« ForrigeFortsæt »
That there is a close relation between rheumatism and puerperal heart-clots has been observed for a long time. Barker says that several of the patients whose cases he reports had suffered recently from rheumatic fever and endocarditis. It would be rash, however, to affirm that this relation depends entirely upon endocardial changes. Many women who have roughened pulmonic valves, go through confinement with no more trouble than others who are not so afflicted; and yet there can be no doubt but wbat such a condition predisposes to the formation of clot. Rheumatism affects the blood very much as child-bearing does, and it certainly renders it less alkaline, which of itself would increase the chances of coagulation.
About eight years ago, I attended a woman in her fourth confinement. She had suffered with inflammatory rheumatism during the period of gestation, and endocarditis was recognized at the time. She did well until the seventh day, when, while reaching for some object on the foot of the bed, she was seized with extreme dyspnoea and died almost immediately. This had every appearance of a case of heart-clot, and yet I do not pretend to report it as such because I have no notes and my memory can hardly be trusted to give all the details. It served, however, to put me on my guard and make me very suspicious of women who during their pregnancy had been afflicted with rheumatism.
My next case of this kind was Mrs. K., twenty-six years of age, weight about one hundred and ten pounds. It was her first pregnancy, and she was very apprehensive as to the outcome of it. Six months before, she had been sick for about two weeks, with what was considered a light attack of inflammatory rheumatism. She suffered, at the time, a good deal, with an uncomfortable sensation at the heart. This continued for several days after the other symptoms had disappeared. There being no objective symptoms of heart trouble, her physician considered that the distress was purely muscular.
I first saw her professionally about three weeks before her confinement. She had not felt very well since her illness in the spring but laid all her bad feelings, which, by the way, were of a somewhat indefinite character, to malaria and to her condition. I examined her heart very carefully, but could detect no murmur or other sign of disease. She seemed much reassured when I told her of this.
I was called to attend her on the morning of Oct. 25th. She had been in labor all night. About 2 p. m. she was delivered of a healthy eight-pound girl. The position of the child was occipito-posterior and considerable damage to the perinæum resulted. This I repaired at once. I applied a bandage as tightly as my patient would permit, and soon after left her in good condition. I was obliged to use the catheter for thirty-six hours, but after that she voided urine without assistance. Owing to the extreme terror of my patient at the mere suggestion of catheterization, I was compelled to administer a few drops of chlo. roform at each operation—nine in all. On the third day she complained of vesical pain and tenesmus. This continued until the fifth day, when it gradually disappeared. During this time her temperature rose slightly over a hundred, but dropped to normal again on the fifth day. Her milk came later, but was plentiful.
When I made my call on the morning of the tenth day, I found her sitting up in bed fondling her baby and anxious for my permission to join the family at dinner in the evening. At my request, however, she promised to remain in bed two days longer, though she said she never felt better in her life. At 3 P. M. I was called in great haste.
While straining slightly at defecation, she had been suddenly attacked with extreme dyspnoea and a sense of oppression at the heart. I found her in a state of asphyxia, cold, pulseless, deathly pale, lips and finger tips purple. I shall never forget her expression of anguish as she greeted me with, "Oh! Doctor, give me some air, or I shall die.” Brandy, digitalis and ammmonia were given immediately, and bottles of hot water were applied to her feet, along her limbs and under her arms. All, however, was in vain, for in thirty minutes from the time of seizure she was dead. After her death, I was informed for the first time, that, during the night previous, she had complained of that “old feeling' in the region of the heart.
This was, I think, a typical case of heart-clot, and that it was dependent, somewhat, upon the antecedent rheumatism, I could have no doubt.
One case of any disease, is not enough to draw many reliable conclusions from, but such cases are so exceedingly rare that I have made bold to present it this evening as the subject of our discussion.
If all of these cases could be reported, we would in time be able to draw deductions from them, which would enable us to make a fight for prevention.
That I could find no evidence of endocardial disease, in no way proves that such disease was not present. We all of us. have seen cases which could be detected only long months after the mischief is done.
I have very little to offer regarding treatment. Barker feit certain that he had prevented the formation of heart-clot by keeping his patient on her back for a long time after confinement and guarding her from necessity for muscular effort.
I would suggest plenty of alkaline mineral waters before confinement with small doses of digitalis if there is any indication of weak heart action. Small doses of bichloride of mercury would be indicated both as a tonic and for its power of overcom. ing the coagulating tendency of the blood. Beyond this little seems possible.—Brooklyn Med. Jour.
