The forceps were tried, but it was impossible to effect the delivery. This ex- professor proposed the Caesarean section, but the family dissented in the most positive terms. The doctor insisted that he would withdraw from the case, if the operation was refused. The impaction was so firm, the mother’s condition so how, and the child’s vitality in such doubt, that craniotomy was the only resort.
In this connection we beg permission to call attention to a remarkable case of Caesarean section reported in the December number of the Chicago Clinique, by our esteemed colleague, Prof. R. Ludlam. We have give an abstract of the case:.
A woman some months pregnant, was found to have a contracted pelvis, with two fibroids blocking up the uterine outlet. An exploratory incision was made, and the uterus was found to contain a living foetus. One of the fibroids was removed, and the incision was closed. When the pains came on, at the full term of gestation, in December following, Dr. Ludlam performed the Caesarean section, with antiseptic precautions, and removed a healthy child, weighing eight pounds, and saved both mother and child. It is due our friend Dr. Ludlam, to state that his conception of the complicated difficulty was not only bold, but brilliant and practical in the extreme.
In the matter of therapeutics peculiar to utero-gestation and the puerperal state, there is is such a growing tendency to consider these states physiological and normal, as to discourage the practice of drug administration almost altogether.
In obstetrical therapeutics we have recently made more advance in the uses of electricity than in any other direction. This agent has come to the front recently after fashion in commerce, science, art, propulsion and heat, as to make one’s head almost giddy when he stops to think of present realities and immediate future promise. To the obstetrist it possesses peculiar interest in the management of uterine inertia, and spastic irregular uterine action. In the severe lumbar pains of the first stage it serves a valuable purpose; also for cramps of the lower extremities in the second stage. For such purposes, both the galvanic and faradic currents will be found useful, in accordance with the special symptoms.
The destruction of the foetus in extra-uterine pregnancy by the faradic current has been recently proposed, and received practical attention. If the dead foetus becomes encysted so as to convert it into a benign tumor, we may have relatively a happy solution or conclusion of a grave difficulty. Should signs of decay and disintegration take place after the faradic application, we should promptly resort to laparotomy to save the patient from the horrors and complication of a widespread septicaemia. We should say of such cases as we did of occipito- posterior position: it is much better to escape then altogether than to be responsible for management and result.
The puerperal state is subject to various febrile disorders; some transient, some more permanent. We think the peritoneal form usually known as puerperal fever is less frequent than formerly, and even now not so frequent as may be supposed. We believe there is a puerperal fever which is a zymotic affection or an essential disease, and other forms that are septicaemia. No doubt the majority of puerperal fevers originate from heterogenetic causes, and may be regarded as puerperal septicaemic. This is the opinion of the majority of clinicians, who esteem it de facto as a septic process and closely allied to surgical fever.
No doubt cases of puerperal fever may occur form auto- infection as well as hetero-infection. When the results of traumatism are considered, it would seem, in certain cases, to be independent of either. The practical thought to be kept in mind is, that woman the puerperal state is much predisposed to the adverse influence of any toxic agent that may happen to be near her. Precisely the reverse is true during utero-gestation. But in the puerperal state neighborship to cases of any malignant or contagious form of disease always renders puerperal fever probable.
Physicians in attendance upon diphtheria, scarlet fever, or malignant typhus should decline all obstetrical calls or engagements. Physicians afflicted with obstinate chronic ulceration and discharges, e.g., ozena, should never trust themselves in the lying-in chamber. It does not seem probable- only exceptionally-that this fever is propagated by any specific contagion, as we find in the causation of small-pox, scarlet fever, measles, and whooping-cough. Yet of two women in the same ward or room, both in the puerperal state, if one should chance to get puerperal fever, she will very likely communicate it to the other.
As perfect asepsis in labor is the first care of the obsterist, antiseptic agents should be always within reach. There is quite a list of those that possess distinct virtues.
