Imatges de pÓgina

ed, the os tineæ being so completely contracted, that all hopes on that head were annihilated. The pulse continued full, and the symptoms equally violent.

Although I had exceeded the quantity of bleeding and opiates laid down by the professors on midwifery whose lectures I consulted, I still thought myself justified, both in theory and practice, to extend the plan heretofore prescribed ; and, indeed, I considered no other method of relieving but that of relaxing. At 7 P. M. sixteen ounces of blood were again taken from the arm, and I directed her to be placed in a warm bath for twenty minutes, and ordered the following medicines to be administered:

R Tinct. opii 3i.
Aq. Menthæ pip. Ziss. M. ft. haust. omni hora su-

mendus, c. ii. pilul. sequent. Ro Gum. opii gr. vi. divid. in pilulas vi. She bore the operation of bleeding and the bath extremely well ; had three pains whilst in the water ; afterwards she was placed in bed, and bladders filled with warm water were ordered constantly to be applied to the epigastric region. I directed a steady perseverance in the medicines, and left her, with a most sanguine hope of its alleviating the violent agony she laboured under.

At eleven at night I was obliged to visit her again, and, to my great surprise and mortification, considering the quantity of opiates taken, and how far the system had been depleted, the disease was not overcome. The most remarkable circumstance was that of the opiates not affecting the head, producing delirium, or sleep, considering the enormous quantity exhibited. The pulse at this time was 70 in a minute, and rather full; thirst considerable; she had made no urine since the morning. I thought that the pains did not return so frequently as when I saw ber last, and I flattered myself that, by pursuing my old plan a little farther, complete success would attend my efforts. Therefore sixteen ounces of blood were abstracted from the arm, and the draughts and pills repeated, each pill now containing three grains of opium. She went through the operation of bleeding very well; and, notwithstanding she had four pounds of the vital Auid abstracted from the arm in twelve hours, she did not appear in the least exhausted. I left her for the night, and directed the medicines to be given regularly, and herself to be kept quiet. About two o'clock the next morning I was called up. They intormed me that the pains were relieved, but, to use their own expression, they could not confine her in bed. I naturally concluded, that, as the excitement in the system was alleviated, the opiates in all probability produced the delirium which I conceived to be the cause of her uneasiness. As the bowels were constipated, the following aperient was administered :

R Infus. sennæ simpl. Zii.

Magnes, sulph. Zss.

Tincturæ Rhæi palmat. Zi. M. ft. H. statim. sumendus. The draught operated several times, and the head was soon relieved She had about three hours sleep in the night. I entertained great hopes the paroxysms would not return. About seven the next morning she had a relapse of the pain. On placing my hand on the abdomen, I could plainly perceive the uterus contracting as violently as ever, and the paroxysms returning at intervals with equal impetuosity. Anxious as I was to relieve, I must acknowledge I felt fearful of depleting the system any farther, although the pulse was at 60, and rather strong, as I had exceeded almost the bounds of moderation. Never having before met with a case of this nature that shewed such obstinacy; and as the loss of too much blood frequently produces anasarcous swellings from relaxing the absorbent system, I contented myself by extending the opiate plan. The follows ing was taken:

R Tinct. opii zi.

. gum. acaciæ 3ij.
Spt. æther nitros. Zss.

Mistur. camphor. Zij. M. ft. haust. omni hora, sum. With each draught, a bolus, containing four grains of opium, was given.

About one P. M. I visited her again, and was extremely happy to find the pain abated by the first dose of the medicine. The effects of the opiates were desired to be kept up, with an intention of preventing a recurrence. On the 7th, I found her quite tranquil. She had slept most part of the night, and perfectly easy. She complained of a violent soreness of the abdomen. She vomited some bile several times this morning. The irritation of the uterus most probably produced the sickness by sympathy. The head was but slightly affected. The pulse at 80. Directed her to continue her anodyne draughts three times a day, each containing gtt. xxv. tincturæ opii, and to remove the abdominal affection, the cathartic draught was repeated. On the morning of the 8th, I visited her again. She passed a quiet night; the soreness of the abdomen nearly removed; the bowels quite regular; head very little affected ; the vomiting still continuing at intervals. The prescription below was taken :

B Carbon potass. 3ij.

Tinct opii 3j.
Misturæ camph. Zij. M. ft. mistura cujus sumat

cochlear. ii. major. 4tis horis, cum cochlear. i. mag.

succi limon. incipiente ebullitione. Notwithstanding there was a considerable quantity of bile regurgitated into the stoniach, from the violent action of the system, still there is no doubt that the effects of the opium rendered the digestive organs somewhat torpid; a circumstance that frequently occurs, when it is necessary to persevere in it for any length of time. With the intention of restoring it to its pristine state, the mixture in the act of effervescence was directed to be taken. On the 9th the head was perfectly easy ; passed B quiet night ; the nausea nearly subsided. Pulse at 70, and rather full. Ordered her to continue the saline mixture three times a day. Appears to recover rapidly. On the 10th the nausea and vomiting completely removed. Pulse natural, and in fact she appears perfectly well ; not the least debility existing, notwithstanding the quantity of blood abstracted.