OPERATIVE EXPERIENCE WITH ECTOPIC GESTATION.-Dr. E. B. Cragin (Amer. Jour. Obstetrics) says:
When the diagnosis is made before the rupture of the tube, the best interests of the patient are subserved by abdominal section and the removal of the pregnant tube; and this I would state recognizing full well the claims of the advocates of galvanism and faradism. The following reasons force me to the above conclusion: Before the rupture occurs, the operation for removal of the tube is one of the simplest of abdominal sections. The operation at this period may be performed with selected, trained assistants, and with careful attention to all antiseptic details. By this operation the patient is removed from the danger which momentarily threatens her—the danger of rupture and fatal hæmorrhage before surgical aid can be secured. She is also saved the trouble which is liable to arise from a tube once pregnant but not removed.
When the product of conception has escaped from the tube into the peritoneal cavity, either through the wall of the tube or
by "tubal abortion, the only safe rule of action is abdominal section, removal of the tube, and cleansing the abdomen. The writer believes that not in a few cases the product of conception has escaped from the tube with slight hæmorrhage, both foetus and blood-clots have been absorbed by the peritoneum, and the patient has recovered without operation. While frankly admitting this as a possibility, we are forced to confess that we never can foresee those cases in which the hæmorrhage is to be slight; and while one has survived such an experience, many have perished. A few hours, nay, even a few moments, will sometimes change the condition of a woman from one of apparent health to that of imminent death from internal hæmorrhage. This short time is our only opportunity to save our patient. Shall we neglect our opportunity?
When the rupture of the ectopic-gestation sac has occurred between the folds of the broad ligament, excepting the rare condition where the life of the foetus continues, operation is not in. dicated unless suppuration occurs or unless repeated hæmorrhages threaten a secondary rupture into the peritoneal cavity, In both these conditions the writer's method is vaginal incision and drainage. Four cases of hæmatosalpinx which resembled cases of ectopic gestation have been operated on by me, but, as positive proofs of the true condition have been absent, they have not been included in this paper.-American Lancet.
UTERINE TOLERANCE PREGNANT WOMEN.—The fact that pregnant women will tolerate the most severe lacerated and other wounds of the abdomen alone, or abdomen and uterus combined has been amply demonstrated by the comparatively large number of cases found in medical literature.
When we take all the circumstances surrounding such cases into consideration, we can only marvel at the wonderful resistance both of a physical nature and of a mental condition which is proven by the records. Dr. Robert P. Harris has contributed a clear-cut study of this in a paper which appears in the New York Journal of Gynecology and Obstetrics. He has tabulated twenty cases of animal horn-rips of the abdomen and of the abdomen and uterus in pregnant women, some of which
have hitherto been unpublished. The cases cover a space of time extending from 1830 to 1888. Out of the entire number but four died, making a mortality of twenty per cent. Two died of shock and one was instantly killed. The fourth one died forty-one hours after the injury, which involved the bladder, and was twelve fingers-breadth in extent.
Commenting on these cases and comparing them with Cæsarean section, Dr. Harris is led to say that the surgical world has been long in error as to the proper measure of danger to be encountered in the Cæsereang operation, and had the horn-rip cases of this paper been collected twenty years ago, down to number seventeen inclusive, it must have much surprised the operators of Europe and America to consider their results in contrast with the best work done under the knife. The much better results now attained by the obstetric surgeon, particularly in Germany and Austria, has a tendency to diminish the measure of our surprise at those recorded of the work of horned ruminants; but we are led even now to ask ourselves two very important questions, viz.: 1. Why did so large a proportion of women recover af. ter the horn-Caesarean rip than after a delivery by the knife, under the old method of operating that prevailed up to the year 1876? 2. Was it the mode of operating with the knife, the condition of the subject at the time of her delivery, or both in combination, that made the difference of results? As we must ad. mit that the knife is much the better instrument of the two, and is capable of performing its work with much less shock to the system, we must also admit that an operation before labor is likely to be much better borne by the woman than in the state of exhaustion produced by its long continuance. We believe that the secret in the horn-ripped and other lacerated cases lies in the fact that the subjects were healthy and in good physical condition when forced to endure the shock of a violent abdominal injury. Had one of these women been already under the effects of labor-exhaustion, her death would, uo doubt, have followed.
The labor and time expended in collecting together the cases of injury presented in this paper will have been spent in vain, if they are to be regarded simply in the light of marvels or curiosities in obstetrical literature. They were certainly not collected