of tenaculum forceps or a
tenaculum, a pair of haemos-
tatic forceps and suture ma-
terial. A vaginal douche of
a gallon of bichloride solu-
tion, i to 5000, at a tempera-
ture of 100 F., may first be
given. Antiseptic precau-
tions having been taken with
the operator's hands and in-
struments, a simple lacera-
tion, as shown in Fig. 115,
is to be closed with silk or
silver wire, by passing the
sutures beneath the entire
wound from the lower end
upwards. The letter a repre-
sents the highest point of the
laceration. In Fig. 116 the
same laceration has been al-
tered in its shape by drawing
the point a upwards with a
tenaculum forceps, for con-
venience in approximation.
It is frequently the case,
in primiparge especially, that
in addition to a central tear
in the perineum, lacerations
are found extending up into
the vaginal tissues on one or
both sides. In Figs. 117 and
LACERATION OF THE PERINEUM AND PELVIC FLOOR. 247
FIG. 118.
FIG. 119.
118 such lacerations and their closure are illustrated by diagrams,
the point a being the highest point in the true perineal laceration.
In Fig. 119 the method of closing
a laceration extending into the
bowel and upwards into the vagina
on each side is illustrated. The
bowel is closed from within out-
wards by stitches of fine catgut, and
the laceration is thus converted into
one illustrated in Fig. 120, and
closed by silk or silver as there re-
presented. When an obstetrician
has become experienced in the use
of catgut, and possesses catgut of
good quality, he may close perineal
lacerations by the continuous catgut
suture as shown in Figs. 121 and
122. Where primary union does not
result after the closure of perineal
injuries, in eight or ten days after
operation the patient may be anaes-
thetized, the granulating surfaces
scraped with a curette and closed
by suture. If thoroughly done this
procedure rarely fails.
The after treatment of these cases
consists in careful antisepsis. Three
or four douches to the perineum and
lower portion of the vagina should
be given in twenty-four hours of
bichloride solution, i to 8000, or
creolin. i per cent. Antiseptic pads
or napkins should be kept on the vulva. The use of the catheter
should be avoided, and the parts cleansed after each urination in-
stead. Loose bowel movements should be obtained after the third
or fourth day. It is an unnecessary precaution to bind the legs
FIG. 120.
248
MANUAL OF PRACTICAL OBSTETRICS.
FlG. 121.
together in rational, reasonable patients. If the sutures do not
annoy the patient they may remain ten days, when union results.
In extensive laceration they may be left two weeks. The patient
should remain recumbent for at least
two weeks after the laceration is
closed.
SUDDEN DEATH DURING LABOR
is caused by the formation of a clot
in the heart, by the entrance of air
into the circulation through the
uterine sinuses, and by sudden shock
and syncope occurring after uterine
rupture. The symptoms of threat-
ened death are those of cardiac syn-
cope, faint rapid pulse or sudden
cessation of the pulse, pallor of the
features, sudden mental alarm and
distress, with rapid unconsciousness. The most prompt stimula-
tion for the heart and brain is demanded. Hypodermic injec-
o
tions of ether, raising the foot of the bed several feet, atropia,
ammonia and brandy or whiskey by hypodermic injection, and
LACERATION OF THE PERINEUM AND PELVIC FLOOR. 249
where oxygen is available the inhalation of this gas are all de-
manded with the greatest promptness. Manipulations to accom-
plish delivery must cease, and attention be given to resuscitating
the patient. Unfortunately many of these cases perish before
more than one effort can be made to save them. The possibility
of heart-clot and the entrance of air through the placental site
should be borne in mind in cases of post-partum hemorrhage,
and such patients should not be allowed to sit up and should be
prevented from sudden exertion so far as possible. In removing
a placenta in these cases, as little violence as possible should be
exerted, and uterine contractions maintained by pressure and
massage over the uterus.
THROMBOSIS OF THE VEINS ABOUT THE VULVA AND VAGINA is
an accident of labor which may result from violence during de-
livery or without apparent cause. The appearance of a bluish-
red tumor near the labium, with the complaint of pain on the
part of the patient, enables the physician to recognize the acci-
dent. If labor can be completed without rupturing the tissues
which cover the thrombus, care should be exercised that the ex-
ternal air does not find entrance. If bleeding goes on and the
thrombus is accompanied by the extravasation of blood into the
cellular tissue through the rupture of capillary vessels, the tumor
should be laid open under careful antiseptic precautions, the clot
turned out and the cavity packed with antiseptic gauze. Labor
should then be completed, and a compress and antiseptic napkin
worn after delivery. The after-treatment of such a cavity con-
sists in its thorough -disinfection, and securing healing from the
bottom by the continued use of the tampon. When labor is
completed without rupture, an antiseptic pad and pressure by a T
bandage will favor the absorption of the clot.
