THE TREATMENT OF PUERPERAL SEPSIS, WITH SOME NOTES ON THE BACTERIOLOGY OF PUERPERAL/ FEVER* /

By C. A. F. HINGSTON, C.I.Z., o.b.E.,

UEUT.-COI,., I.M.S.,

and

A. LAKSHMANASWAMI MUDALIAR, b.a., m.d.,

Madras Government Maternity Hospital.

PuErpKral sepsis is still one of the most

serious complications in the puerperium and stands perhaps foremost among the causes

of maternal mortality following childbirth.

Despite all the improvements in bacteriologi- cal technique and the knowledge gained from a close study of the bacteriology of puerperal fever, it must be stated that there has been no

appreciable difference in the incidence of this disease within the past twenty years even in Great Britain. Statistics show that. In this

country the incidence of the disease is very much greater. In Southern India maternal

mortality from sepsis is at least 6 to 8 times as great as it is in England and Wales, and in the city of Madras the returns show that 1 out of every 60 mothers dies from puerperal sep- sis. The problem then of prevention and cure of this serious complication is one that deserves the close attention of all obstetri- cians in this country more than anywhere else, and it is to focus that attention and to stimu- late a discussion that we have ventured to sub- mit this paper to the Congress. At the Government Hospital for Women and Children in Madras about 3,000 women are confined

every year, while a large number of women confined outside are admitted suffering from puerperal sepsis of varying severity. The

scope then for a close study of this disease as it manifests itself under local conditions has been considerable, and while we do not lay any claim to any new line of treatment, we think it will not be out of place to put on

record our experience in regard to the treat- ment of this disease.

During the last twenty years it has been the practice in this hospital to segregate all women who are in labour but who 'have been examined outside to a separate wing, where the patients are delivered in a separate labour ward and accommodated in the puerperal wards adjoining. No patient is refused admis- sion and all women confined outside and

brought in with or without signs of puerperal sepsis are likewise kept separate in the septic block. This has to a very large extent reduced the chances of infection in the hospital. Prophylaxis.?This undoubtedly is of the

greatest importance and naturally commands

* Being a paper read at the Indian Science Congress, Lahore, in January 1927.

April, 1927.1 TREATMENT OF PUERPERAL SEPSIS : HINGSTON & MUDALIAR. 183

the greatest attention in a training institution such as ours. Perhaps no factor is of greater importance than that of the ante-natal care ?f the mother. Our experience is that sepsis is very much rarer among the batta women

who are kept under our personal observation during the last two or three months of preg- nancy and given a daily dole of two annas. These women are carefully looked after and attended to at an early stage.

It needs no emphasis to say that the most Potent factor in the production of sepsis is the attendant, and while we are not prepared

deny the possibilities of intrinsic infection, may safely be stated that extrinsic infection

0r possibilities of it s'hould never be ruled out so long as any sort of manual interference has been attempted. Strict antiseptic precau- tions are required whether gloves are used 0r not, and vaginal examinations should be made only when considered inevitable. The

Proper cleansing of labia and perineum and

^are^ in vaginal examination and the intro-

duction of the finger by sight after well

Separating the labia are of importance. In normal labour a vaginal douche is never

given. In cases of prolonged labour, when the cervix is not fully dilated and the mem- branes have ruptured, and in cases where the ^v?man has been handled outside and the

Vagina badly bruised or where a purulent paginal discharge is present, a hot vaginal douche with lysol (1 drm. to the pint) is given.

. Our experience is t'hat there are greater

risks of sepsis in the application of forceps man in most of the other obstetric operations, excepting the manual removal of placenta. We have rarely met with severe sepsis in cases of version even when performed in cases

.neglected transverse presentation. In

Particular where the forceps are applied in

?ccipito-posterior or mento-posterior PreT Sentations, or in minor degrees of contracted Pelvis or where the head is high up, in cases Wnere the cervix is rigid or the anterior lip 1? Prolapsed, the cervical and vaginal lacera- 1Qns that are almost inevitable are fruitful

Causes of sepsis. We have practically given UP the operation of high forceps, and prefer Veision and extraction, provided there are no

