septic peritonitis is present is still a subject of investigation, and
is not proven.
In puerperal sepsis of pyaemic character, abscesses may form in
the serous cavities of the body including the joints, and by for-
mation of septic thrombi and emboli in the connective tissues.
Incision and drainage, with thorough antisepsis, is the only
treatment.
In puerperal sepsis, infecting emboli and thrombi may be car-
ried to any of the organs of the body. Thus an area of a lung
may become infected by the lodging of an infected embolus, and
septic pneumonia results. Hepatic, cerebral and splenic abscess
have a like origin. Multiple joint emboli may simulate rheuma-
tism. Sudden blindness, followed by the rapid destruction of an
eye, denotes that an embolus has reached the eye. The state-
ments of those who do not practise antiseptic precautions in ob-
stetrics, and deny septic mortality are explained, in part at least,
when we find that such practitioners lose patients from "malaria,"
from " pneumonia " and "jaundice" after confinement. A better
knowledge of the pathology of puerperal sepsis would have enabled
them to recognize in these cases the late complications of puer-
peral septic infection.
CHAPTER XL.
COMPLICATIONS OF THE PUERPERAL STATE.
IN addition to septic infection, the puerperal patient is exposed
to several complications which affect her recovery and the well-
being of her child. The interests of both are involved in dis-
orders of the breasts, and MASTITIS and ENGORGEMENT of the
breasts are among the most common of these disorders.
ENGORGEMENT results from sudden distention, and from neglect
to support the breasts and favor the free discharge of milk. The
glands become greatly enlarged, the skin over them tense and
shining, the veins well marked and the axillary lymphatics en-
larged and tender. Lancinating pain is felt, extending into the
axillae. A rise in temperature to 100 F., and in nervous women
a sensation of chilliness may be present, but no well marked rigor
occurs, and the sharp disturbance which characterizes septic infec-
tion is absent The condition of engorgement predisposes to
inflammation by causing congestion, but suppuration and septic
fever do not occur unless a micrococcus finds access to the breasts
through some fissure of the nipple or from the infected blood of
the mother.
When pain and swelling of the breasts occur the obstetrician's
first duty is to assure himself that septic infection is not present.
Simple engorgement having been diagnosticated, the indications
are to support and compress the breasts, to promote the free exit
of fluid from them, and to promptly drain the lymphatic chan-
nels of the mother of a considerable quantity of fluid. The com-
plaint of pain is to be met by the application of heat or cold,
whichever the patient finds most grateful.
The breasts may be conveniently supported and compressed by
the breast binder, which has been described in the treatment of
261
262 MANUAL OF PRACTICAL OBSTETRICS.
the normal puerperal state. By tightening or loosening the band-
age and shoulder straps, and by observing that the apertures for
the nipples are large enough to permit fluid to flow easily, the
bandage will be of considerable service. Fluid may be removed
from the engorged breasts by the breast pump, the simple bulb
pump being best. The prompt use of saline laxatives will pro-
mote the subsidence of the engorgement ; a teaspoonful of a satu-
rated solution of magnesium sulphate, given every hour or half
hour until free watery stools are voided, will be found useful.
Over the bandage may be placed an ice-bag, or hot fomentation,
as is most conducive to the patient's comfort. Her diet should
be light, and fluid taken as sparingly as possible. The child may
nurse at regular intervals ; should symptoms of intestinal irritation
appear, it may be fed for several meals until the secretion of fully
formed milk is established.
MASTITIS. Septic infection may find access to the breasts and
produce inflammation and suppuration. This complication of the
puerperal state commonly accompanies the development of gen-
eral septic infection, the infecting material gaining access to the
gland through a fissure in the nipple. Mastitis is most often seen
in women with poorly developed nipples, where the efforts of the
child to nurse wound the epithelial covering of the nipple, and
infectious material from the vagina or the child's mouth enters
through the abrasion.
Symptoms of mastitis are pain, tenderness and swelling of the
gland, with lymphangitis. The lymphatics of the breast show in
reddened lines, the axillary lymphatics are large and tender, and
a decided rise in pulse and temperature, with often a pronounced
rigor, complete the clinical picture. Infection finding lodgement
at the nipple may remain limited to the areola and tissues about
the nipple, or, following the lymphatics deeper, may infect an
acinus of the gland or several acini. Suppuration soon follows,
and fluctuation can be detected on careful examination. In ne-
glected cases the gland may become honey-combed by suppura-
tion, and the pus may burrow in the axilla.
