If the patient has a purulent vaginal discharge a vaginal douche should be given before delivery, and should be repeated twice a day after delivery. Care should be taken that the vulva is washed clear of lochia with antiseptic lotion night and morning in all cases, and oftener if any laceration of the perineum or vagina has occurred (see under Perineum, Rupture of).
Treatment.—Many distinct lines of treatment have been advocated in puerperal fever, ranging from a policy of absolute non-intervention to the recommendation of such heroic operative measures as ligature of the pelvic veins and even complete hysterectomy. The difficulty in deciding between the rival claims of different methods lies to a large extent in the very doubtful and uncertain prognosis in many given cases of puerperal Every obstetrician of experience can recall patients desperately ill who recovered, and cases seemingly mild which went steadily from bad to worse, the event in neither being much influenced apparently by the treatment adopted. Such experiences as these lead one to considerable scepticism with regard to the results published from time to time in favour of any particular method.
The practitioner should first exclude general or systemic diseases accom panied by fever as possible causes for the rise of temperature. He should make sure that he has not to deal wi th a mastitis orphlebitis, and if abdominal pain be present he should exclude pyelitis, appendicitis and torsion of an ovarian cyst. When he has satisfied himself that the rise of temperature is due to a uterine condition, he should keep clearly before his mind the possibilities. The fever may be due to septic absorption, and this may be from lochia retained either in the vagina or in a uterus which has become acutely anteflexed or, less commonly, retroflexed. In such a case the symptoms usually arise in the first week, commonly about the fourth day. The lochial discharge becomes scanty or disappears, and if the uterus is at fault the fundus, which could he felt a day before well up in the abdomen, has become lost to the touch or is felt just behind the pubes. In these cases the rise of temperature and pulse-rate is slow and not very marked, and the general symptoms arc comparatively slight, unless the case has been allowed to run on for some time without being diagnosed or treated. A vaginal examination discloses the presence of a pool of fetid lochia in the vagina or the kink in the uterus. It may be said here that in examining or giving local treatment to any case of puerperal fever the practitioner should always wear boiled rubber gloves, unless he is prepared to give up attendance on all other midwifery cases until the septic patient is out of his hands. These are the cases which are often cured by a smart
purge, especially if the patient is encouraged to sit up for the movement of the bowels. They are always cured by a hot (sloe F.) douche of saline or very weak antiseptic solution, vaginal or intra-uterine as the case may be. To prevent recurrence of the symptoms the patient should be encouraged to sit up in bed. A mixture containing is-min. doses of Ext. Ergot. Liq. and I to 2 grs. of Quinine may be given three times a day to promote involution and firm contraction of the uterus, and for the same purpose a hot vaginal douche may be given night and morning.
In other cases septic absorption is going on from fragments of decom posing placenta, membrane or retained blood-clot. Here the lochia are copious, very foul and often blood-stained. The same methods of treat ment may be adopted as for retained lochia, but in addition it is wise to explore the uterus with the fingers and to peel off the wall any adherent fragments of placenta which can be distinguished. The curette may be used to remove fragments which are firmly adherent. It should be remembered that the placental site is always rough and shaggy, and it is better to err on the side of caution. The intra-uterine manipulation should be followed by a copious hot intra-uterine douche of I in to,000 Perchloride or Biniodide, drachm to the pint Lysol or Creolin, or drachm to the pint common salt. It is recommended to pack the uterus in these cases with iodoform gauze wrung out of 7o per cent. alcohol or Hydrogen Peroxide solution (so yols.). The cervix for this purpose is seized with volsella, and the pack is carefully applied with uterine dressing forceps up to the fundus. It is allowed to remain for 12 to 24 hours, and its removal is followed by an intra-uterine douche. The douche may be repeated once or twice a day as circumstances dictate until the tempera ture comes down to normal. Drug treatment may he on the lines of the Ergot and Quinine mixture mentioned above. If the pulse is rapid and weak, Tr. Digitalis (Iltv.) combined with 'Fr. Nuc. Vom. (11tx.) should be given. The diet should he sloppy hut nourishing. Milk, eggs, beef tea, chicken or mutton broth, with arrowroot, cornflour or some other light and easily digested form of starch.