^?ntra-indications. It is of great importance 0 repair all tears w'herever possible and we ^und tjle application of Tr. Benzoin Co.

p'ficient in arresting the oozing and prevent- !n? sepsis in all cases of vaginal and cervical macerations. Two conditions especially predispose to

Puerperal sepsis, post-partum haemorrhage, and retention of membranes, blood clots or bits

placenta. Every care should be taken to Prevent the latter, but we are definitely against tlny intra-uterine manipulation to remove

membranes or small bits of placenta immedi- ately after delivery. Treatment.?The treatment of puerperal

sepsis depends very much on the condition of the patient when first seen and whether the

patient is suffering- from a localised infection of the generative tract or from a generalised infection. If the temperature rises above 100?F. during the puerperium, an immediate investigation should be made to find out the cause, and in the absence of any definite causa- tive factor, the case should be deemed to be one of puerperal sepsis. In this country some of the factors which may give rise to fever

during the puerperium are malaria, dysentery, pneumonia, kala-azar, tuberculosis, and in-

testinal worms. When however none of these

causes are present, a careful examination of the patient is needed. The pulse and tempera- ture and the general condition of the patient is noted. The height of the uterus should be noted and whether it is well contracted or

flabby, painful and tender. The lochia should

be observed, its colour, smell, method of

staining, its character and quantity, particular care being taken to note the presence or ab- sence of clots, fragments of placenta and mem- branes. The perineum should be examined

with a view to find out if there have been any lacerations, or if sutured whether the sutures

are taking and the perineum healthy. We gener-

ally examine the patient on the table in order to "note the condition of the cervix and vagina. At the same time cervical and uterine swabs

are taken for bacteriological examination. A hot vaginal douche is given, any ulcers present in the vagina or cervix are touched with a

fairly strong antiseptic such as medical izal, tincture of iodine, tinctura benzoinae co.,

or a saturated solution of picric acid, and if

the perineal stitches are unhealthy they are

removed and the perineum laid bare to promote free drainage.

The. vaginal douche.?In cases of sapraemia hot vaginal douches are given every four hours if necessary, the solutions used being lysol (1 in 160), iodine (1 in 80), eusol, and saline.

Where the lochia are very foul smelling, iodine douches are preferred. The vaginal douche

helps to clean the parts, favours free drainage and provokes uterine contractions.

In cases where there is extensive sloughing of the vaginal walls and cervix?what is termed here the

'

cesspool vagina '?continu- ous irrigation with a mild antiseptic is very efficient. Weak lysol or saline is generally used and the douche is given continuously except for an interval of 2 hours by day and 4 hours by night. In case the perineum is (edematous or badly ulcerated hot boracic

compresses are advisable.

The Uterine Douche.?The place of the uterine douche in the treatment of puerperal

184 THE INDIAN MEDICAL GAZETTE. [April, 1927.

sepsis is a debatable point. We have for some years past considerably limited the scope of t'he intra-uterine douche. With all pre- cautions, it is not free from risks, and in most

cases^ its value is doubtful. In cases of pyo- metria no doubt it helps to drain the uterus and there is a sharp fall in the temperature and marked improvement in the general condi- tion of the patient. The mechanical use of the intra-uterine douche in all cases of sepsis or even in cases of pyrexia during the puer- perium cannot be too strongly condemned. It is by such methods t'hat a mild case is con- verted into a severe one. Since discontinu- ance of the frequent use of the uterine douche we have noticed that the period of pyrexia in sapraemic cases is very much less and that fewer cases develop into the severe forms of sepsis.

Curettage and Ecouvillonage.?We have found that even in cases where t'he uterus is filled with decomposing lochia, drainage with the help of a Budin's tube is sufficient. This

may be repeated on alternate days or even

daily if necessary and has the advantage over the uterine douche that the patient does not suffer from s'hock or hyperpyrexia. In cases

where it is suspected that bits of placenta or membranes or disintegrating blood clots are left behind in the uterus, it is advisable to

remove them by digital evacuation of the uterus. With the patient under chloroform it is often possible to completely explore the uterus by careful bimanual manipulation. The next method adopted in this hospital is

a modified ecouvillonage. Instead of using the brush, a rough piece of sterilized gauze is wound round an intra-uterine forceps and the whole of the inside of the cavity is swabbed round. This is done three or four times till all the debris is removed. It may be done after digital exploration and has proved very useful.

