably of the same variety as the harmless saprophytic Streptococci found in the aborting uterus.7. Mechanical intrauterine manipulations in these cases likewise cause a flooding of the blood stream with organisms.8. In a certain proportion of febrile abortion cases, actual infection with virulent organisms is present, and operative interference in these cases causes dissemination of the organisms into the blood stream, and inoculation more deeply into the tissues.9. In the puerperium itself organisms do not invade the blood stream from the interior of the uterus in the same massive way unless there is interference.10. When organisms do appear spontaneously they are in the vast majority of cases pathogenic and are derived from a septic phlebitis, or an endocarditis, or a general septicaemia is present.11. In the puerperium as in incomplete abortion, interference can cause invasion of the blood- stream from the interior of the Uterus and can convert a surface inflammation into a general blood infection.12. The retention of a piece of placenta is not the factor which determines whether a patient is going to develop a severe infection or not.13. No attempt should be made to remove such a piece of placenta while the patient is febrile, because of the above danger.14. Severe bleeding which is likely to endanger life is the only indication for intrauterine manipulation in these cases.