When the nipples are developed during pregnancy, the epithe-
COMPLICATIONS OF THE PUERPERAL STATE. 263
lium healed by ointments, and antiseptic precautions are exer-
cised in the conduct of labor, mastitis is infrequent. When it
occurs, it should be treated by the measures advised for the
treatment of engorgement, with prompt incision and disinfection
when pus forms. A suppurating breast is to be treated like any
other abscess. The child is to be taken from the affected breast
at once.
CHECKING LACTATION. When the fetus dies and when the
mother proves unable to nurse her infant, the secretion of milk must
be checked, to prevent engorgement and threatened mastitis. Com-
pression by the bandage, the application of cold, if the patient is
not depressed by it, and the use of belladonna are indicated. A
convenient and comfortable way of applying belladonna consists in
cutting a circular piece of surgeon's lint, with an aperture to permit
the nipple to protrude, smearing belladonna ointment upon it,
placing it upon the breast and applying the compressing band-
age over it. The breast should be disturbed as little as possible,
tension being relieved by the cautious use of the breast pump,
which does not require the removal of the bandage.
Where an ointment is objectionable, a similar piece of lint may
be sprinkled with a solution of atropia, four grains to the ounce,
and applied in the same manner. An eruption resembling that
produced by croton oil occasionally follows the use of bella-
donna, but does not cause serious inconvenience.
Simple FISSURE of the NIPPLES will occasion pain when the child
nurses, and, unless precautions are taken to avoid infection, soon
ends in inflammation. Scrupulous cleanliness and the free use
of boracic acid solution are indicated ; the nipple must be pro-
tected by a nipple shield, and the application of an ointment of
equal parts of cosmoline and lanoline, with ten grains of boracic
acid to the ounce, or painting with the compound tincture of
benzoin, will usually result in speedy cure. In neglected cases
nitrate of silver may be required.
The tardy contraction of the genital tract to nearly its former
dimensions is known as SUB-INVOLUTION. Septic infection and
inflammation, retention of portions of the placenta and mem-
264 MANUAL OF PRACTICAL OBSTETRICS.
branes, and failure in the patient's nutrition and vigor are the
most common causes. When the uterus continues large, and the
vaginal walls remain relaxed and engorged with blood, the phy-
sician's first duty is to ascertain that no pathological condition
within the uterus is causing sub-involution. The womb should
be explored with the curette and thoroughly douched with a hot
antiseptic solution. An iodoform or boracic acid suppository
may then be left within the uterine cavity. The vagina should
be examined to see that no ulcerated surface is present. Lacera-
tion of the cervix and perineum and vagina may be closed after
the first ten days of the puerperal period, and if antisepsis be
practised, such operations will be attended by little or no dis-
turbance of the patient's general condition.
The constitutional treatment of sub-involution is scarcely less
important than the local treatment of the genital tract. Consti-
pation must be avoided ; massage, judicious feeding, the admin-
istration of ergot, arsenic and nux vomica or strychnia, and oxy-
gen are of great service. The upright posture is to be avoided
for a considerable time ; the patient can walk with less injury
than when she remains standing. The avoidance of improper
clothing is also of great advantage in preventing constriction of
the abdomen, forcing the abdominal viscera downwards, and
favoring prolapse of the genital tract.
In cases in which the bowels are not properly moved during
pregnancy, fecal accumulation exists to a considerable degree.
Unless especial precautions be taken to empty the large intestine
thoroughly soon after labor, FECAL TOXAEMIA may occur. The
absence of pain or tenderness about the genital tract ; rapid pulse ;
fever (102-103 F.); perspiration; furred, coated tongue; and
apathy and discomfort, with loss of appetite, are the usual symp-
toms of this condition in the puerperal patient. After a careful
examination has established the absence of septic infection, free
purgation will speedily terminate the disorder. The value of
copious hot rectal injections in these cases is to be kept in mind.
Fever in the puerperal patient may also follow EMOTIONAL DIS-
TURBANCE. A diagnosis in these cases must be made by closely
COMPLICATIONS OF THE PUERPERAL STATE. 265
watching the patient and her surroundings, after a thorough
physical examination has excluded septic or other acute infection
and fecal intoxication. The removal of the perturbing cause,
with the administration of a sedative addressed to the nervous
system, will speedily end the fever.