It may not be improper to observe, about two months previous to this attack, she was affected in a similar manner. А draught composed of gtt. xl. tinct. opii, and blood-letting to 12 ounces, afforded instant relief; and she continued perfectly well, until the affection now detailed. As the quantity of opium in this instance was much greater than what is generally given, the subjoined table, as to the manner and quantity administered froni the 5th of June to the 8th, probably may not be uninteresting

The exact particulars are as follows, taken from my day-book:

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The first day she became indisposed, 840 drops of the tincture, and 27 grains of the solid gum, were administered.

My only object in forwarding this case for publication is, to


prove how far the depleting and opiate plan may be carried, without injuring the constitution. The quantity of blood abstracted, and opium taken, really appears to be enormous ; but it is evident to me, that, if this plan had not been persevered in to the extent mentioned, dissolution must certainly have been the consequence--most probably from too great a de termination of blood to the head. I was fully aware, where spasm and pain existed, that opiates might be given in considerable quantities, without affecting the system in any other way than alleviating the misery the patient laboured under, as is conspicuous in this instance. Although my patient had taken 840 drops of the tincture, and 27 grains of the gum, the first day of the attack, it neither affected the head nor constipated the bowels, so long as the irritation remained ; so soon as that was alleviated, it instantly operated on both. Opium, when taken where there is excessive irritation, does not produce that constipation, (that generally affects the bowels when the system is labouring under a disease where irritation does not exist); it operates as a specific stimulus, and generally destroys the excitement, without producing vertigo, or any other unpleasant affection. In this instance the quantity exceeded all I have ever seen or read of; but, as the case terminated favourably, it proves the plan may be extended much farther than is

generally pointed out on such occasions.

On the 29th of the same month (June) I was desired to revisit the above patient. It was 11 A. M. and I found that premature labour was approaching from the dilatation of the os tincæ ; pains coming on regularly, and at proper intervals; but as there was considerable rigidity in the uterus, the labour did not make much progress, and nothing could possibly be done except waiting for the operation of nature. At one o'clock, I could perceive the uterus had dilated considerably since I examined her before; and at three P. M. labour had advanced so far, that the head rested on the perinæum. Still a great rigidity remained, and a considerable disposition in the uterus to contract. After remaining nine hours in this state, without making the least progress, and as her pains were in a great measure abated, the pulse sinking, I thought myself justified in using art to assist nature in her efforts ; consequently, at midnight, I applied the forceps, and the head was delivered in about ten minutes. After this was effected, the pains began to return, from the stimulus the uterus had received, when I endeavoured to extract the body. I found it was utterly impracticable, owing to the violent contraction of the uterus on some part of the child. Still willing to give nature a chance to exert

her own powers, I waited three hours without using any extension, concluding the womb would relax and expel the fætus. At the expiration of the above time, I gave her tuo grains of the gum. opii, with an intention of obtaining a relaxation of the uterus. Some hours after this was administered, I endeavoured to make a gentle extension, which proved to be fruitless. No doubt existed in my own mind but what this was an hour-glass contraction, so frequently spoken of by lecturers, and so seldom met with in practice. When the child was delivered, my idea proved correct, as the difficulty was from its contracting on the buttock of the child. As my patient's situation at this time was very precarious, and considerable weakness existed, I consulted with a medical neighbour. After sufficiently considering the case, he was of my opinion, that it was impossible to deliver at this time by extension, as the contraction remained with equal violence. Had we so proceeded, a laceration of the uterus would most probably have been the consequence ; consequently I proposed to administer gtt. cl. of tinctura opii, which was given immediately, and suffered her to remain quiet. The effects of the opiate procured sleep, and after remaining in that state two hours, labour-pains returned, and instantly expelled the fætus. Nothing remarkable occurred after delivery. She was treated in the usual manner, and is now perfectly restored.

The power opium possesses over the uterus is really surprising. In a few hours it alleviated all the excitement, and rendered the labour manageable. Depletion would have been used in this instance, bad it not been for the great quantity of blood abstracted in her former attack. The contraction in this case was more violent than I ever saw or met with in any of my medical researches. The disposition which the uterus evinced to contract at so early a period, struck me forcibly as indicating that the case would be difficult and laborious ; and had it not been for the repeated depletion, in all probability it would have proved more obstinate, and of an unfavourable termination.

July 12, 1815.


Two Cases of Wounded Artery in Venesection cured by Compres

sion. By C. K. CRAWFORD, Surgeon, R. N.


T was surgeon of the Venerable, under Admiral Durham, two cases of puncture of the brachial artery in bleed.


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