Gonorrhea in the Puerperium. Read in the Section on Obstetrics and Diseases of Women, at the Forty- Seventh Annual Meeting of the American Medical Association at Atlanta. Georgia, May 5-8, 1896. BY ALBERT H. BURR, M.D. ATTENDING PHYSICIAN PBOVTOHnT HOSPITAL. CHICAGO. REPRINTED FROM THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, AUGUST 1, 1896. CHICAGO • American Medical Association Press. 1886. GONORRHEA IN THE PUERPERIUM. BY ALBERT H. BURR, M.D. In these latter days of widespread knowledge of aseptic measures for shielding the parturient woman from harm, the occurrence of puerperal sepsis is looked upon, even by the laity, as evidence that some one has blundered, and the attendant is fortunate if he escapes the charge of criminal negligence or inex- cusable ignorance. If the infection of the lying-in woman happened only during labor, or her subsequent stay in childbed, the charge might be sustained with justice, but we are convinced that it happens more frequently than is apprehended that an infection has antedated childbed by weeks or months, if indeed it has not preceded conception itself and invaded terri- tory absolutely beyond the reach of any possible anti- septic treatment. With a unilateral pyosalpinx, or a tubal infection, existing before pregnancy, or a subsequent gonorrheal infection of vulvo-vaginal glands or urethra, whd can be certain, even though forewarned, that he can be effectually forearmed against such dangerous and hid- den foes? I confess to a feeling of insecurity in every approaching case of confinement where I know beforehand, or have reason to suspect, the existence of gonorrheal infection, either active or latent. In an obstetric experience of five hundred cases I have had three fatalities, each of which is directly traceable to gonorrhea. In many of the remaining cases of puer- peral sepsis, more or less severe, I have found by clin- ical history or by microscopic verification, the pres- ence of a gonorrheal infection. An epitome of the 2 fatal cases, with a few added cases of non-fatal sepsis, culled for their instructive features, may serve to emphasize dangers too often ignored by the unwary. Moreover, it may comfort the troubled soul of some good brother who, believing he has neglected no rea- sonable precaution for the safety of his patient, has met with disaster where it was least expected. It may enable him in the future to trace the offending cause and place the responsibility where it rightfully belongs. Case 1.-Elizabeth B., single, aged 20; French Canadian; primipara of vigorous physique, progressed in labor without incident until the separation and expulsion of the placenta brought with it a gush of most offensive fluid, the stench of which drove other attendants from the chamber. No odor was present at the rupture of the amnion. Nothing abnormal was apparent in the secundines. The child was robust. Here was a case of encysted septic material behind the placental attachment which no possible foresight or treatment could have reached in preparation for an aseptic confinement. Thor- ough infection of the whole placental site and of the parturient canal with a most deadly poison was instantaneous and inevit- able. Peritonitis developed in thirty-six hours and ran its dis- tressing and fatal course in less than a week, despite anti- septic uterine irrigations and other recognized treatment. In the absence of an autopsy the only logical conclusion is that the location of the decidua over the cornua had converted an infected tube into a closed sack which discharged its sapro- phytic contents into the uterus when the detachment of the placenta had freed its uterine orifice. The vocation of the Woman makes gonorrhea the most probable cause of a pyosalpinx. Case 2.-Emma M., aged 20 years ; German ; married ten months; remarkably strong in physique; consulted me soon after marriage for metrorrhagia. Examination revealed an acute vaginitis, characteristic of gonorrhea. Subsequent examination of the husband showed an acute urethritis. These symptoms in the wife yielded promptly to treatment and pregnancy soon put an end to metrorrhagia. Both hus- band and wife, however, had recurrent attacks of sub-acute gonorrhea during the wife's pregnancy. Confinement was normal, on March 12, 1888. Antiseptic vaginal irrigation was practiced for several days. No untoward symptoms resulted until March 20, the eighth day, when a severe chill occurred followed by high fever, but without pelvic symptoms which never became a factor throughout her fatal illness. General systemic intoxication, however, persisted to a high degree. 