CHAPTER XLI.
RETENTION OF THE PLACENTA.
WHILE in normal cases the placenta is expelled within half an
hour after the birth of the child, it is occasionally retained. It is to
be remembered that a retained and an adherent placenta are very
different in pathology and indications for treatment. Simple re-
tention of the placenta results from atony of the uterine and abdom-
inal muscles, and usually follows exhausting, complicated labors.
In women of deficient physical development, in those whose nerv-
ous system has been greatly taxed by labor, and in cases where care
has not been taken to secure good contractions of the uterine and
abdominal muscles after the foetus is expelled, placental retention
frequently results. When summoned to such a patient, the physician
will find the relaxation produced by exhaustion, or the tetanic,
irritable contraction of the uterus which follows exhaustion of the
nerve centres in some cases, demanding his attention. After
carefully antisepticizing the vagina and his hands, a thorough vagi-
nal examination will inform him regarding the case.
In atony and relaxation he will find the placenta in the lower
uterine segment and cervix, an edge of placental tissue often accessi-
ble to his grasp. His left hand should rub the uterus to secure tonic
contraction, and placing the thumb in the centre of the fundus
and the flexed four fingers behind the uterus, it should be com-
pressed downwards and slightly backward. Care should be exer-
cised that the uterus is grasped in the centre and kept in the central
line of the abdomen, as otherwise an enlarged ovary may be com-
pressed, and violent pain and shock be inflicted. The fingers in
the vagina will be able to assist in bringing the placenta into the
vagina, whence it can be readily delivered. This method of
uterine compression and placental delivery is known as Crede's.
266
RETENTION OF THE PLACENTA. 267
Where the placenta is retained by a contracted but exhausted
uterus, the condition of uterine tetanus must be first removed be-
fore the placenta can be delivered. So long as no haemorrhage
occurs, the pulse remaining good and the uterus readily outlined
in the abdomen, rest without interference is often all that is
necessary. Under careful observation the patient may remain
quiet for half an hour or an hour, when massage will often cause
a normal contraction of the uterine and abdominal muscles, and
the placenta will be expelled. When the patient's condition de-
mands the immediate removal of the placenta, an anaesthetic
should be given, when the condition of tetanic contraction will
yield and the placenta may be delivered by C rede's method.
Chloroform is especially useful in these cases. In patients greatly
prostrated by prolonged and difficult labor, the hypodermic use
of morphia and atropia, and also brandy, may be indicated before
anaesthesia can be prudently commenced.
ADHERENCE OF THE PLACENTA AND MEMBRANES is the result of
previous endometritis accompanying syphilis, gonorrhoea, or endar-
teritis of the vessels of the endometrium of unknown origin. In
these cases the usual efforts at placental expulsion are made by
the patient, but the placenta remains wholly or partly adherent
to the uterine wall. This is among the most trying and danger-
ous of the complications of labor and the puerperal state. The
indications are to remove the placenta and membranes, as the
normal forces of labor cannot do so, and yet the effort to empty
the uterus may result in violence and infection to the interior of
the uterus. Under the most careful antiseptic precautions, with
anaesthesia, a gentle but patient and thorough effort must be
made to introduce the fingers or the entire hand within the
uterus, peel off the placenta and membranes and remove them.
The finger-tips should be turned toward the centre of the uterine
cavity, away from the wall of the womb, to avoid wounding the
endometrium, while the fingers separate the placenta as a paper-
knife passes between the leaves of a book. After the removal of
the placenta the uterus should be thoroughly disinfected, and an
antiseptic suppository left within the cavity.
268 MANUAL OF PRACTICAL OBSTETRICS.
When, however, the placenta cannot be removed without vio-
lence, the obstetrician will do well to wait until necrosis of the
cellular tissue where the placenta and uterine wall join has oc-
curred, when the placenta can be removed. It is of the greatest
importance that the genital tract be carefully maintained in an
aseptic condition during this time. Four vaginal douches of
bichloride of mercury i to 5000 may be given in 24 hours. The
patient should wear an antiseptic occlusion dressing over the
vulva. Her temperature is to be watched, and at any considera-
ble rise the uterus must be emptied and disinfected. If infection
can be prevented, in a few days the placenta will have been loos-
ened by innocuous necrosis without suppuration. It is well to
thoroughly curette the uterus after the delivery of such a placenta,
to remove diseased decidua and endometrium.
