PUERPERAL INFECTION OF 
THE URINARY TRACT AND 
OF THE RECTUM. 
BY 
Richard C. Norris, M. D., 
Obstetrician in charge of Prestqp, Retreat, etc:, 
Philadelphia. 
Reprint from The American Gynaecological and 
Obstetrical Journal. [Reprinted from the American Gynaecological and Obstetrical Journal 
for January, 1895.] 
PUERPERAL INFECTION OF THE URINARY TRACT 
AND OF THE RECTUM* 
By Richard C. Norris, M. D. 
Obstetrician in charge of Preston Retreat, etc., Philadelphia. 
The topic assigned me in the discussion of sepsis following labor 
is not so important as infection of the parturient tract since the urinary 
organs and the rectum are not so frequently involved in septic pro- 
cesses. 
The literature of this subject, however, is sufficient to convince 
one that infection of the urinary tract is not only not uncommon but 
may, indeed, be a very disastrous complication of the puerperium. 
Thus Schwarz noted, in 1,100 carefully observed puerperse, catarrh of 
the bladder in 2.9 per cent, of the cases. The records of severe types 
of cystitis in childbed show a mortality of 38.8 per cent. Add to this 
the results of infection spreading along the ureters to the kidneys 
with consequent pyelitis, pyelo-nephrosis or nephritis and the sum of 
possible injury is well worth close attention by every one practicing 
obstetrics. 
It will be convenient to classify infection of the urinary tract as 
(1) ascending infection i. e. from the bladder or adjacent structures 
along the ureters to the kidneys ; (2) descending infection-in which 
the kidneys are primarily, the bladder secondarily involved. Of these 
the former is more important because less generally recognized as a 
possible and dangerous puerperal complication. 
Ascending infection usually begins in the bladder, the infecting 
poison gaining access to this viscus in one of several ways. Com- 
monly the catheter carries the infecting agent into the bladder, either 
being itself not chemically clean, or if properly sterilized, but im- 
properly introduced, it may become contaminated by decomposing 
lochia, at the time of its introduction into the bladder. These 
dangers of the catheter can be avoided but there remains one other 
danger which, unfortunately, it is difficult to escape, namely, the 
* Read before the Philadelphia Obstetrical Society, December 6, 1894. 2 
Richard C. Norris, M. D. 
danger of introducing into the bladder micro-organisms which are 
commonly found in the otherwise normal urethra. Gawronsky * ex- 
amined 62 women with no symptoms of urethral or cystic disease and 
found pathogenic bacteria in the urethra in 24 per cent, of those ex- 
amined. Of 10 women examined by Rovsing, bacteria were found 
in the urethra in six cases. Further, Rovsing f records 29 cases of cys- 
titis, in all of which the urine contained pathogenic bacteria and as 
20 of these cases followed catheterization with a clean catheter, he 
concludes that the cystitis was caused by the urethral microbes car- 
ried into the bladder by the catheter. Hofmeister concludes from 
his investigations that it is not decided whether the bladder in health 
contains pathogenic micro organisms, but that the urethra is certainly 
rich in them. From these facts but one conclusion can be drawn, 
viz. : that the catheter at best is a dangerous instrument. That cys- 
titis does not more frequently follow its use is doubtless due to the 
fact, pointed out by Bumm, Dubelt, Rovsing and others, that a 
healthy, uninjured bladder can resist the action of micro-organisms 
when introduced. 
In the puerperium, however, this resisting power of the bladder is 
commonly not present on account of the pressure and contusion the 
bladder receives during labor. The experiments of Rovsing and 
those of Guyon are therefore of great interest and value to the ob- 
stetrician. They found that by ligating the urethra and thus causing 
overdistention and injury of the bladder, a catarrhal cystitis was pro- 
duced but when micro-organisms were subsequently introduced the 
cystitis rapidly became suppurative. These facts, then, explain why 
the use of the catheter is especially dangerous in puerperse. 
Ascending infection cf the urinary tract may rarely occur inde- 
pendent of the use of the catheter. Kaltenbach first called attention 
to the frequency of pyelitis following labor and pointed out its con- 
nection with inflammatory processes about the uterus. Stadfeldt has 
also demonstrated the same affection following distention cf the ure- 
ter and pelvis of the kidney, the ureter being occluded by pressure of 
the puerperal uterus. 
Recent clinical and experimental studies of cystitis, particularly 
by Dogen, Clado, Halle, Albarran, Rovsing, Morelle, Denys, Schnitz- 
ler and Krogius apparently prove that micro-organisms located in 
any of the pelvic viscera may find their way into and infect the blad- 
* Milnehener med. Woehenschrift, March 13, 1894, p. 204. 
f Cystitis-its Aetiology, Pathology and Treatment, Berlin, 1890. Puerperal Infection of the Urinary Tract and of the Rectum. 
