If the removal of the placenta, membranes, or clots can be readily ac complished, we must begin by this. but we reject all those methods which come to us from the other side of the Rhine, and which consist in remov ing these remnants by means of curettes. We allow such remnants to detach themselves, and we prefer to wash them out by means of injec tions, or wait for their appearance at the cervix before attempting their removal. It is only in cases of absolute necessity that we interfere. Here the local condition does not amount to much, but it is the general condi tion which calls for action, and we limit our efforts to inunctions of bella Anna and to laudanum poultices over the abdomen.
Sustain the patient by soups, beef extracts, alcohol; fight the sepsis by sulphate of quinine and phenie acid douches—such are the methods which are for us rational. We thus gain time, and we thus give Nature a chance to shake off the putrid matter, and the patient a chance to eliminate the poison.
[From the criticisms made in Vol. IL, under the subject of Miscarriage, it is apparent that we cannot accept this doctrine. Indeed, as soon as we suspect the presence of any foreign body in the uterus, we would at once proceed to remove it by the finger if possible, by Munc1(..'s curette and forceps if the finger failed. We contend and we know that such mani pulation is harmless if performed with care, and we utterly fail to see what is to be gained by waiting on Nature. The source of the sepsis is in the uterus, and as long as it remains there the patient is more deeply impregnated. The experience of some of our most distinguished authori ties, here and in Germany, proves that manual or instrumental removal of placental debris, secundines or clots, is safer for the woman than leav ing them in the uterus. We insist anew, therefore, on the justifiability of a practice very much opposed to the one which Charpentier recom mends. It goes without saying that these are the cases of all where the intra-nterine douche is indicated, but always together with removal of the products of decomposition.
We would emphasize here again Lusk's words, that the necessity for such intervention will not exist where the labor has been properly con ducted.—Ed. ] 3. Purulent Injection.—Ilere the chances of recovery are less still. The patient is more profoundly affected and will almost infallibly die. The local state is nothing compared to the general. Here often the cause of infection cannot be determined. The patient is assailed by a true purulent diathesis, and all we can do is to fight the different manifesta tions as they appear. Alcohol and sulphate of quinine are to be given
in high dose, since they seem to be more advantageous than numerous other remedies which have been recommended, such as aconite, saly cilic acid, salycilate of soda. The muscular abscesses are to be opened as they form; the articular abscesses are to be treated by blisters.
[This form, the pyEemic, we have twice seen in the practice of others follow close upon the preceding. In both instances a portion of the pla centa had been left for Nature to eliminate. She failed, and when the physician was allowed to attempt removal, the putrid infection had passed into the purulent. The issue in each case was fatal.—Ed.] 4. True Septiecemia.—Here the entire system is in the grasp of sepsis, and alternately one and another organ is affected, without the lesion be ing at all tangible. This is the gravest of all forms. We have seen re covery in only one case, and then contrary to all our expectations. We cannot lay down any absolute rules for treatment. We have used phe nic acid internally, but without success. The disease, in short, abso lutely disarms the physician. He is utterly powerless, so rapid in its pro gress, so intense and variable its manifestations.
[It is in place to give here briefly the treatment of use in puerperal diphtheria, of which, as we have stated, Garrigues would make a special puerperal affection. He recommends repeated cauterization of the patches with a one to one solution of zinc chloride. Lusk and others prefer the sub-sulphate of iron and iodine, equal parts, as being just as effective and not so likely to cause cicatrization.—Ed.] 5. Phlegmasia alba dolens.—This is a benign affection in the great ma jority of instances, and its tendency is towards spontaneous cure. The treatment is simple: Elevate the limb extended on a splint, immobilize it, cover it with poultices, or belladonna or mercurial ointment, and keep the patient quiet as long as possible. Where the temperature is high we give quinine. The patient should never be allowed to rise until the fever, pain, and oedema, have disappeared. We must never forget that phleg masia predisposes to embolism, and that this is the most common cause of sudden death during the puerperal state. The women then must as sume the erect position by slow degrees, and they must walk only when all morbid phenomena have vanished. For months afterwards the pa tient should wear an elastic stocking.
Where the phlegmasia proceeds to abscess, this should be opened exten sively on strict antiseptic surgical principles.