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RUPTURE OF THE UTERUS.-REPORT OF A CASE IN WHICH THE ENTIRE UTERINE CONTENTS
AT FULL TERM ESCAPED, UNRUPTURED,
By FRANK W. Ross, M. D., of Chemung County.
THE following is the report of a case which occurred in the practice of Dr. William Woodward, of Big Flats, Chemung County, N. Y.:
Mrs., aged forty-two, native of the city of Poole, Dorsetshire, England; small in stature; weight, ninety pounds.
She brought a letter from Dr. Philipott, of Poole, stating that "her pelvis was unusually small, and so much contracted by the projection of the sacral prominence as to render the superior strait almost cordiform; that it was impossible for her to give birth to a living child at full term." Dr. Woodward was called to attend her in labor, July 8, 1882, soon after her arrival from England. He was told that she was advanced to the seventh month, which was evidently her condition. On examination, he found the pelvis contracted, leaving only a fissure on the left of the sacral promontory of about two inches in width, and an opening on the right side of about three and a half inches in diameter. The breech was presenting at the larger opening, and with some difficulty he succeeded in bringing down the feet and delivering, the cranial bones yielding to the pressure, being still soft and not yet ossified.
In the summer of 1883, she was again pregnant, the fœtus being expelled without assistance at about the seventh month.
In March, 1884, she announced to Dr. W. that she was again pregnant, about three months advanced, and was advised that
premature labor must be induced unless she became relieved at an early period by a miscarriage. Two months later, she announced her determination to hazard going to full term, hoping to bear a living child. She was advised not to proceed and was warned of the danger, but to no purpose. Her desire for a living child was so strong that she insisted on attempting to give birth to one if her life paid the forfeit, but agreed to send for aid on the first appearance of labor.
August 20, 1884, between 2 and 3 P. M., Dr. W. was sent for, and found his patient with the countenance pale, lips livid and exsanguine, and the surface of the body bathed in a cold perspiration. She had been taken with labor-pains at about 5 A. M.; and at 10 A. M., the pains were very severe, not like labor-pains, but tearing and constant. She had vomited frequently and flooded profusely. The pain was most excruciating, and she begged for a powder to relieve her suffering. Supposing that it was a case of placenta prævia, an examination was made per vaginam, but Dr. W. could reach neither the placenta nor any presenting part of the fœtus. At this time the hæmorrhage was slight; but within ten minutes after his arrival the patient was dead.
At the autopsy, the following condition was found: The fœtus was lying in the peritoneal cavity upon the intestines, invested with the membranes intact, the placenta being still attached to the sac, all having escaped through the uterus and lying free in the abdominal cavity, the rupture having taken place at the placental site. On removing the child, a full-grown male, the fissure, about eight inches in length, could be seen along the anterior portion of the uterus, as can be readily noted by an examination of the specimen here presented. Considerable blood was found in the abdominal cavity, most of the hæmorrhage coming from the torn uterine sinuses at the point of rupture.
This was her tenth pregnancy.
This case is an instructive one; and I present it to the Association, not giving details of ætiology, pathology, or treatment, but simply to draw a few practical inferences which may be of value to some of us in the future and impress on our minds the fact that such accidents occur often when there is no deformity.
This remarkable case is of special value, aside from its rarity,
it being the second ever recorded (the other by Dr. John Ramsbotham) in which the entire contents of the uterus escaped, unruptured, into the abdominal cavity. It gives the typical symptoms of a ruptured uterus; viz., the sharp, agonizing, tearing pains, a sensation of something giving way, followed by a pain which is constant and unremitting, with the escape of blood through the vagina. The rupture being at the placental portion of the uterus, and large enough to permit the escape of the fœtus with the sac entire, may explain the modus operandi of a similar condition which has been observed a number of times, in which the foetus escapes, at term, with the membranes intact, through the vagina.
This case illustrates the folly and danger of attempting to carry a child to full term in a pelvis which is known to be deformed, and in this instance it gives a sad example, with the terrible results of a fatal and criminal omission on the part of patient and friends, in neglecting to call medical aid; for in this case the woman survived the rupture four or five hours, and it was not until she was dying that aid was summoned. Without doubt, had the physician been called in time, he would have crushed the head and delivered; or, if the rupture had taken place while he was present, he could have easily recognized it, opened the abdomen at once, and delivered by Casarean section.