3 
der. Reymond's * observations are especially interesting. In two cases 
of cystitis where the micro-organisms in the uterus and bladder were 
identical, treatment of the bladder was without result but after curet- 
ting and disinfecting the uterus the cystitis rapidly disappeared. In 
seven other cases a cure of the cystitis followed removal of the dis- 
eased pelvic organs. His four experiments upon animals showed that 
the introduction of organisms into the pelvis outside the bladder 
walls gave rise to cystitis with the micro-organisms in the bladder 
and not in the blood current of the pelvis. In Wreden's f experi- 
ments intestinal micro-organisms or those intentionally placed in the 
bowel were found in the bladder. All of these observations are of 
value to obstetrics as an added argument for the necessity of sur- 
rounding the patient with strict cleanliness and antisepsis for they 
show that sepsis of the parturient tract can and does sometimes 
spread to the urinary organs. 
Having thus briefly indicated how the bladder and ureters may 
become i. fected during the lying-in period it is easy to understand 
that Iq continuity of structure tl e kidneys finally are involved in the 
septic inflammation. Every obstetrician of wide experience will now 
and then see pyelitis, pyelo-nephrosis or nephritis follow infection of 
the bladder and ureters. 
The time required for the spread of the inflammation from the 
bladder or adjacent structures, along the ureters to the kidneys varies. 
The usual time, is about ten days or two weeks after the appear- 
ance of cystitis. It can, however, in rare cases occur almost from the 
outset, before or coincident with marked bladder symptoms and in 
some cases the kidneys become infected only after a long-standing 
and persistent cystitis or ureteritis. I have elsewhere J referred to 
seven cases of infected kidneys following labor and wish now to 
briefly report a case of ureteritis and pyelitis, at present under my 
care, which I believe to be the result of an infected ureter following 
childbirth without preceding implication of the bladder. The 
patient, Mrs. C., had been treated for several months for what seemed 
to be repeated attacks of nephritic colic. There had been frequent 
micturition and pain in the lumbar region since the birth of her first 
child four years ago. The attacks ot nephritic colic first appeared 
when she had advanced to the sixth month of her second and last 
* Ann ales des maladies des organ, genito-urinaires, April, 1893. 
\ Centralblat. f. Chirurgie, No. 27, 1893. 
f Transactions of the American Gyncecological Society, 1893, 4 
Richard C. Norris. M. D. 
pregnancy and they increased in frequency and severity after she had 
been delivered. There was a history of mild infection after each of 
her two unassisted labors. Upon examination the right ureter was 
enlarged, exceedingly tender and readily palpated from its vesical 
orifice along the base of the bladder and upward as far as the finger 
could reach. The right tube and ovary Were enlarged, tender and 
adherent. There was a tumor with distinct fluctuation in the region 
of the right kidney. The urine contained pus, a small amount of 
albumin but no casts. A perinephritic abscess was opened and 
drained. There was no stone, and the kidney was apparently normal. 
After five weeks the urinary fistula in the loin refusing to close a No. 
7 catheter was passed through the opening in the loin down the ureter 
to its pelvic portion but would not pass further. Vaginal examina- 
tion found that the tenderness and thickening of the pelvic portion of 
the ureter.had not disappeared and obstruction was believed to have 
occurred at this point, from inflammatory deposit. A ureteral bougie 
was passed through the opening in the loin, down the ureter into the 
bladder and allowed to remain three days. The bougie was there 
after passed every third day, and the ureter daily injected with boric- 
acid solution. After two weeks of this treatment the tenderness and 
thickening of the ureter has almost disappeared and within a week 
or two the drainage-tube will be removed with the expectation of cure 
by spontaneous closure of the opening in the loin. 
That this case is not one of tubercular origin is apparent from the 
disappearance of all purulent discharge and inflammatory deposit as 
well as from the negative result of analysis of the urine for tubercle 
bacilli. Cases analogous to this, reported by Skene* and by Mann f 
have been attributed by then, to simple pressure of the child's head 
or of forceps during delivery, but it seems more rational, in the light 
of the experiments above referred to, to consider infection subsequent 
to traumatism more important than traumatism alone. 
It now remains to briefly discuss the descending form of infection 
of the urinary tract, i. e., infection attacking the urinary organs pri- 
marily in the kidneys. This is most commonly found when there is 
gene>al sepsis, metastatic abscesses occurring in the kidneys as in 
other organs. There are, however, cases recorded which would seem 
to prove that the kidneys of the puerpera, in their effort to eliminate 
toxic agents from the body, become infected and finally give evidence 
* Transactions of the American Gynecological Society, 1890, 
\ Ibid., 1894. - Puerperal Infection of the Urinary Tract and of the Rectum. 
5 
of suppurative or less marked inflammatory change such as catarrhal 
nephritis. The observations of Cornil, Bourget, and Griffiths* make 
it probable that these inflammatory changes result from the passage 
through the kidneys not only of micro-organisms themselves but also 
of their pathogenic products, the toxines acting upon the kidneys 
practically as mineral poisons. 
Diagnosis.-The early symptoms of septic puerperal cystitis are 
those of cystitis under other circumstances. In very severe cases ex- 
foliation of the mucous membrane or even of the muscle walls of the 
bladder may occur and occasion severe tenesmus or retention of urine. 
