H.B. Vincent
1879 The Lancet  
9 become sore and itchy. At the same time patches of raised, stinging eruption had appeared on both arms. So far as could be ascertained, there was no overt cause for the·e outbreaks, and no dietetic indiscretions were acknowledged. The eruption on the arms had passed away, and caused no further annoyance, but the ears continued troublesome. The patient could give no account of the appearance presented at this time. She had procured some ointment from a druggist, which, on application to the
more » ... s, had apparently done more harm than good. On examination there were seen to be several darkpurplish patches on the helix of each ear. These were hard, puckered and dry in places, and presented at first sight much the appearance of portions of dry gangrene about to become detached. In the less dry patches there was evidently effused blood. There were no signs of purpuric affection in any other part of the body. The tongue was flabby and slightly furred. There had been no previous attacks of urticaria, or of any similar affection. The heart was found to be natural, and there was no history of rheumatism. Unguentum zinci was ordered locally, and some carbonate of soda in bitter infusion given internally. In a week there was most marked improvement in both ears, and the patient did not return. Several of my colleagues saw the case, and agreed in the diagnosis of urticaria occurring in a haemorrhagic form on the ears. The long duration of the case was no doubt due to the extravasations, and it is not unlikely that some irritating ointment had added to the original trouble. It seemed right to excludeboth the affection described as purpura urticans, and any variety of multiform erythema in which haemorrhage sometimes occurs. ON August 26th, 1877, I was summoned about 4 A.M. to see A. C-, aged nineteen, a fine, well-made, healthy woman, unmarried, but eight months advanced in first pregnancy. Had always enjoyed good health; family history good ; onset of present illness sudden. When I first saw her, the puerperal convulsions were well marked, being very severe, and occurring frequently. The insensibility to external impressions of all kinds was very profound. She was passing water very freely, and her bowels were much relaxed. On making a vaginal examination, I found the head presenting. The os would barely admit the tip of the finger, and there was not the least sign that labour was likely to set in. I applied sinapisms to the calves of the legs, and prevented the patient from damaging her tongue, and waited. As the convulsions increased in severity, and the insensibility was becoming very profound, I bled her to fourteen ounces from the arm, but this seemed to have no material influence. At the end of six hours from first seeing her, finding that the patient's condition did not improve, and that there were no signs of labour coming on, I drew off a small quantity of urine, which was highly albuminous and very dark, then introduced the smallest of Barnes's bags, and slowly dilated the os with warm water. After introducing the largest bag, and dilating it as far as possible, I removed it, and found the membranes protruding. I waited a short time to see if the pains would come on to dilate the os a little further before rupturing the membranes; but as no pains came, I ruptured the membranes, discharging a small quantity of discoloured and very offensive liquor amnii. I then applied the long forceps, and with great difficulty delivered, with only a slight rupture of the perineum, not sufficient to require a stitch. The child had been dead some time; the head had undergone considerable compression from the furceps. The placenta was adherent, and I had to introduce my hand to remove it. During the whole of the proceedings the convulsions continued, the insensibility remaining profound. The time taken, from the introduction of the first bag to the delivery, was nearly an hour. When seen in the evening she was still unconscious; very quiet; breathing freely; pupils contracted; fair amount of discharge. Catheter used; about one pint of urine, oneeighth albumen. Temperature 1020; pulse 120. Had three slight convulsions since the morning; takes beef-tea and milk ; tongue very much lacerated by the teeth ; vagina to be frequently syringed out. Aug. 27th.-Slept well; slightly conscious; unable to speak; no return of convulsions; has taken nourishment well; bowels not open. Catheter used; urine acid, specific gravity 1015, about one-eighth albumen. Temperature 99°; pulse 120; respiration 24. Lochia fair in quantity, inoffensive. 28th.-Has had a profound sleep; consciousness quite restored; can speak fairly well; appetite good. Catheter used; urine slightly albuminous; breasts painful. Extract of belladonna ordered. Temperature 990; pulse 108; respiration 30. From this date the patient progressed well. The albumen gradually disappeared from the urine; the breasts gave no trouble; has had no more return of the convulsions, and her health has been excellent. Remarlis.-I have brought this case forward in order to hear the experience of members of the profession in cases of severe puerperal convulsions occurring before labour has fairly set in, and in which the convulsions are continuous and severe and the coma profound and unintermitting. Whether venesection, the administration of purgatives, antispasmodics, sedatives, and the inhalation of chloroform, have proved useful allies in their hands, or whether these temporising agents are not fraught with mischief, in this class of convulsions, where the exciting cause is peripheral and not central, the correct interpretation of the pathological conditions seeming to me to point rather to the speedy evacuation of the contents of the uterus (the mortality of the mothers being one in four), and as in the great majority of cases the foetus is dead (about one in three), we have less compunction of conscience in using means to reduce the bulk of the child in order to facilitate its rapid removal. Therefore, supposing a case of severe convulsions to occur in which the os was closed, rigid, and undilatable, and in which, as far as human judgment could foretell, the profound coma would end fatally, would one, in the face of the accumulated experience of surgeons in dealing with the abdominal cavity under the antiseptic method, be justified in resorting to Cassarean section in order to attain what I believe to be the goal of treatmentviz., rapid delivery ? East Dereham, Norfolk. , aged eighteen years, came under my notice, and I was informed that for some days past his manner had been strange and confused. On the evening of my visit his friends became alarmed, as he wandered in his mind, threatening to cut his throat. His mother had ascertained that for three weeks past he had been taking an ounce of sweet spirits of nitre in water at intervals during almost every day. I found the patient on my arrival delirious and incoherent in his manner, drowsy, as if he had been taking alcohol, which was not the case. When he was roused he could answer questions, complained of headache, and said he had found it difficult to walk straight of late. He could see clearly, the irides being somewhat dilated, acting feebly. Skin and tongue were dry, breath smelling strongly of ether. Pulse 60, small and hard. Constipation well marked. No vomiting. Urine had not passed since early morning, and had been scanty of late. Bladder empty on pressure above pubes. Diaphoretics (solution of acetate of ammonia), warm bath, aperients, and a linseed and mustard poultice over the renal region were ordered. March 30th.-Had a good night. Skin was beginning to perspire. Constipation and suppression of urine unrelieved, although he had had two doses of aperient medicine. Calomel and jalap were now prescribed in pills, and a linseed-meal poultice to be continuously applied over the kidneys. At 6 P.M. evidently better. Bowels had acted twice, and one ounce of urine voided with the first motion, and more with the second. Pulse 80, softer. Not so drowsy; less headache. A little urine was passed for examination,
doi:10.1016/s0140-6736(02)42345-8 fatcat:nztsq73zmbe7niz5ry6e46pcji