In difficult delivery by forceps or version and extraction the
PUBIC JOINT has been RUPTURED. This accident is marked by
sudden pain, and yielding of the joint which is appreciated by the
physician. It may or may not be accompanied by laceration of
the tissues beneath the pubes. If the joint surfaces do not be-
come infected by sepsis compression, by plaster-of- Paris bandage,
250 MANUAL OF PRACTICAL OBSTETRICS.
or by a firm binder is sufficient. Suppurating arthritis has fol-
lowed injury to the pubic joint during labor, making it necessary
to drain and disinfect the articulation. Recovery, with firm
union, usually results in these cases.
In sudden death during labor the physician's duty to the un-
born child is a subject of interest and importance. Immediate
delivery is the indication, to be accomplished as the circum-
stances of the case will best permit. If the genital canal is dilated
and the head or breech presents the forceps may be found effi-
cient. In multiparae, where the foetus is not favorably situated
for the application of forceps, version has been successful.
Where the genital canal is undilated, the extraction of the child
by Csesarean section is indicated where the pregnancy is suffi-
ciently advanced to give reason to hope that the foetus can sur-
vive.
CHAPTER XXXVIII.
PUERPERAL SEPSIS (PUERPERAL FEVER).
THE most important, because the most deadly complication of
labor and the puerperal state is septic infection. At the present
day it is quite needless to raise the question as to the nature of
puerperal fever. The exact mode of its origin may not be clearly
proven, but the fact that it is an infection, produced by an infecting
agent which can be communicated, rests upon grounds beyond
question. By puerperal fever we do not refer merely to rises in
temperature occurring after labor; such fevers will be considered
later. But prolonged variation in pulse and temperature of con-
siderable degree, accompanied by constitutional symptoms which
denote the presence of an actively poisonous agent, and by anatomi-
cal lesions, necrotic in character, form together a clinical picture
formerly named puerperal fever, better known as puerperal sep-
tic infection. This disorder is identical with septic infection
occurring in any recently wounded patient, whether a man
crushed by machinery whose wounds become infected during
handling by a careless surgeon, or a woman whose torn perineum
is infected during labor by the dirty fingers of her attendants.
This infection is produced by the action of living ferments, which
directly destroy the tissue or plug up the circulatory channels of
the body, or indirectly poison the patient by producing toxic
alkaloids which are absorbed.
The question arises as to whether these infecting germs are
always communicated from without, or whether they may be
found independently in the patient's body; in other words,
whether puerperal infection is ever auto-genetic. While it is
true that the body of the healthy woman never contains and can
never develop these germs, it is also true that in the course of.
251
252 MANUAL OF PRACTICAL OBSTETRICS.
diseases previously communicated to the patient, poisonous agents
are introduced which gain access to the wounds in the genital
tract made during labor, and produce puerperal sepsis by infect-
ing these wounds. Thus the germs of gonorrhoea, syphilis or
cancer may be present in the body before pregnancy; and, find-
ing access directly to the circulation through the wounds of labor,
may produce sepsis.
The symptoms of puerperal sepsis will be best understood if
we remember that the infecting germs may gain access through
the lymphatics of freshly made wounds in the vagina and vulva,
or go directly into the circulation through the open sinuses at the
placental site. In the first instance vulvitis and vaginitis, with
the formation of a puerperal ulcer, develop, in three or four days,
from contact of a dirty hand or instrument in the vagina after
labor. In the second mode of septic infection, the infected hand
of a careless obstetrician, who performs version or separates and
delivers an adherent placenta, lodges infecting germs in the uterine
wall, where the placenta was attached, and direct infection through
open sinuses results.
The course of puerperal sepsis can best be comprehended by
recalling the anatomy of the lymphatics of the genital tract, as
the infection usually follows the course of these channels. The
lymphatics of the vulva and lower fourth of the vagina commu-
nicate with the superficial inguinal glands, and thence through
the saphenous opening to the deep inguinal glands or along the
deep blood-vessels, finally entering the abdominal cavity. An
infection planted in the vulva or lower portion of the vagina
may finally spread to the peritoneum. Considerable time would
be required, however, for this result to occur, and the usual
symptoms of vulvitis and vaginitis, with puerperal ulcers at the
posterior commissure, would have given ample warning of threat-
ened danger.
