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pism was applied to the abdomen ; after which the anodyne was repeated, and I left her more comfortable, at daylight, than she had yet been. Next morning, 21st, at half past nine o'clock A. M., she had no pain, nor did the vomiting recur till during the last few hours of her life. She had slept; the enema had operated again once or twice; the abdomen was much softer, not tender to the touch, and the uterine tumor could not be felt. Some calcined magnesia was administered with effect during the day. The skin retained its warmth, the pulse its tension and frequency, and the countenance its natural expression; the tongue was clean, pale, moist, and broad. At 10 P. M., every thing remained as before, but the pulse was less tense, though not less rapid ; the countenance was rather more livid, and sweat was breaking out upon the brow and upper lip, and the skin felt moist. I feared that nature was about to yield in the struggle which she had so fiercely maintained; repeated the anodyne, and desired that wine whey should be given during the night. My fears next morning (Sunday 22d) were fully realized. The patient was completely hydrotic. The face was sunken and pale, the lips livid, the skin cold, and covered with moisture, the pulse feeble, and so rapid as scarcely to be counted. The intellect was unclouded. Brandy toddy was freely administered; Ammonia and Quinine given hourly; the patient covered with blankets; bottles of hot water in numbers placed around her in the bed, and sinapisms applied in various parts of the person. In and for a little while, re-action seemed to ensue; the skin regained some warmth, the lips became a little rosier, and a slight Alush tinged the corpse-coloured cheek. Not wholly without hope, I left her for three hours, enjoining a continuance of the treatment. On my return, she was moribund.
Her breathing was laborious, and constituted, she said, her only but great distress. She said that she was “going as fast as possible,” and that her eyes were clouded in death."
Yet she readily recog. nized her afflicted husband at my request, and expressed her perfect satisfaction with my attempts to relieve her from her predicament. In a very few moments she became insensible, heaved a few gasping breaths, and expired.
Such is a true and concise account of this, to me, most painfully interesting case, The difficulty, though sufficiently common, is not one which it often falls to the lot of the obstetrician in ordinary practice to meet with. A considerable business in this line has afforded me but few
opportunities of encountering it. Of the five cases which I now distinctly remember, one only before this proved fatal, and that from the obstinacy of the patient, in refusing to allow of the performance of any operation until too late.
The case was one which seemed well adapted to the performance of the method recently recommended by Dr. Simpson, of detaching the placenta from the neck of the uterus, and extracting it before the child. I took the subject into my consideration, and decided against it for the following reasons. I had never done it, and did not feel confident of successfully accomplishing the operation. I observed that Dr. Robt. Lee was not an advocate for its performance, and did not consider that Dr. Simpson's tables, “however imposing in appearance, furnished any evidence to justify any practitioner in departing from the rule which has been established in the treatment of cases of placental presentation during the last two hundred years." It took away the only chance from the child, which I would gladly have saved, and, lastly, I found that the plan was recommended by Dr. Simpson to be adopted only in cases when rupturing the membranes was insufficient, and turning either inapplicable or unusually dangerous, neither of which existed. Ashwell, too, I found, was opposed to the practice, and I thought it safer, therefore, to adhere to the old method, than to adopt a newer one, which seemed to be as yet of doubtful superiority, and with the performance of which I was practically unacquainted. I did not at first rupture the membranes, because I was sure I could control the hæmorrhage till the proper moment for delivery arrived. I did not expect the occurrence of any vigorous contractions after it, when so much blood had been lost, and since turning was inevitable, I preferred rather to perform it in a quiet and full uterus, than in an empty and possibly a contracting one. The diagnosis of the case subsequent to the delivery was ob
The extreme rapidity of the pulse, the soreness, the tympanites, the pain and the vomiting were symptoms of most serious import. But in opposition to the idea that they depended on Peritonitis, were the facts, that the pulse had been rapid previous to delivery; the pains had, as far as could be learned, the character of after pains; the soreness might depend upon the excessive tympanites, which is of itself, in some degree at least, an attendant upon parturition, and not always a sign of inflammation. There are, it is well known, cases occurring after delivery, characterized by all the usual symptoms of Puerperal fever, which are not cases of inflammation, and which yield to anodynes and warm fomentations. Of this truth, the interesting paper of Dr. Gooch furnishes ample evidence. Again, the very early period at which the symptoms occurred after the delivery, the previous rapidity of the pulse, the absence of the usual green
fluid ejection by vomiting, in cases of the peritoneal fever, the continuance of the lochia, the natural aspect of the countenance, the subsidence of pain and vomiting upon the third day, when the diminished tumidity of the abdomen allowed a more careful examination, which showed but little tenderness and no enlargement of the body of the uterus ; all gave grounds for a faint hope that the symptoms might depend upon nervous irritation only, for which abundant cause had existed, or be connected in some way with the reaction following the excessive loss of blood; a hope which governed my expressed prognosis, and which the result of the case proved but too surely to have been wholly fallacious. I do not suppose that, had the case been viewed as one of inflammation from the beginning, the result would have been different. No amount of active depletion could have been borne in a person so enfeebled by previous hæmorrhage and the shock of the operation : nor in the cases which I have seen of this terrible disease, has there been any difference in the result, whether they were depleted vigorously, or treated by other less debilitating means. The attempt made upon the second day to obtain the specific constitutional effects of mercury and opium, failed, as has been noticed, by an error on the part of her attend. ants, and the subsequent rapidity of the progress of the case, precluded all hope of its accomplishment. Upon the third day, I entertained some faint hopes of her recovery, but this, the evening visit again served to dispel.