Hot sterilized water, Boric acid, Calendula, Listerine, Corrosive sublimate, Creolin, and Lysol all have their especial uses as antiseptic agents, but after sterilized water Lysol is the most reliable. It is one of the most powerful germicides that we possess, and in gynaecological and obstetrical practice is perfectly innocuous. It is not costly, being derived from tar- oils by boiling with alkaloids and fats. It is employed in solutions of from one-half to three per cent. Sublimate, which is a powerful germicide, and is dangerous to some patients. Drs. Welsh and Vance think that it has already done more harm than good.
We are not quite ready to banish it from the accoucheur’s armamentarium, but it must be used with great caution. In a solution of 1/10000, in our own experience, it is absolutely safe. In organic kidney affections it is contra-indicated. The trouble with it would seem to be that it is an agent so powerful that we are all the while in danger of getting more than we bargained for. The puerperal woman would seem to be especially susceptible to its toxic action, as deaths have been reported from its use when used in a solution of 1/1500, and possibly in solutions still weaker.
The obstetrist will by no means seem to have discharged his whole duty without suitable attention to the little stranger. Formerly, if the said stranger indulged anticipations as to the immediate future after his arrival, he expected a hearty scrubbing in hot soapsuds, as a means of bodily renovation, at the expense of damage to both skin and eyes. Now we treat him to frictions in warm oil, followed by a warm bath without soap, and drying frictions with warm soft cloth, all accomplished so dexterously and quickly as to save exhaustion and bodily depression. If he arrives in anything like a feeble or had condition, he gets the warm oil frictions only, and is at once enveloped in a soft warm blanket.
The former elaboration of finery in dress for the young child should, in all cases, give place simply to a canton flannel gown, a buttock napkin, and the “belly-band”.
The eyes and mouth should be carefully washed with a new sponge and warm water. Should there be a reason to suspect any specific or unclean condition of the mother’s genitals, the eyes should be treated to a drop of Corrosive sublimate, 1 to 4000, or a drop of nitrate of silver solution, I per cent. strength, to be followed by a 10 per cent. solution of Boric acid, three times a day as a lotion, for one week. This precaution may save the practitioner as well as the child from the horrors and consequences of ophthalmia neonatorum.
If the child be a made, carefully examine the aperture of the foreskin, and if very narrow dilate at once and completely expose the glans, in order that it may be kept clean and that there shall be no phimosis.
And now, Mr. President and Members of the Congress, the limited space and time which I may prudently occupy on this occasion, when there are so many others with something valuable to say, have only allowed me to east about and touch points of interest and importance in the most causal way. If I have in the smallest degree contributed to your entertainment, I shall feel profoundly thankful for the use I may have been able to make of my opportunity. In any event, allow me to indulge the hope that you will a t least esteem me diligent and conscientious in the discharge of the duty you have imposed upon me-Quod Erat Demonstrandum-Amen.
SCARLETINA IN THE GESTATIVE AND PUERPERAL STATES.
BY JOHN C. SANDERS, M.D., CLEVELAND, OHIO.
OF all the varied zymotic maladies possible to the gestative and puerperal states of woman there is none more obscure in its aetiology, or ambiguous in its symptomatology, or problematic in its diagnosis, or more freighted with peril in its issue than scarletina, which has been chosen as the theme of this brief paper. Scarlet fever may attack either the gestative or the puerperal state. We will consider the subject in this order:.
I.-As declaring itself in the gestative state.
If the exposure to the infection has occurred in the early months of gestation the attack follows not much beyond the average period of incubation in the non-gravid state, and predominantly is inductive of abortion. That this should occur doubtless depends on two causative conditions; one is the exceeding high temperature of the maternal blood, for no other fever carries so high a temperature either in adult life or childhood, and this alone would very surely compromise embryonic life, and another is the doubtless direct toxic effect of the virus on the embryo, for it admits of no question that the embryo becomes infected through the virus, of which the mother’s blood can be the sole bearer.