CHAPTER XLII.
DISORDERS OF THE FOETAL APPENDAGES.
AMONG the most common of the disorders of the foetus and its
appendages is DECIDUAL ENDOMETRITIS. Its cause is not clearly
known, but several forms have been observed. Polypoid ; diffuse or
hypertrophic ; cystic, and catarrhal changes in the decidua have
been described. Catarrhal inflammation of the decidua may occa-
sion confusion in diagnosis, from the fact that the discharge of a
catarrhal secretion occurs during pregnancy, which may be mis-
taken for a discharge of amniotic fluid. When the fluid is closely
observed, however, it will be found to be a mucous secretion instead
of the yellowish amniotic liquid. When inflammation of the
decidua persists, it not infrequently causes foetal death. It is not
amenable to treatment, and the physician can only confine him-
self to curing endometritis when the patient is not pregnant.
ADHESION OF THE AMNION and compression of the foetal limbs is
a frequent cause of malformation in the foetal members. Webbed
fingers and toes are often seen as a result of this condition. Am-
putation of a foetal limb also follows this complication. Deficiency
in the amniotic liquid (oligohydramnios) often accompanies amni-
otic adhesions, and malformations of the lower extremities are
ascribed to this pathological condition.
Excess of amniotic fluid, POLYHYDRAMNIOS, may be diagnosti-
cated by an unusual and symmetrical distension of the abdomen,
with unusual mobility of the foetus on palpation, and faint foetal
heart sounds on auscultation. It is sometimes dangerous by reason
of the excessive size of the abdominal tumor and the enormously
distended uterus which may threaten rupture. Pregnancy is often
interrupted by the over-distended condition of the uterus, and at
labor malpositions of the foetus are caused by the sudden, free
escape of an excess of fluid.
269
270 MANUAL OF PRACTICAL OBSTETRICS.
Ordinarily it is not necessary to interrupt pregnancy because of
polyhydramnios, but caution should be observed at labor to avoid
a malposition of the foetus and prevent precipitate labor. In
excessive polyhydramnios, fluid may be cautiously withdrawn by
an aspirator needle or trocar.
The chorionic villi which form the placenta are occasionally
the seat of a myxomatous degeneration which produces a VESICULAR
MOLE. When the disease occurs before the formation of the pla-
centa, the entire chorion may become involved ; when limited to
the placenta, the affection occasionally destroys the placenta
entirely, substituting a mass of vesicles or cysts for normal pla-
cental tissue. Symptoms of myxoma of the chorion or vesicular
mole are rapid increase in the size of the abdomen, uterine
haemorrhage at irregular intervals, and the discharge of grape-like
cystic bodies. The death of the foetus commonly follows this
condition ; interference is rarely indicated except in cases where
the excessive growth and bleeding of the degenerated villi threaten
the patient's strength, when the uterus should be emptied.
The PLACENTA may be the seat of syphilis, producing gummata,
infiltration of the perivascular spaces, with cellular proliferation
occluding the vascular spaces of the placenta. A syphilitic pla-
centa is larger, heavier and paler than normal, and islands of
syphilitic tissue can be detected by their grayish-yellow color.
In non-syphilitic cases endarteritis of the placenta is also observed,
of unknown origin. Apoplexy of the placenta results in destroy-
ing the function of limited areas, and such areas may be recog-
nized by hsematine staining, visible on inspection. Fatty and
calcareous areas are observed in placentas otherwise normal, and
in cases where the foetus is normal.
The UMBILICAL CORD may be abnormally long, or deficient in
length. The first condition predisposes to the formation of knots
and coils about the foetus, and may lead to foetal death by
asphyxia. A short cord may occasion delay in labor by prevent-
ing the descent of the foetus, and may result in premature separa-
tion of the placenta.
The coiled condition of the cord about the foetus may be diag-
DISORDERS OF THE FCETAL APPENDAGES.
,271
nosticated in some cases by the detection of a murmur in the
cord. When a sound synchronous with the foetal heart sound,
and complicated by a murmur resembling a very faint cardiac
murmur can be heard, a presumptive diagnosis of a cord coiled
about the foetus may be made. A positive diagnosis cannot be
established before labor. When the head is born and the cord
is found coiled around the neck, the endeavor should be made
to slip it over the head or shoulders by loosening it with gentle
traction. Failing in this, it should be ligated, and delivery
hastened. The foetus is often asphyxiated in these cases.
