After 24 hours the labour pains recurred, and as it was evident the membranes had burst, it was allowed to have its own At 10 p. M. the progress was very slow course. though the pains were strong enough. The os had opened out just biofor the the of of introduction the enough tip finger. At 12 P. M. no progress had been made, when it was decided to the os the dilatation the of by gently help pressure of the finger at its rim. Within an hour the dilatation was active and complete and the breech presented. At 2 A. M. the child was born with the arms extended and the cord coiled round the neck. The child appeared still-born, but cried lustilv after the dashing of cold water on the face. Hemorrhage The placenta came out entire about 20 was insignificant. minutes after. All seemed well and I left the patient with congratulation on having come to such a favourable termination of her series of troubles, when two hours after her confinement she was taken ill with strong shivering followed by fever, I ascribed the fever to her predisposition, and treated her with quinine and cannabis, but although it intermitted, the next day it returned with redoubled severity, the temperature going up to 104? and never came below 103?, Pulse 120. On the 3rd day there was good deal of tenderThe external parts were ness complained of over the uterus, an swollen with erysipelatous blush: discharge foetid, The patient lay obstinate diarrhoea and prostrate and listless with low muttering delirium and dry tongue. The uterus was injected with weak carbolic acid lotion. Poultice applied over the abdomen and a mixture of SulphoTr. opii prescribed. carbolate of soda, Turpentine and But as it seemed to increase the diarrhoea, it was changed to Sulphuric ether and Tr. Ferri niuriat. and quinine anct opium injection per anum. Brandy 4 oz. in 24 hours. After remaining in a critical condition for 4 days, during which the symptoms did not abate, there was some change for the better. The irritability of the stomach was combated with Bismuth and tympanitis with animal hydrocyanic acid mitxure and the to be washed out twice charcoal. The uterus continued still the fcetor was indaily with carbolic acid lotion, but sufferable from the gangrene of the external parts which supervened. The subsequent progress was a steady one interrupted only once after a fortnight by fever and diffuse erysipelas of knee passing down to the sole of the foot. About this time whilst attempting to stand up she passed a rotten mass which proved to be a circular ring of vagina which had sloughed off from the internal surface. A portion of the labia and the vaginal wall at its outlet was also gangrenous and separated in time.^ She left this place about the middle of April for Calcutta when the ulcers were healing. There was no vesico or rectovaginal fistula. _
tympanitis.
remarks.
NOTES ON A CASE OF PUERPERAL FEYER.
\
By G. C.
Roy,
M. D.,
F.R.C.S.
Mrs. S. came into this station in August 1881. She was of delicate constitution and extremely nervous temperament. In the beginning of October she was troubled with morning sickness, which became so aggravated in nature that she could not retain any food for days. This however subsided in time, but she became subject to periodic fever, which used to come on about once a month. With each attack there were uterine pains and threatening of abortion, relieved by the administration of opiates. She confessed to having had syphilis before, but how long since and whether attended with any secondary eruption or not, my information is silent on these points. On the 1st March she had her usual attack of fever with uterine pains. The uterus was enlarged midway between umbilicus and sternum. On internal examination the os was found almost closed up, in fact a dimple on the posterior and dependent position of the cervix was the only indication of its site. The heart sound of the foetus could be heard. A good dose of opium followed by one of chloral was given to stop the pains, which were of a continuous nature. This quieted the pain and gave her rest, but she noticed at night discharge of fluid tained with black stuff, which proved to be meconium,
The case is important in many clinical points. Previous history of syphilis and threatened abortion stand to each other in the relation of cause and effect. To this was superadded a malarial cachexia and conjoined with depression of mind consequent on domestic troubles and a rather tedious labour, you have an array of causes that seldom fail to develope puerperal fever. Puerperal fever is said to be of specific origin, the specificity consisting in the genesis of a septic poison in the blood either from the putrefaction and absorbtion of uterine discharge, or from residence in an ill ventilated locality, or from the direct contagion of a pre-existing germ or from previous bad health, in which condition the natural secretions of the body have a tendency to putrefactive change. It may manifest itself in metritis, peritonitis, phlebitis or erysipelas, and in all these different manifestations they are essentially the one and the same disease. Saprasmia or Ichoraemia or the fever due to absorbtion of products of inflammation either in its crude or decomposed state is the preliminary stage of septic fever or septicaemia, and may pass off without merging into the other. But still in condipuerperal tion it is of grave import. As .an antiseptic I have given Sulpho-carbolate in some of these cases but the diarrhoea following its use has been a serious drawback. I do not think there is a better antiseptic than quinine, which is of double efficacy for its antipyretic virtue. Combined with Iron, uterine wash and opium, by the rectum in preference, all the indications of treatment of fever are obtained. puerperal In conclusion I shall say one word with reference to the ecbolic virtue of quinine, I transcribe what I wrote 2 years ago in my Annual Report, which was never intended to see the
July 1,
1882.]
