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Sudden death that may come to a recently delivered mother.

IN CHOOSING THIS subject I find there are several good reasons for undertaking the study of sudden deaths that may come to a recently delivered mother.

By sudden death, let it be understood, one that comes with relatively little warning when all seemed to be going well. This may occur within the first twenty or thirty hours after delivery, or may happen, without warning, any time within the first week.

The literature on this subject is very limited, and the study made as preparation for this article covered many authors, and few seem to have much to add to our source of supply for material. That fact that child-birth is a physiological process, and not a pathological one, would at first thought make it seem out of order to take up such a subject.

However, "step-mother nature" has her own troubles, and the pregnant mother seldom realizes what may happen before she again is up and around with her new babe.

One of our best authors states, "That more women die and are wounded in confinement every year than men die and are wounded on the field of battle."--(De Lee, p. 286.) While this statement is actually true, we should stop and consider why does this occur, and what causes such a record.

The possibility of sudden death from disease already known to exist in the mother, such as valvular heart lesions, hemophilia, nephritis, and diabetes, is apparent. These diseases, as we might know in advance, are such as to give a guarded prognosis, and the nurse should be on the alert to observe any symptom that demands immediate attention.

The danger of a relaxed condition of the uterus would give rise to hemorrhage, embolism, retention of dots, favoring sepsis and subinvolution.

Air embolism is one of the most sudden conditions to arise which would bring a fatal result.

Postpartum hemorrhage may come some hours after delivery as well as near the time, and it will depend upon the nurse, as well as the physician, whether the profound anemia and collapse are fatal or not.

Liver disease and faulty elimination, producing varying degrees of toxemia, and resulting in an acute nephritis with eclampsia, is a condition that may appear very suddenly. The sudden obstruction in the circulation of an organ far from the uterus is the most fatal; as, "pulmonary embolism, or thrombosis of the pulmonary arteries,--this condition bringing about pulmonary edema with rapidly fatal outcome.

The cardiac paralysis, which may come following the maternal efforts during delivery in a tubercular patient, or one with chronic kidney disease, is also a sudden source of death.

The brain may also be the seat of edema, in an eclamptic patient, or a cerebral thrombosis and hemorrhage.

One of the aggravations in the few hours following the delivery in an eclampsia patient may be an acute deglutition pneumonia. Any mucus, or blood from a wound of the tongue injured during a convulsion, may be inspired into the lung during the coma following the convulsion.

The rupture of the uterus has been known to cause death, and very sudden syncope and collapse will follow.

The hemorrhage of a placenta previa may also cause profound anemia and collapse.

Abruptio placentae, where the placenta may become detached entirely or partially from its site, with the symptoms of hemorrhage, pallor, fainting, weak pulse with some external hemorrhage as well, present a very bad prognosis for both mother and child.

The writer had such a case and the mother was delivered normally, but the placenta showed where it had been partially detached; the child was normal, and is now nearly a year old. Alas, the mother, twenty hours after delivery suddenly showed marked dyspnea, and pulmonary edema developed rapidly, with fear of impending death and marked cyanosis. Although the patient was perfectly conscious until three minutes before death, there was the awful air-hunger and progressing degree of cyanosis. Suddenly the click of an edematous glottis closed the tragedy: The lungs were profoundly edematous, due to pulmonary thrombosis. That was one of four cases of sudden death the writer has witnessed in the past twelve years. The others were:

An eclampsia patient, in profound coma, was delivered by vaginal Cesarian section and convulsions subsided, but death came some four hours after delivery, from pulmonary edema and acute inspiration pneumonia. The patient had many convulsions before any medical attendant was called.

Both cases just mentioned were primiparae.

The first case seen of this series of sudden-deaths was some eight years ago, when I Was called to deliver a multipara who had been under care of a midwife thirty-six hours. The "sac of waters" had broken twenty-four hours before I was called and an arm had extended from the vagina some fifteen hours. "They had waited for everything to get through." But, alas, nature had had no help! I had delivered the same woman successfully of a transverse child exactly two years before, and this time the midwife thought she could manage. I reduced the prolapsed arm and secured the feet and delivered; but the mother died within an hour, of exhaustion and cardiac paralysis. She had an old rheumatic heart.

The fourth case was a diabetic patient who developed maniacal symptoms at frequent intervals during her fifth and sixth month of pregnancy. These cleared away until she was about eight and one-half months pregnant, when she called me for a terrific headache. This was the hottest August day this country had ever known. I examined her as she expressed a degree of abdominal pain but declared she was not in labor. However, I found the os the size of a silver half-dollar and prescribed for the headache, and sent for her nurse. She was delivered in five hours from the time I was called for the headache, all the time declaring she was not in labor, and insisting that the nurse and doctor go home. But as soon as her child was born, she seemed perfectly herself mentally, and greeted the nurse and doctor, and wondered she had not known they were there. She was mightily pleased to see her babe, and begged she might take a nap.

The physician stayed about two hours, and confidently assured the husband that now his wife might expect to clear up mentally and recover. However, in about three hours the nurse telephoned, post haste, for the doctor, and when the physician arrived he found a profound diabetic coma, from which the patient never rallied. Before the end came, there was most terrible edema of the eye-lids, and bulging eyes with dilated pupils. Suddenly, like a flash from a gun, all was over.

That the unexpected may happen to the patient who apparently is relatively normal before and at the time of delivery, and that such a sudden fatality may come quite as much of a surprise to the physician as to her husband or grandmother and neighbors, is only to be learned by actual experience.

We, as fellow physicians, ought all to realize what a large number of causes may bring such results, and should be careful about expressing an opinion of a brother physician's case without knowing the facts. Right along this line fellow practitioners can either do one another great harm or good.

There are many turns in the road of the practice of obstetrics, and where today it may be I who have to sign the death certificate soon after a birth is recorded, tomorrow it may be you.

CLARENCE E. HEMINGWAY, M.D. Oak Park, Illinois

Reprinted from The Chicago Medical Recorder (October 1908). Courtesy of Morris Buske, Historian, the Ernest Hemingway Foundation of Oak Park.

"Letter to the Oak Park Boys" and "Sudden Death That May Come To A Recently -Delivered Mother"

Clarence Edmonds Hemingway

Hemingway's father was a natural historian by avocation, and his 1895 "Letter to the Oak Park Boys" details the botany, zoology, and geology of the Isle of Man, revealing the type of instruction that led to his son's understanding of the natural world. An obstetrician by profession, "Ed" Hemingway also reviews for The Chicago Medical Recorder the deaths of four patients in his care, showing himself to be an unflinchingly honest and self-critical physician. The father's work illuminates the tragedies of birth and death we see in the son's fiction, as well as the origins of Hemingway's clinically accurate and emotionally neutral style.
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Title Annotation:essay by Ernest Hemingway's father, Dr. Clarence Hemingway
Author:Hemingway, Clarence E.
Publication:The Hemingway Review
Geographic Code:1USA
Date:Mar 22, 1999
Previous Article:Letter to the Oak Park Boys.
Next Article:Tales of old Nantucket: Grace Hall Hemingway.

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