Again, the septic absorption may he taking place from a puerperal ulcer, the name given to a sloughing, inflamed or suppurating wound of the perineum or vulva. This condition is recognised on inspection of the vulva, which is swollen and inflamed. On separating the labia the laceration may be seen either covered with an unhealthy slough or with red and angry-looking granulations. No vaginal examination should be made, nor should a douche be given for fear of carrying virulent organisms up to the cervix. Any stitches present should be removed, the wound should be swabbed with pure carbolic acid, and a light iodoform gauze pack introduced between its lips. A compress of i in 2,000 perchloride under oiled silk may he applied to the vulva and perineum. The dressing should be repeated twice a day until inflammation has subsided and healthy granulations have sprung up. The perchloride compress may be renewed each time the bladder or bowels are moved.
The lines of treatment in a case of septic absorption, whether from re tained lochia or placenta or from an infected wound of the vulva, are easy to lay down, and may be followed with all human assurance of success. In dealing with a septic infection, on the other hand, we are face to face with one of the most difficult problems in obstetric therapeutics, and too often the event proves how complete has been our failure to solve it. Nor is the difficulty confined to cases which from the beginning show signs of septic infection. Only too often a case of septic absorption is combined with or develops into infection. The headache and slight fever due to retained lochia are suddenly succeeded by the rigor that marks systemic infection, the staphylococcus or streptococcus is invading the endometrium or the placental sinuses while a piece of decomposing placenta is inducing a flow of putrid lochia, or a streptococcal inflammation is making its way along the vaginal lymphatics to the parametrium before the slough has disappeared from the surface of a puerperal ulcer. Remembrance of such facts as these should make the practitioner very watchful for the first signs of fever. The temperature at night should always be taken and recorded, and a rise above too° F. should entail on the part of the attendant at least an inspection of the vulva and an abdominal examination for evidences of pelvic or uterine tenderness. The custom of making visits in the morning often leads to a nightly rise of temperature being overlooked until the condition has become serious enough to produce general and continuous symptoms, and it is remarkable how often in practice one finds on making inquiry that a patient who is supposed to have taken ill only a few hours before has had headache, chilliness, a flush of heat or even a rigor for a night or two previously. Had the temperature been taken in these cases, an early warning would have been given that all was not well, and many patients would be saved from a long illness, and not a few from death, if the earliest symptoms of sepsis were noted and suitable treatment promptly instituted.
The course and the physical manifestations of infection may vary considerably. Thus, in the cases already considered under the category of septic absorption, the onset of infection may be marked by the occur rence of rigors or there may be only a progressive rise in the temperature and pulse-rate, with a coincident change for the worse in the aspect of the patient. When the case is one of infection from the first, the rise of temperature is usually rapid, and the pulse becomes correspondingly quickened. Rigors usually occur, but are not infrequently absent in the worst cases, in which the temperature also may he comparatively low (rno° to To2° F.).
The local conditions are also very variable. In very had Cases the infection may be a systemic one from the beginning, and there may be little local disturbance. In others the uterus itself may be inflamed, tender and flabby, or the connective tissue around it or the peritoneum covering it may be involved (see under Pelvic Inflammation). The uterine discharge may he foetid or sometimes purulent. The fact that it is quite sweet does not exclude sepsis; if anything, it rather increases the probability that the infection is of a virulent type. Not uncommonly one result of the fever is that the lochia becomes much lessened in amount or ceases altogether.
Of the various lines of treatment that may be followed I shall first consider the expectant treatment, because in the first place it has a large and increasing weight of expert opinion in favour of it; secondly, it is pre eminently the form of treatment which can be carried out as efficiently by the practitioner as by the specialist, and as readily in an average comfortable home as in a hospital; and, lastly, because, whatever the result, it least exposes the practitioner to the imputation or to the con sciousness that the measures he adopted had only the effect of lessening his patient's chances, and in so deadly a disease as puerperal infection our motto should be first and foremost Minium ne nocaere. The rationale of the treatment is to support the patient's strength and to assist her con stitutional resistance in the hope that her tissues will he able to conquer and kill off the invading micro-organisms. She is to be kept absolutely at rest in a warm and well-ventilated room. Her strength is sustained by abundant fluid and easily digested nourishment. Milk, warm or cold, and with or without dilution; eggs raw, whipped or in custard; milk and egg puddings made with arrowroot, cornflour or tapioca; beef tea, beef juice, chicken broth, chicken jelly or mutton broth may be given every 2 hours. It is a good plan to draw up a list, marking down some article of food to he given at a specified time, and let the nurse administer it like medicine.