What can have been the cause of the Peritonitis? The version was easy, and how often is this operation performed without any such result ?
Was it owing to the cold and friction upon the abdomen and uterus? These, too, are daily employed without bad consequences in cases of hæmorrhage. The bandage was indeed firm, but removed as soon as complained of, in the course of a few hours. The frictions were such only as were necessary to secure a sufficient contraction of the uterus, although, it is true, they were long and perseveringly employed. I am unable to answer the query. Is it probable that the peritonitis began before the deliverp? That such an occurrence is possible, we have the authority of Denman, Clarke, Collins, and Churchill, for asserting; and when I reflect upon the early rapidity of the pulse and speedy supervention of the symptoms, I confess that this is the opinion to which, in the case before us, I am inclined to lean. The termination of cases of placenta prævia in Peritonitis is not, I suspect, very common; for, in a number of cases which are at this moment under my observation, I do not find this termination mentioned. I do not know that there is prevalent among us any Puerperal Epidemic fever ; but, in examining the City Inspector's Report for some' weeks past, I have noticed several deaths attributed to this cause; and an obscure and fatal case of the kind was a day or two since mentioned to me by one of our most cautious practitioners. I have delivered, since this case 'was attended, five patients. I approached them with dread, but happily they have all so far done well. On examining the placenta in Mrs. S.'s case, I found it large, the chord implanted centrally, and the organ torn from one side of it quite through to the opposite circumference.
The peculiar termination of puerperal fever in profuse sweats, with death-like coldness of the skin, lividity of the face, &c., has not been, I think, so far as the limited examination which I have just given to the subject enables me to discover, generally alluded to by writers on the disease. All the cases which I have seen fatal, have presented this feature at their close, and I have seen it in no other form of fever, or peritonitis, in
other affection except the malignant cholera. It approximates closely to the Hydrosis of Blundell (Lectures,) who, although he describes • Hydrotic fever” as a disease, presenting itself under seven varieties, has evidently included under this head cases of what is strictly Puerperal Fever, (peritonitis, phlebitis, &c.,) and would be generally so called. Uterine hæmorrhage, he thinks, predisposes to this form of disease.
I hope I am correct in the belief, with which, after careful consideration, I console myself under the distressing circumstances of this case, that no modification of the treatment pursued would have led me to a happier result.-N. Y. Annalist.
Abstract of a Report on the Inhalation of Ether in Labor, by
JONATHAN CLARK, M. D., of Lower Merion, near Philadelphia, taken from the Medical Examiner, of October, 1847.
Dr. C. reports six cases of parturition, in which he administered the ether. Five of these were natural labors; in four the patients were unconscious of the birth of the child, and declared that they had felt no pain; in the fifth case the patient was conscious of the birth, but remarked, " although she appeared to suffer so much, and complained so bitterly, that she should not have lived through it, if it had not been for the gas.' In all these cases the recovery was as rapid as usual, and without an unpleasant symptom. The pulse fell while the patients were under the influence of the ether, in four cases where the fact was observed; in the other two it is not recorded.
The fourth case in the series of Dr. Clark, was complicated with terrific puerperal convulsions. When he saw the patient she had had six; her perceptive saculties were totally obliterated, and every contraction of the uterus ushered in a paroxysm. At this period but little progress had been made in the labor; the os uteri was dilated to the extent of an inch and a half, and the membranes were entire. Her pulse was one hundred and ten in the minute, and sufficiently strong, in the opinion of Dr. C., to justify bleeding
Venesection, to the amount of sixteen ounces, had no favorable effect; on the contrary, the spasms increased, and the pulse rose to one hundred and thirty-five in the minute, and was much weaker; the extremities became cold, and the surface generally was cool and clammy; added to this, the contractile power of the uterus was so far diminished that no progress was making in the labor, and the os uteri was not sufficiently dilated to allow of the introduction of the hand for the purpose of turning. In this condition, and after the ninth convulsion, Dr. Clark applied a sponge, well moistened with ether, over the mouth and nostrils. The effect is thus described : “ The patient soon began to rub her nose violently, pushing away the sponge as soon as it was re-applied, till she was prevented by holding her hands. Her countenance, in a minute or two, lost its deathly hue, and resumed a more natural appearance. In less than ten minutes, the whole surface became warm and much more natural. The pulse fell to one hundred and twenty-five; the intervals between the paroxysms increased more than one half, and their duration, when they did recur, was much lessened. Uterine contractions now ceased to have their former effect of bringing on the convulsions, so that I could observe several distinct and efficient pains or contractions between the paroxysms. The os uteri, as a consequence, began to dilate, but not yet sufficiently to admit of the introduction of the hand.” Dr. C. continued the ether cautiously, taking care to remove the sponge when the patient became passive. This course was persisted in for three hours and a half, when the uterus was sufficiently dilatable to admit of the introduction of the hand-turning was successfully accomplished, and a living child was brought away. There was no flooding. No vapour was given after the child was delivered. The mother still continued in a stupor, and the convulsions recurred with diminished force, at intervals of about forty-five minutes, for some hours, when they ceased.
Calomel, followed by fluid extract of senna, was administered, until copious black and fetid evacuations were induced after which the patient rapidly recovered, without an unpleasant symptom.
The paper of Dr. Clark is one of great interest, and we regret that our limits will not admit of copying it entire.