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Puerperal Convulsions without Albuminuria (in a case of twins,) treated
by Chloroform and the Artificial Induction of Labour. By DONALD MACLEAN, M.D., L.R.C.S.E., Professor of the Institutes of Medicine, and Lecturer on Clinical Surgery, Queen's University,
Kingston. Case.-Mrs. C., (Township of Storrington) aged 32. Pregnant for the sixth time, has had twins once before.
All her previous pregnancies and confinements having been, so far as she is aware, quite normal. Her general health has always been excellent, until within the last three months, during which she has been subject to severe attacks of neuralgia in the head, face and neck. Six weeks ago she applied to me on account of one of these neuralgic attacks, and I succeeded in instantaneously arresting her severe sufferings by the hypodermic injection of solution of morphia.
The respite lasted for a fortnight, but at the end of that time she again applied to me and with the same result, by the same means as on the previous occasion.
I heard no more of her until the 29th ult., when her husband called on me and stated that Mrs. C. had been suffering very severely from neuralgia in the head, neck and left shoulder for several days, and that on the previous day (Sunday the 28th) spasmodic movements (twitehings) had appeared in the left arm, that these movements, as well as the neuralgic pains had gradually increased in violence, until sometime through the night, they culminated in what appeared to him a regular epileptic fit, which left her in a state of stupor, from which she had not altogether recovered when he left her early on Monday morning.
I at once suspected puerperal convulsions and acceded to Mr. C's. request, to see her as soon as possible. We arrived at Mr. C's. house, which is twelve miles distant, at 2 p.m. on Monday, and found the
patient in a strong convulsion, which the attendants informed us was the third since Mr. C. left home.
I immediately administered chloroform with the effect of arresting the convulsion and setting her to sleep. She slept soundly and naturally for more than an hour, and then sat up in bed and conversed with remarkable intelligence and cheerfulness. She informed me that she was just entering upon the eighth month of pregnancy, that she thought the child was dead and had been so for some days, and that she had felt for some time that “ all was not quite right.” She attributed all her present troubles to a fall from a buggy some weeks previously, since when she had not felt right. It was soon after this fall that the first attack of neuralgia came on. During the three hours that I stayed with her on Monday there was no return of the eclampsia, but the twitching of the left arm continued; otherwise she appeared quite well, the neuralgia had entirely disappeared, and she partook of some refreshment with a relish.
On examination, I found that the fatal heart was beating a little to the left of the middle line, at a point about three inches above the pubis. I could hear it only in this situation, so did not suspect the presence of twins, although the uterus was unusually distended. At this time there was no appearance of labour. Having given the nurse full directions how to use the chloroform if the convulsions returned, and having procured a small quantity of urine to test for albumen, and to examine microscopically, I left her and came home.
The urine contained neither albumen nor casts, on the contrary appeared to be quite normal.
Early on Tuesday morning a messenger came from Mr. C., with the information that Mrs. C. was much worse, (the fits were becoming gradually more and more frequent, and the chloroform had lost its effect,) and a request that I should lose no time in visiting her. At ten (a.m.) I found her to all appearance “in extremis.” The convulsions were very violent and almost unintermitting, pulse nearly imperceptible, extremities cold, no signs of labour coming on. The attendants stated that she had been quite insensible since three o'clock (a.m.), and that the chloroform had no effect in arresting the fits. Notwithstanding this latter very discouraging statement, I determined to resort once more to chloroform, and the result was that in a very few minutes all reflex action had ceased, and the patient lay perfectly quiet, but in a condition very closely resembling coma.
After the lapse of ten minutes, the arm began to twitch violently, and it was evident that another fit was coming on. The chloroform was immediately resumed, and very soon the patient was quite quiet once more.
The fit appeared to have been summarily arrested by the anæsthetic. By this time I felt convinced that the cause of all the trouble was the overdistended condition of the uterus and that the only course for me to adopt with a view of saving the life of the mother and child was to remove the cause, by artificially inducing labour.
This I at at once proceeded to do by introducing into the uterus a flexible catheter and by injections of cold water into the vagina, the fits being kept in check meanwhile, by chloroform.
In a short time, I was gratified to observe the uterus contracting and the os uteri sensibly dilating. The latter process I endeavored to promote by digital pressure.
So soon as the os had opened to rather more than the size of a half dollar silver piece, I ruptured the membranes, when an immense quantity of water gushed forth and an arm presented.
I attempted to perform podalic version, but found myself unable to do so, (no doubt on account of the presence of a second child,) but the os was now nearly fully dilated, the uterine contractions were very strong and frequent, and the child very small; I therefore used the crotchet and delivered the child double. As soon as this child was born there was another great gush of liquor amnii, and on introducing my hand a second child was found, presenting by the feet, and was very rapidly born, and almost simultaneously the double placenta was expelled, without any flooding, the uterus contracting as rapidly and firmly as could be desired. Both children were alive, and though very small and evidently premature, seemed likely to live.
The mother was kept thoroughly under chloroform until the binder was applied, and some of the wet bedding replaced by dry.