From the cervix uteri and upper three- fourths of the vagina,
the lymphatics communicate with the deep iliac and sacral
glands. Hence a focus of infection in the uterine cervix or in
the upper part of the vagina readily infects the peritoneum.
PUERPERAL SEPSIS (PUERPERAL FEVER). 253
In the uterine cavity lymphatic spaces are numerous in the
uterine decidua, communicating with lymphatic channels in the
serous covering of the uterus. From this surface lymphatics pass
through the broad ligaments to the glands situated deeply on the
posterior wall of the abdomen, in the lumbar region. It can
readily be seen, then, how direct infection of the uterine decidua
speedily causes peritonitis.
The least dangerous form of puerperal sepsis is vulvitis and
vaginitis, resulting from infection of the vulva and lower fourth
of the vagina. It is most common in women who have torn
perinea or fissures in the mucous membrane at the opening of
the vulva. In forty-eight to sixty hours after labor, the patient's
temperature rises to 101 F., or 102; slight pain, burning,
smarting on micturition are felt about the vulva ; a rigor may be
experienced by nervous patients. The pulse is 100 to 120.
On examination the labia are swollen, the mucous membrane
reddened ; at the posterior commissure abraded or lacerated sur-
faces are found, covered by a yellowish or faintly greyish deposit.
The lochia may cease for a short time, to be slightly purulent and
offensive later. If the perineum has been sutured, the surfaces
will not be healing by first intention, but the edges of the
wound will be separated by pus, and the stitches will have loos-
ened slightly.
The treatment of this condition consists in douching the vulva
and lower portion only of the vagina with bichloride of mercury
solution, i to 5000, douches to be given four times in twenty-four
hours. Half a gallon should be used for a douche, at a temper-
ature of 100 F. The physician should thoroughly apply to
ulcerated or fissured surfaces peroxide of hydrogen upon absorbent
cotton, or tincture of iodine and a saturated solution of carbolic
acid in glycerine equal parts, followed by the free use of iodo-
form or boracic acid as a dusting powder. It is well to thor-
oughly unload the bowels by calomel, gr. 2*^, and soda, gr. 10,
followed by a saline or an abundant hot enema. Abdominal
pain is best relieved by placing upon the abdomen a flannel
wrung out of hot water, on which spirits of turpentine have been
254 MANUAL OF PRACTICAL OBSTETRICS.
freely sprinkled. If stitches have been introduced, they should
be at once removed, and ununited surfaces freely disinfected.
The patient's diet should be of the most nutritious and digestible
character, and alcohol should be given early to debilitated pa-
tients.
In cases where the infection begins at the uterus or upper por-
tion of the vagina, the rapid spread of septic germs soon produces
inflammation of the tissues about the uterus, and of the peritoneum
which covers it. The first is /<?r/metritis ; the second, para-
metritis.
The symptoms of perimetritis are tenderness on deep pressure
at one or both sides of the uterus, with pain, fever and increased
pulse rate. The symptoms of parametritis are pain on deep
pressure directly over the uterus, swelling of the abdomen, with
acute pain over the womb. Parametritis soon merges into general
peritonitis, in which the abdomen becomes distended, very pain-
ful ; the pulse rapid and feeble ; fever continually high ; while
great thirst, prostration and often delirium complete a clinical
picture of gravest import. If a vaginal examination be made in
perimetritis, parametritis, or general peritonitis following either,
an exudate will usually be found in one or both broad ligaments,
which in some cases fixes the uterus as in a mould. Suppuration
may occur in these cases, and pelvic abscess, limited by the pelvic
peritoneum, which becomes inflamed and adherent, is frequently
observed. Following parametritis the lymphatics of the uterine
muscle become infiltrated with septic material, the muscle becomes
enlarged and softened, and metritis is said to be present. The
wall of a womb which is the seat of septic inflammation is much
softer and more easily perforated than normally, and hence the
need for caution in intra-uterine manipulation in septic cases.
Septic infection of the uterus produces first a brief cessation of
the lochia, and then purulent, offensive lochia. The occurrence
of the symptoms of perimetritis and parametritis, with foul lochia,
leaves no room for doubt that the uterine cavity is in a septic
condition. Its prompt and thorough disinfection is the impera-
tive duty of the obstetrician.
