Surgery of Persistent Ductus Arteriosus
Authors: R. Nicks, P. J. Molloy
Journal: BMJ (1956)

UMBILICUS M,, easily transfer Str.pyogenes to her hands and clothing.Herein lies the danger of transfer of infection either to a mother or to anotber infant.Enough evidence was found in the outbreaks described above for a plea to be made to include swabbing of the umbilicus of the infant in any routine investigation of puer- peral infection.It cannot be stressed too often that swabbing should always precede treatment.In the first paper on the use of antibiotics in haemolytic streptococcal puerperal infection, James (1945) showed how quickly a vaginal swab became free from haemolytic streptococci when an infected patient was treated with penicillin.The whole pattern of an out- break may be obscured by treatment.Antibiotic therapy need not be delayed more than the few minutes needed to carry out the swabbing.When the results are presented by the bacteriologist, the clinician may either confirm or modify his treatment.These same principles certainly apply to the swabbing of the neonatal umbilicus. Neonatal InfectionThe possibility of haemolytic streptococci playing a pathogenic role in the infanrt has not so far been considered.In our experience these organisms did not a,ppear to give rise to any signs on the cord stump itself.Indeed, there is very little in contemporary obstetric literature describing clinical signs of any sort of infection of the cord stump.Older writers, however, made some comment on inflam- mation of the navel.Mauriceau (1683) mentioned inflam- mation and ulceration of the navel, and so does Jane Sharp (1725).James Hamilton (1813), in a section on diseases of infants in his father's textbook of obstetrics, described an " erysipelatous inflammation " which sometimes " begins at the belly."Trousseau (1844) described a disastrous out- break of fatal erysipelas of the abdominal wall in newborn infants.In nearly every case the umbilical area was in- volved.Meynet (1857) described similar epidemics of both erysipelas and gangrene of the umbilicus in newborn infants.The last two disasters occurred in or near the decade 1850- 60 which Colebrook (1955) has described as " perhaps the blackest period in all the story of hospital infection."Nowadays manifest umbilical sepsis in the newborn appears to be a rarity.It seems possible that the haemolytic streptococci could gain access to the peritoneum via the umbilical cord and cause streptococcal peritonitis.This presumably does not often occur, because none of the 14 infants followed up during the second outbreak was clinically ill.However, one infant in the first outbreak who was acutely ill recovered after treatment with chlortetracycline.Swabs from this infant were unfortunately not taken before treatment was started.This infant may have been suffering from streptococcal peritonitis, but in the absence of laboratory examination it would have been very difficult to establish the diagnosis.In a comprehensive review of peritonitis in the neonatal period Rickham (1955) states that peritonitis is a "not un- common cause of disease and death in the neonatal period."He mentions streptococcal peritonitis as a blood-stream infection.Gubern Salisachs (1951), in discussing two cases of streptococcal peritonitis in the newborn, suggests the umbilicus as a portal of entry for the haemolytic strepto- coccus.Cullen wrote in 1916 "that in every instance of illness in a newborn infant it should always be the rule to inspect and if necessary reinspect the navel."One might add that this inspection should include a bacteriological examination. Summary and ConclusionsTwo outbreaks of group A streptococcal infection in maternity units are described.In each outbreak infants in the nursery were found to be carrying Str.pyogenes on the umbilicus.Carriage of Str.pyogenes was found to continue up to eight weeks.A general investigation into the bacteriology of the infant's umbilicus is described.The umbilicus of the newborn infant might provide the means of spread of streptococcal infection to its own mother, to other mothers and infants in the same maternity unit, to midwives, and in domiciliary practice to members of the household.Bacteriological examination of the umbilical swab may help to solve some epidemiological problems in puerperal sepsis.We wish to thank Mr. R. M. Williams for permission to make use of the clinical material at Glasfryn Maternity Home; Dr. Rees Evans, the Medical Officer of Health for Carmarthenshire, for his co-operation