When the chloroform was removed, which it was at 1 p.m., there was no appearance of a return of the convulsions, but the patient was hardly conscious, she was in a state of stupor which lasted for fully thirty-six hours, during which, when spoken to in a loud voice, she would say, yes or no to any question, which admitted of being thus replied to; but any question requiring a longer reply she did not attempt to answer.
For twelve hours after parturition she appeared to be very thirsty, asking frequently for “drinks."
On Tuesday evening she fell into a calm and natural sleep, and with the exception of occasional attacks of twitching in the left arm, all reflex action had ceased.
On Wednesday, I was prevented from seeing her, but received a note from Mr. C., informing me that mother and children were progressing favorably; that the former, though still oppressed by the stupor, was
looking fresher and more natural than she did the day before, and that there had been no return of the fits.
On Thursday I visited her and found everything going on well, (except that one of the twins had died convulsed a few hours before my arrival). Mrs. C. had had her bowels freely opened by castor oil.
She looked remarkably well, pulse about 100. She had completely wakened out of her lethargic state, had asked for chicken soup. Still the twitching of the left arm continued, and she complained of great weakness; her skin was dry and harsh, for which I ordered sponging with tepid water and vinegar, after which she felt much more comfortable in consequence no doubt of the slight diaphoresis produced.
On Sunday, the 4th inst., I saw her for the last time; all reflex action had now ceased, and she was evidently making rapid progress towards recovery.
Since then, Mr. C. and others have called here and reported always most favorably as regards the mother, but the other child died on Thursday the 8th in the same manner as his brother had done some days previously.
I ought to observe that at each of my visits to Mrs. C., a specimen of urine was obtained and examined, chemically and microscopically, but nothing abnormal could ever be detected.
Commentary. This case undoubtedly constitutes an exception to the great general rule that " Puerperal convulsions are intimately connected with diabetes albuminosus or acute Bright's disease.”
True, some eminent authorities as Marchal, Liebert, Depaul, Legroux, L'Huillier, Stoltz, Seyfert, Levy & Scanzoni, have assailed the theory of the identity of uræmic intoxication in acute Bright's disease, and puerperal eclampsia, but equally eminent writers as Frerichs, Litzman, Braun, Wieger, Oppolzer, Matthews, Duncan, and many others have, with equal ability, and I think better success, defended this theory, for at the present day it is the generally received view.
The first mentioned authors have endeavoured to prove that the Brightian degenerations of the kidneys, which, it cannot be denied, are found in the bodies of those who have died of eclampsia, are consequences merely of the convulsions only accidental secondary phenomena of the hypervemia caused by the eclampsia, and of hydroæmia."
The result of analytical investigations is thus summed up by Scanzoni:
"1. In the most recent times the post mortem examinations of persons dying of eclampsia have shown, only in a minority of cases, so profound a degeneration of the kidneys, as to justify the diagnosis of Bright's disease.
“ 2. It is not proved that albumen in the urine and the presence of fibrin cylinders always precede the outbreak of the convulsions.
On the contrary, there are circumstances which show that this anomaly is frequently developed for the first time during the delivery or the convulsions. “3. The arguments which have been brought forward to prove
that uræmic intoxication has taken place, are not by any means equally strong arguments for our holding that the true eclampsia parturientum is always the result of uræmic intoxication originating in Brightian degeneration of the kidneys.
“4. Eclampsia puerperalis presents general clonic convulsions of the voluntary muscles, proceeding from the spinal cord, with removal of consciousness. These convulsions have their immediate cause in the irritability of the motor system of nerves which has been induced by pregnancy and increased by the act of delivery."
The case of my patient, Mrs. C., would seem to give support to the above views.
That she suffered from true eclampsia cannot be doubted, and still, so far from the convulsions being preceded by the presence of albumen and of fibrin cylinders in the urine, these abnormal phenomena were not observed at any period in the history of the case. It certainly seems impossible to account for the convulsions in this case in any other way than by “the irritability of the motor system of nerves which had been induced by pregnancy,” and not only of the motor, but also of the sensory system. The neuralgia from which Mrs. C. suffered was the first palpable evidence of that nervous irritability which resulted directly from the unusually great distension of the uterus, and which in the end culminated in true eclampsia.
Dr. Braun, in his text-book of midwifery, (Lehrbuck der Geburtshulfe mit Einschluss der operativen Therapeutik, der ubrigen Fortpflanzungs-funtionem der Frauen und der Peurperal processe Von Dr. Carl R. Braun, K.K.0.0., Professor der theoretischen Geburtshulfe und Geburtshulflichen Klinik fur Arzte an der K. K. Universital in Wein, &c., Wein, 1857) devotes one chapter to the subject of puerperal convulsions, which chapter, owing to its completeness and erudition, has been translated into English and published in a separate form by Dr. Matthews Duncan, Lecturer on Midwifery, &c., &c., Edinburgh. From this translation the following graphic description of uræmic eclampsia is quoted; and I may here observe that this description applies with singular exactness to the convulsions which I observed in my patient, Mrs. C.