HenryW.J. Cook
1898 The Lancet  
AT 5 A M. on Nov. 28th, 1897, I was sent for to attend <a woman, aged thirty-three years, in her fourth confinement. Her previous confinements had all been rapid and normal, aU the children except one being alive and healthy. She was curetted for endometritis twelve months before the present occasion and became pregnant soon after the opsration. I had casually seen the patient several times during her pregnancy, which advanced in a perfectly normal manner, the only point worthy of notice being
more » ... hy of notice being that she was of a very highly neurotic temperament. On examining the abdomen as far as I could make z , out the presentation was normal ; there was no unusual -disteBsion, the child's movements could be plainly felt, and I heard the fcetal heart sounds below and slightly to the left of the umbilicus. Per vaginam I found a ,capacious, roomy pelvis ; the os was dilated only to about the size of a shilling, the head presenting normally, and the ,membranes unruptured. The pains, which had only lasted I a couple of hours, were moderately strong and regular. As the case was evidently in an early stage I left the patient, xeturning about 7.30 A M., when 1 found that the pains had become much more severe and the os had now dilated to the size of a half-crown, the head being engaged in the pelvic brim. I remained with her, intending shortly to rupture the membranes, and to allow her to sit about the 1I'00m a little. About twenty minutes after, during a severe pain, she suddenly became very faint and pallid, so much so that she almost dropped on the floor, where I let her lie 1for a few minutes. According to her own statement the pain was so severe as to make her feel faint. Her ipulse, previously normal, was rapid and soft, beating a.t about 120 to the minute; she vomited some milk and water which she had taken shortly before. I administered a Bhypodermic injection of brandy, after which she stood up and with the assistance of the nurse and myself got on the bed, complaining then only of slight pain in the abdomen. Her petticoat was wet with fluid and there was some blood coming from the vagina, though not in great quantity; the guid was evidently liquor amnii. I immediately proceeded to examine her per vaginam and found at once that something unusual had taken place. The head had comfpletely vanished; indeed, from the interior I could feel absolutely no part of the child ; where the os and cervix should have been I could feel a raw ragged surface which iat first felt to me exactly like placental tissue and I thought at first that I must have in some unaccountable way in my ,first two examinations missed a diagnosis of placenta prsevia, tevecially as she was now losing some blood. I then turned my attention to the abdomen and at first sight saw that I had a case of ruptured uterus with the child floating free in the abdominal cavity. The abdomen was irregularly elongated transversely and in the right umbilical and lumbar regions K could plainly feel a foot through the abdominal wall and '00 the opposite side was an eminence which I made out to be a sboulder. On feeling again per vaginam (inserting my ,hand) could now clearly distinguish the state of affairs ; Bthere was an extensive rent extending upwards from the 'Upper extremity of the vagina up the posterior wall of the uterus reaching almost to the fundus; what I at first had taken to be placenta was the edge of the rent and the .posterior surface of the posterior wall of the uterus which had evidently become somewhat inverted ; through the rent I could feel the intestines but no part of the child or of the placenta. The examination caused the patient great pain :and I could go no further without an ansesthetic. Being alone, with the exception of an untrained woman as nurse, 'I deemed it advisable to wait till I could get more assistance. 'The patient was almost pulseless and I preferred to wait and 'keep her going with stimulants rather than have her die ,under an anesthetic without anyone else to help. I therefore aent a messenger on horseback to my nearest medical neighbor, Mr. W. H. Brown, of Colac, twelve miles distant. He arrived in two and a half hours and in the meantime I had rallied the patient and j just succeeded in keppiog her alive with brandy injected hypodermically and per rectum, salt, solution injection, &c. Ether was now administered and the band was inserted into the vagina through the rent posteriorly (the uterus was partially contracted) and into the abdominal cavity. After some trouble a foot was seized and drawn through into the uterus, the rest of the child following easily, with the exception of the head which somehow caught in the tear; after considerable difficulty it was pulled through and then delivered with ease, there being a large, well-developed pelvis with absolutely no obstruction. There was slight prolapse of intestine which was returned easily. The child was dead. On tying the cord and dividing it the next thing was to find the placenta. This turned out a rather difficult matter, but after some search and by dint of following up the cord to its insertion it was found high up, almost under the liver. The uterus and vagina were douched out with solution of iodide of mercury, two hypodermic injections of ergotine were administered into the buttock, and the uterus, including the rent, was firmly packed with iodoform gauze. We haC to finish hurriedly, for the patient being all but dead we turned our attention to rallying her. She improved so far as to be able to talk to her friends with the help of such means as raising the lower end of the bed, stimulants, salt-solution, compression of the abdominal aorta, &3. In the end, however, our efforts were unavailing, for she died six hours after the accident from pure shock. A post-mortem examination was not made. I have deemed this case worthy of publication owing to its rarity and to the absence of any apparent cause. This legion, at any time uncommon, generally occurs only in the lower segment of the uterus, and I believe tears beyond the cervix are mostly transverse. In the present case, however, it was almost longitudinal, and reached without a doubt nearly to the fundus. As regards the cause this, as I have stated, was quite unapparent. As far as we could ascertain there was no growth in the uterus nor were there any sharp processes of bone growing from the pelvis likely to cause laceration ; the pelvis being large and roomy I fully expected a rapid delivery, and no ergot or other means had been used to produce excessive uterine contraction. The only way to account for the accident was the fact that the patient had suffered from endometritis and the uterine wall must have been affected as a result. The symptoms were well marked and unmistakeable almost immediately after the occurrence. Regarding the treatment, the woman was so much collapsed that abdominal section was out of the question ; she would certainly have died in the middle of it; besides, her surroundings were very unfavourable for such an operation. We were fortunately able to deliver her, though with much difficulty, per vias naturales. HONORARY DENTAL SURGEON TO THE GENERAL INFIRMARY, LEEDS. ON Dec. 29.h, 1896, I was asked to see a patient, aged nineteen years, in No. 3 ward of the Leeds General Infirmary. He was a canal boatman and during the early morning of the 28th was winding a lock windlass when his foot slipped on a piece of ice and the revolving arm struck him across the jaw, causing a double fracture of the inferior maxilla and more or less concussion of the brain. On examination I found the jaw fractured through its body between the second bicuspid and first molar teeth on the left side and between the first and second bicuspids on the right side. The anterior portion was much depressed, and although there was no external wound there was considerable swelling and the patient was in an irritable condition. On the 30ch he was ai3msthetised and I adopted the method of wire suture which I described in THE LANCET of Dec. 3rd, 1892. In this case. however, I brought into use an instrument I have devised for metallic suturicg. It is applicable in this or any other situation where osseous suture is required, and I found it answer so admirably that I fefl justified in placing before the readers of THE I AXCNT a somewhat detailed description
doi:10.1016/s0140-6736(01)95371-1 fatcat:cvhow4hiobcz5krujznqsibrk4