PUERPERAL SEPSIS (PUERPERAL FEVER). 255
After the vagina has been thoroughly disinfected by a copious
vaginal douche of bichloride of mercury solution, i to 5000, the
uterus should be explored and thoroughly douched. The patient
should be placed across a bed or upon a table, her hips at the
edge. A gallon of creolin solution, 2 per cent., carbolic acid,
2 per cent., thymol i to 1000, saturated solution of boracic acid,
or alcohol i part and water 2 parts should be in readiness, at a
temperature of 110 F. Bichloride of mercury should not be
used for intra-uterine douches, on account of the danger of
poisoning which attends its introduction into the uterus. As an
instrument for douching the uterus, and also removing retained
portions of placenta and membranes or diseased decidua, the
writer has found Carl Braun's douche-curette of great service.
This is a dull, spoon-curette upon a long, hollow handle, which
may be connected with the hose of a fountain syringe. The
syringe being filled with the antiseptic solution chosen for irriga-
tion of the uterus, which is allowed to run through the curette,
the curette is gently introduced, the cervix being steadied if
necessary by grasping it and pulling upon it by a tenaculum
forceps. While the antiseptic fluid continues to run, the endo-
metrium is gently but thoroughly scraped by the curette, and thus
the double purpose of an intra-uterine douche and an exploration
of the uterine cavity is secured. After thorough cleansing of the
uterus with the douche- curette, a suppository containing sixty
grains of iodoform is grasped by uterine dressing forceps and
carried well within the uterine cavity. After the use of the curette
and iodoform suppository, it is often unnecessary, and even inju-
rious, to enter the uterine cavity again with any instrument. If
the uterus is once thoroughly disinfected, and symptoms of septic
infection persist, the infecting material has entered the blood and
must be combated by constitutional treatment.
If, however, the physician has no douche-curette and the in-
ternal os is not firmly contracted, an ordinary glass vaginal douche
tube may be used. The stream should run freely through the
tube, before it is introduced, to prevent the entrance of air, and
the bag of the fountain syringe must not be higher than three
256 MANUAL OF PRACTICAL OBSTETRICS.
feet above the patient's bed. Many intra-uterine douche tubes
are in market, and have their several advocates. In common
with other instruments, that which is simplest and most easily
cleaned is best. We have found an intra-uterine douche tube
of hard rubber, made in two pieces, of great convenience. In
cases where it is difficult to enter the uterus, this tube can be bent
like a pessary to any curve. Its simple construction admits of
its easy disinfection ; the upper portion, which remains in the
vagina, forms an excellent tube for washing out the foetal head
after craniotomy (Fig. 123).
Whatever douche tube be used, a fountain syringe and the force
FIG. 123.
HARD RUBBER INTRA-UTERINE DOUCHE TUBE.
of gravity is to be chosen for irrigating the uterus. The compres-
sion bulb syringe is not to be selected for this purpose, from the
danger of the entrance of air and difficulty in cleansing the
syringe. At least a gallon of hot antiseptic solution should be
allowed to run before the tube is removed and the iodoform sup-
pository introduced. The effect will be a powerful stimulation of
uterine contraction and usually a fall in the patient's temperature.
If the uterus shows a tendency to relax, ergot or quinine may be
given to advantage. Four vaginal douches of bichloride solution,
i to 5000, should be given in each twenty-four hours, and after
a douche the iodoform suppository may be repeated, if needed.
If the first disinfection has been thorough, it will rarely be neces-
sary to repeat it, and the frequent use of intra-uterine douches is
to be avoided. When foul lochia and fever persist, an intra-
uterine douche may be given once daily for a few days.
In doubtful cases of fever after child-birth, it is the obstetrician's
PUERPERAL SEPSIS (PUERPERAL FEVER). 257
first duty to examine the patient carefully for signs of septic in-
fection. If no other cause, as fecal retention, be found for
fever, the genital tract, from the fundus uteri to the vulva, should
be thoroughly antisepticized. By so doing, sepsis is excluded, a
diagnosis can be more readily made, and the patient's interests
have not been jeopardized.
n*
CHAPTER XXXIX.
THE CONSTITUTIONAL AND SURGICAL TREATMENT OF PUERPERAL
SEPSIS.
SCARCELY less important than the disinfection of the genital
tract is the constitutional or general treatment of puerperal sepsis.
