If the woman miscarries in two stages, if the fcetus has been expelled, and the placenta remains, what is to be done? Usually nothing: nature can do the work, the placenta may remain seven to fifteen days, before being expelled: whilst there is no complication, wait, at least till the placenta is engaged in the cervix and detached from the uterus, and then extract quickly.
If the placenta is not engaged, and the cervix is closed: wait, and, in case of hemorrhage, tampon and give ergot, never the latter alone.
If the placenta, still adherent, is in part engaged in the cervix: give ergot, for the cervix can no longer retract, since its canal is filled by the placenta. If the placenta is at the fundus, and adherent: wait still in case there exists no complication; interfere rapidly, in case of accident. If it be hemorrhage--the tampon and ergot. If it be putrefaction of the placenta—recognize this, and extract at once.
How are we to recognize putrefaction of the retained placenta or membranes? Ordinarily this is an easy matter. The first symptom is fetor of the lochial discharge, fetor which, at times is such as to per meate, and extend beyond, the lying-in room. The discharge, further, loses its normal character, and diminishes in quantity, becoming black in color, or deep brown. It is no longer bloody, or sero-sanguinolent, but is composed of reddish-black detritus, the debris of the retained mass.
Involution ceases, and the uterus becomes sensitive to pressure. At ' times, slight tympanites supervenes, with or without diarrhcea, and this too may be fetid. The woman has chills. Sometimes the chill is vio lent and single, sometimes many, separated by intervals of one or two days; there exists fever, with elevations even to 104°-105° F. The pulse ranges to 120 and above. The temperature shows marked remissions, often, but the pulse remains high, and thus it may be day after day, until the woman dies. At times again, these remissions are not marked, the fever being continuous. The general condition alters for the worse, the eyes are sunken, anorexia, vomiting, and diarrhcea exist; the woman grows weaker, and, if we cannot suppress these symptoms, the woman dies of septic poisoning.
[A truly classical picture of sepsis ! Has the physician any business to allow the woman to enter into such a state ? Is he doing his full duty by her, when he sits, with folded hands, awaiting the onset of sepsis before acting? His condition is one of armed expectancy. He knows what he will do in case of the onset of sepsis, but action then, however prompt, may be of no avail—the woman may still die of septicemia. Seeing then,
that in no given case of retained placenta or secundine can it be predicted whether sepsis will develop, or not, which is the wise course, we had almost said the non-criminal course, to do at the outset what may eventually be forced upon us, or to do it when it may be too late for good, and when cdr tainly action is far more difficult ? Again, we repeat, the immediate re moval of the secundines is safe, and easy, and guarantees the woman forthwith against sepsis.—Ed.] W.hen the first symptoms of sepsis appear, we must not hesitate, but we must immediately extract the placenta, or the secundines, and this, it is understood, is all the more difficult the more completely the cervix has closed. If the cervix is permeable to the finger or to instruments, the operation is easy. If closed, then we must dilate at once with sponge, or laminaria, with a branched steel dilator, or with Barnes' bags. We prefer the latter in urgent cases. Dilatation once accomplished we must proceed to extraction. and this must be done by the finger, or by instruments, according to the case. We reject absolutely both traction on the cord, and intra-uterine injections. The former will simply end in rupture, the latter will disinfeet, but will not detach the secundines or the placenta. We further reject, cold applications, electricity, expres sion, ergot—all these are too slow.
When the cervix has been dilated, the woman is chloroformed, and, lying on the back, the hand on the abdomen depresses the uterus as much as possible. The index finger of the right hand is then introduced into the uterine cavity as deeply as possible, and the adherent remnants are detached, and brought out by the finger, which is bent like a crook. This procedure is repeated until the uterus is empty. If the finger do not suffice, because the placenta is too friable, or firmly adherent, in struments--like Prof. Pajot's curette—take the place of the finger. The cavity should then be washed out, through a double-current catheter, with plenic acid solution, and these injections practiced every day, as long as the catheter can be inserted. Vaginal injections are still to be con tinued by the nurse. Intra-uterine injections must always be given by the physician. At the same time, both quinine and alcohol should be adininistered. Certainly 15 grains of the former should be given daily— the object being to keep the patient under the continuous action of the drug.