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March 18th, Sunday, at 8 p.m.—Complained of blindness, and sent for the Matron, who, on going to her immediately, found her in a convulsion. This was followed by drowsiness and partial insensibility; half an hour afterwards she had another convulsion. I saw her just after the spasm had ceased, she was then in a condition of deep stupor, but could be roused by a loud question, and complained of severe headache. We removed her to the Lying-in Room. I then drew off the urine, it was very high-colored, contained at least 80 per cent. of albumen. Pulse 120; skin moist and cool. No convulsions for an hour.
At 11 p.m.-Dr. MacCallum visited her and ordered pulv. jalap co., to be given at once ; potass bromide, grs. xx every hour, 3rd dose to be intermitted and replaced by 20 grs. chloral. If purgative did not act in 3 hrs., she was to have an enema. Patient was now in complete stupor. Pulse 120. Foetal heart heard very loudly about an inch below umbilicus in median line. On making vaginal examination, found os uteri firmly contracted, uterus high up almost out of reach, presenting part could not be felt through the walls of uterus. No uterine contractions. (Preceding convulsions lasted about 1 minute each.)
1 a.m.—7th fit lasted 90", followed by stertorous breathing for about 5 minutes. 2 a.m.—8th fit, very severe.
No action of the bowels; gave an enema; brought away a small amount of fæcal matter. Head rolling from side to side, convulsive twitching of eyelids, eye balls rolling, pupils much dilated but respond readily to light Legs and arms in constant motion. From this time (2.30) till 7 a.m., she had seven more convulsions, long and severe, and occurring at intervals of 30 and 45". Emptied the bladder only about 385. of urine, dark in color, and more albuminous than before.
7 a.m.- 16th fit, lasted 1 minute ; pulse 130; surface warm but somewhat cyanosed; conjunctiva insensitive to touch ; pupils normal; irregular spasmodic jerking of body and limbs.
7.15.—Lasted one minute, followed by stertorous breathing.
7.30.-Same in character. 7.40.-Lasted one minute ; foetal heart cannot now be heard.
7.50.—An attack of well marked opisthotonous lasted two minutes ; tongue swollen and protruding; no clonic spasms.
8.15.- Lasted 80". Face and upper extremities now quite cynaotic. Pulse 140; weak, can hardly be counted ; swallows with difficulty. Loud mucous gurgles in trachea and pharnyx. Respiration seemed to be impeded by the accumulation of mucous ; the handle of a spoon was inserted crosswise between the teeth and kept there, the result being of manifest advantage.
10.00 a.m.—Lasted one minute; less rigidity. Patient appeared a little better. Fit preceded by spasmodic contraction of recti muscles.
11.45,- Lasted 45 "; omitted regular dose of chloral.
1.40 p.m.-Very severe ; lasted two minntes; gave P. Jalapæ co. 3i, followed by an enema at 4.30 p.m., which removed a large amount of serous fæcal matter. Has taken beef-tea freely to-day.—Brandy now added.
4.30.-Removed Zi of dark, smoky-looking urine—the accumulation of three hours. Pulse 1.40; respiration moaning. Urine solidifies on testing.
5.00 p.m.–Uterine contractions noticed. Os dilated, size of half a dollar. Labor proceeded regularly; no more convulsions. Breech presentation. 2nd dorso posterior or 4th position-child delivered easily. Pains strong; scarcely any intervals between them. Delivery occurred at 8.00. a,m. The medicine was discontinued at 5 p.m. Child-female-still born, weight, 3 lbs.
Placenta, adherent, but easily removed ; uterus well contracted, not uneven.
10.00 p.m.--Pulse 140; temperature 1020.
Very restless throughout the night ; difficult at times to keep her in bed from the tossing about.
20th.—Urine more abundant this a.m.; color more natural; only 20 per cent. albumen. Pulse 120 ; temperature 101o.
Afternoon.—Patient quiet-protrudes tongue when asked to do so. Temperature 101.
21st.—Quite conscious; feels very sore. Breasts enlarging ; is aphonic; throat sore, cough, headache.
7.30 p.m.— Temperature, 100; feels better ; pulse 120, Lochial discharge free.
22nd.-Pulse 120; still hoarse ; looks well ; is very low spirited. Albumen in urine about 10 per cent.
23rd.— Pulse 100; still low spirited; has had general headache and amaurosis ; at times, flashes of light ; sees things coloured green, red, &c. This state of things is decreasing. Bowels have been moved two or three times each day since delivery. Hoarseness less marked. Pharynx rather more sensitive, though it can still be freely handled without producing much discomfort.
25th.—Spirits good; pulse 98. Tongue clean and moist. Eats well. Urine still contains a little albumen.
28th.—Recovered voice and is now quite convalescent.
