Thomas Newham
1878 The Lancet  
841 and insensibility in the commencement partook of the natur of syncope, presumably from the quick formation of the clo and incomplete passage of blood into the aorta. Soon th impulse of the heart was aroused to overcome the ob struction, and caused a larger current of blood to pass. Bu the stream supplied to the brain must have become less ani less arterialised, or charged with oxygen, owing to the dis turbed function of the lungs, and thus a comatose condition was induced. Everything seemed
more » ... . Everything seemed to point to the stat called cardiac thrombosis. This inference was strengthenec not only by the general symptoms and auscultation, but b the fact that the patient's easy and quiet mode of life, won derful appetite and digestive power, with ample means o procuring all that she desired, were circumstances favour able to that condition of the blood termed hyperinosis. Again, the puerperal state has been shown to be conduciv to coagulation of the blood through the increase of th( fibrine-generators and the pale corpuscles. In the presenc( of such increase in these constituents of the blood, may w( not conclude that whatever disturbs the delicate balanc( by which they are held together in the normal state wil lead to the conversion of plasmine into fibrine to such ar extent as to cause coagulation within the vessels ? Should we, then, regard in the present case the actioi of the typhoid poison on the blood, as the active agent o: factor in the process of coagulation ? Or should we rathe: attribute the change to the retardation of blood in the pul monary veins ? Experience of the effects of stagnation o blood in the vessels, and the period of time at whicl thrombosis appeared in the present instance-namely, after not before, the pneumonia,-lead me to adopt the latte view. To be certain that I had not overlooked some fault in th( valves of the heart which might have produced a mechanica effect, I visited the patient six days ago-i.e., nine month: after her recovery. No valvular disease or irregularity of the heart's action could be detected. But although sh( looked, and stated t.hat she was, "as well as she had beer before her severe illness," a close examination elicited, "that if she hurried upstairs an unusual feeling of giddiness seized her, and sometimes led her to fear that she might fall." Her pulse was regular at 72, but weak. Weakness of the heart would account for the giddy feelings and "swimming of the head" under increased exertion. But my belief rather leans to the existence of a small embolus, the remains of the reduced cardiac clot, which, under the influence of increased circulation, is carried up into one of the cerebral arteries, and thus temporarily interrupts the circulation in a portion of the brain. In the treatment of the case, the ordinary management of a typhoid patient was carried out, and no complication was encountered till pneumonia set in. For the latter the usual treatment was employed, the most beneficial means being extensive counter-irritation with acetum cantharides, followed by hot poultices. Bleeding was not employed. As soon as thrombosis was diagnosed, it became a question not only of supporting the patient by stimulants (of which sulphuric ether proved of most service as a medicine, brandy and water and champagne as drinks, whilst beef-tea, milk, and farinaceous foods were used as nutrients), but, chiefly, how to get rid of the clot. As the latter was in all probability closely interlaced at one extremity, or whipped in among the chordæ tendineæ, could any chemical or resolvent means be used for dissolving or diminishing its bulk, if not wholly removing it from its attachments ? Experiments upon blood immediately after its removal from the living body, and the researches of Dr. Richardson, indicate that the alkalies have the property of softening and resolving such deposits. Accordingly, bicarbonate of potash in doses of ten grains, with sesquicarbonate of ammonia in doses of five grains, were administered every two hours when the patient was awake. Subsequently five-grain doses of iodide of potassium were combined. Occasional fits of dyspnœa were benefited by sulphuric ether, tincture of belladonna, and tincture of Indian hemp. The liver and bowels were kept in order by occasional doses of calomel, followed by sulphate of magnesia and bicarbonate of soda. At a later period compound tincture of bark was combined as a tonic with the soda. The progress of the case was exceedingly slow, and tried the patience of the sufferer and the friends, but a gradual improvement showed itself after the first week, and by Dec. llth I was able to give up the case as cured. IN the following record I adopt the plan laid down by Mr. Plaister in THE LANCET of October 20th, 1877. Of the total number of children born (1013), 518 were i males and 495 females. -Tivins occurred nine times. In all cases the second child f followed immediately after the first. In two cases both heads presented; in three cases head and breech; in one case breech and arm; in one case both children presented by ; the breech; and in two cases the presentations were head ; and hand. All, except one, were born naturally. Triplets occurred twice. In one case all were head presentations ; in the other, all footling. Children born alive, 1 but died within three days. i The beech presented in fourteen cases, and in three of these the blunt hook was used. i Arm presentations were only two in number. Turning in r both was comparatively easy. r The face presented in six cases. No special difficulty occurred, but all the labours were lingering. E Footling cases occurred six times. i. The head and one hand presented nine times. There was , no special difficulty except in one case, where turning was r performed easily. The placenta was adherent in eleven cases, and had to be removed by the hand. Two cases of hour-glass contraction t were speedily overcome by the action of chloroform. In no case had there been excessive hæmorrhage. Forceps were used in thirty-three cases, and were ren-, dered necessary chiefly from failure of expulsive pains when the head was at the outlet of the pelvis; in two cases . (mother and daughter) from contraction of the brim, both of , which were exceedingly difficult, narrowly escaping cranio-, tomy. Five cases were owing to the large size of the child, and occurred in primiparse. Rupture of the perineum has occurred only to a slight ; extent, in no case requiring any other treatment than keeping the legs well together for a few days. ! With Mr. Plaister I regret that I have kept no record of cases in which ergot was used. Unlike him, I have the greatest confidence in the certainty of its action and in its beneficial results. I have given it always in the form of fresh powder, in doses of one drachm, stirred up in warm tea. This dose has rarely been repeated. There were many cases where the forceps would have been necessary but for the action of the ergot, and I need scarcely point out that the patients infinitely prefer the medicine to the operation. In cases where I formerly used forceps I have since found the ergot sufficient for delivery, and I am convinced that it is much less productive of contusion and laceration of the soft parts. I attribute the absence of excessive hsemorrhage in my cases to the free use of ergot just before delivery. The child is expelled, the placenta detached, and the uterus contracted in a few minutes. One pale, flabby woman has been attended in five consecutive confinements. In the first two there was adherent placenta. Warned by this, and by her slow recovery, I have given ergot the last three times, with the effect of rapidly completing the labour and accelerating recovery. I have no doubt that ergot has been administered in fully one-third of my cases. No death has occurred from purely puerperal causes. Two women died within one month, from phthisis; one within twenty-four hours, from malignant disease of the liver of long standing; one woman, subject to epilepsy for several years, had an attack of decided epileptic character at the moment the child passed into the world, and before the placenta was extracted. In this case the labour progressed well up to the time of the attack. Urine, passed a few minutes before, had no trace of albumen. One case of death was remarkable. The patient was attended by me in six labours. Soon after the first she became the subject of ovarian disease. Its progress was unusually rapid, and paracentesis was performed at the sixth month of her second pregnancy, when three gallons of fluid were evacuated. No . difficulty ever occurred in her labours. Between every succeeding pregnancy she was tapped, and the same quantity of fluid drawn off. During the last pregnancy the operation
doi:10.1016/s0140-6736(02)44123-2 fatcat:csadawjvinhm3g7voojf5xp4ie