Media vita in morte sumus

penetrating and lacerating wound of abdomen of pregnant woman“In the midst of life we are in death”, in the words of the funeral service of the Book of Common Prayer. That sentence expresses the Christian notion that death is not the irrevocable end, but also a new beginning. Sometimes in medicine death and new life are indeed inextricably linked – as, for example, in this extraordinary case reported in the Medical Record in 1867:

On the evening of April 5, 1867, Mrs. E, aged 42, the mother of eight children, and then in the eighth month of pregnancy, was struck in the abdomen by the horn of an enraged cow. The horn did not tear through her clothes, but she felt the child drop out, caught it in her dress, and took a few steps homeward.

A horrible accident to befall a pregnant woman – but the first signs were not too ominous. She was still able to walk, and the fact that her clothes had not been torn suggested that her injuries might not be too severe

Here she was met by a neighbor, who assisted her to the house, distant about twelve yards from the place of accident. With this assistance Mrs F. walked to the house, and then sat down, but the neighbors soon laid her on the floor. Her friends up to this time, supposed that the child had come per vias naturales

‘per vias naturales’ meaning ‘through the natural passages’. They assumed that the shock of the incident had caused her to go into labour – and, after eight previous pregnancies, it would be reasonable to assume that labour would be quick and straightforward.

…but when they lifted up the clothes they found the bowels protruding and “reaching to the feet,” as one of them stated.

Oh my word. The affair now took on a far more worrying aspect.

They cut the umbilical cord, removed the child, endeavored to replace the bowels as far as possible, covered them with a clean cloth, and left her in this condition until my arrival. I arrived at the house about three-quarters of an hour after the accident, and found the woman lying on the floor, extremely prostrated, pale, and with a rapid and barely perceptible pulse.

Dr Marsh found that her clothes were soaked in a ‘considerable’ amount of blood, and there was a trail of blood between the scene of the accident and the house.

I removed her to a mattress, and, on examination, found several feet of intestine and the uterus lying exposed, protruding through a wound of the abdominal wall.

This was a fairly ghastly injury. The womb had also been lacerated and partially inverted, with the placenta attached and visible on its inside wall.

The wall of the abdomen was torn for about five inches, the wound extending from the umbilicus outwards and somewhat downwards on the left side, in an almost straight line. I returned the intestines, removed the placenta, and replaced the uterus.

On the other side of the Atlantic, Joseph Lister had just started to use antiseptic measures to reduce infection after surgery or injuries, but such novelties were as yet unheard of in rural New York. There was an overwhelming danger that her wounds would be colonised by bacteria – especially given that the lacerations were caused by a cow’s horn.

I then united the wound with sutures, plaster, and put on a broad bandage. She was entirely conscious, complained little of pain, but was very restless, throwing her arms about and rolling about the bed.

This is hardly surprising: she must have been in agony. The measures employed by Dr Marsh for pain relief seem to have been woefully inadequate to the job. Opium or its more powerful derivative morphine were both available by this date, so it is perhaps surprising that he did not use either:

I had given her constantly from my arrival small quantities of brandy and water, but she did not in the least rally from the shock; the pulse soon became imperceptible, and in about an hour and a half from the reception of the injury, she died.

Sad but, in the circumstances, not unexpected. It was unlikely the doctor could have done much for her. But amid the gloom, one small ray of light:

The child was a boy, was not injured in any way, and is still living.

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