Laryngeal Diphtheria.- Tracheotomy. Recovery. — Under
DR. RODDICK - Reported by H. N, VINEBERG, M.D. L. L., æt. 6, was admitted January 15th, 1878, into the wards of the Montreal General Hospital, with symptoms of laryngeal diphtheria, great dyspnoa, labored breathing, base of chest retracted, and lips and finger nails quite cyanotic. On examination the tonsils were found enlarged, and covered with a greyish-white membrane, which extended downwards as far as the naked eye could
There was no enlargement of the cervical glands. Three days before admission the little patient was attacked with a "sore throat,” but croupal symptoms did not set in until forty-eight hours afterwards. The usual treatment for laryngeal diphtheria having had no effect, and the symptoms becoming more alarming, the medical attendant advised the parents to bring the child to the Hospital, with a view of performing tracheotomy. Accordingly the child was admitted at 12, noon, and very shortly after, as there was no time to lose, Dr. Roddick, assisted by Dr. Ross, performed tracheotomy, (the high operation) in the ordinary way. The operaNO. LXXY.
tion was attended with scarcely any hæmorrhage. Just as the incision was being made into the trachea, there was intense spasm of all the respiratory muscles, but as soon as the tracheotomy tube was introduced, the spasm passed off, and quite a mass of membrane was brought up through the tube. After a few powerful expiratory efforts the breathing became much improved, and within an hour after the operation, the patient's lips and finger-nails regained their natural colour. Carbolized lint and oiled silk was introduced between the rim of the tube and the edges of the wound, and a large woolen cloud was wrapped around the patient's neck. He was then put in the
. “ Infectious Ward.” Steam, impregnated with carbolic acid, was kept up about the patient's head, and he was ordered to be given salicylate of soda, grs. 5, in solution, every three hours plenty of milk and 3 oz. of brandy.
January 16th.-Coughed up several pieces of membrane this morning. Carbolized lint removed, and nothing but oiled silk intervening between the tube and the wound. Wound healthy looking Takes plenty of nourishment.
17th.—Removed the tube to-day for the first time since the operation. After cleaning it, it was re-introduced. The patient had to be put under chloroform at the time. Cervical glands slightly swelled, poultices to be applied to them. Ordered to burn 3gs of sulphur in the ward every two hours. Takes plenty of milk, but cannot be made to take the brandy. To have beef tea. Tinct. ferri mur. and glycerine in equal parts were ordered to be applied to the inside of the throat, but the nurse found it impossible to carry this out.
19th.-Has brought up, through the tube, several pieces of membrane. Breathing considerably embarrassed to-day, and it is feared the disease had extended downwards. Removed tube and replaced it by one of Trousseau's. Considerable redness about the wound, and a number of small white vesications near its margin. Lead lotion to be applied. At 4 p.m. the breathing became much easier after bringing up a small piece of membrane. Moderate discharge of a puriform fluid through the tube ever since the operation.
20th.- Vesications about the wound are extending. Appearances suspicious of diphtheritic action. To add hydrocyanic acid to the lead lotion.
21st.-Removed the tube. Patient doing well. Tested the power of breathing in the natural way, by closing the opening in the trachea with a cork, and found it to be very defective. Accordingly after the tube was cleaned it was re-introduced. Tincture Ferri. Mur. in small doses was ordered, but the patient could not be made to take it. The swelling of the glands has almost entirely disappeared. The white vesicles are diminishing and have been caused, no doubt, by the glycerine and carbolic acid dressing. A weaker solution to be used hereafter. Ordered lime water spray through the tube. Temperature since the operation has ranged from 100° to 101° F. Pulse from 112 to 140. Respirations from 24 to 36. Pulse, resp. ratio from 31 – 5 to 1.
22nd.—Not so well to-day. Had a severe fit of coughing early this morning Breathing somewhat laboured.
Discharge through tube increased. Does not take his nourishment go well. Urine is clear, copious, and contains albumen (33 per cent.) for the first time, it having been tested daily. Tongue is coated with a heavy white fur, a few coarse bronchial rales heard over the chest. Temperature 100° F. Pulse 112. Respirations 30.
23rd.—Passed a good night, and is much better to day.Changed for the better yesterday evening. On removing the tube it was found very much discoloured. Tested breathing, and finding it still defective, the tube was reintroduced. Redness and vesicles about wound disappearing. Takes plenty of milk, but will not take stimulants of any kind. Urine of amber colour, deposits a slight sediment, and contains 25 per cent. albumen. Under the microscope an occasional hyaline cast, and a few white globules are seen. Temperature 99.4°. Pulse 108; respirations 30.
25th—Yesterday afternoon, the nurse noticed little bits of orange coming out through the tube after the patient had partaken of some. Complains of considerable pain on swallowing.