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nate, nux. voin. is sometimes indispensable, and when peritonitis threatens, the cold coil externally, and belladonna internally are used with advantage. When the temperature rises, and chilliness and shuddering indicate suppuration, calcium sulphide, with the carbonate of lime, have often been of material benefit.

TWO CASES OF RUPTURE OF THE UTERUS IN THE
PUERPERAL STATE.

BY

S. MARX, M.D.,

Ex-House Surgeon to the New York Maternity Hospital; Int. Assist, to the Royal LyingIn Asylum, Munich.

IN one of the cases cited below, the diagnosis of a rupture was verified on autopsy, and all the symptoms were clear and well defined; while in the other, although the symptoms and all the circumstances connected with the case were such as to warrant me in making a diagnosis of uterine rupture, no autopsy could be obtained, so that the correctness of this supposition could not be substantiated.

CASE I.-Primipara, æt. 23; single. Previous history good. Has always been well since infancy. Slender blonde; good muscular and osseous development, and looks the picture of health. Labor began at term, March 2d, at 2 A.M., with slight nagging pains. Called in a midwife who found os just beginning to dilate. Head fixed in the pelvis; child alive. Its heart tones clear, distinct, and of normal frequency. General condition of patient good; pulse and temperature normal. Pains good and regular all day.

March 3d. Labor progressing very slowly; membranes ruptured some time during the night. Heart tones of child not heard this morning. Os size of twenty-five cent piece; rim sharp and well defined, in close contact with the head, which was now firmly fixed in the pelvis. Pulse accelerated; temperature 103.3°; condition the same all day. Called to see the patient at 6 P.M. and found her in fair condition. Pulse and temperature but slightly increased. Examination revealed a large child in the V. R. Ŏ. A. position. Loud uterine bruit present. Child's heart tones not heard. Os dilated to size of fifty-cent piece; very sharp and tense; low in the pelvis. Vagina in normal condition. Discharge

slightly bloody; no fetor; no cause ascertainable for the tedious. labor, except the premature discharge of the amniotic fluid, as the pains were strong and good, and everything favorable for a speedy delivery. Ordered hot douches. From the midwife's notes I record the following: Pains good all night and os slowly dilated, so that the head descended to the pelvic outlet. Temperature during night 101.3°; pulse 100; vaginal discharge not noted.

March 4th, 9 A.M. Called and found patient in deep collapse, which came on with great pain in the abdomen at the height of a contraction. The head, which was at the outlet, did not recede. Child speedily delivered, found dead and macerated, placenta and membranes expressed entire. The mother's condition was that of profound collapse; the abdomen had become very suddenly tympanitic. The distention extended high up under the costal cartilages, driving them out in a marked degree. Percussion note highly resonant, so that any dulness in the abdomen was not discoverable. In spite of all treatment, the patient died in one hour.

The diagnosis in this case was clear, a rupture of the uterus. Autopsy. I shall record only the condition of the genitalia: High in the vagina was a puerperal diphtheritic line of ulceration which extended over the cervix in the median line. The endometrium of the anterior uterine wall was the seat of the same ulcerative process. Above, it terminated in a circular spot of ulceration at which point the fatal rupture occurred. The lesion extended through the mucous membrane and partly into the muscular coat, leaving the serous covering unaffected except for a slight fibrinous exudation at this point.

Here, then, we have a vaginitis, endometritis, and diphtheritic metritis terminating in a rupture.

There can be no doubt that the primary cause of all this trouble was an infection of a septic nature, occurring before the termination of labor, which produced such lesions of the mucous and muscular coats of the uterus that, in its weakened condition, it could not withstand the pressure of an active contraction. That the infection was direct from midwife to patient cannot be doubted, as all the features of the case, the rise of temperature, depression of the pulse, the septic condition before death, and the evidences shown at the autopsy, I think, are conclusive enough to show that the infection was introduced early in labor. Why not say it was due to atmospheric infection, as is frequently done when some person is trying to shield himself from blame? That the atmosphere is rarely, if ever, the carrier of infection has been proved almost beyond a doubt (Winckel, "Path. u. Therapie d. Wochbet."). There is no more truth in the theory of atmospheric infection than there is in the statement that there is such a disease as milk fever. A diagno

sis of such a disease is absurd, for in every case should the physician look further; he will find some other cause for this thermal rise. A congested mamma, constipation, ulceration in the vagina, and so on, will give a temperature quickly, and a high one at that. This case was to me of great interest for several reasons: 1st. As being a case of uterine rupture. 2d. As being a case of so-called puerperal fever, the cause of which was a direct infection occurring before labor terminated. 3d. As showing evidences of a diphtheritic ulceration which certainly must have been present during the progress of labor. 5th. On account of the unusual cause of the rupture-a diphtheritic ulceration.

