grains in 24 hours. Under this treatment, with the addition of full doses of tincture of iron and a liberal diet, the patient began slowly but steadily to convalesce. April 14th, 1883, I made a careful examination and found a bilateral laceration of the cervix uteri, but I also found that nature had almost completely restored the perineum. Case No. 2.-January 9, 1883, at 4 o'clock A. M., I was called about four miles in the country to see Mrs. McD., who was about to be confined with her third child, thirteen years having elapsed since her last confinement. I found that Mrs. McD. had retired the night before in her usual health and slept well, until she was aroused by the rupture of the membranes and the flooding of her bed with the amniotic fluid. With the discharge of the water there was no further pain. The labor did not begin until one week later, when the "pains' began, and the labor progressed slowly but satisfactorily. On the morning of the 16th a small but healthy living child was born. The mother continued well until the third day, when I received a note from her husband asking to see his wife immediately, saying that she had a slight chill during the night, followed by a temperature of 102. By the time I reached her the fever had subsided and the patient's condition was quite natural. Supposing that it was the "milk fever," I gave myself no concern about it. The following night we had a repetition of this condition, a slight rigor, followed by fever, with a temperature of 103 and a sweat, which thereafter continued for some days. Accompanying this was great prostration and a sharp pain in the left groin, shooting down the leg, being particularly severe in the calf of the leg. There was tenderness in the groin and calf, but none in the thigh. This condition of things continued for two days-continuous pain, but varying in intensity, down the left leg, with fever (103 or 104) at night, with nearly a normal temperature the next morning. On the third day (sixth day of confinement) I found that the pain had entirely left the left leg, and had appeared with increased severity in the right groin and leg. This confirmed my suspicions that I was again dealing with malarial neuralgia, rather than phlebitis, which seemed to be the case at the outset. I accordingly prescribed quinine in 10-grain doses three times daily. Not being fully relieved, the family physician, Dr. Charles O'Donovan, was called in. The Doctor, for certain reasons, suspected specific cause of the neuralgia, and suggested substitution of iodide of potash for the quinine which I was giving. To this I assented. After three or four days' trial of the iodide our patient had daily increasing fever, and manifestly grew worse. I then advised a return to the quinine. The patient's stomach bore the quinine so badly that we determined to administer it per rectum. We gave 30 grains at night and 20 the following afternoon. Under these doses the temperature, which had risen to 104, was reduced to 101, and finally to 99, at which it continued for several days, and the patient went slowly on to convalescence. Case No. 3.-January 19, 1883, was called to see Mrs. S., primipara, aged 19, apparently in excellent health. For about twelve hours the pains were rapid and very strong, yet they were wholly unable to dilate the os, which obstinately continued to present a diameter of about two inches. In this emergency, as is my habit, I administered chloroform quite freely, and in a short time had the satisfaction of seeing the os dilate. Still the head would not descend. The labor was terminated by the forceps without any special difficulty. Everything progressed favorably until the sixth day, when a slight chill ushered in a high fever, with a temperature of about 103. During the day the temperature receded nearly to normal. The next day there was a repetition of this condition. This satisfied me that I was again dealing with a malarial disease. Two 20-grain doses of quinine prevented the return of the chills and fever, and in about one week my patient was convalescent and my visits ceased. I have reported these cases that I might direct attention to some very interesting facts which they reveal with great clearness. 1st. These cases occurred about the middle of January during weather of unusual severity. 2. The first of these patients lived in the country (at Mt. Washington) during the summer, and in town during the winter; the second one lived exclusively in the country; the third one exclusively in the city. 3. They were all well and strong, with no signs of disease until after their confinement. 4. They were all attacked with malarial fever a few days after their confinement. 5. The third case was one of simple intermittent fever, and promptly yielded to the moderate use of quinine. Case No. 2 presented peculiarities that rendered the diagnosis very obscure for a few days. The labor in this case was perfectly natural after it fairly began, there was no delay in the delivery of the child, no injury to the organs of the mother. Everything was entirely satisfactory until the 3d day, when there was a slight, very slight, chill, followed by fever (102) and subsequent sweat, which continued for some days. This condition was followed by prostration, and sharp pain extending down the left leg, which was especially severe in the calf of the leg. With this pain was great tenderness in the left groin over the region of the crural nerve and vein. What did this mean? What is crural phlebitis? I felt embarrassed by the situation and could make no positive diagnosis. In order to gain time, and also to relieve the pain, I ordered 20 grains of bromide of potash and 5 drops of tinct. of aconite root every three hours. This apparently acted with great promptness, for that afternoon the pain and fever were gone and the patient was relieved. The following night, however, the chill was repeated with increased fever, temperature 103, but there was no pain in the leg. This cleared the diagnosis to my mind, and led me to conclude that I was dealing with malarial fever. This was verified by the fact that the case was cured by larger doses of quinine, viz. 50 grains daily. The first case presented still more difficulty in diagnosis. In this case there was a ruptured perineum, a lacerated cervix uteri, there were chills, high fever (temperature at 104), continuous sweating and great prostration. Thus everything seemed to indicate septic fever. This appeared to be the opinion of my consulting colleagues, and their judgment seemed to be corroborated by the persistent return of the high temperature in face of the administration of 50 grains of quinine. Notwithstanding these adverse circumstances, the great fluctuation in temperature, which ranged from 100 in the evening to 104 in the morning, induced me to think that the attacks were malarial. I have never seen so wide a range of temperature in septic conditions. I therefore urged increased doses of quinine, and accordingly we gave six grains every two hours, until 72 grains were administered. This quantity effectually broke down the temperature, which never afterwards rose above 100, and there was a slow but steady return to health. Another interesting feature, which was common to the three cases, was the occurrence of these malarial attacks in the midst of the most severe weather of the past winter. They seemed to originate de novo, because neither of these patients, so far as I could ascertain, had ever before suffered from malarial disease. They certainly did not do so during the previous fall. Prior to their confinement they were apparently in vigorous health. Can it be that they had been poisoned by malaria, and had the strength to resist its influence until they were weakened by their puerperal condition? LIST OF PRESIDENTS-1799-1883. Upton Scott, 1799-1801. Philip Thomas, 1801-15. Ennals Martin, 1815–20. Robert Moore, 1820-26. |