We are definitely of opinion that the curette is not a safe instrument to be used in the

puerperium. It is ineffective, lays open fresh channels of infection, causes severe haemorr-

hage at times, may lead to risks of perfora- tion and generalised infection. Since the

practical abandonment of the curette we have noticed a distinct diminution in the number

of severe cases of sepsis and a more rapid recovery in cases treated without curettage. We must state that we have frequently come across cases where curettage has been done

for uterine sepsis with the result that the condition has become much worse and septi- caemia has supervened. Even in cases where

curettage is supposed to have been beneficial, we are inclined to the belief that the cases would have improved under a more conserva- tive line of treatment. We must add how-

ever that the use of the curette in infection

occurring as a result of abortion in the early

months of pregnancy is not only justifiable but is attended with very favourable results.

Postural Treatment.?A good method of

favouring drainage is to raise the head of the bed or put the woman in Fowler's position. This generally helps to drain the uterus and vagina and tends to limit the possibilities of the spread of infection into the peritoneum. It may be stated here that distension of the bladder leads to the retardation of the free flow of lochia and thus favours a lochiometria or pyometria. In all cases of instrumental delivery care should be taken to see that the bladder is emptied in time, as otherwise the uterus may be pressed upon and get displaced backwards.

In cases of sub-involution ecbolics are

needed, a mixture of the liquid extract of

ergot wit'h quinine being commonly given. Injections of pituitrin given daily or twice a day are also of considerable value. Hot

vaginal douches should be given, at least twice a day.

Operative measures.?The question of

operative treatment in cases of puerperal infection has been much discussed of late. The operations suggested are hysterectomy, laparotomy, salpingectomy and oopho- rectomy, posterior colpotomy, ligature or

excision of the pelvic veins. We have not been in favour generally of t'he principle of operative treatment in cases of puerperal sep- sis and the results obtained by those who ad- vocate such methods of treatment have not been encouraging. We have limited the use of operative measures to definite indications. In cases where there is a definite swelling in Douglas's pouch which is fluctuating, the abscess may be drained by an incision into the posterior fornix. Even here it may be stated that in many cases of pelvic cellulitis the in- flammation subsides with absolute rest in bed, hot vaginal douches, warm boric bowel washes, icthyol and glycerine (10 per cent.) tampons to the vagina. In a large proportion of cases the symptoms gradually subside and the exudate is almost completely absorbed in the course of a few weeks.

When the cellulitis goes on to suppuration, the abscess should be opened in the most favourable position for drainage. In many cases the abscess can best be opened by an incision along the iliac region parallel to Poupart's ligament.

In cases of infection of the Fallopian tube and ovary, we hold that a conservative line of treatment is indicated. We are not in favour of the removal of an acute pyosalpinx or

ovarian abscess, and our experience is that it

is very much better to decide the question after the acute stage has subsided. The treat- ment should in the meantime be directed to the peritoneal symptoms.

Aprii,, 1927 ] TREATMENT OF PUERPERAL SEPSIS : HINGSTON & MUDALIAR. 185

Opening- and drainage of the abdominal

cavity has 'been done in cases of puerperal Peritonitis, but the results

have not been satis-

factory. Jn cases following abortion the

?Peration is more successful.

Scrum and Vaccine Therapy.?Antistrepto- coccic serum in cases of puerperal sepsis