The temperature curve will often be of value as a means to determine 
when the septic inflammation invades the ureters and kidneys. The 
fever accompanying the inflammation of the bladder is usually moder- 
ate and gradually disappears after three to six days. Should this 
gradual defervescence be followed, for ten days or two weeks, by an 
almost afebrile curve, and this by a prompt secondary rise, rapidly 
reaching a much greater height than had previously existed and ac- 
companied by pain and tenderness over the kidney, the diagnosis of 
secondary or ascending infection of the kidneys may be assumed. 
Should the fever curve rise to a great height-above 103°-at the very 
beginning rapid infection of the kidneys has likely occurred. 
Microscopical examination of the urine also offers diagnostic signs 
of the extent of the inflammation, by the presence of large amounts of 
albumin, renal epithelium and casts. In very rare cases bacteriological 
examination of the urine will be necessary to determine infection of the 
urinary tract since it is possible to have infection without the appear- 
ance of purulent urine and without marked bladder symptoms. This 
is a fact to be borne in mind when those rare cases of puerperal sepsis 
with continued fever, rapid pulse, and extreme prostration, can not 
be accounted for by demonstrable local signs of sepsis along the par- 
turient canal. It is also desirable to make repeated examinations of 
the urine in all cases of puerperal sepsis since it is possible for the kid- 
neys to be coincidently involved, with either ascending or descending 
infection. The damage thus done to the kidneys may be very insidi- 
ous and explains some of the cases of eclampsia, occurring, as late as 
the fourteenth or eighteenth day of the puerperium, in patients with 
previously healthy kidneys. Siredey has reported such a case. 
Prognosis.-The prognosis of septic cystitis, fortunately, is favor- 
* Quoted by Vinay, Traitd des Maladies de la Gross esse et des suites des Couches, 
Paris, 1894. 6 
Richard C. Norris, M. D. 
able, provided proper treatment is begun early. Neglected cases, with 
ulceration and exfoliation of the bladder wall have a mortality of 
thirty-eight per cent., and of those who recover, the bladder, ureters 
and kidneys are usually permanently damaged. Pyelitis or pyelo- 
nephrosis is a common sequel, and chronic nephritis has thus origi- 
nated. Mayer has recorded some cases ultimately dying from the 
kidney lesion long after their labors. 
Treatment.-The most important part of the treatment of infection 
of the urinary tract after labor is its prevention. In view of the dap- 
ger of introducing germs into a bladder, more or less wounded, and 
therefore less resistant to the action of micro-organisms, the use of the 
catheter after labor should be delayed as long as safety will permit and 
other means should be employed to secure urination. Often this will 
be accomplished by repeatedly placing under the patient the bedpan, 
filled with hot water ; by the sound of running water ; by assisting the 
patient into an upright position on her knees ; by pressure over the 
lower portion of the abdomen, etc. While avoiding the catheter, how- 
ever, the danger of overdistention of the bladder must not be forgot- 
ten, since this renders the organ more vulnerable to infecting agents. 
As a rule, after twelve hours, if the bladder has not been spontaneously 
evacuated a chemically clean glass or soft-rubber catheter should be 
passed visually, having first cleansed the meatus thoroughly with a 
pledget of cotton and an antiseptic solution. To make assurance 
doubly sure it would be well, although often impracticable, to irrigate 
the urethra before passing the catheter into the bladder. When cysti- 
tis develops, in spite of prophylaxis, irrigation of the bladder should 
be carefully employed, at intervals of four hours, with mild antiseptic 
solutions-creolin one half of i per cent, or boric acid gr. xv to the 
ounce. Irrigation, warm applications over the bladder and diluent 
drinks will usually check the disorder in a few days. When the 
symptoms continue and the patient becomes septic, the free use of 
stimulants is necessary, frequent irrigation of the bladder being mean- 
while continued. When constant dribbling from the bladder is re- 
pla.ced by retention of urine, occlusion of the urethra by an exfoliated 
portion of the bladder-wall should be suspected and the separated 
portion should be removed, delating the urethra for this purpose, if 
necessary. Before the kidneys are involved in the septic process, the 
administration of salol will be useful. After the kidneys were invaded 
in one of my cases, the daily administration of thirty grains of salol 
was followed by the appearance of blood in the urine so promptly that it 
had to be discontinued. Large doses of iron, inhalations of oxygen Puerperal Infection of the Urinary Tract and of the Rectum. 
7 
and the free use of stimulants comprise the general treatment on which 
most reliance can be placed. 
Infection of the rectum is very rare, as a primary condition; a 
few cases have been recorded, occurring in hospital practice, from 
the use of an infected syringe nozzle. Rectal infection accompany- 
ing infection of the parturient canal is not infrequently seen. Two 
yeirs ago my friend Dr. Stahl consulted me about a case of sepsis 
following a miscarriage. The patient first developed infection of the 
vagina and endometrium, was douched, catheterized and was given 
rectal injections with the same syringe used for the vaginal douches. 
She developed besides the septic endometritis and metritis, a virulent 
septic cystitis and septic proctitis. Pus and mucous casts of the 
bowel were discharged from the rectum. In spite of septic endo- 
carditis, albuminuria and convulsions, the patient finally recovered, 
but with a crippled heart and with damaged kidneys.