3 Knowing the previous history, uterine irrigation was prac- ticed twice daily. On March 24 temperature suddenly arose to 108 degrees, which was quickly reduced by cold packs and antipyrin. Dr. H. W. Byford saw the case in consultation the following day and curetted for diagnostic purposes, with nega- tive results. March 30 temperature reached 108.5 degrees with delirium and typhoid state, severe arthritis of shoulder and hip joint, followed with temperature of 103 to 104 degrees, till fatal termination April 5, on the seventeenth day of fever and twenty-fourth day from confinement. The good health of the patient at childbirth, the sudden onset of high fever, the absence of bowel symptoms, exclude typhoid fever. My dis- Plate 1; Case V.-Gonococci from ophthalmia neonatorum, fifth day after birth. tinguished consultant concurred with me that gonorrheal infec- tion was the most probable direct or indirect cause in this most singularly virulent case. Case 3.-Luella B., American, single, aged 18, consulted me because she had not menstruated for several months. Under a suspicion of pregnancy an examination was obtained, reveal- ing a four months' pregnancy and an acute vaginitis, believed to be gonorrheal. The case was lost sight of until summoned to her confinement. Labor was normal in all respects. On the fourth day there was a chill followed by high fever from an acute metritis. This was controlled after two or three days 4 and patient was dismissed on the eighth day. In one week there was a recurrence of symptoms which again responded to treatment as before. Patient was about the house again when she had a second recurrence, under the care of another physi- cian, and died, as I learned, one month after childbirth. The following three cases of puerperal sepsis are interesting on account of microscopic verifications. Case 4.- Ida H., four months married, was delivered at full term by a midwife. On the fifth day after the confinement I found her with a temperature of 105 degrees and an acute arthritis of hip joints with immobility of lower extremities. The child was suffering from acute ophthalmia. The pus, from which a slide was prepared, showed the gonoccocus in abundance. The father acknowledged having had gonorrhea a few months before marriage. Mother and child made a good though tedious recovery under appropriate treatment. Case 5.-Mrs. Ida T., age 21; ten months married. Labor normal. On the fifth day child developed ophthalmia of gonorrheal infection. (See plate I.) The condition was at once explained to the father, who stated that he had an attack of gonorrhea four months before marriage, but considered him- self cured at the time he wedded his wife. He remembered having had some gleet (?) afterward. On the seventh day the mother had a chill with fever and acute arthritis of shoulder joint of right side. As pelvic symptoms were absent, no irriga- tions were given. Mother and child were discharged conva- lescent on the twelfth day. Ten weeks later the mother came to my office suffering from sub-involution. Microscopic exam- ination of cervical discharges showed gonococci. (See plate II.) Case yielded promptly to treatment. Case 6.-Mrs. Amelia S., age 26, primipara, was well advanced in second stage of labor when seen for the first time. Labor terminated without incident. Child developed gonor- rheal ophthalmia on the fifth day. (See plate III.) On the tenth day the mother was dismissed, after a good recovery, much to the relief of an anxious medical attendant. Two days later an urgent call in the early hours of morning cut short my slumber and dispelled my sense of security. Patient had a violent chill in the night, followed by high fever, with acute metritis and pelvic pain reflected to the diaphragm, caus- ing dyspnea and a sense of suffocation. Before making intra- uterine irrigation a slide from the cervical discharge was obtained and the inevitable coccus came to light. (See plate IV.) The husband being an actor an investigation behind the scenes was undertaken, disclosing a history of infection a few weeks before the confinement of his wife, whom he unfortu- nately infected also before he was aware of his own condition. This complication was almost a fatal experience, but finally yielded and the mother was again convalescent in one month. 5 The ophthalmia in the child was also quite obstinate for some time, though daily applications of silver solution, grains xxx to the ounce, was faithfully and thoroughly applied with brush to the whole conjunctival sack. This list of well determined gonorrheal sepsis in childbed could be extended, but enough has been detailed to serve our purpose. To summarize: All the above cases were primiparse much above the average in jihysique and general good health. Their delivery was without complication or Plate 2; Case V.