Although a ruptured uterus is a rare condition, it is an accident which may occur in the practice of any one of us, even when we least expect it, at the most inopportune time and place, as in this case, in a little country town, in the practice of a man who has spent over a half-century in the practice of medicine, with a vast number of obstetrical cases, and yet this accident occurs to him but once and at this late day; while in the practice of the youngest of us it may occur at our next case. When the accident does occur, the symptoms as a rule are well marked. In the present advanced condition of abdominal surgery, we should be prepared to open the abdomen at once and deliver, with reasonable hope of success.
FATTY STOOLS DUE TO ORGANIC DISEASE OF THE PANCREAS.
By CHARLES S. ALLEN, M. D., of Rensselaer County.
I was called, September 1, 1883, to visit Captain P. P. Staats, seventy-six years of age, and nearly six feet in height. He had, in his earlier days, been very strong and muscular, and was for many years a captain on the Hudson River. He had been complaining occasionally for the past year, and had taken advice and remedies from various physicians. The late Dr. Parmelee, of Greenbush, had treated him for malaria. After examining him thoroughly, I was unable to diagnosticate the disease; but, as every discase, like a child, must be named, I christened it adipose diarrhoea, though his stools were not of a liquid character. My reason for giving it this name was a very peculiar appearance of the alvine discharges. A liquid resembling melted or hot fat separated from the fæcal matter, and, when cold, would congeal like tallow over the surface. It appeared to be from one eighth to one quarter of an inch in thickness, according to the quantity passed; and, when cold, it had a yellowish appearance, resembling the yolk of an egg. At first, before the discharge, he would complain of pain near the umbilicus, attended with borborygmus, and would immediately go to stool. The fæcal matter which accompanied the liquid was partially consistent and formed, of a grayish color, in large quantity, and attended with much flatulence. The odor from the stool was unbearable, compelling the attendants to open the windows to ventilate the apartment. He would have three, four, or more movements of this kind daily. Not only was the fæcal matter formed, but it seemed to be composed of fasciculi or bundles laid together side by side, the pecul
iar fluid I have mentioned being discharged at the same time, but separate from the other substances. The appetite was variable, no fever, extremities cold, temperature low, pulse irregular, urine variable in quantity and of a dark color, and the muscles soft and flabby. He slept tolerably well, and had no pain, except just before going to stool. Taking all these circumstances together, I ventured to call the disease chylous, or adipose diarrhoea. His wife asked what my opinion was as to his recovery. I said, He is an old man and I can not give you much encouragement, as, from his present condition, his recovery seems very doubtful. I prescribed equal parts of pepsin and pancreatin, gr. v, three or four times per day; also a pill composed of pul. opii, gr. ; pul. ipecac, gr. ; camphor-gum, gr. j., one pill at night. Should the pain continue, the pill was to be repeated three times during the day. I also advised rest in bed, and prescribed for food, softboiled rice, milk-toast, and tea, forbidding meat, fatty substances, and spirituous liquors. Having continued this treatment for several days, and being convinced that he had less adipose matter in his discharges and less pain before going to stool, I asked my son, Dr. William L. Allen, to visit Mr. S. with me, thinking he might throw some light upon the case. After giving the patient a thorough examination, he came to the conclusion, as the pain was mainly in the right hypogastric region, that the pylorus was implicated in the disease. Tenderness in that region was also manifest, and it was thought that some obstruction at the head of the pancreas must necessarily exist. He advised the continuance of the pepsin and pancreatin as before. The pill was changed to argentum nitrate, gr. ; pul. opii, gr. ; pul. ipecac, gr. j; to be given at a dose, three times daily. We both called on the next day. The patient had no pain, stools darker in appearance and fewer in number, urine better color and in usual quantity, the adipose matter less, and in a day or two it disappeared entirely. There still remained the coldness of the hands and of the lower extremities. I therefore gave him 3-gr. doses of quinine sulph. every four hours, and continued the first medicine as before. He had no pain, and expressed a desire for more substantial diet. I therefore directed a piece of broiled beefsteak for his dinner, and prescribed Wyeth & Co.'s elix. calisaya bark, iron, and strychnine three times per day, after eating, and a small wineglass of port