Fatal Staphylococcus Bronchopneumonia Following Ritual Circumcision

J. B. was born on December 1, 1942. His weight was 3,628 Gm. Initial examination revealed no defects. The mother was unable to nurse for lack of milk. On the fifth day, a sterilized, evaporated milk formula was given ; first as complemental, then as supplemental food. On the seventh day, the bleeding time (Dukes method) was 45 seconds ; the coagulation time (Lee and Whites method), 2 minutes and 15 seconds. Ritual circumcision was performed by a mohel, in the hospital, on the ninth day. The umbilical cord dropped off on the tenth day. On that day a tightly bound, blood-soaked bandage was removed, aseptically, by a nurse. This was accompanied by rather profuse oozing of blood. A sterile gauze bandage was applied but not as tightly as the original. The infant was apparently well while in the maternity nursery, but gained weight rather slowly. There had been no fever, stools were normal, and the weight was 3,350 GM. (7 pounds 6 ounces) on the tenth day, when mother and infant left the hospital.

On the thirteenth day, the rectal temperature was 103.2° F. The infant was pale. There was no cough ; anorexia was marked. The heart, lungs, abdomen, throat and ears were found to be normal. The weight had not increased. The circumcision wound was definitely infected. When the pus was wiped away from the glans with sterile gauze, a slight defect at the corona could be seen. Apparently the circumcision blade had accidentally cut away a slight amount of the glans penis. The infection seemed to center at this point. In the abdominal wall, about one centimeter above the base of the penis a subcutaneous, slightly elevated movable gland, smaller than a pea could be seen and palpated. Sulfathazole ointment (5 per cent) , spread on sterile gauze, was applied to the penis and changed frequently each day. Sulfadiazine, 0.12 GM., was given in a teaspoon of food 4 times daily for three days. Anorexia persisted, but clinical signs were absent. There was no cough. The infant was not examined thereafter. At midnight on the eighteenth day of life, several cubic centimeters of blood and mucus were vomited, spontaneously, and the infant expired before medical aid arrived.

The only necropsy findings were: multiple (over fifty), sharply demarcated, grey abscesses (3 to 10 mm. in diameter), distributed throughout the lungs. The circumcision wound had nearly healed. The papable gland, noted above, had disappeared. Pus, taken from one of the aseptically incised lung abscesses, showed on direct smear, many single, gram-positive cocci; there were were no chains. Capsule stain showed no encapsulated organisms. Culture showed Staphylococus aureus in pure culture.

An infected circumcision wound and an accidentally incised glans penis were the portal of entry for this fatal staphylococcic blood-borne infection of both lungs.

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