-Gonococci from cervical discharges, ten weeks after childbirth. Subinvolution. instrumental interference. All necessary examina- tions or manipulations were guarded against sepsis. In no case was there more than the usual slight lacer- ation. In all, the presence of gonorrhea is closely proven except in case 1, w'here the tubal abscess is believed to have been the result of a gonorrheal infec- tion previous to conception. Three of the cases developed rheumatoid arthritis during the pyrexia. This is a well known complication due to systemic 6 infections of the gonorrheal germs or their ptomains. No doubt exists in my mind from the evidence in the cases above enumerated and others which I could add to the number, that the microscope and other means of investigation as to the gonorrheal infection would clear up the etiology of many septic complications and fatalities in childbed. These unnecessary woes too frequently attendant on motherhood, and the sad lessons taught on the tables of our gynecologists, take awTay the bliss of ignorance from our profession and add to our knowledge the responsibility and impera- tive duty of vigilant measures for prophylaxis. Every case of gonorrhea in the male should be treated as a matter of serious import, for even though it may seem trivial to him, it may blight the lives of those to whom he may and probably will transmit the dis- ease. Who of us having daughters do not look with apprehension as to their future health and safety in the relation of wives and mothers? If "whatsoever a man soweth, that shall he also reap," were harvested by himself only, the baneful results were evil enough, but when he sows pathogenic seed to germinate in the organisms of innocent, unsuspecting, unprotected mothers and babes the calamity is ten fold, for the perils of death, of invalidism, of sightless eyes, are far beyond the dangers he willingly hazards to gratify his sinful lusts. To what extent these things prevail can not be fully known, but every physician who is not stupidly ignor- ant or w'ilfully blind to the fact, knows that they are of very frequent occurrence. When we consider that the majority of males (Ricord estimates 80 per cent, for France; Noeggeratli believed the same ratio held good for New York City) have been affected at some period of life with a gonorrheal experience more or less persistent, how can it be otherwise, under the present sociologic conditions, that a large number of prospective mothers in or out of wedlock, innocent victims or particeps criminis, become the unfortunate hostesses of pathogenic germs that place them in 7 dire perils at childbirth, perils which are all the more deplorable because unnecessary and preventable. Noeggerath believed that "90 per cent, of males affected with gonorrhea remain uncured, and of every hundred women who had married men formerly affected by gonorrhea hardly ten remain well." These may seem like extreme views, but even liberally dis- counted the figures would still show a lamentable state of affairs. Prince reported that 60 per cent, of the blind in the asylum in Jacksonville, Ill., were the victims of oph- thalmia neonatorum. Noeggerath gave us the warning that gonorrhea was the most fruitful cause of woman's pelvic woes long before Neisser discovered the specific diplococcus, so beautifully demonstrated in the photo-micrographs exhibited with this paper. Man is so constituted as to remain indifferent to many evils by reason of their frequent and long- Plate 3; Case VI.-Gonorrheal ophthalmia in babe five days old. 8 accustomed occurrence. He is also averse to any measures that curtail the indulgence of his animal instincts, regardless of consequences to others, but the day will come in that higher evolution of prevent- ive medicine when an enlightened public will demand protection by quarantine, by restrictive legislation and by penal enactments against individuals infected with this loathsome and dangerous disease. It will be a righteous advance when the State shall Plate 4; Case VI.-Gonococci from cervical secretions, twelve days after confinement. Acute metritis and pelvic cellulitis. afford some protection to the innocent by placing legal barriers to the marriage of all individuals who, by competent medical inspection, can not present cer- tificates of freedom from all contagious and hereditary diseases. Nor should the line be drawn on the male sex only. The advanced medical woman could con- fer no greater boon upon her sex and humanity than the accomplishment of reforms along these lines. 2036 Indiana Avenue.