We possess at present no antiseptic which may be introduced into
a patient's blood in quantities sufficient to destroy the micrococci
of sepsis, which will not destroy life, with the possible exception
of alcohol. This drug, by reason of this property, and also its
utility as a food, is especially adapted for use in these cases. As
a rule, beverages containing a high percentage of alcohol are best
borne and most advantageous. Brandy and whiskey diluted, or
alcohol and water, are often tolerated when wines are refused.
When wines can be taken, port and sherry are best adapted, and
maybe taken in quantities limited only by the patient's tolerance.
It is impossible to give exact rules for the use of alcohol in sepsis.
So long as the patient is not intoxicated, the breath not smelling
strongly, the pulse becoming slower and stronger after adminis-
tration of alcohol, it is doing good.
With the administration of alcohol goes, with equal importance,
the giving of food. Milk, peptonized if needed, eggs beaten up
with milk or whiskey, or brandy, freshly made broths, well sea-
soned and served hot, are the basis of feeding. Koumyss; rich,
pure ice cream; milk, curdled by rennet, and scraped beef may
be added if craved by the patient, and well borne.
The time and manner of feeding and giving alcohol cannot be
understood without reference to the antipyretic treatment of
puerperal sepsis. Of the various modes of lessening fever, the
application of cold is best. Antipyretic drugs (antipyrin, anti-
febrin, phenacetin) are of value only as nervous sedatives. Their
use in doses of fifteen to twenty-five grains obscures diagnosis
258
THE CONSTITUTIONAL TREATMENT OF PUERPERAL SEPSIS. 259
early in a case of puerperal sepsis, lessens the patient's strength,
and impairs capacity for food and alcohol. Antipyrin in 5 grain
doses, phenacetin in 5 grain doses and antifebrin in 2^ grain
doses relieve nervous restlessness, and favor rest and sleep. They
often take the place of opium for simple restlessness, without its
injurious effects on digestion.
When fever rises to the point of oppressing the patient (103,
104, 105 F.) sponging with cold water should first be tried.
Where cold water serves to depress the patient, rapid sponging
with hot water, to which ammonia or alcohol has been added,
may be substituted.
In either case heat is lost by evaporation from the patient's
skin. If this suffices to refresh the patient, half an ounce of
whiskey or brandy and a small cup of milk, or broth, or an egg
may be taken. It will be found that antipyretic treatment of this
sort and feeding can be given to advantage at convenient inter-
vals, from every two to every four or five hours. When sponging
does not suffice, the body pack is convenient and useful. This
consists in exposing the patient's trunk, from the pubes to the
episternal pit. Towels are then wrung out of ice water, and laid
across the body from the pubes to the neck. By the time the
last one is placed, the first is warm and should be removed, wrung
out and replaced. By wringing them out in rotation an efficient
and convenient pack is obtained, which may be given without
wetting the patient's bed. The whole pack, in a wet sheet, and
the cold bath are less often needed. In parametritis and peri-
tonitis the ice bag or better, ice water coil, placed over the womb,
is useful. The pain of abdominal and pelvic inflammation may be
often relieved by turpentine stripes or by cold. When very severe,
it must be controlled by morphia and atropia hypodermically.
The treatment of peritonitis by salines is useful only in the
first few days of the attack. An eliminating diarrhoea is fre-
quently observed in these cases and should not be checked unless
excessive, when salicylate of bismuth in thirty grain doses will be
found useful. So far as tonics are concerned, quinine in five grain
doses, with pepsin, is of advantage in greatly debilitated patients.
260 MANUAL OF PRACTICAL OBSTETRICS.
THE SURGICAL TREATMENT OF PUERPERAL SEPSIS is of import-
ance, because a more extended trial of this resource may lessen
the mortality of this disease. When pelvic abscess can be diag-
nosticated, it should be emptied and disinfected, either through
the vagina or by supra-pubic incision. The symptoms of such
abscess are an elastic tumor felt through the vagina beside the
uterus, following septic infection, with the general symptoms of
pyaemia.
When a collection of pus can be diagnosticated in the perito-
neum, encysted by peritoneal inflammation and adhesions, incis-
ion and drainage are indicated. Continued peritoneal inflamma-
tion; protrusion of a portion of the abdominal wall with an area
of well marked dullness, are diagnostic signs of encysted peri-
toneal abscess. The utility of laparotomy when diffuse general