Prolapse of the cord during labor threatens the life of the foetus
from compression and asphyxia. An endeavor may be made to
replace a prolapsed cord by passing a doubled piece of silk liga-
ture or a string through an
English catheter, bringing it
out at the eye, passing it about
the cord and catching the
loop of ligature over the end
of the catheter. By pulling
upon the ligature at the end
of the catheter the cord can
be kept firmly grasped while
the catheter and cord are
FIG. 124.
passed into the uterus ; then
the ligature is slackened, the
catheter withdrawn and the
ligature slips off the end of
the catheter, leaving the cord
in the uterus (Fig. 124).
The most efficient treat-
ment of prolapsed cord con-
sists in anaesthetizing the pa-
tient and placing her in the
left lateral or knee chest position. If this is impossible she may lie
across a bed, with her hips at the edge and raised several feet
above her shoulders. The cord is then grasped by the antisepti-
REPLACING THE CORD WITH A
CATHETER.
272 MANUAL OF PRACTICAL OBSTETRICS.
cized hand and carried into the uterus and placed above the
foetus. If it cannot be felt to pulsate, or if it persistently prolapses
when the grasp of the physician is relaxed, the child should be at
once delivered by version and resuscitated if possible.
CHAPTER XLIII.
DISORDERS OF THE FCETUS.
THE foetus while in the womb is subject to disease and to mal-
formations, which may cause its destruction or complicate labor.
EXCESS OF DEVELOPMENT in the foetus occasions difficult labor
and the effort to complete delivery often results in injury which
may prove fatal. In performing version and extracting a large
child, fracture of the clavicle not infrequently occurs. In bring-
ing down an arm when it has become extended in breech labor
the humerus is not infrequently fractured. Such, however, are
rarely compound fractures, but are what are known as "green
stick ' ' fractures, in which the periosteum is not ruptured, but
the fragments are retained as the pieces of a sapling are held by
its thickened bark. These cases require simple retention dress-
ings, and union without deformity usually results.
Injuries to an unusually LARGE FCETAL HEAD by forceps were con-
sidered when treating of that instrument. As the surgical treat-
ment of complicated labor becomes better known and more ex-
tensively practised, the conservative abdominal operations will
render the extensive and often fatal injuries to the head caused
by the irrational use of forceps to become practically unknown.
DEFICIENCY IN FCETAL DEVELOPMENT, when it causes a sym-
metrical but undersized foetus, results in precipitate labor in vigor-
ous women. Should a small foetus assume a complicated position,
it can be most safely delivered by version, as the grasp of the
forceps is not secure upon a small head.
The after treatment of ILL-DEVELOPED CHILDREN requires the
exercise of great care and patience. When such infants show a
persistent tendency to abnormally low temperature, they should
be kept in an incubator, and removed only when necessary to
273
274 MANUAL OF PRACTICAL OBSTETRICS.
obtain food or maintain cleanliness. A simple but efficient in-
cubator may be prepared by using an ordinary large clothes-
basket as a crib, and surrounding the child by bags of sand,
which may be heated. If an abundance of padding be supplied
and a sufficient number of sand-bags, so that some can be con-
stantly heating while others are changed, a temperature of 100
F. can be readily maintained. More elaborate and efficient in-
cubators are Tarnier's and Auvard's simpler form of Tarnier's,
in which hot water supplies heat.
In ill-developed children who have not strength sufficient to suck
the breast, it is often necessary to obtain milk by a breast-pump and
feed it to the child by a spoon or medicine dropper. Milk may
be introduced into the stomach by passing a small soft catheter
into the stomach, attaching a funnel to it and pouring milk
through the funnel ; this is known as gavage. By the use of the
incubator and by careful feeding, the age of viability for infants
has been advanced to 6^ in place of 7 months.
The presence of a TUMOR in some portion OF THE FCETAL BODY
may threaten foetal life and complicate labor. Such are a con-
genitally enlarged thyroid gland producing goitre ; enlarged
spleen from malaria or sarcoma ; sacral tumors associated with
defect in the walls of the spinal canal and the protrusion of the
membranes and fluid ; cerebral meningocele or deficient cranial
walls with protrusion of the brain and its membranes and fluids ;
and hydrocephalus. In all of these cases the continuance of the