Induction of Premature Labor; Manual Dilatation; Fatal Result to Both Child and Mother

1882 Boston Medical and Surgical Journal  
she resided. Still I could hardly venture to acquaint either her or her husband with the true state of affairs, and presently I was placed in a very embarrassing dilemma, as she was about to go abroad, and asked me for letters to some of the English physicians describing the nature of her case. It was a very delicate matter, I assure you, to convey the intelligence of the specific trouble to the medical men to whom I addressed my letters, and yet conceal it from her, as she would naturally
more » ... ould naturally expect to peruse them, but I did the best that I could under the circumstances. I was gratified to learn afterwards, however, that she concluded not to go abroad, and I believe she still has the letters in her possession. PHTHISIS, BRIGHT'S DISEASE, AND THROMBOSIS OP THE FEMORAL OR ILIAC VEINS. In regard to our last patient to-day, as was the case in the first, I may say that he presents an interesting field for pathological study on account of the variety of the affections from which he is, unfortunately, suffering. In the first place, he has considerable pulmonary trouble, there being present the physical signs of excavation and solidification in the lung. Next there is distinct evidence .of renal disease. The urine has a specific gravity of 1034, and contains albumen in pretty large quantity, as well as abundant granular casts. Then he has still another affection, and it is to the latter that I wish especially to call attention. When the lower extremities are uncovered you perceive that the right limb is very much swollen as compared with the left. He has, indeed, a condition which used to be designated as phlegmasia dolens, or milk leg, from the fact that it was supposed to be connected with the function of lactation in the puerperal woman. Ou a further examination we find that the limb is not only greatly enlarged, but is also markedly oedematous, and there can be no doubt that we have here a case of oedema of the lower extremity, due to thrombosis of the femoral or iliac vein. The vein becomes filled with coagula, and there is great danger of fragments of larger or smaller size becoming separated and carried iuto the circulation. When thus transported they pass into the right cavities of the heart, aud may thence be driven into the pulmonary artery, giving rise to obstruction of this vessel or its branches. Here let me pause to say, lest I should forget it later, that in all such cases the first requisite is to keep the patient absolutely quiet, so as to avoid as far as possible the danger of disintegration of the clots, which may result in sudden death from a plugging of the pulmonary artery by a mass of fibrin. The following is a case in point. A gentleman received a severe injury about the hip from being thrown under the wheels of a cart, and this resulted in thrombosis of the femoral vein. The most absolute rest was enjoined, and the danger liable to result from movements was fully explained to him. He was self-willed, however, and insisted on having an apparatus in the bed, by which he might raise himself, against the protest of his medical attendant. The consequence was that in some of his exertions a portion of the thrombi became dislodged, aud a sufficiently large mass to obstruct it was forced into the pulmonary artery, producing instant death. The enforcement of perfect quiet is, then, a very practical point in this affection. Restoration is accomplished by the gradual enlargement of the neighboring veins, by which the circulation of the part is rendered normal once more, but sometimes this does not take place, and the oedema remains indefinitely. The history of the case is briefly as follows : George K., nineteen years of age, a native of the United States, aud admitted to the hospital one month ago. He has bad a slight couj;h for several years, but last December this became considerably worse. About the same time he noticed that his urine was often scanty and high colored, and that it sometimes occasioned a burning sensation in its passage. The right leg first became swollen, and later he liad considerable general dropsy. On admission the physical signs of cavity in the right lung were found, with cough and expectoration. The heart was normal. There was general anasarca of the body, and the urine was found to contain granular casts and seventy-five per cent, of albumen. Within three weeks after his admission the cedema of the face and of the left lower extremity had almost disappeared, but the condition of the right limb has not varied much from that which you now observe. In regard to the treatment of the latter, all that we can do is to use anodyne applications and gentle friction. The friction must be made with care, especially near the affected vein, as any rough handling of the part might cause dislodgment of some of the thrombi. It should also be applied from below upward, so as to facilitate the emptying of the veins. So far as the renal disease is concerned, it is only necessary at present that the condition of the urine should be carefully watched to see that a proper amount of urea is being excreted. As to the disease iu the lungs, that requires the same treatment which would be necessary were the case simply one of phthisis without complications.
doi:10.1056/nejm188210191071602 fatcat:cr3lgtlrpvf4dfvf76lueig3pm