A MIRROR OF HOSPITAL PRACTICE
light of publicity. Further experience has confirmed the opinion then expiessed. In the case of Mrs. S., if quinine, had been given in the first instance it would have been credited with the unhappy result. I will take this opportunity of refuting the opinion now gaining ground of the ecbolic virtue of quinine and the apprehension felt in its administration to pregnant women for fear of causing abortion. If the present type of fever be conceded as a "fair field for deduction, I am prepared to meet the theory with positive and negative facts. There "
were
3 cases under my otvn immediate treatment, one of
whom, subject to previous abortion for syphilitic cachexia, ill with high fever, in the 8th month of her pregnancy, and in whom io grains of quinine was sufficient to check its
was
recurrence without any bad symptom. Another in her 7th month was laid up with fever, when her medical attendant, with the dread of quinine in his head, abstained from its administration, and the result was the fever every day gained in intensity and abortion threatened every night till 2 doses of quinine during intermission prevented the recurrence and obviated the very result of which he was in dread. The 3rd, a hospital patient, was given 10 grains of quinine in whom although the fever recurred the next day, no bad effect of quinine was experienced. On the other hand Civil Hospital Assistant Hurry Mohan Bhattacharjee states several instances in his practice in which he, as well as the relatives, avoided giving quinine in any shape whatever, and yet abortion was induced. Only one conclusion may be arrived at from the foregoing array of facts, that the ecbolic virtue of quinine has been deduced from the post hoc propter hoc method of ratiocination, and that the effect of fever has been wrongly credited to quinine, the administration of which was a mere coincidence. Quinine may by its strong impression on the nervous system indirectly excite the action of an irritable uterus, but no proof has been brought forward to show its action on the organs in the same sense as the other oxytoxis. Of course, in such delicate constitutions it should be judiciously given and guarded with opium if need be, but to withhold its use altogether, is to precipitate events and jeopardise the patient's life,''
}81
tympanitis.
remarks.
NOTES ON A CASE OF PUERPERAL FEYER.
\
By G. C.
Roy,
M. D.,
F.R.C.S.
Mrs. S. came into this station in August 1881. She was of delicate constitution and extremely nervous temperament. In the beginning of October she was troubled with morning sickness, which became so aggravated in nature that she could not retain any food for days. This however subsided in time, but she became subject to periodic fever, which used to come on about once a month. With each attack there were uterine pains and threatening of abortion, relieved by the administration of opiates. She confessed to having had syphilis before, but how long since and whether attended with any secondary eruption or not, my information is silent on these points. On the 1st March she had her usual attack of fever with uterine pains. The uterus was enlarged midway between umbilicus and sternum. On internal examination the os was found almost closed up, in fact a dimple on the posterior and dependent position of the cervix was the only indication of its site. The heart sound of the foetus could be heard. A good dose of opium followed by one of chloral was given to stop the pains, which were of a continuous nature. This quieted the pain and gave her rest, but she noticed at night discharge of fluid tained with black stuff, which proved to be meconium,
The case is important in many clinical points. Previous history of syphilis and threatened abortion stand to each other in the relation of cause and effect. To this was superadded a malarial cachexia and conjoined with depression of mind consequent on domestic troubles and a rather tedious labour, you have an array of causes that seldom fail to develope puerperal fever. Puerperal fever is said to be of specific origin, the specificity consisting in the genesis of a septic poison in the blood either from the putrefaction and absorbtion of uterine discharge, or from residence in an ill ventilated locality, or from the direct contagion of a pre-existing germ or from previous bad health, in which condition the natural secretions of the body have a tendency to putrefactive change. It may manifest itself in metritis, peritonitis, phlebitis or erysipelas, and in all these different manifestations they are essentially the one and the same disease. Saprasmia or Ichoraemia or the fever due to absorbtion of products of inflammation either in its crude or decomposed state is the preliminary stage of septic fever or septicaemia, and may pass off without merging into the other. But still in condipuerperal tion it is of grave import. As .an antiseptic I have given Sulpho-carbolate in some of these cases but the diarrhoea following its use has been a serious drawback. I do not think there is a better antiseptic than quinine, which is of double efficacy for its antipyretic virtue. Combined with Iron, uterine wash and opium, by the rectum in preference, all the indications of treatment of fever are obtained. puerperal In conclusion I shall say one word with reference to the ecbolic virtue of quinine, I transcribe what I wrote 2 years ago in my Annual Report, which was never intended to see the
July 1,
1882.]
A MIRROR OF HOSPITAL PRACTICE
light of publicity. Further experience has confirmed the opinion then expiessed. In the case of Mrs. S., if quinine, had been given in the first instance it would have been credited with the unhappy result. I will take this opportunity of refuting the opinion now gaining ground of the ecbolic virtue of quinine and the apprehension felt in its administration to pregnant women for fear of causing abortion. If the present type of fever be conceded as a "fair field for deduction, I am prepared to meet the theory with positive and negative facts. There "
were
3 cases under my otvn immediate treatment, one of
whom, subject to previous abortion for syphilitic cachexia, ill with high fever, in the 8th month of her pregnancy, and in whom io grains of quinine was sufficient to check its
was
recurrence without any bad symptom. Another in her 7th month was laid up with fever, when her medical attendant, with the dread of quinine in his head, abstained from its administration, and the result was the fever every day gained in intensity and abortion threatened every night till 2 doses of quinine during intermission prevented the recurrence and obviated the very result of which he was in dread. The 3rd, a hospital patient, was given 10 grains of quinine in whom although the fever recurred the next day, no bad effect of quinine was experienced. On the other hand Civil Hospital Assistant Hurry Mohan Bhattacharjee states several instances in his practice in which he, as well as the relatives, avoided giving quinine in any shape whatever, and yet abortion was induced. Only one conclusion may be arrived at from the foregoing array of facts, that the ecbolic virtue of quinine has been deduced from the post hoc propter hoc method of ratiocination, and that the effect of fever has been wrongly credited to quinine, the administration of which was a mere coincidence. Quinine may by its strong impression on the nervous system indirectly excite the action of an irritable uterus, but no proof has been brought forward to show its action on the organs in the same sense as the other oxytoxis. Of course, in such delicate constitutions it should be judiciously given and guarded with opium if need be, but to withhold its use altogether, is to precipitate events and jeopardise the patient's life,''
}81