"as not been found to be as useful as

was first anticipated. In cases where the

patient is already septicemic, we have found

practically of no value. Used as aprophy-

actic, its value is undoubted. During last

year the serum has been used in every case

;vhere the placenta had to be manually re-

moved. Out of ten cases in which the serum

fl.as Use<^> eight recovered. It may be stated

hat in seven of these cases the patient was

confined at home and brought in 6 to 12 hours

ater in a condition of collapse with seveie

ruising of the vagina and cervix and the

placenta adherent. Only one case died. The

lnitial dose given was 20 c.c. and this was

repeated daily. The temperature did not rise

above 102?F. and the patient showed signs of

sapraemia. We are of opinion that the

result in these cases is not accidental and that

antistreptococcic serum has its place as a pio-

Phylactic in puerperal sepsis. It may also

be

stated that in one of the fatal cases, uterine

culture revealed the presence of Bacillus coli

and perhaps this accounts for the fact

that the

Serum was of no use. Stock vaccines (poly-

valent) were used in a large number of cases

^vith uniformly poor results. Autogenous

vaccines have been tried in a few cases but

Owing to the delay in their preparation and

he severity of the cases selected, it is not

Possible for us to speak of their value with

ariy authority. We have recently isolated

a

arg"e number of the different strains of strep-

ococci, hemolytic and non-hsemolytic, as well

as other organisms occurring in cases of puer-

Peral sepsis and a polyvalent vaccine has been

Prepared and is being given a trial. The

results we shall watch with interest.

General treatment.?Careful nursing and a

stimulating line of treatment should be fol-

owed in these cases. The diet should be

'Sht, liquid and easily digestible. Milk,

arrowroot, Ovaltine, Benger's, are among

the

common foodstuffs given. Essence of chicken

0r Bovril is also used with advantage. Eggs,

or as egg-flip, are usually well taken.

.Ucose and brandy or champagne may

be

?lven at intervals of two to three hours

and

are of value in cases of severe exhaustion.

For the pyrexia, hydrotherapy is generally

Practised. Strong antipyretics^ are to be

deprecated. Injections of quinine have been

?"lyen and occasionally proved beneficial. In

cases of B. coli infection, hexamine in doses

7 to 10 grains has been given intravenously,

ut the results have not been satisfactory.

In cases showing- severe toxaemic symptoms saline solution has been used, either subcutane- ously or per rectum.

Infection of the urinary tract is always a troublesome complication in septic cases. The use of the catheter during- the puerperium should be discouraged as far as possible. An- other cause of infection is tears of the clitoris and urethra, particularly in forceps delivery, where in attempting to save the perineum the forceps is carried too far forwards. The use of urinary antiseptics with the administration of Jarge quantities of barley water generally suffices in most cases. Occasionally an as-

cending infection of the urinary tract results and the pyrexia may persist for a long period.

A complication of grave prognosis is the severe anaemia that occasionally develops in cases of puerperal sepsis. The anaemia though of the secondary variety progresses very rapidly and proves fatal. In such cases the

patient fails to respond to any treatment and sinks gradually. Sometimes cases of puerperal sepsis develop

severe pains in the pelvic joints and are un- able to move the limbs. This is accompanied at times with several neuralgic pains shoot-

ing down the thighs. Calcium therapy has been of some benefit in some cases but not in all, and the exact causation of t'his trouble- some complication is not known. Conclusion.?We have attempted to des-

cribe in a general way the treatment of puer- peral sepsis as carried on at the Madras Government Hospital for Women and Child- ren. During the past 10 years (1916-25) there were 26,531 deliveries. The total number of septic cases treated was 1,574 of which 282 cases were cases of puerperal septicaemia. There were 95 deaths from septicaemia and 7 from severe sapraemia. The mortality rate

for septicaemia would thus be seen to be 34.68 per cent.

Our thanks are due to Dr. M. B. Prabhu, m.b., B.S., who was responsible for carrying out the actual treatment in these cases and whose careful notes and statistics were of

great help to us in our work.

An analysis of1 results of Bacterioeogicae Examination of Uterine; and Vaginae SWABS IN CASES of PuERPERAI, SEPSIS, THE Normal Puerperium, and Pregnancy.

(Performed by Assistant Surgeon J. H. Theodore, i.m.d., King Institute, Guindy.) The study of streptococcal incidence in cases

of puerperal fever was first undertaken. In this series a group of 120 cases were examined and streptococci were isolated from 77 or

64.2 per cent, of the cases examined. The

relatively higher proportion of streptococcal

186 THE INDIAN MEDICAL GAZETTE. [April, 1927.

findings in relation to the severity of the cases may be seen from the following- table:?

Mild. Severe. Fatal.