CASE II.-Mrs. H., æt. 40, IV para. Stature small. Development and general condition poor. Fairly marked anemia. Had rachitis when a child. Has had three children. Their birth not attended with any difficulty. Children at birth very small, probably premature, from the history of their condition as stated by the mother. Previous health good. During present pregnancy her health had been excellent. Labor commenced at full term, March 23d, 2 A.M. Immediately called in medical attendance. Os was found nearly fully dilated. Head still movable above the brim. This condition remained about the same all day, with strong pains, which were intensely painful. Saw the case this evening about dusk. External examination showed the head to be engaged. Back of child on the right abdominal side, feet upper and left side. Heart tones to the right below the navel, very irregular, running from 70 or 80 to 120. A strong umbilical souffle was heard at this point. The internal examination revealed at V.R.O.A. position. Head fixed, the small fontanelle anterior and to the right. Os fully dilated. Vagina edematous, hot, and painful. In order to examine the pelvis thoroughly, I introduced the hand into the vagina, and found considerable contraction at the inlet. The promontory jutted forward considerably, making almost an acute projection into the pelvis. The diagonal conjugate was less than ten centimetres. The head was very large, and a decided caput succedancum had formed. Meconium discharge was present. Temperature 100°. Pulse 100, full but very compressible. Patient felt worn out and tired. Urine and bowels moved spontaneously. Owing to the threatened death of the child and the condition of the mother, I proceeded to apply Simpson's forceps, the application of which proved very difficult. The left blade would be almost every time displaced by the projecting promontory. After repeated attempts I finally locked them. The delivery proved difficult, and more force was applied than was safe to either mother or child. After traction of ten minutes, the forceps were removed, but the head had not perceptibly moved. Listening to the heart tones of the child, I found them still weak and about 80 per minute. Knowing how difficult the delivery

would be, I favored perforation and extraction, but was met with a stern refusal by my colleague. Argument did no good. I had an extreme conservatist to deal with. Placing the woman on the right side, the forceps were again applied, direct backward traction made, and after about twenty-five minutes, the head passed the contracted portion with an audible snap. Perineum intact. Placenta and membranes entire, half-hour post partum. Patient came out of the narcosis in good condition and expressed herself as being happy that the child was born. Child male, strongly asphyxiated when born. Resuscitated by Schultze's method. Weight 4,500 grammes (average 3,200). Its head was hydrocephalic and had a circumference of 37.5 centimetres. The head was badly wounded; a deep depression about the breadth of two fingers was found at the upper and right portion of the left os frontis, produced by the continuous pressure against the promontory. On the upper part of the right facial region, including the right eye, the epidermis was absent, the parts black, and the eye closed. On the left parietal bone was also a deep furrow. The two latter places were the contusions caused by pressure from the forceps. On the second day, a hematoma appeared on the left parietal bone, which suppurated and was opened. On the sixth day, the child showed symptoms of an acute meningitis and died the next day.

Post Partum History of Mother.-No reaction followed the delivery.

March 24th, A.M.-Patient in good condition. No pain or tenderness anywhere. Temperature normal. Pulse good, 80. Lochia scanty, bloody, and sweet.

March 24th, P. M.-Notes the same. Condition very satisfactory.

March 25th, P. M.-Patient, who had been in good condition previous to this hour, suddenly collapsed. The midwife noticed the pale, anxious countenance. The medical attendant gives the following history: The woman complained of sudden abdominal pain. Lochia scant and sweet. No evidence of bleeding. He found the patient in an extreme collapse. Respiration superficial and sighing. Pulse small and compressible, 180. Temperature 97.1. No paralysis present. No cough or bloody sputa. Mind clear.

Heart.-Rapid and feeble; except this, nothing abnormal

found.

Lungs.-Suspecting an embolus of the pulmonary artery, the lungs were as carefully examined as the condition allowed. Percussion and auscultation normal, except somewhat sharpened breathing on the right side behind. The abdomen had become suddenly very tympanitic, except at the dependent parts in a circle from right to left, where the percussion note was very flat. Uterus could not be mapped out, neither by palpation nor percussion. The examination was not pushed further, on account of the death of the patient.

An autopsy was not allowed, so that a positive diagnosis could not be made, but by carefully excluding those conditions which might be mistaken for it, by thoroughly weighing each symptom individually, the sudden collapse without premonition, the absence of striking pulmonary symptoms, the marked abdominal symptoms, I concluded to diagnose this case as one of rupture of the uterus on the second day post partum. Numerous as the conditions are which simulate this case, time will allow me only to mention a few of them. The most frequent causes of sudden death in the puerperal condition are:

I. Embolus of the Arteria Pulmonalis. Absence of a murmur in the pulmonary vessels, indicating an obstruction, the absence of local symptoms, as dulness on percussion, or a decided change in the vesicular character of the breathing, the intensity of the sudden pain in the abdomen, with the intense meteorism present, are all against the diagnosis of embolus. Cases have been recorded in which general symptoms only were present, very much like those in the above case; especially have I reference to the case of Cruveilhier, whose patient died on the sixth day. On percussion nothing at all was found, and on auscultation only a few almost inaudible mucous râles were heard.

II. Syncope and heart paralysis, whether depending on an organic or inorganic trouble. Among the organic lesions may be mentioned fatty heart and acute myocarditis. These conditions, especially the former, can be at least surmised if not diagnosed by auscultation and previous history of the patient, and, furthermore, they do not come on so suddenly as to throw the patient into a fatal collapse without premonitory symptoms, especially is this so in cases of fatty heart. In my case, there was nothing to be noticed in the heart up to the time her malady appeared. An interesting case of death in the puerperal week from an acute myocarditis is cited by Spiegelberg. In this patient, there occurred a heart rupture on the third day post partum. No symptoms whatever occurred to indicate any trouble, so insidiously did it come on. Besides the above troubles, one might think of entrance of air into the circulation, and rupture of the gut from pressure causing ulceration, the differentiation of which I shall not attempt; finally, a very acute case of virulent septicemia which runs its course in a short time, so quickly that the local symptoms have hardly time to manifest themselves. But, in the above case, the absence of

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