Puerperal Diseases of the Uterus 575 



space and advanced until one of the cotyledons is encoun- 

 tered. The chorion should then be grasped upon either side 

 of the cotyledon, from the uterine surface. By exerting 

 traction upon the placental margins of the chorion these 

 borders should be pressed toward each other, which tends 

 to cause the chorionic tufts to pull out of the crypts of the 

 maternal placentae, as indicated in Figs. 29 and 30, with- 

 out traction upon the cotyledonal stalk or uterine wall. In 

 many cases it is found that, after separating a few cotyle- 

 dons at the cervical end of the uterus, the retention is more 

 severe anteriorly. The operation needs then to be suspended, 

 and all or most of the detached membranes left connected 

 with the undetachable portions. It is especially important 

 that a goodly mass of membranes be left in the cervical 

 canal, since their presence tends to insure a continued dila- 

 tion of the part, enabling the operator to introduce his hand 

 at future dates. If the detached portions of the membranes 

 are cut or broken off short, the remaining portions drop 

 back into the uterus, the cervix contracts, and future man- 

 ipulations are rendered difficult. The progress of the dis- 

 ease is then to be carefully watched and the removal of the 

 membranes completed as early as prudent. 



When the membranes are permanently undetachable from 

 the maternal placental tissues and separate instead by 

 necrosis either of the placental portion or of the entire 

 cotyledon, the membranes with the necrotic cotyledons 

 should be removed early unless they are promptly expelled 

 by the uterus. The latter is improbable, because as a rule, 

 when necrosis of the cotyledons occurs, the uterus is so 

 badly diseased that it is not competent to expel its con- 

 tents. Usually the necrosis is slow and, before it is com- 

 pleted and the cotyledons sloughed off, the cervix, the mus- 

 cular walls of which usually escape the ravages of the dis- 

 ease, has contracted, closed the cervical canal, and impris- 

 oned the putrefying mass. Therefore it is important that 

 the uterus be relieved of necrotic cotyledons with any at- 

 tached fetal membranes as early as practicable. As in the 

 ordinary simple type of dehiscence, the actual date at which 