Number of cases. 67 36 17 Number of cases asso- |

ciated with strepto- > 40 24 13 coccal infection ..

>

Proportion .. 59.7% 66.6% 76.4%

The total of 77 positive findings when fur- ther subdivided into the hsemolytic and non- hemolytic varieties, group themselves as

follows:?

Mild. Severe. Fatal. Total.

Hemolytic variety .. 36 22 9 67

Proportion .. 90% 91.6% 69.2% 85.1%

Non-hsemolytic variety 4 2 4 10

Proportion .. 10% 8.4 30.8% 14.9%

The streptococci fell into one or other of Holman's groups.

The possibility of organisms other than

streptococci being associated factors in puer- peral fever was next considered. The next

series of swabs from cases of puerperal fever were examined with a view to ascertaining their entire flora. The results obtained are

tabulated as follows :?

xn cq w P O

Sapraemia ..9 2 11 3 4

Septicaemia .. 6* 3

* Of these, streptococci were found in association with pneumococci and staphylococci in one case, and with B. coli in another.

The 29 cases of saprsemia, when analysed to shew the relation the isolated organisms bore to the severity of the case, indicate that strep- tococci and B. coli were associated with the more severe form of cases.

Sctprcemia Cases, 29.

"G u -T3 C U O *2 Ctf ?

n ?

?? ?-> O g u

2 := Jc & 2 H, j? cs .?7 *? th cq xjrx P O

Alild .. 3 1 9 3 3

Severe .. 6 1 2 1 ?

Fatal

Note?Oi the 3 streptococci findings two were from both uterine and vaginal and one from the vaginal swab only, the remainder isolated were for the most part from both uterine and vaginal swabs.

Septicemia Cases, 9.

Mild ? ? ?

Severe .. 4 2 ?

Fatal ..2 1 ?

The above table shows rather forcibly the predominance of streptococci and B. coli in

the more severe and fatal forms of our cases, with a complete absence of t'he less virulent

organisms which were so closely associated with the milder form of the disease.

Note.?The isolations in each instance in this series were from the uterine discharge and for the most part pure cultures. One of the fatal streptococcal infections gave in addition a growth of B. coli.

Vaginal Flora in 21 cases of full term. Pregnancy.

The results obtained in this group are as

follows?

| ? S o

hn i2 "S +J P &) O (U

m *5 <v S ft ^ ? O 2 .S* u

. a!

? >h Q tn xrx eq 05 ^

7 6 4 1 1 2

The figures obtained in this table will be considered in the discussion of the endogenous nature of puerperal infections. A series of 12 cases from which uterine and

vaginal swabs were separately examined dur- ing a normal puerperium, gave the following results:

3 o -M O u'

? ? 8 ? ? j= o J-H (f) A-I ^ In Jfl

j .a a i- o <u

A 1 P in m m in

Uterine .. 9 3

Vaginal .. 3 10 2 2 2 2

In 8 of the vaginal findings more than one organism was found, diphtheroids being as- sociated in two instances with each of the

following: yeasts, staphylococci, sarcinse and

saprophytic bacteria.

Conclusions.

The above analysis shows that streptococci play a prominent part in the production of

puerperal fever. The haemolytic variety is

more often associated with the serious cases,

but its exact pathogenicity requires further

investigation. From an examination of the discharge?

uterine and vaginal?in cases of puerperal fever, we noted that the following organisms were present in addition to streptococci in

cases of saprsemia: B. coli,. staphylococci,

April, 1927.1 USE OF FISHES FOR CONTROL OF M OSQL 1TOES: I-TORA. 187

diphtheroids, the B. vaginal'* alic! u,

organisms. In septicemia however t ^

organisms isolated were streptococci

We examined the vaginal flora of j1? ^

Pregnant women in 21 cases, and exc p a case where a streptococcus and

one in ?

staphylococcus was present no

organisms were isolated. Twelve of th??

cases were followed up after d'elive ^

examination of the uterine and vagina <

ln the puerperium showed that ^nntained swabs were sterile in 9 cases an ao-jnal only diphtheroids in 3, 1

? j ^and swabs showed mainly diphther